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NATIONAL LIBRARY OF MEDICINE
NLH DD555MMb 3
ARMY MEDICAL LIBRARY
FOUNDED 1836
      ANNEX
WASHINGTON, D.C
NLM005554463 
DUE TWO WEEKS FROM LAST DATE
OPO  807422 
 
 
 
 
 

REPORT
COLUMBIA HOSPITAL FOR WOMEN
LYING-IN ASYLUM,
WASHINGTON, D. C.
J. HARRY THOMPSON, A. M., M. D.,

        SuRGEON-IN-pHIEF.
AN APPENDIX
    ^ "     <r>



     ■'■■.'/: kv..n**
    WASHINGTON:
GOVERNMENT PRINTING OFFICE,
        1873. 

o  v 
                                             Columbia Hospital,
                                   Washington, I). C, October 31, 1872.
     Sir :  In compliance with your request I have prepared and herewith
transmit a summary of the  principal  operations  performed by me in the
"Columbia Hospital for Women," from March, 1866, to June, 1872.
     A few cases which have occurred outside the hospital are included in
the report as illustrating the  advantages or disadvantages of special forms
of treatment which have been pursued.
     The brief time allowed for the preparation of this report has precluded
the possibility of giving the details of all the surgical  cases, (some seven
hundred in number,)  or entering  at any length into the history of the vari-
ous  diseases which have required surgical interference.   Little more has
been attempted than a faithful clinical record.
     Much of the  success which  has attended my labors  in this  institution
has been due to the liberal appropriations  made by Congress, which  have
enabled the directors to furnish  competent nurses, talented assistants, and
place at my disposal every necessary appliance.
     With the increased accommodations afforded by the enlargement of the
building, and its  perfect system of heating and ventilation, it may  rea-
sonably be expected that the future record will be  an improvement upon
the past.
     Accompanying this report is  one from  each of three of the departments
of the  dispensary connected  with  the hospital: "Diseases of  women,1'
"Diseases of children," and "Diseases of the eye  and ear;" while contain-
ing much of interest,  they are  necessarily incomplete, as  it was impossible
to allow sufficient time for their preparation.
     I have the honor to be, very respectfully, your obedient servant,
                                     J. H. THOMPSON, M. D.,
                                                      Siirgeon-in-chief
     Hon.  Columijus  Delano,
           Secretary of the Interior. 
 
PREFATORY   REMARKS.
     The medical art, in its crude beginnings, grew out of the absolute wants
 and necessities of mankind.  With the progress, of civilization, and the grow-
 ing requirements of an advanced condition and  augmented population, its
 appliances and laws have been developed, and its scope expanded, until what
 was first mere haphazard experiment has assumed the accuracy and almost
 positiveness of a broad inductive philosophy.
     Medicine  has  moved, pari passu, with  other sciences in the march of
 intellect, and  the demonstrations of its excellence and progress were never
 more startling than at this moment.  The perfection of medicine as a science,
 however, we  dare  not affirm.   Struggle  and approximation, learning to
 " labor and to wait," fortunately constitute the law of our intellectual con-
 stitution, thus affording that constant stimulus to study and experiment with-
 out which indolence would take possession of the student, and mental dis-
 covery cease altogether.
     The disposition to cultivate scientific medicine,  both in theory  and
 practice, was  never more earnest than  at  present.   Natural philosophy,
 chemistr}^  anatomy, physiology, pathology, are, each and all, pouring their
 contributions into the common stock, and aiding in the development of prin-
 ciples.  Prominent  among the agencies which are  adding largely to practi-
 cal results may be mentioned the enlarged facilities for clinical observation,
the more frequent devotion to specialties, and, last but not least, the  careful
description of the  history, treatment, and results of cases  in  the wards of
well-regulated hospitals.
     No department of pathology has been so little understood or appreciated
as that embracing the accidents and maladies peculiar to the female sex, and
it may with equal truth be asserted that in no branch of practice have the
labors of the specialist been attended by  more enlarged discoveries or more
satisfactory results.   Among those who will be regarded as pioneers in this 
2
region of inquiry and experiment, the  names of Henry Bennett, Simpson,
Baker Brown, Emmet, Sims, Atlee, Thomas, Storer, and others, will promptly
suggest themselves to the mind of the gynaecologist.  As a gleaner in a field
so successfully reaped by others, the author of this report has, through the
generous provision made by the Government in aid of private enterprise,
been enabled to establish a hospital for the wants  of lying-in women, and
for the surgical treatment of accidents  and diseases of the uterine  system.
Since its organization  it has been in his  power to treat a large number  of
cases with gratifying  success, the most of them calling for surgical interfer-
ence.  The operations have been  chiefly confined to cases of cystocele,
rectocele, vesico- and recto-vaginal  fistula, prolapsus uteri, the restoration
of aggravated forms of lacerated perineum, and obstructive dysmenorrhea.
     Well-regulated hospitals, having the proper hygienic appliances, with
careful medical attendants, and skilled, judicious nurses, are constantly fur-
nishing material of great interest to the community, and of inestimable value
to the profession.  It is expected of the chiefs of such institutions that they
will not content themselves with the mere eclat of practical surgery, in the
ward or  theater, surrounded by  an admiring class of students and associate
practitioners, but carefully  record and digest the history of all important
cases, and publish them for the benefit of  the  medical public and the
advancement of scientific truth.   Animated by this view, the author  tenders
his report as  an humble contribution to a department of surgery which has
enlisted his liveliest interest and most careful study and reflection.
     As yet, the Government has caused to be established two hospitals in this
District,  the Insane Asylum and  Columbia Hospital for Women.  The flour-
ishing condition of these suggests the propriety of developing, by the estab-
lishment of additional model hospitals, other important specialties.  Let each
of these institutions be presided  over by suitable talent, and full reports be
required  annually upon each  and  every  case treated.    The  aggregate
of such annual reports would constitute a library in itself of incalculable
advantage to the  whole nation.  The  Government has  already indicated
extraordinary appreciation and liberality in the publication and free diffusion
of important scientific  truths.   Let  this spirit find  further expansion, until
other branches of knowledge, important to the physical well-being of the
population, shall be enlarged and rendered practical under the fostering care
and direction of our beneficent republic. 
3
     A great boon would be conferred by the establishment of a department
of hygiene, its object being the prevention of disease.  This, we are happy
to know, has been  already anticipated by an eminent medical gentleman
of the District, who has had presented  to  Congress  f. bill  and memorial
looking to the organization, by the Government, of a  grand,  national,
sanitary bureau, for the purpose of collecting and distributing reliable infor-
mation on every conceivable subject connected  with  public hygiene, and
by thoroughly sustained  observation and experiment enlarging the present
limits of knowledge in this most important department of labor.  This enter-
prise, we  are gratified to say,  has almost universally received the indorse-
ment of the leading sanitarians of the country, and the American Sanitary
Association, recently organized, have deemed it of sufficient importance to
appoint a committee for the  purpose of advancing the success of the move-
ment,
     Already the  scientific world  owes much to  the efforts of the Govern-
ment at the capital  of the nation.   The brilliant labors of Surgeon-General
Barnes and his distinguished collaborator, Dr. Woodward, and others, have
attracted  universal attention and admiration.    Nor must  be overlooked
the valuable reports of the Agricultural and Educational Bureaus,  which are
annually flooding the  land  with light upon the  special subjects of which
they treat; or the commendable interest and zeal manifested by Mr. Delano,
the  present Secretary of the Interior, in the medical and other institutions
under his immediate supervision and direction.
     In this connection it ma}' not be considered inappropriate to present a
resume of the operations of  the institution under my charge, from its com-
mencement in March, 1866,  to  the end of June, 1872 ;  and I cannot permit
this  opportunity to  pass without most cordially congratulating the directors
upon the prosperity of an institution which  they have labored to establish
upon its present firm  basis,  and to  rejoice with them in the consciousness
that the institution  is free from debt, its buildings and grounds paid for, and
its future support secured by the fostering care of  a beneficent government.
     The year 1861 found the city of Washington, the  capital of the United
States, with a population of over one hundred thousand souls, without a civil
hospital or dispensary to which the  poor of its resident or floating popula-
tion could apply for medical  assistance in case of disease or accident.   Such
a condition of things constituted an anomaly in the history of municipalities. 
4
     Large numbers of females were attracted to the city during the war, in
search of relatives and friends, or for information from the Departments.
Anxiety and fatigue, as a natural consequence, caused suffering and disease,
and hundreds of women, prostrated by sickness, and without means, were
tin-own upon the charities of the residents of Washington and the representa-
tives from the different States to which they belonged.  With the perseverance
and zeal characteristic of the order, the Sisters of Charity succeeded in open-
ing Providence Hospital, which took the place of the old infirmary; but its
accommodations, strained to their utmost capacity, were inadequate to  the
demand. *
     The  absolute want of a hospital  exclusively for women was apparent,
but  the exigencies of the war  were so vast, and the demands upon private
resources so great, that it was deemed inexpedient to attempt its establishment
until the fall of 1865. In November of that year I laid my plans before
the Rev. Drs. A. D. Gillette and C. H. Hall, and Moses Kelly, esq., whom I
invited to co-operate in the enterprise.   They lent their valuable influence
and service most readily, and,  upon  consultation with Surgeon-General
Barnes, it was decided to lay our plans before Hon.  E. M. Stanton, then
Secretary of War.   His comprehensive mind required  no argument to con-
vince him that such an institution was needed, and that, to  be successful, it
must be fostered by the Government. Indeed, nine-tenths of its beneficiaries
would necessarily be wards of the nation, coming, as they did, and still  do,
from all portions of the country, and, although temporarily resident  here,
claiming citizenship in the States from which they came.
     As was his wont, he unhesitatingly assumed the responsibility of author-
izing the  Surgeon-General to  furnish completely fifty beds,  and to issue a
"full supply of medicines and medical stores; insisting, however, that twenty
of those beds should be used exclusively for the wives and widows of soldiers
of the United States Army.
     Liberal contributions from Messrs. Charles Knapp, H.  D. Cooke,' Philp
& Solomons, and others, enabled us to lease the Hill mansion and grounds,
on the corner of  Fourteenth street and Massachusetts avenue, into the  pos-
session of which we entered  February, 1866.
     Mrs. A, J. Brown, ever foremost in every charitable enterprise, became
     * Since writing this report, I find that the credit of establishing Providence Hospital is due to Dr.
Toner, of this city, and not to the Sisters  of Charity, they having taken charge of it after he had estab-
lished it. 
5
warmly enlisted in  behalf of the institution, and, by her personal efforts,
secured donations sufficient  to  furnish the  parlor and executive portion of
the building.   A  board of directors was organized, of which the Rev. Dr.
Gillette was president, and  the Rev. J. N. Coombs secretary, and, on the
4th day of March, 1866, the Columbia Hospital opened its doors  for the
reception of patients, with a heartfelt prayer to Almighty God that He would
bless the undertaking and prosper the efforts of its founders.
    Application was made to Congress for a charter, which was granted,
and approved June 1, 1866.
    The same year Congress appropriated  ten thousand dollars to assist in
the support of the institution, and each year, since that time to the present,
the appropriation has been enlarged with the increasing demands of the hos-
pital.   At the expiration of the lease of the  Hill mansion, the proprietor dis-
posed of the building and grounds,  and we were  compelled to  leave.  The
present building was then leased from Dr. Maynard for two years, at the
end of  which  time a conditional purchase was  made of the building  and
grounds, upon most advantageous  terms to the  hospital, the details of the
negotiation having been conducted by Moses Kelly and A. S. Solomons, esqs.
    At the last session of Congress an appropriation was secured sufficiently
large to enable us to  complete the  purchase and deed the property to the
United  States, in accordance with the  conditions  of the bill.
    Thus, after six years of untiring  efforts, we have eventually  accom-
plished  what was so earnestly desired—the  permanent foundation in Wash-
ington of a hospital devoted exclusively to the treatment of diseases peculiar
to women.
    Accompanying the appropriation for the purchase was one for repairs
and alterations, which, with the amount in the  hands of the  treasurer, is
sufficient to provide for the present alterations.   These, when completed,
will give us an abundance of room for the free patients, and provide  a num-
ber of private rooms for pay-patients.
    The  committee  appointed to  carry out these repairs and alterations
consists of General J. K. Barnes, chairman, J.  T. Mitchell, esq., and the
Hon. George Taylor.   They have secured the services of Mr. Clark, Archi-
tect of the Capitol Extension, who  has kindly taken charge of the work
giving his services gratuitously.
    The  design  for the alterations was made by General Barnes.  It is 
G
comprehensive, and eminently practical.  The objectionable features of the
building have been  removed, thorough ventilation  and sewerage secured,
and, when all has been completed, we shall be in the possession of a build-
ing of which we may be justly proud.
     Much has been said by the enemies of the District as to the unwilling-
ness of  the  people to support their poor, and render their fair share of aid
to such charitable institutions as  have sprung up in their midst; but our
experience is very different.   The old city government and the present Dis-
trict government have done their full  share toward the support of such of
the inmates of this institution as were properly chargeable upon the District,
have made the necessary appropriations promptly and generously, and have
in no respect drawn  on the General Government for the support of their
local poor.
     By comparing the reports of this institution for the last two years with
the reports  of similar institutions  in other parts of the country,  it will be
found that, in  proportion to our fixed population, we furnish gratuitously
medical and surgical relief to at least  twenty per cent, more patients than
are relieved at the hospitals in  New  York, Philadelphia, and other large
cities.
     The number of deaths that have occurred in the hospital are very much
below the average; and, during  the last four years, not one single case of
death has occurred as  the  result of  surgical  interference, although within
that time a large number of very important operations have been performed,
all of which  have been successful.
     The lying-in wards of this hospital have  been free from any epidemic
during the whole time they have  been open, and not one death has occurred
from difficult or natural labor where the patient has  been under observa-
tion for a reasonable time prior to parturition.
     The number of patients treated at the hospital during the current year
has been more than double that of last, and nearly as many as the four pre-
ceding years. 
(
                          Summary of cases treated.

The number of patients under treatment on June 30, 1871, was...............    106
Number admitted during die year ended June 30, 1872, as outdoor patients. ...  4,10!)
Number of indoor patients...............................................    301
Total.............................................................. 4, 570
Number of prescriptions compounded......................................  8, 105

                                  RESULTS.

Number cured............................................................  3, 70S
Number relieved......................,...........  ......... ..........    501
Number died............................................................     21
Number incurable......................  .................................     35
Number results unknown.........................  ........................    101
Number under treatment.................................................    150
Total............................................-................ 4, 57G
                                  NATIVITY.

American......'........................................................... 3, 230
English......................................'  ..........................    13
Irish................................................................... 1,080
German.....................................................-.........- -   212
French................................................................  .     3
Spanish.................................,...............................     5
Eussian...................... —........................................     1
Canadian ... -..................................:.....: - - - -.....-  - -.......     1
Scotch ............................,:.............:.. .. ................    22
West Indian.............,.........  .-:■•••.....:.....................  - - -     3
Total..................  ......,..................................  4, 57G
                                CITIZENSHIP.

District of Columbia . T. ? . - ?.............................................  2, 312
Virginia............,...................................................  1, 018
Maryland ..,..,.,,,....................................................   940
Texas.................................................  .................     5
Ohio................................................................      13
Massachusetts............................................................     2G
Maine...................................................................     12
Vermont.................................... ............................     2
Connecticut..........................................................     7
Illinois..................................................................     15
New York................................................................     46
Michigan..............................................................     8
Indiana................................................................     21 
New J ersey..............................................................    20
Delaware.............................................................    23
Unknown.................. ............................................   102

      Total  .....•..........................:............................. 4, 57G
Summary of the entire operations of the hospital from March 4, 1866, to June
                                 30, 1872.

Total number of patients admitted....................  ...................  11, 455

                                 RESULTS.

Number cured..........,...„<>............................,..............   0, 457
Number relieved................................................'..........   1, 081
Number incurable......................................................     257
Number died..........................................................     .81
Number sent to Insane Asylum..........................................       7
Number results unknown.................................................     422
Number under treatment June 30, 1872 ....---............ ,...............     150
Total.............................................................  11, 455
                                 NATIVITY.

American..............................................................   8,116
Irish................................................................   2,132
German.............................................,..................     899
Scotch..............................  ..................................     109
English.................................................................     147
French..................................................................      17
Spanish...............................................................      14
Austrian.....................................'.....,....................       7
Mexican........................  .....................................        4
Russian.................................................................       1
Hungarian...............................................................       4
West Indian ...........................................................       4
Canadian................................................................       ]
Total.............................................................: 11, 45
                                CITIZENSHIP.

District of Columbia.....................................................  4 9^7
Virginia............................................................  ..  o 210
Maryland.............................................................  2,106
New York..............................................................    392
Pennsylvania................................ ...........................    227
Massachusetts..........................................................    yi\
North Carolina...............................................  ........     227 
                                    9

South Carolina........................
New Jersey.............................
Ohio.....................................
Iowa.....................................
Indiana..............  ..................
Missouri..............................___
Connecticut........  .....................
Delaware................................
Michigan................................
Vermont.................................
Maine..................................
Texas..................................
Illinois...................................
Florida..................................
New Hampshire..........................
Kentucky..............................
Rhode Island.............................
Unknown ................................

     Total..................................................... ....... 11, 455
     With these discursive  prefatory remarks, I present the report of my
labors as chief of the Columbia Hospital for Women, trusting it will neither
disparage the  Government which  has so  generously come to the aid of the
institution, nor do discredit to the  profession with which I am proud  to be
associated.
                                        J. H.  THOMPSON,  M. D.
     1324 Massachusetts Avenue.
           2
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482 
 
OPERATIONS
                               FOR THE

RADICAL CURE  OF  LACERATED OR  RUPTURED  PERINEUM,
REPORT OF THIRTY-FOUR SUCCESSIVE OPERATIONS RESULTING FAVORABLY.
     Since I have  been in charge of Columbia Hospital I have operated
fifty-three times  for the cure of this most distressing of all the accidents
attending labor.  In each case the operation has been eminently successful.
     Few years have passed since this accident was considered incurable, the
difficulties attending an  operation for its relief having been looked upon
as insurmountable.   Attempts were therefore rarely made at surgical inter-
ference, and these proved mostly unsuccessful.
     The following cases have been  selected as comprising all  the varieties
and complications of this accident, the remaining nineteen being similar in
character to those reported.
     I claim little originality in the treatment of this lesion, simply modify-
ing in some respects the operation as practiced by that illustrious pioneer in
gynaecological surgery, Baker Brown.
     The tabulated reports from the lying-in hospitals of Europe and Amer-
ica furnish no data from which we can judge of the relative frequency of
this accident to the number of women delivered.  Their silence on this sub-
ject can only be accounted for by a neglect to examine the parts after delivery,
or from the mistaken notion that a ruptured perineum necessarily reflects
discredit upon the attending accoucheur.   It certainly is  an  accident of no
uncommon occurrence, both in private practice and in public institutions,
and  under the care  of the most accomplished obstetricians; its frequency
behiii' roadilv a.ccounted  for  when we  consider the various causes which, 
12
 either singly or in combination, may produce the lesion.  Churchill gives
 thirteen causes:
      1. Sacrum too perpendicular.
      2. Arch of the pubes too acute.
      3. Thickened state of the urethra and subjacent parts.
      4. The too rapid passage  of the head.
      5. Exostosis in any part of the pelvic cavity.
      6. Excessive breadth of the perineum.
      7. Rigidity  of the perineum.
      8. Tissues of the perineum weakened by disease.
      9. Occlusion of the lower outlet of the hymen.
     10. Malposition of child's head.
     11. Malpresentations.
     12. Exercise of too much voluntary force by the patient.
     13. Want of care when instruments are used.
     Tyler Smith  only alludes to the seventh division of Churchill, "rigidity
 of the perineum."
     Gaillard Thomas  gives four causes: parturition, use of forceps, manual
 delivery, craniotomy.
     Graily Plewitt simply refers to difficult labor.
     Byford  gives as  causes: straight sacrum, rigidity of perineum, large
 and unusually ossified head, too narrow arch to the pubes, unskillful use of
 instruments.
     Baker Brown suggests as the principal causes,  "the dimension of  the
 child's head being too  large absolutely and relatively for the capaciousness
 and expansibility of the maternal outlet;  an unnatural rigidity of the  peri-
 neal tissues,  or extreme width of the same; unskillful use of instruments;
 parturition for the first time at a very early or late age."
     Of the fifty-three  cases which have come under my care, thirty-three
 were of long standing,  i. e., varying from one to seventeen years, and  their
 histories, obtained principally from the patient, are  not altogether reliable.
 Twenty were recent cases.  In forty-four instances the accident occurred at
 the birth of the first child;  the remaining nine were multiparae.  In two of
the multiparae, instruments were used, as  also in sixteen of the primiparae.
In no case could I  discover any abnormal acuteness of the arch of the pubes, 
13
and in only two was the sacrum unusually straight.  Two had been breech
presentations, and eleven were extremely rapid labors, accompanied by vio-
lent expulsive  pains; the  patients stating in these cases that they felt  the
tissues tear, calling  the attention of the attending physician to the circum-
stance.
    From my own  experience I consider the principal exciting causes to be:
    1. Violent expulsive  efforts by the patient, on contact of the child's
head with the perineum, in most cases  induced by too much manipulation.
    2. Unusual width of the child's shoulders in proportion to the size of
the head.
    3. Extreme width of the perineum.
    4. Inelasticity  of the perineum occasioned by fatty degeneration of its
tissues.
    5. Unskillful use of the forceps.
    The fourth cause occurs most frequently after thirty years of age.
    The  varieties  of  lacerated  or raptured perineum are : complete  but
uncomplicated, the  sphincter ani remaining  intact;  complete and compli-
cated, attended by rupture of sphincter ani; incomplete, when the laceration
extends only a part of the distance between the fourchette and  anus; per-
forating, this last being extremely rare.
    The  consequences of this accident are extremely grave, and, in many
cases  of long standing, incapacitate the patient for any exertion in the erect
posture.
    The principal sequelae are:  prolapsus of the posterior wall of the vagina
and anterior wall of the rectum or "vaginal rectocele ;" prolapsus  of the ante-
rior wall of the vagina and the posterior wall of the bladder, or "vaginal
vesicocele;" procidentia of the uterus,  with all the complications attending
each of these conditions.
    These are not supposed results of the accident, but necessary consequen-
ces, as we  can readily comprehend when  we examine the anatomy of the
female perineum and maternal outlet, and the relative anatomy of the "gen-
ito-urinary organs."   From some inexplicable cause we find the anatomy
of the female perineum neglected in most works; the male perineum occu-
pying the whole attention.
    By reference to Fig. 1, Plate 1, we shall find that the posterior fibres of
the sphincter vaginae and the*anterior fibres of the sphincter ani are inserted 
14
into the tendinous structure and fascia of the perineum.  When a complete
rupture occurs, the sphincter ani,  contracting from its posterior insertion on
either side of the coccyx,  draws the anterior wall of the rectum backward;
the fibres of the sphincter vaginae,  being torn from their posterior attachment,
lose all power of drawing the posterior wall of  the vagina forward and
upward; the transversalis perinei draws the  lacerated edges  outward and
upward, widening the gap made antero-posteriorly; and the vagina, which,
normally, is a  closed canal, becomes a mere chasm, and the  floor  of the
pelvis  is lost.
     Fig. 2, Plate 1, shows the relative anatomy of the female genito-urinary
organs in the normal condition of the  perineum.   Fig. 1, Plate  2, shows the
change produced in the plane of the inferior strait by the loss of the perineum,
and will readily explain the causes of the complications which attend all
cases of long standing
     The  posterior wall of the vagina becomes straightened, and the tissues,
being  relaxed, permit of  the formation of a pouch at the lower portion,
immediately above the  internal sphincter, in which the faeces accumulate,
and vaginal rectocele soon follows, drawing on the posterior cid-de-sac of the
vagina, and changing the axis of the  uterus, which now hangs perpendicu-
larly over the external outlet.  All support being lost, it descends, drawing
with it the anterior wall of the vagina and the bladder.  A cid-de-sac of the
bladder is soon  formed, in which the  urine is retained, and the bladder can
only be completely emptied by the patient introducing her finger into the
vagina and temporarily replacing the  uterus.   In addition to her physical
sufferings, a woman in such a condition is totally unfitted for the marital
relation.
     It is unnecessary to use argument to convince an unprejudiced mind of
the advisability of an operation, however severe, which affords a reasonable
prospect of restoring the parts to a normal condition and  the woman to a
life of usefulness.
     The difficulties attending the operation have been greatly overrated.  In
the hands of a skillful surgeon it is one of the simplest and certainly most suc-
cessful operations in obstetric  surgery.  The profession is indebted to Mr.
Baker Brown for the best method of operating yet devised for the radical
cure  of ruptured perineum, as  demonstrated  by his eighty-one reported
cases. 
Fig.  i.
I.  Sphincter ani muscle.
2.  Perineal center, with inter-crossing of the sphincter ani and sphincter vaginoe muscles.
3.  Sphincter vaginae muscle.
4.  Transversus perinei muscle of the female.
5.  Erector clitoridis muscle.
Fig. 2.
Relative position of the genito-urinary organs of the female.  (Normal.) 
 
15
    As this report is submitted with the hope that it may be useful to some
of the younger members of the profession, I may be excused  for entering
more  fully into  the  details  of the  operation and the after-treatment than
would be otherwise necessary.
    In some of the important stages of the operation I follow the plan laid
down by Baker Brown, differing from him, however, in my treatment of the
sphincter ani, and also in some points of the after-treatment,  It may be  as
well to point out the difference here: Baker Brown divides the sphincter ani
on either side of its coccygeal attachments, and considers it a sine qua non to
success; I never divide it unless it has been torn through anterior^,  believ-
ing that it increases the risk of the operation  by exposing  so  much more
surface to the process of inflammation and  suppuration, and  at the same
time the irritation set up necessarily interferes with the chances of union by
first intention in the wound immediately in front.   It is, however, absolutely
necessary that the sphincter remain quiescent during the process of union,
and until  the new tissue has become thoroughly organized.   To secure this,
I adopt the plan  first suggested by  Professor Van Buren, of New York, i. e.,
"paralyze the sphincter." This is done perfectly by introducing the thumbs
into the anus, seizing the nates on either side, and making gradual traction
until  the thumbs touch the tuber ischii. The paralysis following this remains
for two or three weeks, but is never followed by permanent loss of  power,
which is sometimes the result of division.
     Instead  of the bougie, I have  had made some  hard-rubber tubes, the
sii'e of an ordinary catheter, perforated at intervals of one-fourth of an inch.
The advantages I claim for these over the bougie are, first, a uniform sup-
port on either side, not yielding at the parts  between the sutures, as is the
case with  the bougie;  secondly, they are more  cleanly, hence less irritating.
     In place of  waxed thread I use silver wire.  I need say nothing as  to
its superiority.    The mode of  fastening it will  be explained when I detail
tha steps of the operation.
    In the after-treatment, instead of keeping the  bowels constipated,  as
recommended by Baker Brown, I keep them in a soft condition, securing a
passage every day.   The discharges are painless, no  resistance being offered
by the sphincter.  The vagina should be washed out twice a day with the
following:
                      R Aqua* pime, \] ss.
                        Glycerine,  fss.
                        Acidi carbolic!, l;t. viij. 
16
    The urine must be drawn every six hours.  For this purpose I educate
my nurses, and never consent to operate without one of them  being in
attendance from the commencement until the patient is perfectly recovered,
as the least indiscretion or  clumsy manipulation  of an ignorant person
would jeopardize the success of the case, and thus injure  both patient and
surgeon.  In about twelve  to eighteen hours after the operation, the parts
may become  cedematous.   This  is to be treated by making several punc-
tures with the lancet, which will  liberate the serum and relieve the tension.
     Operation.—The patient, being fully aetherized, should be laid  upon a
firm table of  convenient height for the operator when sitting;  the buttocks
brought to the edge; the thighs flexed upon the abdomen;  the knees turned
out, and held in position by assistants.  Eemove all hair from the parts, and
with a small,  sharp-pointed scalpel, mark the outline of the part you intend
to remove, taking care to  allow for the contraction which will necessarily
follow cicatrization.  The width of the part to be removed must not be less
than three-fourths of an inch  antero-posteriorly, and extend the same width
upward on either side to  the point where the perineum started before the
accident.
     It is very important that the dissection be carefully made, and hence it
is better to remove the membrane in one piece.   For this purpose the knife
is better than scissors.
     The next step is to insert the  sutures.  I use a strong curved  needle,
about three inches long, with a cutting-point only.   This is armed with silk
doubled, so that, when drawn through, a loop remains at the point of entry.
Insert the needle an inch or one and one-fourth  inches from the external
edge  of the wound, and press it directly backward for about half an inch
before you turn the point toward the inner edge of the wound, at which part
it is to be brought out; enter it again on the  opposite side on the inner
edge, and make it traverse the  same  direction to  the  point of final  exit.
Select a piece of silver wire of medium size,  about ten  inches long, bend the
end over and hook it into  the loop of silk, draw the silk out, and  the wires
will follow without kinking.  Three to four sutures are generally necessary.
The first must be entered  at  the bottom of the wound, so as to control the
parts around the anus.  The wires, being in position, are to be passed through
the tubes, and secured on  the patient's left side first, by means of perforated
buck-shot, the shot being strongly compressed on the wire, the terminal end 
Plate II.
Fig. i.
Relative position of the genito-urinary organs of the female after rupture of the perinaeum.
Fig. 2.
Position of suture and quills before coaptation of the denuded surfaces. 
 
17
of which  should be bent sharply over, as seen in the illustration, Fig. 2,
Plate 2.  Bleeding having ceased, the cut  surfaces are to be  carefully
cleansed, and the parts coaptated by drawing first on the central wire, an
assistant gently pressing the soft parts together.  The right tension being
obtained, slip the shot  down to the tube, and securely clamp it.  Proceed
next with the lowest suture, and finish at the top ; the superficial edges are
to be brought together with the interrupted suture.
     The patient, having been removed to her bed, should be placed on her
side, her knees tied together, and cold-water dressings applied for the first
twenty-four hours.
     The deep sutures should  be removed on  the third day;  the superficial
ones on the ninth.
     For the first month great care must be taken to prevent undue traction
upon the newly-cicatrized tissue.   Fig. 2,  Plate  2,  shows the outline of
incision, with the sutures in position, ready for the parts to be brought into
coaptation
                                Case  1.
              Complete rupture, ivith Prolapsus uteri.—Cure.
     Mrs. M. C, aged twenty-seven, admitted to Columbia Hospital, June
28, 1866.  She gave birth to her first  child twenty months ago,  which is
still at the  breast, the  offspring being a fine, healthy boy.   Patient com-
plained of constant pain in the sacral region, with profuse leucorrheea, and
prolapsus of the uterus.  To retain the womb within the vaginal canal, she
was compelled to wear a T-bandage and pad.  Her general condition was
very anaemic.  Vaginal  examination, the patient having been placed on her
side, disclosed a complete rupture of the perineum, which originally must
have measured at  least one and  three-fourths inches in extent.  Os uteri
patulous, with granular erosion of both lips, which were much hypertrophied.
There was a  general catarrhal condition of  the mucous membrane of the
vagina; the pelvis  was very capacious.  Her labor had  lasted but half an
hour.
     General treatment.—The child was weaned immediately, and the mother
placed upon generous diet, with six ounces of wine daily.   Iron was admin-
istered in full doses, absolute rest in the recumbent  position having been
strictly enjoined. 
18
     Local.—Chromic acid was applied to the erosions resulting from friction
against the pad, and  a pledget of raw  cotton, soaked with the following
preparation, passed up into the posterior cid-de-sac, and allowed to remain
twenty-four hours, when it was removed, and a fresh one introduced:
                          R^  Glycerine, |iv.
                            Tannin, 3ij.
     This treatment was continued for three weeks, the patient improving
rapidly in her general health.   The rest and astringent application had pre-
vented any descent of the  uterus; the mucous membrane had gained con-
siderable tone; and the patient was considered in a sufficiently good condition
to bear the operation for radical cure.
     July 22.—Patient,  having  been fully aetherized, was placed in the posi-
tion advised, and the operation proceeded with as directed.
     12 p. m.—Ten hours after operation, patient suffering considerable pain,
very restless,  pulse  120,  and  irritable, ordered aq. ext. opii, gr. ij, to be
administered immediately; ice-water dressing  to the vulva, to be  changed
every few minutes; and the anodyne pill to  be  repeated in four hours,
unless the patient should become quiet.
     July 23, 8 a. m.—Slept after taking  the  second  pill;  much less pain;
pulse 100, -and softer;  one  grain of the opium to be taken every four hours
until free from pain.
     10 p.  m.—Pulse 88,  and  soft; little  pain since noon;  complains  of
thirst; suspended opium, and gave the "effervescing mixture."
     From this time  onward  everything  progressed favorably.  The deep
sutures were removed on the morning of the fourth day, and the superficial on
the ninth,  the result being complete union by first intention.
     Patient was  retained three weeks longer  in the hospital  to continue
the general treatment, being still somewhat anaemic.   Discharged,  cured
August 21.
     On July 24, 1867, eleven months and three days  after leaving the hos-
pital, she was  delivered of a well-developed boy at full term.  The labor
was rapid, and the perineum lacerated for about a quarter of an inch but
on the side of the cicatrix.  This was allowed to take care of itself, as there
remained intact fully one and a  quarter inches.   She made a good recovery,
and has since  given birth to another child without  any further laceration. 
19
                                Case .2.

              Complete rupture, complicated with Coccyodynia.

     Mrs. S----, aged forty-one, married in 1854, delivered of her first child
March, 1866, nine weeks previous  to  the time I saw  her.  Patient com-
plained of severe pain when sitting, and upon the passage of faeces or flatus
from the bowels.   The  history,  given by her  medical attendant, was as
follows: The labor had been protracted over three days, the patient suffer-
ing severely most of the  time.  A consultation was  had on the morning of
the fourth  day, when  forceps were applied, and the woman delivered of a
living child.  A perineal  rupture was noticed at the time, and every attempt
made to bring about union of the parts by keeping the  limbs tied  together
and applying local stimulants, but without success.
     Upon digital examination I found a fracture or dislocation of the coccyx,
about half  an inch from  the terminal point, which doubtless accounted for
the severe pain.  The fractured parts were disturbed on every contraction
of the levator or sphincter ani muscles.  There  was also a complete rupture
of the perineum.
     It was decided to adopt the treatment recommended  by Professor Simp-
son, of Edinburgh, for the injured  coccyx, and then to proceed with the
operation for the restoration of the perineum.
     The double operation it was proposed to perform was fully explained
to the patient,  and her consent obtained, but she positively refused to inhale
any anaesthetic.
     The patient being placed on  her side, a tenotomy-knife was introduced
at the back part of the coccyx, and  its muscular and tendinous attachments
liberated from  both sides and from the tip, the operation occasioning but
little pain.  After a few minutes' rest, she was placed in  the position for the
major operation, which was  proceeded with after the usual manner, and
lasted fifteen minutes.
     The result was very gratifying.  The severe pain which she had suffered
from the injury to the coccyx was immediately relieved;  her convalescence
became rapid, and continued without one untoward symptom.  The restora-
tion of the perineum was  complete, union having taken place by first inten-
tion throughout its whole extent, 
                                  20

                               Case 3.

Complete rupture, involving the sphincter ani and recto-vaginal septum.—Cure.

    Mrs. T----, aged thirty-one ;  mother of four children.   She was deliv-
ered of her last child four months since, at which time the accident occurred.
    There was nothing  connected  with the history of this case which could
satisfactorily account for the rupture.  The woman was well-proportioned,
of fine physique, and the  infant had  no abnormal development of the head or
shoulders.   Her labor had been of average duration, and not severe, and
the same  medical gentleman attended her with the last as with the three
previous children.   No instruments had been used.  Her convalescence had
been  slow; she was unable to sit  up  before the  seventh week, and it was
four months after the birth of her child before  she could endure the fatigue
of journeying from her home in Pennsylvania to Washington.
    I saw  her  the day after her  arrival,  and, upon examination, found a
complete rupture of the perineum, and sphincter ani muscle, the  laceration.
extending  about one and  three-fourths inches  up the recto-vaginal  sep-
tum.   She had had little trouble in controlling the bowels, being naturally
of a very  costive habit, but flatus passed involuntarily.  When the bowels
were  moved, she suffered great pain, occasioned by the ulcerated  condition
of the edges of the upper part of the laceration.  There had been no  pro-
lapsus, and the mucous  membrane  of the vagina was in a healthy condition,
except the edges and apex of the laceration.
    It became necessary to perform two distinct operations—first, to restore
the integrity of the  sphincter ani and recta-vaginal septum;  and,  secondly,
to restore the perineum.
    July 3.—Patient, having been aetherized, was placed upon her back,  with
limbs well flexed upon abdomen.   The thickened  edges on both sides of the
laceration were removed by the scissors, the incisions extending half an inch
beyond the apex of the rupture,  in order to  secure healthy tissue.    The
edges were carefully approximated by the interrupted  wire-suture, and the
sphincter ani divided on both sides  of the coccyx.   The wires were removed
on the ninth day, and the parts found to be perfectly united.
    August 11.—The operation for restoration of the  perineum Avas  per-
formed in the usual manner.  The sphincter, having but imperfectly recovered 
21
from the previous division, was not interfered with.   On the second day
after the operation there appeared so much oedema of the  parts engaged
within the sutures  that I was fearful it might  become necessary to remove
them;  but free puncturing and the application of ice proved sufficient.  The
deep wires were not removed until the fifth day, when it was found that
suppuration had formed in the track of the middle  suture, the pus flowing
freely upon its withdrawal.  This accident was the result of retaining the
deep sutures in situ two days longer than was necessary;  but it in no way
interfered with the success of the operation, union being perfect in every
part.   The superficial sutures were removed on the ninth day.   Patient left
for her home on September 18, cured.
                                Case 4.

              Complete  rupture, eight years' standing.—Cured.
     Mrs.  H----,  admitted into Columbia Hospital, September 17, 1866;
seamstress by occupation;  mother of two children;  complains of severe
pain in the sacro-lumbar region, profuse  leucorrhcea, and  smarting  after
urination.
     Examination revealed complete rupture of the perineum, with eversion
of  the lower  portion of the  vagina, which was intensely inflamed.  The
inflammation  was rapidly reduced by  the use  of  glycerine and aqueous
extract of opium.
     The operation for restoration of the perineum was performed  September
27, and the patient left the institution, October 24, cured.
                                Case 5.
                           Incomplete rupture.

     Mrs.  S----, wife  of a physician, was delivered of her  first child after
a protracted labor, the head having rested upon the perineum for six hours.
The rupture was discovered  on the birth of the child,  and I saw her a few
hours  afterward.
     The  laceration extended one-fourth  of an inch from the  anus.  The
parts having  been carefully sponged with a weak solution of carbolic acid
in water, the edges were approximated and retained in position by the quilled
suture. 
22
     The after-treatment differed little from that pursued in cases of long
standing.   The patient made a good recovery, the operation having  been
entirely successful.

                                Case 6.

         Complete rupture, Recto-vaginal fistula, and Prolapsus uteri.

     Mrs. M----, widow, aged  thirty-seven;  mother of five children, the
youngest being three years of age; complains of constant pain in the back;
profuse and  offensive  discharge  from the vagina;  loss of appetite and
extreme  debility.
     Examination revealed a  complete rupture of the perineum, and a fistu-
lous opening into the rectum two-thirds of an inch in length immediately
below the posterior cid-de-sac.  The uterus measured four and one-half inches,
and bled freely upon the withdrawal of the sound, although great care had
been used  in its introduction;  cervix hypertrophied, os patulous, but no
ulceration or abrasion.
     Treatment.—Hot-water irrigation  of the uterus morning and evening,
and the following ointment introduced into the cavity of the uterus every
third day with the view of reducing the endometritis :
                        R  Ungt. simplicis, 3iv.
                          Argenti nit. cryst., gr. x.
                          Aq. ext. opii, 3j.
     A pledget of raw cotton soaked in glycerine, containing four grains of
carbolic acid to the ounce,  was passed into  the cid-de-sac morning and even-
ing, the former to reduce the hypertrophy of the cervix and the latter as
an  antiseptic.  Tonics were  freely administered,  and the  patient kept in a
recumbent position.
     On the seventh week  from the commencement of treatment "Sims's"
operation for the closure of the fistula was performed with perfect success.
     Three weeks afterward the perineum was restored by the usual opera-
tion.  The patient  made a good  recovery, and  left for her  home in West
Virginia, January 22,  1867, cured.
     I have since  learned that this lady married in the following June, and in
due time gave birth to a child, but did not  learn with what effect upon the
perineum. 
23
                                Case 7.

              Complete rupture, of five years' standing.—Cured.

     Mrs.  C----,  admitted into Columbia Hospital January  12,  1867 ;
mother of one child;  patient complains of uterine prolapsus wdienever she
stands or walks; constant pain in the lumbar region, offensive leucorrhceal
discharge, so abundant as to  compel her to wear a napkin;  menstruation
occurs once a fortnight.
     Upon examination there was found a complete rupture of the perineum,
the cervix uteri protruding between the labia, os patulous, and cervix hyper-
trophied.   Patient was placed  under  constitutional and local treatment, with
the view  of restoring the uterus and its  functions to a  healthy condition
before attempting the restoration of the perineum.  Her recovery was very
slow, it being nearly three months  before she was in a condition to endure
surgical interference.
     April 8.—Operation for radical  cure performed in the presence of the
clinical  class.  There was considerable  difficulty in arresting haemorrhage,
owing to the unusual size of the arterial branches, which were wounded  in
the dissection.  A ligature being inadmissible, we  were  compelled to rely
on  torsion, which, in this instance, failed to accomplish the object as per-
fectly as desired.  The deep sutures were removed on the third day; the
superficial, on the eleventh.  Union perfect.
                                Case 8.
                         Complete rupture.—Cure.

     Mrs.  B----, admitted into Columbia Hospital March 19, 1867 ;  preg-
nant with her first child.   Upon making an examination,  in order to ascer-
tain the probable  time of labor, it was found that the vaginal  orifice was
extremely small, as also the lower part of the vaginal canal.   The perineum
was thick and inelastic, feeling like  cartilage.   This condition of the parts
made it probable  that during delivery  there would be  a rupture  of the
perineum  and lower part of the recto-vaginal septum.  The labor was very
rapid, and every effort was made to prevent the anticipated accident, but,
so tar as the  perineum was concerned, without success.  A severe attack of
metro-peritonitis followed delivery, and it was some weeks  before an attempt
could be made to restore the integrity of the lacerated parts. 
24
     May 23.—The usual operation was performed in the presence  of the
class.  The patient's  recovery was rapid;  union perfect by first intention.
She left for her home in North Carolina, June 25th.
     The large amount of white, inelastic tissue, and the few muscular fibres,
entering into  the  formation of this woman's perineum  makes it liable to
rupture at any succeeding labor.

                                Case 9.

                        Complete rupture.—Cure.
     Mrs. S----, mother of two children, the youngest twenty-eight months
old.   From the history of this case, which was given entirely by the patient,
the rupture must have occurred at her first labor, which was very protracted.
She  suffered the usual discomforts attending the lesion, but  her  general
health was good, although she had taken  but little exercise, owing  to the
uneasiness  about the pelvis.
     May 26, 1867.—Patient having been placed in position, chloroform was
administered, and  the operation commenced, my assistant administering the
anaesthetic.  When the operation had been  about half completed, a sudden
cessation of respiration  and irregularity of the heart's action  supervened.
The tongue was instantly drawn forward, and artificial respiration instituted,
but,  at the  end of  five minutes, there was no apparent improvement in the
patient's condition.  The artificial respiration was continued for nearly thirty
minutes before we were rewarded by a full-drawn inspiration.  Our feelings
may be better imagined than described.   It is hardly necessary to state that
the operation was  completed without the further use of an anaesthetic.   The
patient continued  quite feeble for some  days, but her recovery was perfect.
The  same success attended the operation in this as in previous cases.   I have
since delivered this lady of a well-developed child, weighing eleven pounds,
the perineum  remaining intact.   This is the third case  in my practice in
which the patient, by the use of chloroform, was nearly lost.  I  have ceased
to employ  this agent, finding the sulphuric aether, although slower  in  its
effects, a safer anaesthetic. 
25
                               Case  10.

                            Complete rupture.
    Mrs. B----, aged nineteen, mother of one child four months old.  The
rupture in this case had been produced by the unskillful or careless use of
forceps by a German midwife, who applied them without the consent of the
patient or her  husband.  The  limbs had been kept together, and warm,
stimulating applications made to the vulva; but the urine and discharges,
coming in contact with the lacerated edges, prevented union.
    June 7, 1867.—Operation performed at noon. In the evening the patient
complained  of  great  pain, and was  very restless; ordered  a  full dose of
opium, to be repeated in six hours.   The following morning the parts were
so much swollen that  I found it  necessary to puncture them freely, remove
the middle suture,  and loosen the upper;  warm applications were kept con-
stantly applied.  This treatment relieved  the pain, and no other unpleasant
symptom presented itself.  The remaining two sutures were not removed
until the fourth day, when, contrary to expectation, perfect union had taken
place.
    This patient was very fat about the genitals, and the error which caused
the difficulty in the case consisted in drawing too tightly on the wires, not
making sufficient allowance for the swelling which would necessarily follow
where there was so much cellular tissue included.
                               Case 11.

  Complete rupture, complicated with Polypus of the uterus and Haemorrhoids.
    Mrs. M----, admitted March 7, 1867; aged forty-three, mother of nine
children; married  at fifteen years of age; first child born  before  she had
reached  her sixteenth year;  patient  emaciated, and almost exsanguinous.
She had  haemorrhage from the uterus every few days, and from the haemor-
rhoids whenever the bowels were moved.
    A careful examination was made, and, in addition to a complete rupture
of the  perineum, there was discovered a  group  of ulcerated haemorrhoids.
The uterus had become much enlarged,  and the introduction of the sound
was followed by a copious discharge of blood; a sponge-tent was intro-
duced to determine  the uterine diagnosis,  and upon its  withdrawal the
         4 
26
next day a large polypus was discovered.   The treatment was first directed
to the removal of the polypus, the e'craseur being used in preference  to the
ligature.   The cavity of the uterus was swabbed out with the liquor ferri
persulphatis.   No constitutional disturbance followed the operation, nor was
there any return of the haemorrhage.
     After recovery,  the  haemorrhoids  were destroyed by the treatment
adopted by Professor Markoe, of New York, i. e., the application of fuming
nitric acid to their entire surface, every three or four days, until removed.
The application is almost painless.  It was deemed advisable to defer the
operation for the  restoration of  the perineum until the  patient's general
health should be restored.
     June 28.—Operation  performed without the use of  any anaesthetic, no
unpleasant symptoms occurring during the after-treatment,  and the patient
left for the country, July  19th, cured.

                                Case 12.

               Rupture complete, nine years' duration.—Cure.
     Mrs. F----, aged thirty-one.  In her first and only confinement,  which
occurred nine years before, the perineum was torn completely through, the
child presenting breech first.  For the last seven years she has worn a ball-
pessary, to retain the uterus in situ.
     The pessary was removed, rest in the recumbent position enjoined, and
a strong solution of tannin in glycerine applied to the mucous membrane of
the  vagina daily.   This  treatment was  continued for some  weeks with
success.
     July 11, 1867.—Performed my usual operation, which was followed by
some irritative fever,  controlled  readily,  however, by  opium.  The deep
sutures were  removed on the third, and the superficial on  the eleventh
day.   Union was perfect.
     I met this  lady  eleven months after, when she informed me that she
had suffered no inconvenience since the operation, and had enjoyed better
health than for several years  previous. 
                                   27

                                Case 13.

              Complete rupture, and Fibrous tumor of left labia.

     Mrs. A----, aged thirty-eight, came under my care September 8, 1867;
 has had three children; laceration occurred with the first child.   The tumor in
 the labia was first noticed about three years before,  and during the last
 eighteen months had increased rapidly.  She had been told that rupture of
 the perineum  could not be cured, and I was therefore consulted only in ref-
 erence to the  tumor, which had grown to  be a source of  great discomfort,
 being very large,  and blocking up the entrance to the vagina.  The tumor
 was removed  with some difficulty, its attachments being  strong and deep;
 the operation was  attended with considerable  venous  haemorrhage.  It
 weighed nine  and a  half ounces.
     Upon recovery, the patient, by my earnest recommendation, submitted
 to an operation for the restoration of the perineum, which was  performed
 December 4, and attended with the usual success.

                               Case 14.

    Complete rupture, with Prolapsus of the uterus,  of seven years' duration.

     Mrs. P----,  aged forty;  admitted into  Columbia Hospital January
 20, 1868, on  the recommendation of Dr. Van Buren;  mother of one child
 seven years of age.   Since the birth of this child she has suffered from
 prolapsus of the uterus, and for the last five  years  the uterus and vagina
 have been external to the body, supported by a handkerchief passed round
 the loins.  There was  complete  rupture of the perineum.   The  exposed
 mucous membrane had lost its characteristic appearance and was extensively
 ulcerated.  The accompanying vagino-vesicocele had not been reduced for
 some years, and the bladder had become so irritable from the decomposition
 of retained urine that only a few drops could be tolerated above the amount
 accumulated in the cul-de-sac.   When voided,  it necessarily passed over the
 ulcerated  surface,  and  caused  extreme pain.   It is  difficult  to conceive a
 condition more deplorable than that from which this  poor  woman was suf-
fering.
     The enormous capacity of the vagina would render any attempt to
retain the uterus in situ  by a pessary unsuccessful, and, after consultation. 
28
it was decided to attempt a radical cure by a modification of "Sims's " opera-
tion.  This was performed in the presence of Drs. N. Young, J. Eliot, T.
Morgan, and  the clinical class.  An ellipse, six  inches  in length and four
inches in  width,  was removed from  the  anterior portion  of the vagina,
together with the whole of the thickened tissue  included  within the limits.
Interrupted sutures of silver wire were introduced, one-quarter of an  inch
apart, and the  uterus returned within the pelvic  cavity before the parts
were brought in apposition.  The patient was placed upon her back and the
pelvis elevated, a pledget of raw cotton, soaked  in glycerine and carbolic
acid, introduced daily, and the urine drawn every six hours.  No unpleasant
symptom followed.  The wires were removed on the fourteenth day, when
it was found that every part had united by first intention.
     On March 2d the operation for the restoration of the perineum was per-
formed in the presence of the same gentlemen, and attended with complete
success.
     For about one year this woman suffered no inconvenience, but after
that time the uterus began to descend, and made its appearance externally
eighteen months after the first operation.  She was admitted into the Howard
Hospital,  and  Dr. Reyburn  removed a-further section from the vagina,
which appears to have answered for the time being.
     I am satisfied that many of these operations fail on account of the operator
being too conservative, not removing sufficient amount of tissue, and leaving
an  hypertrophied cervix, which should  always  be removed if found  irre-
ducible by ordinary means.  The perineum had remained intact.
                               Case 15.
               Complete rupture, two months'1 standing.—Cure.
     M. S----, admitted into Columbia Hospital January  24, 1868, upon
the recommendation of  Dr. N. Young; was confined  with her first child
two months previously,  her labor having been very protracted, and finally
terminated by forceps.  An  attempt had been made to restore the perineum,
immediately after her labor, by the interrupted suture, but without success.
     The usual operation for complete restoration was performed in presence
of the clinical class on January 25.   She was discharged, cured, February
27th.
     This woman was confined  with her second  child, eleven months  after
leaving the hospital, without injury to the  perineum. 
29
                                Case 16.

            Complete rupture, twenty-one years' duration.—Cure.

     Mrs. N----,  aged forty-seven;  mother of eight children.  Although
the injury in this case occurred at the birth of her first child, and the incon-
venience attending it had increased with each succeeding year, yet nothing
beyond mere  palliative measures had been suggested for  her relief.  The
uterus had been retained in situ by the daily introduction of a sponge satu-
rated with  a  strong  decoction of white-oak bark.  Her urine was voided
only by catheter, which she had learned to introduce herself.
     When  placed under my charge, March 8, 1868,  she was  emaciated to
an extreme  degree, and anaemic, the irritability of her nervous system being
so great that it was only after repeated attempts I succeeded in keeping her
quiet long enough to make a sufficient examination to satisfy myself as to
her condition.
     The  rupture  of the  perineum was complete, but uncomplicated with
either prolapsus of the uterus or vaginal walls; this usual  accompaniment,
in cases of long-standing, having been prevented by the daily use of the
medicated sponge-pessary.
     It required some weeks of preparation before this patient was in a con-
dition to permit of operative interference;  but, by the free administration of
cod-liver oil, strychnine,  iron, and whisky, I succeeded in  bringing her up
to a point that warranted an attempt at radical cure.
     June 8.—Assisted by Drs. Ashford and Eliot, I performed the usual
operation.  The deep sutures were removed on the third,  and the superficial
on the  twelfth day;  every portion having  united by first intention.  For
three days after the operation this lady suffered from a continued  series of
hysterical paroxysms, which large doses of  the bromide of potassium (one
drachm every two hours) seemed inadequate to control.  They ceased at
last, apparently from sheer exhaustion.
     The  general nervous condition  of this patient,  accompanied by  the
necessity of constant catheterization,  and an indisposition for the  slightest
exertion, which  continued  for some time after the operation, rendered  the
case most difficult of management.
     August 13.—She  left for the springs, not having  been out of her house
before for five years. 
30
                                Case 17.

               Incomplete rupture, two years' duration.—Cure.

     N. S----, aged twenty-seven;  has had three children;  the  first two
 born witliout any unusual difficulty; the last was the subject of a protracted
 labor, the breech presenting.  Her convalescence was  slow.
     The laceration extended to within one-third of an inch of the sphincter,
 and the vaginal walls had commenced to yield to the pressure of the uterus.
 An operation was recommended at once, not on account of any immediate
 inconvenience, but to  prevent the  complications which would present in a
 short time, if the perineal support should not be restored.
     The operation was performed on May 8, no anaesthetic being used; the
 deep and superficial sutures were removed  at the usual time; and similar
 success attended this as had marked former cases.
                               Case 18.

               Complete rupture, immediate operation.—Cure.
     Mrs. R----, aged thirty-two.  This patient was brought into the hos-
 pital May 11,  1868, after she had  been in  labor for sixty-five hours.   She
 was immediately  delivered with the forceps, but, in spite of the greatest
 care, the perineum was torn through to the anus.  The parts were brought
 together by the quill and intemrpted suture, and united  kindly;  the wires
 were removed  at the usual time; and her convalescence was as rapid as if
 no accident had occurred.

                               Case 19.

  Complete  rupture of the perineum, and Prolapsus of the uterus and vagina.

     P. N----, aged forty;  admitted into Columbia Hospital June 2, 1868.
 This woman stated that she had been for several years in the condition in
 which she presented herself at the hospital, unable to work for her support, and
 dependent upon the charities of the public.  The entire vaginal walls were
 exterior to the body, and covered with scales of dried epithelium, abrasions
 and ulcerations, there being no spot of healthy mucous  membrane discover-
 able.   The os uteri was patulous, the index-finger  passing  readily into the
uterine cavity, and the whole organ very much hypertrophied.   See Plate  3. 
Plate  III.
Complete prolapsus  of uterus and vagina.
8999965 
 
31
     Before any operation for a radical cure could be attempted, it became
necessary to restore the vaginal mucous membrane to a healthy condition.
The procidentia was reduced  with  some difficulty, and the  vagina kept
thoroughly anointed by  pledgets  of raw cotton soaked in glycerine and
watery extract of opium.  This application  not  only served to restore the
mucous membrane, but retained the  uterus in situ.
     This treatment, conjoined with a general tonic  course, was continued
for some weeks before the constitutional and local condition of the patient
was sufficiently improved to permit of surgical interference.
     July 3.—Patient, having been fully aetherized, was placed in the ordi-
nary position for lithotomy, and Emmet's modification of "Sims's" operation
for the radical cure of prolapsus uteri  performed, the section being taken from
the anterior wall of the vagina.  The parts united perfectly, and were con-
sidered sufficiently contracted to retain the uterus in position when assisted
by a restored perineum.
     On the  seventeenth day of the  same month the usual perineal  opera-
tion was performed, and on August  20th she left the hospital, apparently
cured.
     Dr. Ashford saw this woman  about one year after the operation.  She
had been working steadily most of the time  since she left the hospital. The
perineum was strong and perfect, but the uterus found to be low down and
resting upon the perineum.
     The same mistake was made in  this as in Case 14, and it will be neces-
sary to amputate the cervix and remove another section from  the posterior
wall of the vagina to perfect the cure.
                               Case 20.

Complete rupture of the perineum, and Procedentia uteri of eleven years1 standing.
                                 Cure.

     Mrs. P----, aged fifty; admitted into Columbia Hospital July 11, 1868.
The condition  of  the patient was similar to Case 14, but she had taken
better care of herself.  By frequent  bathing and anointing the parts with
fresh lard, she had succeeded in preventing the ulcerations and excoriations
of the mucous membrane.
     July 20.—The patient having been fully aetherized, the same operation
was performed as in Case 14, but double the quantity of tissue removed, 
32
the caliber having been reduced  more than  one-half.   No constitutional
disturbance  followed.   The  wires  were removed on the  fourteenth  day,
when every part was found united.
     August 5.—The usual operation for restoration of the perineum was
performed in  the  presence  of my  clinical class.   The deep wires were
removed on the third, and the superficial on the eleventh day, union being
perfect.  Patient left the hospital, September 8, cured.
     There is no probability of a return of the prolapsus in this case, for the
contraction of the vagina was so perfect that the uterus could not descend,
and, there being fully two and one-quarter  inches of sound perineum, the
maintenance of the vagina in its integrity was secured.

                               Case 21.

Complete rupture of the perineum, with Procidentia uteri, of twelve years1 stand-
                              ing.—Cure.

     Mrs. B----, aged sixty;  admitted to Columbia Hospital July 27.-  The
general condition of this patient was good.  Her constitution  had suffered
little from the local trouble, probably owing  to the absence of the periodical
congestions  attending the catamenia,  the climacteric period  having been
reached  at her forty-eighth  year.   The  uterus was much enlarged from
congestion due to malposition, not from any increase of its  parenchyma.
Reduction of the procidentia and rest in the recumbent position for a few
days brought it down to nearly its normal dimensions.
     The size of the vulvo-vaginal opening was enormous, and the restora-
tion of a perineum, of ordinary dimensions, would have failed in retaining
the uterus in situ.   I therefore decided, with the consent of patient, to close
the entire opening, leaving only a portion patent, the size of a goose-quill,
for the escape of the secretions.
     August  8.—The operation was performed in the presence of Drs. Young
and Eliot, Dr. Ashford assisting.  The mucous  membrane was removed on
either side to  the  extent of four inches, and of the same width  as in the
ordinary operation for restoration.   Six deep  sutures were used, and nine
superficial.   The wires were removed at the  usual time, and union found to
be perfect.   She left the hospital, September 13, cured. 
33
                               Cash 22.

       Complete rupture, Procidentia, and Vesico-vaginal fistula.—Cure.

    Mrs. D----, aged thirty-eight; admitted to Columbia  Hospital  Sep-
tember 4, 1868, on the recommendation of Dr. L. Mackall, jr.  She was the
mother of three children, but, from her  history, I could not learn in which
of her confinements the rupture occurred, but that  some months elapsed
after the birth of her last child before she experienced any serious incon-  •
venience.   She then complained of a continuous pain in the lumbar region,
and profuse leucorrhoea.   After  standing for a short time, or making any
extra  exertion, the uterus would protrude through the vulva.
    Upon  making her condition known to her family physician, he recom-
mended the use of astringent injections, and adjusted a ring-pessary to retain
the uterus,  requesting her to return to his office in a few weeks to have the
pessary removed.   She, however,  found herself relieved by the  measures
adopted, and did not see him again for  more than one year.   There had
been  no return of the prolapsus, but  she complained  that her urine con-
stantly dribbled from her, and also of an offensive sanguineo-purulent dis-
charge from the vagina.  The pessary was removed, and ulceration found
to have taken place  through the walls of the vagina  and  bladder, at the
lower portion of the neck, producing a  vesico-vaginal fistula.
    At the time of her admission to the hospital she was much emaciated
and anaemic, and it was several weeks  before any attempt was made to
restore the integrity of the parts.
    The first and second operations for the closure of the fistula were unsuc-
cessful, owing to the unhealthy condition of the tissues, there  being  no
attempt at  union.  On the third  trial I determined to remove every portion
of suspected tissue around the fistula, and, by so doing,  increased  the open-
ing from one-quarter of an inch in its long diameter to one and one-eighth
of an inch.  The wires were removed  on the tenth  day, and  union found
to be perfect,   After some weeks of rest  she had -gained strength  and flesh,
and I restored the perineum by the usual operation.   The deep sutures
were  removed on the  third, the superficial on the twelfth day.
     November 28>she left the hospital, perfectly cured.  I have frequently
heard from this patient  since then.    She is enjoying good health, and has
suffered no inconvenience from her former troubles.
i) 
34
                                 Case 23.

                Complete  rupture, four years1 standing.—Cured.

      Mrs. B----, aged twenty-nine; admitted to Columbia Hospital August
  8, 1868;  mother of three children.   The accident occurred at the  birth of
  her last child, her labor having  been very rapid, and the child's  head and
  shoulders unusually large.   She had applied for admission in March, but
•  was at that time  so  extremely anaemic  that no  operation would  have suc-
  ceeded.   I recommended her to wait a few months, and placed her upon a
  tonic and stimulating course of treatment.  She improved rapidly, and  at
  the time of her admission was in a good condition.
      August 10.—The ordinary operation was performed in the presence of
  the  class, Dr.  Ashford,  my first assistant, administering  the anaesthetic.
  Everything progressed  favorably; the sutures were removed  at  the usual
  time, and union found to be  perfect.  Patient left the  hospital, September
  11th, cured.
                                 Case 24.

         Complete  rupture, Haemorrhoids, and Prolapsus uteri.—Cure.
      Mrs.  S----, aged thirty-five; mother of six children; came under my
  care September 2,  1868 ; has been suffering for several years from haemor-
  rhoids, but during the last six months they have increased so much in size,
  and are attended with so much pain, as to disable her from engaging in her
  household duties.
     It was for this difficulty she consulted me.   Upon examination I dis-
  covered the ruptured perineum, and detected a  horse-shoe pessary, which
 she said she had worn since 1862.   I  recommended, first, the removal  of
 the haemorrhoids, and, then, the restoration of the perineum;  promising her
 she would be able to dispense with the pessary.
     The haemorrhoids were removed with a chain-e'craseur, attended by the
 loss of not more than one ounce of blood.  Three weeks afterward the peri-
 neum was restored by the usual operation. But little constitutional disturb-
 ance followed either operation.  Patient made  a rapid  recovery, and was
 entirely relieved from pain or inconvenience.
     I have seen her  frequently since, and the cure appears to be perma-
 nent :  the uterus is  in its normal position and is disposed to stay there. 
35
                               Case 25

  Complete rupture, with Vaginal reetoeele, of eleven years1 duration.—Cure.

     Mrs. R----,  aged thirty-two ; mother of one cliild;  was placed under
my care  October 4, 1868.  Her labor was tedious, and terminated by the
forceps.  The perineum was entirely gone,  and she had  a large reetoeele;
had worn a ball-pessary for some years.
     A section was removed from  the posterior wall of the vagina, which
relieved the reetoeele, and, after a full recovery from this operation, the cure
was completed by restoring the  perineum in the usual mode.   She left for
her home, December 20, cured.
                               Case 26.
         Complete rupture, with Ulcers of rectum, five years1 standing.
     Mrs. D—---,  aged thirty-seven; admitted to Columbia Hospital,October
17, 1869.   The general condition of the patient not good, but she was urgent
for the operation,  as she had left her family for that purpose and was anxious
to return.
     October 19.—Patient being  fully aetherized, the  ulcers in the rectum
were freely divided, the  sphincter being included in the  division, and the
usual operation for restoration was performed in the presence of the clinical
class.  There was much more haemorrhage than usual, and some time elapsed
before the parts could be brought together. Three deep sutures and six super-
ficial were used.
     October 21, 10 a. m,—Patient has had  a severe rigor, lasting over half
an hour, followed by heat of skin, thirst, and considerable pain in the head;
pulse 120.  There was no unusual inflammation or pain about  the parts to
account for these  unpleasant symptoms.  A full dose of opium was admin-
istered, and ordered to be repeated in six  hours.  At 9 p.  m., skin  moist,
pulse 120, and small;  no marked restlessness; ordered one ounce of brandy
with each dose of the opium.
     October 22, 10 a. m.—Patient bright and cheerful;  less fever, pulse 118,
soft; removed the deep sutures; parts very healthy.
     8 a. m.—Has had another chill, more severe than the first, pulse 130
great restlessness; some cough, but not very troublesome;  gave quinia,
opium, and brandy in full doses. 
36
     October 2:;, 11 a, m,—Skin moist; tongue slightly furred ; pulse 117.  A
careful examination was made to ascertain if any pus had formed in the track
of the deep sutures, but none was found.  She continued in much the same
condition until the twenty-eighth, when the superficial sutures were removed,
and, contrary to all reasonable expectations, there was  perfect union.
     From this time onward the cough was more troublesome, she had occa-
sional rigors, temperature increased, pulse never  below 120, great pros-
tration,  and all the  well-marked  symptoms of surgical  fever.   She  died
December 21, two months from the time of operation.   No post-mortem was
allowed.
     The error committed in this case was operating upon a patient decidedly
below par.  If I had submitted her to a judicious course of medical treatment
for some weeks at least before the  operation, she might have been spared to
her family, and 1 would have been saved  the mortification of reporting a
case which, in its  general results, was a decided failure.
                               Case 27.

    Complete rupture, Prolapsus of the rectum, three years1 standing.—Cure.
     Mrs. S----,  aged thirty-seven; mother of four children.  The rupture
occurred at the birth of her last child, and was complete, extending through
the sphincter.   Whenever the bowels were moved, or  the patient stood for
a few minutes,  the rectum would  become prolapsed to the size of a large
orange, and it was difficult to  return it,
     The treatment  was  directed to the restoration of the perineum and
sphincter ani, being satisfied that the protrusion of the  bowels was a natural
consequence of the loss of support.
     March 21, 1869.—I restored  the  perineum in the  usual  mode, but
departed from my general practice in the after-treatment by keeping the
bowels closed for sixteen days, in the mean time throwing into the rectum,
twice daily, two ounces of a strong decoction of white-oak bark.
     April  8.—The bowels were moved  by one ounce of castor-oil;  there
was no extrusion  of the rectum ; and the perineum was perfectly sound.
     I have seen  this lad}' on two occasions since, and she assures me she
has had no return of the  difficulty. 
37
                               Case 28.
        Complete rupture, uncomplicated, five months1 duration.—Cure.
    F. E----, aged twenty-nine; mother of one child, five months old.
The history of her labor,  as obtained from herself, revealed  nothing of
unusual severity.  Her attending physician  had staid by her  during the
whole time, and, in her own language,  "had rendered her every assistance
in his power."  Her convalescence was protracted, she being unable to move
around for more than six weeks, and then could sit only with difficulty. . No
examination of  the parts was made at the time,  although she complained of
extreme soreness.  The symptoms from which she suffered when I first saw
her were  pain  in the back,  difficulty  in  passing water, and profuse leu-
corrhcea,
     Examination revealed a rupture of the perineum down to the sphincter;
the mucous membrane of the vagina was inflamed and unusually tender, its
anterior wall bulging outward, dragging the bladder with it, thus account-
ing for the difficulty in micturition.
     The vaginitis was reduced by the application of concentrated glycerine
and aqueous extract of opium, and perfect rest. The general condition of the
patient was anaemic, Avhich condition was improved by the chalybeate tonics.
     April 3, 1869.—An attempt was made to {etherize the patient, (Squibb's
aether being employed,) but it was found impossible to bring her under the
influence of the anaesthetic on account of the violent paroxysms of coughing
which it produced.  Chloroform was substituted for aether, and a few inhala-
tions produced profound anaesthesia.   The face became  livid, respiration
imperfect, pulse flagging, and, in  a few seconds, imperceptible at the wrist,
and but a feeble movement of the heart was  discoverable by auscultation.
Artificial respiration was resorted to,  and continued for twenty minutes,
before  the breathing became fully established,  and the imminent danger
disappeared.
     The operation was  deferred until the  following day, when it was per-
formed without the administration of any anaesthetic.
     April 5, 10 a. m.—Patient had passed a  restless  night, had not slept;
she complained of headache, pain in the back, extending from the first dor-
sal vertebra to the sacrum; warm-water application was made to the vulva,
and two grains of the aqueous extract of opium ordered to be administered
e\cry four hours ; beef-tea  diet. 
38
    4 p. m.—Patient had dozed a little, but was no better; pulse 120, and
irritable ; respiration hurried; the same treatment ordered  to be continued;
the opium to be administered every three hours.
    10 p. m.—Complaint was made of stiffness about the neck, and inability
to swallow without great and increasing effort.   A close examination of the
vulva was made;  a little redness marked  the points of entrance of the mid-
dle deep suture, and, upon  touching the wire, it gave  extreme pain, which
was followed by a slight convulsive movement, tetanic in  character.   The
wire was withdrawn, hot fomentations were applied, and  twenty drops of
Magendie's solution of morphine injected subcutaneously; the injection was
repeated at 2 and 4 o'clock the next morning.
    April 6, 10 a. m.—Several hours' sleep had been  obtained during the
night; pulse 110, and less irritable; skin hot, but not dry; respiration less
hurried; the injection of morphine to  be repeated, but reduced five drops;
beef-essence to be administered by  enema if the patient should be unable to
swallow.
     6 p. m.—A decided improvement in the general condition of the patient;
had slept almost continuously since the morning visit, the last dose of  mor-
phine having been omitted  on that account.
     April 7, noon.—Pulse  90, and soft;  respiration quiet  and regular;  a
little stiffness about the muscles of the neck remaining, but all other unpleas-
ant symptoms had disappeared;  suspended the morphine, and ordered milk
and beef-tea diet.
     April 8.—Pulse 90, soft and compressible ; wound looking healthy.
     April  9.—Removed the  deep wires,  and found that every part of the
apposed surfaces had united by first intention.
     The patient continued to do well; the superficial- wires were removed
on the tenth day; and no further attendance was  needed.
     The alarming symptoms which supervened in this patient within twenty-
four hours after the operation were undoubtedly  due to the wounding of a
branch of the pudic  nerve by the needle carrying the wire, and, had the
wire been allowed to remain, the patient would, in all probability, have died
from tetanus. 
39
                                Case 29.
Complete rupture, complicated with Laceration of recto-vaginal septum ; Prolap-
        sus uteri and  Urethral caruncle, eight months1 standing.—Cure.

     Mrs. D----, aged  thirty; mother of one child.   The general appear-
ance of this woman was as unpromising for surgical interference as it could
well be.  She was pale, emaciated, and laboring under great mental depres-
sion.   The passage of  her urine was attended  with agonizing pain;  she
was suffering from chronic diarrhoea, her passages being involuntary.   The
vulva and vagina were  never free from fecal matter;  the edges of the  lacer-
ated bowel had become ulcerated;  the  uterus was in a state of subinvolu-
tion, measuring five inches from os externum to fundus, and proportionately
thick, the principal thickness being posteriorly.
     The indications  were,  first, to  improve  the general  condition of the
patient by tonics, nourishing food and  stimulants, arrest the diarrhoea, and
remove the irritable  caruncle.  The caruncle  was snipped off with scissors,
and its base cauterized; pledgets of cotton, soaked in carbolized glycerine,
were passed to the uterus daily, the ulcerated edges of the lacerations pen-
ciled with argenti nitras, and  the following prescriptions ordered;
                      r> Liquoris ferri pernitratis, gtt. v.
      To be given, in one  ounce of cream, three times daily.
                        EJL- Ferri et quiniae cit.,  gr. x.
      To be given fifteen minutes after each meal.

     This treatment was continued with but little variation  for eleven weeks;
the uterus reduced to three and one-quarter inches ; the edges of the lacera-
tion and continuous tissue were healthy;  the urine was voided without pain;
and the diarrhoea had become entirely cured.   The patient had gained con-
siderable flesh, was in good spirits, and anxious that the operation should be
performed that she might return home; but it was thought advisable to defer
it a while longer.
     June 17, 1869.—The patient, being in a satisfactory condition^ was fully
aetherized;  the edges of the lacerated bowel were freely pared with scissors;
and all suspected tissue removed.   The parts  were united  by thirteen silver
sutures.  The perineum was then restored in the usual manner.
     The deep sutures were removed on the third day, and those in the bowel 
40
and the superficial ones on the tenth day, union by first intention resulting.
It was some months before the sphhicter ani fully recovered its power and
control.
     I have since delivered this woman of a child at full term, of ordinary
proportions and weight.  There was no rapture of the perineum at delivery.
     This woman, prior to treatment, was unable to attend to her household
duties, a burden to  herself and her friends, but is now an active and useful
member of society.

                                Case 30.

Complete rupture and extensive Laceration of the  rectum, with loss of tissue from
                 ulceration.—Duration, five months.—Cure.

     Mrs. G----, aged  twenty-three; very  large  and fat;  capillary circu-
lation sluggish.   Her labor was severe, and  protracted over  three days; on
the evening of the  third day Dr. Gr. T. Elliot, of New York, was called  in
consultation, and delivered her with forceps.  The brief history he gave me
of the case is as follows :
     "I  found the  patient exhausted, heart's  action feeble, skin cold and
bathed  in  sweat.   The vulva was enormously swollen and  discolored, and
the surrounding tissues  infiltrated with serum.   I explained to the attending
physician the alarming  condition of the patient, the necessity for immediate
relief, and the certainty of  extensive laceration during delivery, on account
of the condition of the tissues and the  unusual  smallness of the maternal
outlet.  The forceps were applied with difficulty, but  finally locked, and in
a few minutes the woman was  delivered of a  living male  child,  which
weighed eleven pounds.  Upon examination, I found the perineum and the
whole anterior wall of the rectum split open, and the  vagina dusky in hue.
I feared extensive sloughing, and very much questioned the  recovery of the
patient;  any attempt to bring the parts  together by  suture was out of the
question; warm fomentations  locally and free stimulation  generally were
ordered, and the case kept under observation."
    Three months after her delivery she was brought  to Washington, where
she remained  some  six weeks  before  I  saw her.  I found the  perineum
entirely gone,  the sphincter torn through, and considerable loss  of the tissue
of the recto-vaginal septum.  After corresponding with Dr.  Elliot, I recom- 
41
mended an immediate operation, with a view to complete restoration of the
[tarts.
     May 29, 1869.—The patient declined the administration of any anaes-
thetic, and, being placed in position, the operation was proceeded with in the
usual manner.  Double elliptical flaps were made of the recto-vaginal tissue,
and  the edges  kept in apposition by thirty-one sutures.  One-inch quills,
with two deep wires, were used for the perineum; the posterior attachments
of the sphincter were  freely divided on both sides;  warm-water dressings
were applied, and fight diet ordered.
     The operation lasted over three hours,  during which not one word of
complaint was uttered by my patient, nor was it in any way interfered with
by restlessness  on  the part of the sufferer.
     The deep perineal wires were removed on the third day; the superficial,
and  those from the rectum, on the fourteenth, when every portion was found
to have united,  and the entire operation proved a success.
     No opium  was administered to this patient, it being desirable to keep
the bowels in a fluid state that no strain should be brought upon the parts
by the passage  of hard fecal matter until the adhesions should be firm and
capable of resisting the pressure.
     A repetition of this accident will undoubtedly  occur if this lady should
become pregnant again, and the pregnancy be allowed to run on to full term

                               Case  31.
               Complete rupture ;  immediate operation.—Cure.

     Mrs. F. R----, aged twenty-two;  admitted September 28, 1869; preg-
nant with  her  first child.   This woman was of  unusually fine muscular
development, and in perfect health.  Soon after labor commenced, I exam-
ined her, and found the presentation natural, the head engaged in the supe-
rior  strait, the os well  dilated, the parts soft, and  pelvis unusually roomy.
The  perineum was fully two and one-half inches long, and very thick.  The
labor progressed rapidly;  the pains were violent, and in quick  succession;
the contraction  which brought the head in  contact with the perineum was
instantly followed  by another more violent,  which  expelled the child's head
and  shoulders,  earning the perineum with it.
     As soon as the placenta was delivered and the  parts cleansed, I restored
       6 
42
the perineum in the usual manner.   The deep wires were removed on the
fourth day, and the superficial on the eleventh ;  union found to be perfect.
     Patient discharged one month after delivery.
                               Case 32.
Complete rupture; Prolapsus of uterus, with Hypertrophy of the neck; five years
                            standing.—Cure.
     Mrs. S. D----, aged thirty-five ; mother of four  children, the youngest
five  years  of age.  The accident occurred  at the birth  of the  last child,
which was  delivered by turning.
     Attention was first directed to the reduction of the hypertrophied cervix.
The  patient was  kept in a recumbent  position;  hot-water injections were
directed against the uterus three times daily, being continued on each occa-
sion  for fifteen minutes, after which pledgets of cotton, soaked in glycerine,
were passed into the posterior cul-de-sac.
     In the course of six weeks there was sufficient improvement to justify
a recommendation of the operation  for restoration of the perineum, which
was  performed November 17, 1869.
     The patient was fully aetherized, and placed in the usual position.  An
unusual amount  of hardened tissue had  to be removed, and the  haemorrhage
was very troublesome, but finally restrained by the application of ice.  Four
deep and five superficial sutures were inserted, the quills  being two inches
long.  The sphincter was paralyzed by distension with the thumbs.
     November 18.—The soft parts  were so much swollen that the quills
were cutting into the tissue.   The patient complained of pulsating pain and
extreme tenderness.  About one dozen  punctures were made with a sharp-
pointed bistoury, from which the serum exuded freely; ice-water  applica-
tions, renewed every five minutes, were  continued during the day,  and one
grain of opium was administered every  three hours.
     November 19.—The oedema had  subsided; there was  less pain, and but
little constitutional disturbance; cold-water applications were continued.
     November 20.—The  deep sutures were  removed,  and,  contrary to
expectation, there was no suppuration in the track of the wires.
     November 28.—The superficial wires were removed, and the parts found
perfectly united. 
 
Plate  IV.
Complete rupture of perinseum through the sphincter ani, with laceration of the bowel.  Case 33. 
43
    The occupation of this patient kept her almost constantly upon her feet.
I therefore retained her in the hospital until December 22, to give the cica-
trix an opportunity to become fully organized.  I have frequently seen this
woman since, and she informs  me that she experiences no  inconvenience
from her old trouble.

                               Case 33.

Complete rupture  through sphincters, and Sloughing of recto-vaginal septum ;
                        ten years1 standing.—Cure.
     Mrs. N----, aged twenty-seven;  mother of  one child; .married when
twelve years of age, her child being born before she was thirteen;  admitted
to Columbia  Hospital by request of Dr. Palmer.  She had been previously
operated upon in Philadelphia, and kept confined to her bed for six months,
but unfortunately the operation was a total failure.
     She was suffering from incontinence of- faeces, difficult micturition, and
a profuse and fetid discharge from the vagina, the  anterior wall of which
was extended; the mucous follicles were hypertrophied,  and in a state  of
ulcerative degeneration.
     The  injury in this  case was  so  extreme that,  by the consent of the
patient, I had the accompanying drawing  of the parts taken immediately
before the operation, which, although not as clearly  defined as  I should
desire, nevertheless presents a better idea of their  appearance than could be
obtained in any other way.   (See Plate 4.)
     The  patient having  been fully aetherized by my assistant, I proceeded
to restore the recto-vaginal septum first.   The edges of the laceration were
so irregular that it was found necessary to sacrifice considerable of the sound
tissue before they could be made sufficiently straight to be brought into
perfect apposition; they were retained by seven sutures.   The perineum was
then restored in the usual manner, the posterior attachments of the sphincter
having been freely divided on either side of the coccyx.  Cold-water dress-
ings were applied, and one grain of opium administered every few hours.
     On the second day,  there being a little  too much swelling of the parts,
the middle deep wire was removed from the perineum, and frequent injec-
tions of warm water, impregnated with carbolic acid,  (three grains  to the 
44
ounce,) ordered to be thrown into the vagina.   No untoward symptom was
manifested during the after-treatment of this case.
     Six weeks from the date of her admission the patient left the hospital,
perfectly sound

                               Case 34.

                     Complete rupture; uncomplicated.

     Mrs. B----, aged twenty-five.   Five weeks since she was delivered of
her first child, with  forceps, but the  physician who attended her assured me
that he reinoved the instruments as soon as the head was well engaged in the
inferior strait, and did not again apply them, but that the rupture was pro-
duced by violent uterine contractions, forcing the child through before the
perineum had  been  dilated.  The child was large, and the mother's  pelvis
small;  the  rupture was a natural consequence of the labor. I do not believe
it  could have  been avoided.  The  attending physician was  aware of the
rupture at the time it occurred, and  the mischief should have been repaired
at once, instead of permitting the delay.   This course would have, saved the
patient much suffering and annoyance, and prevented the necessity of paring
the edges of the laceration, which I was compelled to do in this case.
     March 18, 1870.—Operation performed  in the  usual  manner;  deep
wires removed  on the third clay;  superficial, on the thirteenth day;  union
perfect.
     June, 1871.—This patient is again pregnant, and, as I believe it impos-
sible for her to  be delivered of a child at full tenn without again rupturing
the perineum, I shall induce labor at the seventh month. 
    VESICO-VAGINAL  AND  RECTO-VAGINAL  FISTULA.

     While the profession is indebted to Baker  Brown, of London, for sim-
 plifying the details of the operation for restoration of the perineum, suffering
 woman owes a debt of eternal gratitude to that illustrious American surgeon,
 Marion  Sims, for  discovering the means  by which this  serious, and,  before
 his time, incurable, accident can be  relieved.   To  him,  and him  alone,
 belongs the credit of applying silver sutures for the cure  of this most dis-
 tressing accident.  All other surgeons who have made reputations in this
 particular branch  of uterine surgery are merely imitators of this great man,
 of whom America may justly be proud, not only for discovering the  means
 of curing vesico-vaginal fistula, (for prior to his operations there was no  record
 of a single successful case,) but for the equally important discovery  of the
 only means we possess of examining  the vagina and uterus in situ—"the
 duck-bill speculum."
     Believing  that a history of this most important discovery in modern
 surgery would find a fitting place in this report, I make the following extract
 from  Dr. Sims's address,  delivered  before the Academy of Medicine, New
 York:
     " For the  first ten years of my professional  life the treatment of any
 disease peculiar to woman was ignored as far as possible.  Surgery was my
 ambition, and it was gratified, for my head and heart and hands were full.
 This was due, not to any particular merit on  my  part, but to a fortunate
 position  among a  liberal and enlightened  profession in the noble State of
 Alabama,  a profession which, for intelligence and a chivalric esprit de cops,
 is not behind that  of any other State in this great confederacy.
    "Thus situated, a case of vesico-vaginal fistula was sent to me in July,
 1845, which was investigated more because I had a surgical reputation to
 sustain than from any particular interest in the subject.  It was, of course,
 dismissed as incurable.   Two months  after this another presented,  which
 received  a like verdict.  Two cases in  such quick succession, in a country
town,  at  that time, formed an era in one's life.   Imagine my surprise  when, 
46
a few weeks after this, a gentleman called to consult me about a third case.  I
told him promptly that it was useless  to  send her to me, as the injiuy was
wholly  incurable.   He suggested that there was a possibility of my being
mistaken in my ready diagnosis, when I replied that a leakage of urine fol-
lowing a protracted labor was an infallible sign of a vesical fistula.   But my
remonstrances were unavailing, for he sent her to town in spite of me.
     " I investigated the case thoroughly, reading every author I could find
on the subject, but to no purpose, for all was darkness and  confusion; and
thus I was on the eve of sending her home, when a little  incident occurred
that formed the turning-point of my professional career, and without which
the discovery that has engaged  our attention to-night would not have  been
made.
     "A lady was riding in the suburbs of the city of Montgomery, Alabama;
her pony,  taking fright, jumped suddenly,  when she fell  to the  ground,
striking on the  sacrum.   I  saw her  soon afterward; her  sufferings  were
extreme, as she had rectal  and vesical tenesmus from a sudden retroversion
of the uterus.   To replace the dislocated organ was the indication of relief.
Following the teachings of learned professors, the patient (covered with  a
sheet) was placed on the  knees, with the pelvis  elevated and  the thorax
depressed, when, by manipulation through the vagina and rectum, I hoped
to replace it.   Introducing the right forefinger into the vagina, but, remem-
bering how a nervous gentleman had suffered a few days before from a rec-
tal examination, I concluded not to subject this lady to the same disagreeable
operation, particularly as it seemed possible to overcome the difficulty if my
finger was only a little  longer.   My middle finger  is more than half an inch
longer than the index, but it could not be used without its fellow;  and thus
the two were passed, and in  a few seconds I could not touch the uterus, or
even the walls of the vagina, and the  fingers were swept round, as it were,
' in empty nothingness,' which  was to me, at the moment, a most puzzling
mystery, and, while I was endeavoring to unravel it, my patient exclaims,
'Oh, doctor, I am relieved !'  My office was  ended, for my mission was to
relieve her, but  how it was  done  I could not understand.  While I stood
doubting and wondering, my patient, now easy, threw herself down on her
side, producing thereby a  sudden escapement of air from the vagina; and
thus the whole mystery of the  accidental reduction of the dislocated uterus
was explained on the principle of atmospheric pressure. 
47
     "And what was its rationale?  When the  patient was in the position
described, there being a natui'al tendency of the pelvic viscera to gravitate
toward the epigastric region, it would require no great vis a tergo to produce
the desired result in a recent case of this kind.  One finger, however, was
not long enough to throw the organ up, nor were the two; but when they
were both  introduced, in  my varying manipulations and  strenuous efforts,
the hand was accidentally turned  with its palm downward,  which thus
brought  the  broad dorsal surface  of  the two parallel  fingers in  contact
with the vulvae commissure, thereby elevating the perineum and expand-
ing the sphincter muscle,  which allowed the  air  to  rush into  the vagina
under the palmar surface of the fingers, where, by its mechanical pressure
of fifteen pounds  to  the  square inch,  this canal was dilated like  a bal-
loon, and the uterus  replaced by its  pressure  alone.   This  accident—
there are no accidents  in the  providence of God !—this incident, then,
occurred just at the right time.  Had  it happened six  months sooner, its
importance would not have been duly appreciated.  Had it  been six days
later, the golden opportunity for its practical application would  have been
lost forever;  for my mind had been sorely perplexed by the  obscurity sur-
rounding the investigation of  the  cases before alluded  to,  and I  said  to
myself:  'If, by this position, the  atmospheric air can  be made to dilate the
vagina to such an extent,  even  with a force strong enough to reduce a dis-
located uterus, why will not the same  principle allow me to explore this
region, and examine accurately any injury, or  disease to  which it may be
liable?'  Full of the thought, I hurried home, and  the patient, (with vesico-
vaginal fistula,) who was to  have  left on the next day, was  placed  in the
position described, with an assistant on each side to elevate and  retract the
nates.   I cannot, nor is  it needful to, describe my emotions, when the air
rushed in and dilated the vagina to  its greatest capacity, whereby its whole
surface was seen at one view, for the first time, by any mortal man.   With
this sudden flash of light, with  the fistulous opening seen in its  proper rela-
tions, seemingly without  any appreciable process of ratiocination, all the
principles of the operation were presented to my mind as clearly as at this
time.   And thus in a moment, in the twinkling of an eye, new hopes and
new aspirations filled my soul; for a flood of dazzling light  had suddenly
burst upon my enraptured vision, and  I saw in the distance the great and
glorious triumph that awaited determined and persevering effort.  From this 
48
moment, my high resolve was taken; nor did I think or care for the per-
sonal sacrifices I should have  to  make.  I thought only of relieving the
loveliest of all God's creation of one of the most loathsome maladies that can
possibly befall poor human nature ;  and in this I honestly confess that I was
stimulated by feelings of national  pride, as well as by a desire to advance
our glorious profession.   Full of sympathy and enthusiasm, thus all  at once
I found myself running headlong after the very class of sufferers that I had,
all my professional  life, most studiously avoided.   Ransacking the country
around, my medical brethren soon discovered  and placed at my disposal
some seven or eight cases of vesico-vaginal fistula that had  been  quietly
laid up  as incurable.  Building a little  hospital as a special field of  experi-
ment, I readily got  control of these cases, all of them healthy young negro
women; promising to perform  no operation that would  endanger life or
render their condition any worse.   Having  no proper instruments  and  no
instrument-maker, dentists, jewelers, and blacksmiths were  laid under con-
tribution, and soon such rude instruments were made as were suggested by
the peculiar wants of individual cases.   This occupied a period from the
9th of December, 1845, to the 10th of January, 1846, when the first opera-
tion was performed.
     " Several medical friends, among whom were Drs. Boling, Holt, Ames,
Baldwin, Jones;  McWhorter, and Henry, were invited to the  inauguration
of the experimental  series.  When the mechanical contrivances were exhib-
ited, the peculiarities of each  case pointed out, and  the principles of the
operation explained, they thought  my  plan  of procedure promised well,
while some were  but little less  enthusiastic than myself  in  hopes  for the
future.
     " The first was a very simple  case, and one that  any tyro in surgery
could now cure in a week's time.  The fistula was an inch and one-quarter
long,  transverse, in  the  base of  the bladder, with an  abundance of tissue.
Its edges were accurately adjusted,  and I expected to effect at once a magical
cure ; but, greatly to my surprise and mortification, it was a failure.  How-
ever,  the size of the opening was reduced from that to one not larger than a
No. 4 bougie; this  encouraged  me considerably, and the same operation
was tried on another case with a like unfortunate result, and after this, with
various  and constantly-varied modifications on others,  till each one had suf-
fered  numerous operations, but all to no purpose.   And thus I worked on, 
49
not for  weeks and months, but for long  weary years, before a single case
was cured.  My repeated failures brought a degree of anguish that I cannot
now depict, even were it desirable.  All my spare time was given to the
development of-a single idea, the seemingly visionary one of curing this sad
affliction,  which not  unfrequently follows  the fulfillment  of the law pro-
nounced by an offended God, when he said to the woman : ' In sorrow and
suffering shalt thou bring forth children.'
     " Soon my friends began to  despair of my efforts, and, one  by one,
became tired of  such profitless work.  At last Dr. B.  R. Jones, my  partner,
an accomplished physician, who had  stood firmly by, giving  his valuable
advice and assistance, importuned me to cease my efforts;  thus opposed at
home, and deserted by the professional brethren  who once cheered me on
by their personal presence, I now stood alone—alone,  did I say ? no !  I was
not alone ; for I felt that I had a mission, if not of  a divine character, at
least, but little short of it, of divine origin.   I felt that the  God who had
called me to this good work, and inspired me with new views for its accom-
plishment, was with me, and would not desert me.   I  could not have ceased
my labors if I had tried, for something told  me that the fullness of time had
arrived, that the work had to be done, and that, if I should fall, God,  in his
wisdom, would raise up some one as an instrument to carry it forward to a
glorious consummation.  I was not alone, then ; nor was I alone in another
sense, for  I had succeeded in infusing my own courage and enthusiasm into
the hearts of  the half dozen  sufferers who  looked  to  me  for help, and
implored me to repeat operations so tedious, and, at that time, often  so pain-
ful, that none but a woman could, have borne them.
     " To the indomitable courage of these long-suffering women, more than
to any other single circumstance, is the world indebted for the results of
these persevering efforts.   Had they faltered, then would woman have con-
tinued to  suffer  from the dreadful  injuries  produced by protracted partu-
rition, and then should the broad domain of surgery not have known one of
the most useful improvements that shall forever hereafter grace its annals.
     "In  my first experiments the  quilled  suture was used, securing the
ligatures by passing them through little canulae that projected from the
vulva.  The canulae were firmly soldered to the proximal  quill, and,  when
the ligatures were tightened and wrapped round the end that projected from
the vagina, the fistulous edges were neatly coaptated by the quills.   This is 
50
introduced merely to show the slow degrees by which practical truths are
sometimes developed.   After using this machine, variously modified, for
nearly three years, giving attention mostly to the perfection of the self-retain-
ing catheter, I at last concluded that the projecting canulae were a chief cause
of failure, and consequently determined to dispense with them.  But how to
secure the ligatures was the question.  A detail of the numberless expedients
resorted  to is useless;  suffice it to say that I was at last driven completely
to the wall.   I  had resolved never to repeat another operation till I  had
devised some plan of fastening the quill suture without the canulae;  of tying
a  knot where I could not reach it with the fingers.   Thus my brain  was
sorely puzzled;  I had not performed an operation for nearly six weeks, and
my devoted patients were  begging  me, from day to  day, to  ' try only one
more time.'   Notwithstanding their importunities, I had determined, first, to
invent a knot  for my sutures; but it seemed that  my usual readiness of
expedient had  now deserted  me.   My brain was oppressed;  my heart was
heavy;  but never for one moment did I despair of  eventual success.   At
last I happened to remember that, when a boy, I used to make sinkers to
my fishing-lines by cutting a shot half in two, laying the line  in  the  cut,
and then compressing the shot on it with my teeth.  I cannot express the
delight that filled my heart at this simple suggestion.  The idea occurred to me
on the night of the 14th November, 1848.   The contemplation of its beauty,
simplicity, and perfect adaptation to the purpose gave me a sleepless night;
for there I lay, with etherealized brain, performing in imagination a magical
cure on each of my devoted patients.   This was, as I thought, the consum-
mation of all my plans.  After a struggle for three years, victory was about
to crown my efforts.  How I longed for the morning,  that I might put to
the test  of experiment what seemed  so beautiful in theory!  But I  was
doomed to wait another twenty-four hours before proving my principle; for,
just as I was preparing for the operation, a call to the country appropriated
the day, and thus the longest day of my life was lengthened out  by hope
deferred. But, bright and early on the succeeding  morning, I  applied the
quill suture secured by the perforated shot.  It was all I could desire.   I
was never so well satisfied  with any operation in all  my life.  How  anx-
iously I  waited for its results!  I had at last gotten rid of the canulae that
had so long been such a serious obstacle  to  success,  and everything was
propitious;  but these bright hopes  were of short duration, for I  soon had 
                                  51

unmistakable evidence that the operation was a total failure.  What was the
cause of it?  'Why,' said I, 'it must be because the silver quills are too large.'
So I began to lessen their size, till they were not more than a line in diam-
eter, and, on account of the  expense of silver, lead was substituted;  but,
notwithstanding these modifications, there was no mOre success than at the
beginning.   What now was  to be done %   The  principles of the operation
were clear, and its mechanism seemed to be perfect.  At first I had supposed
my failures were due to the imperfection of the  catheter;  that was perfected;
and then I laid the blame on the method of securing the sutures by means
of the canulae; they were replaced by  the perforated shot; and then I
looked to the size of the quills, and reduced  them, so that they burrowed
nicely in the tissues.  It then seemed that  success w^as inevitable; but still
disappointment awaited me at every turn.
     " Thus far, all my experiments were conducted on the principles of a
rational inductive jniilosophy.   The operation was mechanically perfect, but
with no better results ■ than when it w^as rude and clumsy.  There must be
a reason for all this; what was it ?  'Why,' said  I, 'perhaps it is in  the nature
of the material more than in its principle of action.' What a happy thought!
Of course it was,  for a silk thread, introduced  under the skin, and allowed
to remain  a week, becomes  a seton, giving  rise to  the suppurative pro-
cess, and certainly the same thing  must occur with it in the vagina;  and
how,  then,  could  there be cohesive union ?  Here,  then, was the difficulty
at last;  how strange it now seemed  to me  that this fact had not long ago
forced itself upon my mind.   Now the question arose, ' Was there a substi-
tute for silk that would  answer the same purpose,  and yet not  poison the
animal tissue V   Why, lead  remains indefinitely in the body, becomes sac-
culated, and produces  no poisonous or suppurative effect.   Dr. Levert, of
Mobile, had demonstrated the innocuousness and efficiency of leaden liga-
tures  on the arteries in the  lower animals, and  Mettauer and Dieffenbach
had actually used leaden sutures in these very cases; and I had, in my
various  experiments, tried them in  two cases  of vesical and one of rectal
fistula; but, fortunately for science,  the clumsy leaden wire was unsuccess-
ful in my hands.   Was there  any other metal that could be substituted for
lead, possessing its valuable property of harmlessness ?
    "In this train of inquiry, what would be more readily suggested to the
reasoning mind than silver, gold, and platinum ?  Just at this stage of affairs 
52
I happened to pick up a piece of brass wire that had been used in a pair of
old-fashioned suspenders, made before the days of India-rubber;  it was  as
fine as ordinary sewing-tluead.   I  took  it to a jeweler, who imitated it in
silver.   I was now quite as anxious to see the result of an experiment with
this as I was, seven months before, to see the perforated shot applied.   On
the 21st of June, 1849, it was  done.  A young colored woman, who had
never murmured at the preceding failures, was placed on the operating-table
for the thirtieth time, and the silver sutures were applied, with the leaden
bars and the  perforated shot,  In all  previous operations  the urethra, in a
day or two, would become red and tender, and the urine loaded with thick,
tenacious  mucus,  thus showing the  inflammatory  process, which  was
adverse to union;  but, after this operation, the urine remained perfectly
limpid all the time, and on the eighth day the parts were perfectly healed;
the suture apparatus remaining just as  it was  placed, with the cross-bars
somewhat burrowed in the vaginal tissue.
     " I shall not dwell upon my feelings at this time.  At last I had attained
for what I had worked nearly four years; and it was but a  few weeks before
all the cases were cured that had been the subject of experiment for so long
a time.  I was anxious to get  a  few more  cases, to  settle  some doubtful
points, before publishing to the wTorld  my discovery; but, unfortunately,
with the realization of  my dreams, and in the full fruition of my most san-
guine  hopes, came a sad reverse.   An  exacting practice,  and the extreme
mental tension of the past four years, had produced a collapse, long foreseen
by friends, without my consciousness  of its approach.   Having  contracted
the chronic disease of a warm climate, which is almost universally fatal, and
struggled  hard for more than  two years,  and, as it seemed,  hopelessly,
against my fate, thus seeing that death was inevitable, and fearing that I
might die without the world's reaping the benefit of my labors, I determined
to give my  experience, crude as it was, to the profession that I loved  so
much.   And, accordingly, in October, 1851, my paper ' On Vesico-vaginal
Fistula' was dictated, and sent to Dr. Isaac Hays, of Philadelphia, who pub-
lished it in the American Journal of Medical Sciences for January, 1852, as
my last free-will offering on the altar of science.  I little thought.of living
to see it in print;  but it has pleased an all-wise God to restore me ao-ain to
health, and, by a mysterious providence, to place me in your midst, where
I have found naught but friends and kindness." 
53
      It is quite true that, long before Sims's time, many eminent surgeons
 attempted the cure of this opprobrium chirurgia?, but without success.  The
 much-vaunted method of Metzler was pretty in theory only, and  I believe,
 with Vidal de Cassis, that there did not exist  in  the  science of surgery a
 well-authenticated complete cure of vesico-vaginal fistula prior to Sims's pub-
• lication of his method.
      Velpeau, in 1839, thus speaks of the cure of these fistulas : "To abrade
 the borders of an opening, when we do  not  know  where to grasp them;  to
 shut it up by means of needles and thread, when Ave have no point  appar-
 ently to secure them; to act upon a movable partition  placed between two
 cavities, hidden from our  sight, and upon which we can scarcely find  any
 purchase, seems to be  calculated to  have  no  other  result  than to cause
 unnecessary suffering to the patient,"  ■
      In the hands of skillful surgeons the operation for the cure of vaginal
 fistula is now so generally successful that but little importance is attached
 to  ordinary cases.   I therefore omit  simple  fistulas from this report,  and
 confine myself to cases of unusual interest.
     Mary W----, aged twenty-four, admitted to Columbia Hospital, Octo-
 ber 20, 1870;  mother  of one  child, two years of age, of which  she was
 delivered by forceps.  She was confined to her bed for several months after
 delivery,  and has been.an invalid ever since.
     Examination revealed a vesico-utero-vaginal fistula, occupying the whole
 of  the anterior- cul-de-sac, or, it would  be more  correct to say, a series of
 vesico-vaginal fistulas, as the whole anterior wall of the vagina was cribriform
 with them.
     The vaginal tissue of the anterior cul-de-sac had  sloughed away, as, also,
 a large portion of the base  of the bladder. The reflection of the peritoneum
 between the bladder and uterus was distinctly visible, but had lost its char-
 acteristic appearance and looked more like parchment than peritoneal tissue.
 The neck of the uterus had been torn open  beyond the internal  os.   The
 cribriform condition of the anterior wall of the vagina had not been occasioned
by  the burrowing of the urine  in the cellular tissue; for both of the  open-
ings communicated  with the  bladder, and were  independent of each other.
     When the patient  was in a prone  position, the urine flowed almost
directly into the uterus, but little passing into the lower portion of the blad-
der ; but,  when standing, it ran from her continuously.  She  had  been  the 
54
subject of several operations, all of which had been unsuccessful, and  she
was  finally sent by her attending  physician to Dr. Thomas  Miller, of this
city, who placed her in my charge.
     Fig. 1, Plate 5, gives a representation of the appearance of the vagina
when examined by the Sims speculum, the neck being split and turned up,
to show the rent in its posterior lip.
     Fig. 2, Plate 5, shows the same, with the os in situ; the  dotted lines
show the margin of the incisions.
     The loss of tissue had  been so great that it was impossible to succeed
with any ordinary plastic operation.   The injury to the uterus was exten-
sive,  and,  involving the body, as it did,  rendered operative  interference
extremely  hazardous, threatening  metritis as the result of an attempt to
restore its  integrity.  Peritonitis was little to be feared, on account of the
altered condition of that membrane.
     Upon  consultation with Drs. Miller and Eliot, it was decided to pare
the edges of the uterine flaps, and  bring the parts together  by silver wires
and clamps.  The patient having been placed under the influence of  aether,
the ragged edges of the flaps were cut off with strong scissors, and the edges
approximated and retained in apposition by six silver wires passed through
silver quills.  These were allowed to remain for ten days, and when removed
the parts were found united  perfectly.  No metritis or constitutional trouble
of any kind followed the operation, and not a grain of opium was adminis-
tered during the period of recovery.
     On the second day after the removal of the wires her menses appeared,
and  two weeks were allowed to  elapse  before any further operation  was
attempted.
     The patient's condition  was fully explained to her, the probable reasons
given for the former failures, and the option offered her of remaining as she
then was, or of submitting to an operation which would turn the neck of the
uterus into the bladder, and  convert the vagina into a blind cid-de-sac. After
consultation with  her  husband, she  consented to the proposed operation,
with a full  knowledge of its  effect upon her marital  relations.
     December 23.—The  patient having been fully aetherized,  assisted by
Drs. Miller, Ashford, and Barker, I  proceeded to  remove  a strip  of  the
vaginal membrane  one-quarter of  an inch wide, starting at a  point imme-
diately behind the sphincter of the bladder,  and sweeping upward alon«- 
Plate V.
Fig. I.
Fig. 2.
 
 
55
the lateral wall of the vagina, around the posterior cul-de-sac, and  down
the opposite  side to the point of starting.  The raw surfaces were  accu-
rately  adjusted, and retained in apposition  by thirty-two  silver sutures;
the self-retaining hard-rubber catheter was introduced, and the patient placed
on her back.   A small opening was  left  at the point where the  incision
started for the escape of the urine that would necessarily find its way into
the sac formed by the folds of the vagina  included in the operation.   The
after-treatment consisted of frequent injections of tepid water into the vagina,
followed by the carbolized glycerine.  Two capsules of the balsam of copaiva
were given tluee times daily, in order to render the urine bland and unirri-
tating.  No acceleration of pulse, or constitutional disturbance of any kind,
followed the operation.
    January 6, 1871.—The wires were removed,  and  the  surface found
firmly united except in the  region of the lowest sutures,  at which point the
union was imperfect.
    February 3.—The woman being anxious to return home, an attempt was
made to close the remaining fistulous opening, but it totally failed, owing to
the thickened and  otherwise unhealthy condition of the tissues.  Pledgets
of cotton soaked in glycerine were introduced into the vagina every six
hours, the catheter  placed in the bladder, and the patient kept on  her  left
side.  Little urine passed through the fistula.  This treatment  was continued
until  March 25th, when, the parts appearing healthy, another attempt was
made to close this opening.   Six sutures were used, and  allowed  to remain
in until April 7th, when they were removed, and union found to be perfect.
     April 25.—In  the presence of Drs. Miller and Barker the hydrostatic
test was applied to the bladder, but no leakage occurred.  This patient was
kept under observation until May 17, when the same test was again  applied,
in the  presence of a part of my clinical class.   Iodine water was  injected
into  the bladder to its fullest capacity, and the vagina was swabbed  out
with thin starch; by these means the slightest leakage would  have been
visible, but every part was found tight.
     May 22.—Patient dismissed, cured. 
56
   VESICO-VAGINAL FISTULA,  AND ENTIRE LOSS OF
                           URETHRA.
    Mary W----, aged  twenty-seven;  admitted to Columbia  Hospital,
March 12, 1871; mother  of one  child four years  of age; her labor was
very protracted, and finally terminated with instruments.
    Examination showed absence of the urethra, which had been destroyed
by sloughing, and a large fistulous opening into the  bladder at its neck,
about one inch in diameter.  The patient was much debilitated, and  in no
condition to invite surgical interference.  She was accordingly placed upon
tonics, stimulants, and the most nourishing diet.  Under this treatment she
gained flesh rapidly, and her strength increased.  By the middle of June
she was sufficiently restored to health to justify an operation for her relief.
    Plate 6, shows the site of the  fistula and general condition of the parts
at the time.
    June 20.—Patient being fully aetherized, a clean  cut was made along
the upper margin of the opening, the edge  being strongly beveled ; a strip
of membrane one-quarter of an inch wide removed in the direction of the
dotted lines, and the  parts were accurately adjusted and retained  in appo-
sition by twelve sutures.   The point where the internal meatus should be
was left patent, with the tissue in excess;  the urine flowed freely through
this opening.  No catheter was required.
    July 3.—Sutures removed; union perfect.
    August 12.—The patient was again placed upon the table, with a view
of continuing the operation by restoring the urethra.  The  mucous mem-
brane on either side of the urethral track was  loose and abundant, and no
difficulty was experienced in securing a sufficiency for the formation of a new
urethra.  The  edges were denuded on either side of the old track, about one-
quarter of an inch from the margin of what originally formed the upper part
of the urethra,  and closely approximated over an elastic catheter, which was
afterward withdrawn.  The sutures were closely applied, No. 29 wire beino-
used, and were allowed to remain fifteen days.  Upon their removal every
part was found united.   A small  fistulous opening now remained  between
the base of the new urethra and the bladder; this part having been inten- 
<
5810 
 
57
tionally left open, as it would have  been impossible to restore the urethra
without this outlet for the urine.
    September  27.—The  remaining small opening  was  closed  by three
sutures;  and, on their removal on October 8th, the  cure was found  to  be
complete.
    Some time elapsed before this patient recovered the complete control of
her bladder;  but  she assured me, a short time since, that she could  retain
her urine for six and eight hours without inconvenience.
                     VAGINAL RECTOCELE.

     This form of prolapse of the vagina is much less common than vesicocele.
 The vaginal walls being less distensible posteriorly than anteriorly, it rarely
 occurs unaccompanied by rupture of the perineum;  but in some cases, after
 the birth of the first child, the vaginal walls do not recover their tonicity or
 contractibility, leaving the vagina dilated  to  its  utmost  capacity, as when
 giving passage to the child.   This occurs generally in women of phlegmatic
 temperament, with  a redundancy of adipose tissue, and its accompaniment,
 flabby muscle.
     The rectum, losing its support, yields anteriorly, and a pouch  forms,
 which, becoming filled with  fecal matter, presses downward and forward;
 a tumor forming at the vulva, which, in a short "time, increases sufficiently to
 protrude externally.  The. generally relaxed and weakened condition of the
 body which exists in most of these cases, together with the undue traction
 upon the uterine ligaments, tend to produce prolapse, and with it vesicocele.
 Neglected cases of reetoeele generally result in complete prolapse  of the
 vagina, and necessary extrusion of the  uterus.
     There is but one method of treatment by which the patient  can be radi-
 cally cured—a reduction of the vagina to its original caliber by excision of
 a sufficient amount  of its tissue.   In  cases of long standing, and, indeed, in
 many that are recent, there exists a fatty degeneration of the muscular fibre,
 and a loss of  all power in the yellow  elastic tissue.
     Prolapsus of the uterus generally accompanies  reetoeele, and it is a
 common  practice to resort to the use of pessaries, with a view of retaining
the uterus in position.  These  can afford but temporary relief; the parts
       8 
58
 soon become intolerant of their presence, or, if retained, they  frequently
 complicate the difficulty by producing metritis or vesico-vaginal fistula.  In
 the hands of the most  skillful, with the most careful adjustment, they are
 abominations which should  be banished from use  as  rapidly as possible,
 tending, as they do, to produce far more injury, and to increase  the suffer-
 ing of the patient.  This idea of building a scaffold inside the vagina for the
 support of the uterus is contrary to  common sense, in opposition to  good
 surgery, and the theory advanced by those who advocate the use of the pes-
 sary is untenable, not being  based upon sound  philosophical  principle.
 Astringent injections are of little  service.    Acting principally  upon the
 mucus  of the vagina, their force is expended  in its coagulation, no change
 being produced in the sub-mucous tissues, which are the parts affected.
     The  details of the operation for the radical cure of this difficulty depend
 in a great measure upon whether or not the reetoeele has become complicated
 with prolapsus uteri.  In simple reetoeele, an  oval piece of the vaginal wall
 is dissected from its cellular attachments, the whole thickness of the tissues
 being removed.   The  extent of the ablated  part must depend upon the
 redundancy of the tissue.  Enough must be removed to reduce the caliber
 of the vagina to its normal size when the edges are approximated.
     The  dissection must be made with great care,  for fear of wounding the
 bowel.  The method I adopt is as follows: The patient having been placed in
 the position for lithotomy, and brought under the influence of an anaesthetic,
 an incision is made through, the whole thickness of the vaginal wall to the
 cellular tissue connecting it with the rectum.   A steel dilator is then intro-
 duced through the opening, and, by pressing the  handles, the blades open,
 gradually separating the rectum from the vagina to the extent desired.   This
 method of dissection is preferable to the knife, it being bloodless, and, if
 carefully  practiced,  without  danger.  I  am  indebted  to my friend, Dr.
 Thomas, of New York, for the idea.  The instrument is  similar in construc-
 tion to an ordinary glove-stretcher.
     The  part to be  removed  having been thus separated from its deep
 attachments, a pair of strong, blunt-pointed scissors are introduced, and the
 flap cut out. A separated margin of at least one-quarter of an inch  should be
left for adhesion, which, when united, forms a raphe, and adds materially to
the  strength of the part.   The sutures are introduced  at spaces of one-eighth
of an inch, and are carried back so as to include the whole of the margin that 
59
 has  been separated.  Great  care must be taken in the  adjustment  of the
 parts ;  the approximation must be perfect, or the operation will be a failure.
     The sphincter ani should be paralyzed in the same way as recommended
 in restoration of the perineum, and the bowels kept loose.
     The  wires are removed from the twelfth to the  fifteenth day.  The
 vagina must be frequently washed out with tepid water, and a little car-
 bolized glycerine thrown in after each injection.   This operation is simple,
 and, if properly performed, in cases  of uncomplicated reetoeele, is always
 successful.
     The  method adopted by Dr. Sims, and  modified by Dr. Emmet, is
 rarely successful.  It consists in removing a strip of the mucous membrane,
 about one-quarter of an inch wide, on the margin of the tissue to be included
 in the sutures, leaving the deep tissues intact.  A fold of  the hypertrophied
 tissues of the vaginal wall is thus left behind the cicatrix, which forms a
 pouch in which is contained the natural secretion of the included membrane.
 Dr. Sims again modified his operation by denuding the vaginal epithelium
 to the whole extent to be included within the sutures.  This was no improve-
 ment.  It left the deep tissue simply folded up,  and, instead of including
 within the fold healthy mucous membrane, there was left  a raw surface that
 could not be brought in apposition, and which was frequently the seat of
 suppurative inflammation, forming an abscess, producing great constitutional
 disturbance, and  rendering the operation a  failure.   In  addition to these
 objections, in the latter modification the patient loses too much blood.
     The substantial difference between Dr. Sims's operation and my own is
 this: He takes in a thick fold of the hypertrophied membranes, and tries to
 hold them by the adhesion of about one-quarter of an inch of mucous mem-
 brane.   I cut out the whole of the membranes in excess, and unite the edges
 by the entire thickness of the tissues, making a strong, firm cicatrix, which
 forms a raphe, and gives increased support to the uterus.  In private prac-
 tice I performed  several operations after  Sims's method, but none of them
 were successful.  The union, when union did  take place, gave way  early,
 and the reetoeele re-appeared;  but, in the majority of cases, I failed in secur-
ing union, the sutures cutting out  on the fifth or  sixth day.  In hospital prac-
tice, where I have operated by the entire removal of the whole of the tissues,
and in private practice, since I have  adopted this  method, I have met with
no failures. 
60
                               Case 1.

                           Vaginal reetoeele.

    Mrs. R----,  aged thirty-seven;  married;  admitted  to  hospital June
6, 1867; has had several children, the youngest three years  of age;  has
been troubled with constipation for the last twelve years, rarely having an
operation from her  bowels unless  under the influence of  a cathartic.  Her
perineum was ruptured during the birth of her first child, but the  rupture
increased with the  third, which  was unusually  large,  weighing  thirteen
pounds.  From the history of this labor, as given by herself, the head of the
child remained in the inferior strait for several hours, and  was finally deliv-
ered by forceps.   From that time a tumor was apparent at the vulva, which
had gradually increased until the time of her admission.   When her bowels
were moved,  she had to push the tumor up into  the vagina and hold it there
during defecation.  The uterus was not prolapsed, but dragged low down by
the weight of the posterior wall  of the vagina.  The tissues were very thick,
and the mucous membrane was dry and covered with horny epithelium;
the perineum was torn down to, but did not involve, the sphincter.  The
vagina was plugged loosely with cotton saturated with carbolized glycerine;
the bowels emptied daily by an injection; and the patient kept in a reclining
position, the  object  being to reduce the congestion of the  membranes, and
get them into a condition that would permit of union by first intention.
    July 3.—Patient having been fully aetherized *md placed in the position
for lithotomy, an incision was made in the shape of an  ellipse, starting from
the posterior cid-de-sac superiorly, and terminating about one inch above
the internal sphincter, its  width  at the  center being five inches.  The incis-
ion was made through the entire thickness of  the vaginal tissue, exposing
the wall of the rectum.   The dissection of the flap thus formed was made
mainly by the handle of the  scalpel.  The cellular tissue was loose, and the
parts were easily separated.  The bowel was kept back by a retractor dur-
ing the dissection, and, when the flap was removed, it looked  like a  piece of
leather.   There was no contraction;  but it was  as large when separated
as in situ.   The retractor having been removed, the bowel bulged forward,
and formed a tumor almost as large as when covered by  the vaginal walls.
The sutures,  twenty-eight in number, were introduced  one-fourth of an
inch  apart, and three-eighths of an inch from  the edge, giving that much 
61
surface for adhesion.  The sphincter  ani was paralyzed by dilatation, and
the bowels kept relaxed.
     July 4.—Patient a little restless ; pulse 100 ; skin hot;  complains of
an  uneasy^ sensation, but no positive  pain, about the vagina.   One drop of
Fleming's tincture of aconite-root was  administered in water every hour,
and one grain of the watery  extract  of opium every four hours;  beef-tea
and milk-diet.
     July 5.—Has slept well; pulse 100;  skin dry, but not as hot as yes-
terday ; treatment continued. .
     July 6.—Pulse 85 ; skin moist; vagina hot;  bowels moved by confec-
tion of senna; warm-water injections per vaginam to  be used every  two
or three hours.
     July 7.—Pulse 70 ; skin moist; vagina cooler; the tincture  of aconite
to be discontinued ;  the opium to be given in half-grain doses.
     July 8.—All medication to  be discontinued,  there being no indication
for constitutional treatment.
     July 20.—Sutures removed, firm union having  taken place in  every
part of the incision.
     August 4.—The perineum was restored by the usual method; and, on
September 10th, the patient left the hospital, perfectly cured.

                                Case 2.
                           Vaginal reetoeele.
     Maria H----, aged thirty-nine, admitted to Columbia Hospital July 7,
1867 ;  delivered of her first child seven years ago, since which time she has
suffered from difficulty in moving her bowels, and, according to what she
had been  informed,  falling of the womb.   To remedy this, her physician
had introduced an inflated gum-elastic pessary, which,  while it remained in
the vagina, afforded her some relief, but was always displaced during defe-
cation, or in coughing.  On examination, a tumor was found protruding
through the labia, which consisted of the  posterior wall of the vagina and
anterior wall of the rectum.  The finger passed into the rectum and brought
forward could be felt at the bottom of the tumor.
     July 10.—Patient having been aetherized and placed in position,  a  sec-
tion was removed of the same  shape and in the same manner  as in the case
previously  reported.   No pain or constitutional  distm-bance followed the
operation.   The patient left, August 13th,  cured. 
62
                                Case 3.

                           Vaginal reetoeele.

     Mary R----, aged forty-four, admitted August 29,1867; has had eleven
children, the youngest five years old.  She was operated upon twice unsuc-
cessfully.   For the last four years she has worn a pad made of hard wood,
conical in shape, pressed between the labia, to  keep the tumor inside of the
vagina.   The constant  pressure of this pad against the urethra caused con-
siderable irritation, burning, and itching of the vulva, and some ulceration
of the perineum, which  had been partially ruptured.   She was a large, fat
woman, weighing over  two hundred pounds.   The vagina was  unusually
capacious, and its outlet enormous.
     When the patient stood erect and coughed, a large mass of loose, flabby
tissue protruded from the vulva, which, upon examination, was found to be
from the posterior wall of the vagina.   The anterior wall had not yielded;
the uterus was low down, but not prolapsed.  An  injection of a pint of water
was thrown into the  rectum, the nurse placing the finger firmly upon the
anus,, and the  patient directed to strain, when the tissue filled out, like an
inflated bladder, to the  size of a large apple.
     September 3.—I proceeded to operate, anaesthesia having been produced
by aether.   The dissection was very difficult, the rectum being  more inti-
mately  adherent to the vaginal wall  than in  any case I had previously
encountered.   Nearly two hours were  occupied  in removing the flap, the
edge of the knife having to be used throughout.  The parts were united by
twenty-six  sutures, the  ends of the wires having been clamped with a piece
of tea-lead, to prevent  irritation of the anterior wall of the vagina.  The
sphincter ani was paralyzed, as usual in such cases.
     For several days following the operation there was considerable consti-
tutional excitement;  pulse  rapid and wiry;  skin hot; great thirst;  and an
almost entire suspension of the function of the  kidneys.
     The treatment consisted  of aconite and spirits of nitre internally, and
suppositories of one grain of the watery extract of opium put into the rectum
every six hours.  The  vagina was syringed out  every two or three hours
with a weak solution of carbolic acid, three grains to the ounce of water.
By the fifth day all unpleasant symptoms had disappeared, and on the four-
teenth the sutures were removed, and union found to be perfect.
     October 10.—Patient dismissed, cured. 
63
                                 Case 4.

                            Vaginal reetoeele.

     Mary C----,  aged fifty-seven;  has had  five children, the youngest
 being twenty years of age;  admitted into Columbia Hospital  November 8,
 1867, suffering from a severe prolapsus of the posterior wall of the vagina,
 which first began to trouble her fifteen years before.  She had worn pessaries,
 and almost every variety of contrivance, for the purpose  of keeping the
 tumor within the vagina, but to little purpose.   It was inflamed and irritable
 anteriorly from the passage of urine over it, and its posterior surface covered
 with patches  of ulceration produced by the friction of the clothing.   She
 had been ill-fed,  hard-worked,  and poorly housed for several years, which,
 combined with  the constant irritation  about the tumor,  had reduced the
 woman to a most deplorable condition.   She was placed in bed, the tumor
 reduced, the vagina packed with raw cotton soaked in carbolized glycerine,
 and the bowels moved  daily by an enema.   The nurse was ordered  to rub
 her daily, from head to foot, with a dry, pickled towel.   Her diet was varied
 to suit her taste.  Her appetite being capricious,  no special  order could be
 given.  A pint of  porter daily was allowed, and sirup of iron, quinia, and
 strychnine administered as a tonic.  This treatment was continued for three
 months before she was in a condition to permit of an operation for radical
 cure.
     February 17, 1868.—Patient  aetherized; the  full clinical class present.
 Almost the whole posterior wall of the vagina was  removed, the dissection
 being easy, having been effected almost entirely by the handle of the scalpel.
 A few drops of blood only were lost, and the parts were adjusted by twenty-
 three sutures.   The patient was then removed to bed, and placed on her left
 side, this  position causing the bowels and uterus to tip forward, and  thus
 relieving the vagina of their weight.
     From the time of the operation to the removal of the wires, on the fif-
 teenth day, the patient complained of no pain, and there was manifested no
 constitutional  disturbance whatever.  The union  of the parts was perfect,
 and the patient dismissed, March 28th, cured.
     There has been no case in the hospital, since  I have had charge, where
the benefits derived from general and local treatment have  been  more
strongly  marked.   This woman came  into  the  institution an emaciated, 
64
 helpless sufferer, broken down in spirit, and feeling, as well  she might, life
 to be a  burden.   She left physically sound, full of hope, able and  willing
 to labor for her support.

                                 Case 5.

                             Vaginal reetoeele.

      E. S----, aged forty-three ;  mother of six children, the youngest eight
 years of age ; has been  in bad health since the birth of her last child.  She
 complains of constant pain in the back, dragging pain in the groins and
 thighs;  suffers much from constipation, her bowels never being moved with-
 out medicine, which she takes about once in eight or ten days.
      Examination showed an  irreducible femoral hernia on the left side, and
 a large reetoeele, which, by its  own weight, had dragged the uterus down
 with it, the os showing  at the vulva above  the tumor.  The margin of the
 anus was surrounded with irritable haemorrhoids.  The uterus was  but little
 enlarged, its displacement being evidently  due to the reetoeele, and not to
 its own weight.
      The first indication in this case was to  bring the  bowels into a regular
 condition,  and relieve  her of the pain occasioned by the haemorrhoids.  For
 the purpose of relieving the constipation, she was placed upon the "bella-
 donna-treatment," the  particulars  of which  plan of treatment will  be fully
 described in another part of this report.   It succeeded admirably,  as it does
 in all chronic cases.  The painful  condition of the haemorrhoids was relieved
 by hot fomentations, and the application of the following ointment:
                    ft Unguent, gallae, ^ss.
                      Extract, opii, (aq.), fss.
                      Goulard's ext. plumbi,  gtt. xxx.
                      Camphorse pulv., gr. x.

     After the inflammation had subsided, the hard tumors around the anus
 withered, and were  excised with scissors.   During this time, the reetoeele
 had been retained within the vagina by pledgets of cotton soaked in glycer-
 ine, which  were renewed daily.
     February 14, 1869.—Patient having  been aetherized, (the clinical class
present,) a free dissection of the posterior vaginal wall from the rectum was
made, the separation having been  easily and rapidly effected.   A large flap
four inches in its widest diameter,  was cut out, the  parts  adjusted  in the 
                                   65

 usual manner, and the patient placed in bed on her left side.   On the six-
 teenth day the sutures were removed, and union was found to be perfect.
     March 20.—Patient dismissed, cured.

                                Case 6.

                            Vaginal reetoeele.

     Annie T----,  aged thirty-four;  admitted to hospital  June, 1869;
 mother of two children, youngest seven years  old.  Since the birth of this
 child she has  been in declining health, and suffered from pain in the back,
 aching  in the groins, and  profuse  leucorrhoea, often  tinged with blood.
 Marital intercourse was attended with great suffering.  She was haggard and
 care-worn in appearance, and generally emaciated.
     Examination revealed  a uterus one-third  larger than normal, os patu-
 lous, and the lining membrane of the cervix intensely inflamed.   The  pos-
 terior wall of the vagina  bulged forward, and,  when the patient was in the
 erect position, protruded externally.
     Some months elapsed before this woman was in a condition to submit
 to the operation for the radical cure of reetoeele, the condition of the uterus
 and her general health requiring previous attention.
     The general plan of treatment adopted was the same as pursued in  sim-
 ilar cases.
     October 3.—Operation for reetoeele performed in the usual manner.
     October 18.—Sutures removed; union perfect.
     Patient dismissed, cured, November 8th.
     I have since delivered this woman of  a child at full term.  Her labor
 was natural, and the passage of the child through the inferior strait as rapid as
 usual.   Her recovery was perfect.  The vagina regained its  tone, and  the
 uterus remained in situ, although larger than usual.

     Note.—The remaining  cases operated upon by me  for this  special
 difficulty possess no points of particular interest.   They were similar in gen-
 eral characteristics to those  reported; the details of the operation were the
 same in almost every respect, the preceding and  after treatment having been
varied to suit the indications.
     The whole number of cases  operated  upon for this lesion was seven-
teen ; all cured.
      9 
6C
                            CYSTOOELE.

     This lesion rarely, if ever, occurs in women who have not borne children,
being caused by undue distension of  the vagina during parturition.  The
anterior wall of the vagina, having lost its tone, fails to support the bladder,
and, as  the water accumulates  in that viscus, yields and forms a  pouch,
which gradually increases in size, and finally appears  between the labia
and escapes externally.  This pouch or bag is constantly filled with urine,
which cannot be emptied  unless  the patient returns the tumor within the
vagina,  and retains it during micturition.  The retained urine undergoes
decomposition.   The mucus of the bladder, acting as a ferment, decomposes
the urea, one equivalent of which uniting with  two equivalents of water
forms two equivalents of carbonate of ammonia.   This salt is  extremely irri-
tating to the mucous membrane, producing cystitis, with its long train of
attending discomforts, which, rapidly wearing upon the woman, reduces her
to a most pitiable condition.
     There is far more discomfort  attending this form of  partial  prolapse of
the vaginal walls than accompanies reetoeele, and it gives rise to more con-
stitutional disturbance.
     The treatment for its  cure is the same in every respect as that adopted
for the cure of reetoeele, the tissue being removed from the anterior instead
of the posterior wall.   The dissection  is more difficult,  on account of the
intimate adhesion of the vaginal walls to the bladder, which, without very
great care,  might be wounded.
     Twelve cases have  been  operated upon in the hospital, in all of which
the results  were  successful.

                                Case 1.

                            Vaginal cystocele.

     Martha W----, aged  thirty-nine;  mother of one child eleven years of
age; has had eight miscarriages,  each time between the thud  and fourth
month.  After the birth  of her first child, she noticed a small tumor at the
entrance to the vagina,  which gradually increased  in size, and, after a few
months,  pressed  the labia  on one  side and made its appearance externally.
The surface became abraded from friction with the clothing, giving rise to
a discharge which was offensive and irritating to  the  adjoining parts.  She 
67
 complained of constant pain in the loins, a dull, continuous aching over the
 pubes, and a frequent disposition to micturate.  The urine was albuminous
 and fetid.  Her general condition and appearance indicated venereal disease.
     August 17, 1869.—Patient having been fully aetherized, a large section
 was removed from the anterior wall  of the vagina in the same manner as
 described in the operation for reetoeele.  The parts were accurately approxi-
 mated by seventeen sutures, and the patient placed on her left side.  A self-
 retaining catheter was inserted to prevent any accumulation of urine, which
 was removed daily, and the  bladder washed out with carbolized  glycerine
 and warm water.  A good recovery resulted from the operation, the sutures
 having been removed at the usual time, and union found to be perfect.
     The functional disturbance of the kidneys was undoubtedly secondary.
 The irritation commenced  in the mucous membrane  of the bladder, owing-
 to the ammoniacal condition of the retained mine.   By continuity of  sur-
 face, this irritation extended to the ureters, which were  further injured by
 being dragged downward with the prolapsed bladder.   Functional disease
 of the kidneys necessarily ensued.
     The indication, obviously, in this case was to remove the  original cause .
 of the disease.   This could only be accomplished by reducing the anterior
 wall of the vagina to its normal size, retaining the bladder in  situ, relieving
 the ureters of  the strain upon them, and preventing the undue retention of
 the urine in the bladder.  All.these indications were met, and the  result, so
 long as the patient was  under observation, proved very satisfactory.  The
 condition of the bladder rapidly improved, the albumen diminished in quan-
 tity, and the pain in the back disappeared.
     I was unable to follow this case to its  termination, as the patient  left
 for her home much sooner than was desirable.

                               Case 2.

                            Vaginal  Cystocele.

     G. B., aged thirty-two ; married at fourteen ; mother of five children ;
her first  child was not born  until her twenty-third  year, since which time
her menstrual period has not returned on account of intervening pregnancy.
Her  youngest child, which is still nursing, is sixteen months old.
     Examination revealed a medium-sized cystocele, which, she stated,  had 
68
 existed for more than three years, and had increased since the birth of her
 last child.   The cervix uteri was dragged down and hypertrophied.  She
 complained of pain in the back  and uneasiness  about the bladder, with a
 disposition to frequent micturition.
     It being desirable to reduce the hypertrophied os and cervix before
 operating, the patient was kept in bed the greater part of the day, and a
 stream of water, hot as could be  borne, thrown, per vaginam, upon the ute-
 rus for fifteen minutes, morning and  evening, giving the vaginal canal a hot
 bath.   This was followed by the introduction of-cotton soaked in glycerine.
 Thus  treated, the  cervix  rapidly melted down, and, in six weeks from the
 time of admission, the patient was in good condition for operation.
     November 18,1869.—Operation performed; sutures removed December
 2d; union found perfect; and patient dismissed, cured, December 21st.
     Had this woman continued  without treatment there  is  no  doubt she
 would have  gradually  fallen into the same  condition as  Case No. 1, but
 timely interference, before the diseased condition of the bladder became suf-
 ficiently advanced to involve the ureters and kidneys, saved her  from a
 secondary disease  which is seldom curable.

                                Case 3.

                            Vaginal Cystocele.

     Ellen L----,  aged thirty-seven;  mother  of one child,  thirteen years of
 age.  At the birth of this child the perineum was completely ruptured, and
 from that time to the date of her admission, she has considered herself an
 invalid.  For  the.  purpose of keeping the  bladder and uterus within the
 vagina she has, for many years, worn a pad strapped tightly up to a girdle
 which  passed around her waist.   When the parts became too much irritated
 by the pressure of this pad, she would remove it, in order  to  give them an
 opportunity to recover,  but, during that time, she was compelled to lie in
 bed, as the protrusion of the tumor, when unsupported, gave her more pain
 than she could endure in the erect posture.
     The neck of the uterus was enormously hypertrophied, but not  in an
ulcerated condition.  The anterior wall of the vagina  protruded to the size
of a large orange.   It was considered useless to operate on the vagina and
leave the hypertrophied neck  of the uterus, as it would most certainly have 
69
dragged  the bladder  clown  again, and, in a few months, reproduced the
existing trouble.   It was, therefore, determined to amputate the cervix before
operating upon the cystocele.
    February 8,1870.:—The whole vaginal portion of the cervix was ampu-
tated by  the flap-operation, the flaps having  been brought together by the
quill-suture, and a small piece of tea-lead introduced to prevent occlusion of
the os.   The parts united kindly, and the  sutures were removed on the
twelfth day.   Two weeks afterward my usual  operation for cystocele was
performed, with the same success as in previous cases.
    May 15.—The perineum restored.
    No  constitutional disturbance followed either of these operations.
    I have twice examined this woman, at intervals of several months, since
her discharge.  The vagina remained compact, and the uterus elevated and
healthy.
    The remaining cases were  similar in  character to those  reported.   All
were cured. 
70
   DISEASES  AND DISPLACEMENTS OF  THE  UTERUS.

Prolapsus, complete  and incomplete—Tumors—Subinvolution—Cervi-
    cal metritis, acute and  chronic—Endometritis of Cervix—Car-
    cinoma of Body  and Cervix—Pelvic- cellulitis, etc

    Without due reflection, it appears remarkable that the uterus should be
subject to such a long  list of  ailments  as are above enumerated, situated, as
it is, deep in the pelvic cavity, suspended by the most ingenious contrivance
for retaining it in its  nonual position, protected in  almost every direction
from injury, being only exposed to shock or concussion through the vaginal
channel.
    While anatomically thus  protected, its functions are of a character which
render it more liable to disease and disturbance than any other organ in the
female body.   From the period  of puberty, which may be stated to arrive
at about fifteen  years of age, to  the climacteric  period, which generally
occurs at forty-five, this organ is subjected,  every four weeks, to great
functional excitation, forming, as it does, the most  important element in the
group of phenomena known as menstruation.  This occurs, during the ordi-
nary life of a woman who bears no children, some three hundred and ninety
times—three hundred and ninety efforts being made by nature, during these
thirty years, to procreate the species, but, owing to some pathological con-
dition of the uterus, or to the absence  of the spermatozoa, each attempt has
resulted in an abortion.  Let us  look  a little  into  the changes which occur
in the uterus and appendages at each menstrual molimen.
    On the advent of the menstrual period, a Graafian follicle in one or other
of the ovaries becomes the  seat of an unusual vascular excitement.  The
capillaries which surround it increase in size.  From these distended vessels
an abundance of fluid of a light straw-color is poured into the follicle, which
gradually projects from the surface of the ovary, until finally its attenuated
membraneous covering yields to the pressure from within, ruptures, and the
egg escapes. While these changes  have been going on in the ovary, equally
important ones have been taking place in the uterus  and Fallopian tubes.
    The uterine vessels enlarge;  the parenchyma  of the organ becomes 
71
fii-mer; its cavity and the inlets from the Fallopian tubes, as well as the tubes
themselves, become larger  and more patent;  the mucous membrane is no
longer pale and smooth; the minute, tubular follicles, which, in the quiescent
state of the organ, are only demonstrable by a highly-magnifying power,
are now erect and engorged with blood, giving  to the whole internal surface
of the uterus the appearance of cut velvet.  The mucous membrane of the
Fallopian tubes partakes of the same vascularity, and its ciliated epithelium
can be seen in a state of great functional activity, producing a strong current
from the extremity of the tubes  to  their  termination in the uterine cavity;
the fimbriated  extremity becomes directed toward that part, of the ovary
from which the egg is about to escape, and, at the moment the Graafian fol-
licle ruptures, receives the egg within its grasp.  During the passage of the
egg  tluough the Fallopian tube it absorbs some of the fluid it there meets,
and enters the uterus  larger than when it  left the ovary.  By this  time the
changes in the mucous membrane of the uterus  are complete, and everything
is ready for the nourishment of the egg.   The first steps toward the propa-
gation of the species  have been  made, viz: the formation and maturation
of a germ-cell, its passage to, and the preparation of, the uterus for its recep-
tion.  All it now awaits is  the fecundating influence of the sperm-cell.  If
that  remains absent, the egg,  or germ-cell, withers, the vascularity of the
uterus diminishes,, nature disposing of the increased amount of blood she had
directed to that organ for the  nourishment of its new  occupant.   The rup-
ture  of the engorged capillaries of the mucous membrane, mixed with the
natural secretion of the mucous tubules, constitute the menstrual discharge.
An abortion has occurred.  Is it surprising that  an organ, the subject of-such
oft-repeated progressive and retrograde metamorphoses, should be prone to
functional and organic diseases %
     When pregnancy occurs,  and the physiological changes progress nor-
mally to the full period  of gestation, we find .the uterus, which, in the virgin
state, weighs only about ten drachms, has increased  to three pounds, this
increase being produced by the rapid growth of its muscular fibres.  After
delivery, this large mass of tissue has to undergo a  retrograde metamor-
phosis, or fatty degeneration and absorption, until it is  reduced to about two
ounces, always remaining,  however, a little larger  than in the virgin state.
     This phenomenon  of  involution may be arrested at  any stage, and,
instead  of the uterus returning  to  its normal  size, the whole  organ may 
72
remain hypertrophied, or the hypertrophy may be confined ,to the posterior
or anterior wall.  In the first, prolapsus will follow;  in the second, retro-
version or anteversion.
     Further reference to  subinvolution of the uterus will be made in the
reports of the following cases.

               prolapsus uteri, incomplete and complete.

     Incomplete prolapse, or procidentia, may exist in different degrees, from
slight displacement downward, to the more extreme form, when the os makes
its appearance  at the vulva, drawing the fundus of the bladder downward
and  backward,  the anterior wall of the rectum downward and forward, and
putting the vesico-uterine and recto-uterine reflections of the peritoneum on
the stretch.
     By the anatomical arrangement  of this organ  it is maintained in its
normal position by the combined support of the utero-sacral ligaments, the
anterior, middle, and posterior portions  of the broad ligament, the utero-
vesical ligaments, and the  columns of the vagina, the round ligaments hav-
ing  no  share in preventing the descent of the womb.  With these natural
supports in a physiological condition, and the uterus of its normal size,
descent is impossible.
     Various conditions will produce prolapsus in  the unmarried female.
Foremost in the list of predisposing causes is the want of sufficient and reg-
ular  exercise,  without which the whole muscular  system remains  in an
undeveloped condition, digestion is imperfectly performed, and the function
of the whole alimentary canal impaired.   The nervous system, both sympa-
thetic and cerebro-spinal, necessarily suffers in common with the rest of the
body, and fails to afford the normal stimulus to the organs of  organic life.
Such patients  suffer from  impaired  capillary  circulation, as evidenced by
cold hands and feet, and the accumulation of fecal matter in the intestinal tract.
In the first instance, from want of tone in the longitudinal fibres, the pouches
of the colon become impacted, the presence of the impacted matter irritates
the branches of the sympathetic nerve; which principally supplies the circu-
lar muscular fibers of the intestine, throwing them into a state of tonic con-
traction, and obstinate constipation is the result.  The sigmoid flexure of the
colon and upper part of the rectum become filled and gradually distended,
forming a tumor which presses the uterus  downward, backward, and to the 
73
right.   Cathartic medicines (which are generally given in  these  cases)
cause violent expulsive efforts on the part of the intestiues, assisted by the
diaphragm and abdominal muscles, tending  to aggravate the uterine dis-
placement by the increased pressure.   The walls of the vagina are relaxed
in common with the rest of the muscular system, and fail to give the uterus
the support they were intended to afford.   Thus pressed upon from above
and unsustained from below, the ligamentous supports of the womb grad-
ually yield, and the organ becomes displaced downward.   The constipation
continuing, the return of blood from the uterus is obstructed, causing con-
gestion.  Irritation necessarily accompanies it, and hypertrophy of the whole
organ, or the anterior or  posterior  wall, follows.   We then have the uterus
increasing "in weight and its supports diminishing in power.
     With the system in this condition, the woman often subjects herself,
spasmodically, to violent exertion.   Young ladies, who consider themselves
unequal to the task of walking two or three  blocks, will go to a ball and
dance continuously for hours, and that, frequently, when the uterus is still
further enlarged by the congestion attending the menstrual period.   Such a
combination of predisposing and exciting causes cannot fail to produce pro-
lapsus, with its train of attending evils.
     In the married woman we may have all  the predisposing and exciting
causes which we  have enumerated in  the unmarried.   Indeed,  in a  large
number of cases, women marry when, physically, they  are totally unfit to
assume the duties of the  marital relation, the functional disturbance  of the
genito-urinary organs being too serious to permit of healthy intercourse with
the male.   If  the  pre-existing  functional disturbance  has been of  long-
standing, the secretions of the mucous membrane become altered in charac-
ter and increased in  quantity.   The cervix  becomes blocked up with an
abnormal mucus, which  offers a mechanical obstruction to the passage of
the spermatozoa,  which,  if not  destroyed by contact with the unhealthy
secretion of the vaginal tract, are unable to enter the uterine cavity, and the
woman remains sterile. Anxiety and dissatisfaction with  this condition leads
to too frequent connection, which necessarily increases the existing troubles
by the still further congestion and  probable inflammation of the uterus.
     If, notwithstanding  the diseased condition of the  uterus, the woman
becomes pregnant, and gestation continues until the full period, the proba-
bilities are that her recovery from  parturition will be imperfect, the  uterus
        10 
74
remaining in a state of subinvolution.  The muscular tissue of the vagina,
relaxed before delivery, and recently distended by the passage of the child,
remains loose and flabby, and affords no support to the uterus, which is too
large to be retained in position by its  ligaments.
     The most severe cases which the gynaecologist is called upon to treat
belong to this class of patients.
     If the woman be perfectly healthy when she marries, be well taken care
of during the period of gestation and after delivery, and no  untoward acci-
dent occurs  during parturition, (such as rupture of the perineum,) there will
be no displacement.of the uterus  following labor.
     Rupture of the perineum, of  itself, is a sufficient cause  (if not restored
at an early date) to produce complete prolapsus.
     Tumors of any kind which  increase the weight of the organ without
corresponding increase of, power in its supports will  finally  produce  proci-
dentia, either in the married or single.
     The symptoms thus created depend upon the grade of the lesion.  Vesi-
cal irritation is a  prominent symptom in all stages.    Next  in order of fre-
quency coines leucorrhoea, lumbar pains, menorrhagia, dysmenorrhcea, and
extreme fatigue upon the slightest exertion.
     The physical signs are so well marked that  a  digital  examination at
once reveals the true condition.   The diagnosis is easily made unless  the
practitioner be grossly ignorant or unusually  careless, the presence of the
cervix and os being conclusive.
     The complications attending prolapsus of the  uterus  are  grave and
numerous.   In the more.extreme forms of displacement, chronic metritis
and  endometritis, of  greater or  less severity, always  exist; in the milder
forms,  congestion and hypertrophy of the uterus, sub-acute  peritonitis, ree-
toeele, cystocele, and, as concomitants, rectitis and cystitis.   Whatever the
stage of the prolapsus we are called  upon to treat, the indications are the
same :
     First, reduce the weight of the uterus.
     Secondly, strengthen the uterine supports.
     Remove the corsets, suspend the skirts from the shoulders, and let the
patient, during the  early period  of treatment, be placed  in bed  or  in the
reclining position.
     If the uterus be still in the vaginal canal, and (as is generally the case) 
75
the cervix tumid and tender, let a stream of water as hot as can be borne
comfortably be thrown into the vagina, morning and evening, for  fifteen
minutes at a time, giving the uterus a hot bath.   This affords great relief to
the patient, and is  one of the most efficient means of reducing the hyper-
trophy and  subduing  the existing inflammation.  The  stream  should be
continuous, and, during the administration,  the patient must be placed in a
recumbent position.  After each  injection  apply a pledget of raw cotton,
soaked in glycerine, to the uterus, leaving it there until time for the next
bath.   In all these cases there will be found cervical endometritis, if not
corporeal.  I have had more success with the use of pure carbolic acid,
applied directly to the  mucous membrane, than by any other treatment. It
causes no pain by its application, and excites no undue irritation.   It should
be applied on a piece of raw cotton, wound  around "Sims's" applicator, and
used once a week as long as necessary.  A  daily movement from the bowels
must be secured, not by means of cathartics, but, if  there is obstinate con-
stipation, by the belladonna-treatment, as detailed under "Constipation;" if
the constipation be of  a  mild form, a  simple injection will be sufficient to
secure a daily passage.   Tonics should  be  given  to the  point of toleration.
I  have found the  sirup of the phosphates  of ferrum, quinia and strychnia
answer better in my hands than  any other preparation.   There are very
few cases of prolapsus in the first stage  that will not yield  to this treat-
ment in two or three months. If the vagina remains relaxed after the uterus
has been reduced to its normal size, and does not recover tone, a current of
electricity, passed  through its walls daily, will generally suffice to complete
the cure.
    In the second  stage of the disease, where the os appears  at the vulva,
and the uterus is found resting on the perineum, in addition to the treatment
adopted in the first stage, it will  generally  be found necessary to amputate
the vaginal portion of  the cervix, which will be found in a state  of chronic
hypertrophy, the  enlargement being due to  an increase in the  amount of
connective tissue.   This form of hypertrophy will not  yield to topical appli-
cations or general medication, and all attempts at radical cure  will be frus-
trated  unless it is removed.   After the  removal  of  the cervix, a sufficient
time must be allowed for  the vagina to recover its  contractile power, the
patient in the mean time being kept strictly in the recumbent position.  If,
at the  end of two  or  three months, the vaginal walls are still flabbv, and 
76
afford no support to the uterus, the operation of elytrorrhaphy, for lessening
the dimensions of the vagina, must be resorted to.
     The  method of  performing  this operation  is  fully described in the
remarks on reetoeele.
     Whenever the  perineum has been ruptured, it must be restored, what-
ever the degree of the prolapse may be; for if only in the first stage, and,
by rest and the employment of the means suggested, it is cured for the time
being, it will certainly be reproduced unless the perineal support is restored.
     The third stage of this troublesome malady is necessarily accompanied
by eversion of the vagina, the walls of which generally carry with them
both  rectum and bladder.   The  photograph  of C. D.,  illustrating Case 14,
shows the condition of an extreme case, two weeks after the  cervix had
been  amputated.  The operation and history of the patient will be described
in the report of Case 14.
     Plate 7 shows the change produced in the position of the internal viscera
by this lesion, and  affords an opportunity for a better appreciation of the
causes which produce the more serious symptoms accompanying it.
     The  indications  for treatment in this,  the most severe form of uterine
displacement,  are the  same as in  the middle forms,  viz: reduce the size of
the uterus by subduing  any inflammatory  action that may  be going ■ on;
remove the enlarged  cervix;  return the uterus to its normal position, and
retain it there  by the  medicated  cotton; reduce the caliber of the vagina;
and, when lost, restore the perineum.
     This  treatment should be pursued in the order laid down.
    Any treatment short of the most radical surgery for cases of this sever-
ity is confessedly but a mere palliative measure, and should only be resorted
to when, for good and sufficient reasons, an attempt  at radical cure is inad-
missible.  Pessaries, as a means of cure, are worse than useless.  Numerous
operations have been devised, having in view the reduction of the caliber of
the vagina, or the diminution of the orifice of the vulva.   Mend proposed,
after the uterus had been forcibly returned into the vagina, to form an arti-
ficial hymen, which should constitute a sort of diaphragm on which the womb
could rest.
    Fricke's operation consists in removing a portion of the inner surface of
each labium, about two fingers in breadth, commencing above the superior
commissure  and terminating  about  half an inch below the  frenulum, and 
Plate VII.
  The left half of the pelvis and corresponding half sections of the bladder, uterus, and rectum,
with ovary, Fallopian tube, and round ligament;  the three latter still in their natural  relations
with the broad ligament, which is seen on the stretch, pulling strongly on the margin of the pelvis,
sub-peritoneal pelvic cellular  tissue, and  pelvic reflexions of  the  broad ligament.  The bladder
drawn  down  with the  uterus, owing  to the  intimate  connection between the two, and the
posterior wall of the vagina torn  from its  cellular connection with the rectum.—Savage. 
 
77
 uniting the parts by some ten or twelve sutures, forming a sort of scrotum,
 in which the uterus might rest.  This, it was believed by M. Fricke, would
 be amply sufficient to retain the organ to its place   Dieffenbach and other
 prominent men lent the weight of their names to its support.  But, neverthe-
 less, in spite of the high-flown expectations which had been excited concern-
 ing it, the lapse of time, which brought with it calmer judgment, compelled
 its most zealous advocates to admit  "that  its success was, at  the best,
 extremely imperfect, and  that, in the large majority of  cases, the operation
 failed completely."   It, and the various modifications of it, having proved
 so signally  unsuccessful, have been abandoned on  the continent.
     Baker  Brown's modification is much less radical than Fricke's, or, Mal-
 gaigne's improvement  on Fricke, and I must fully concur with West, who
 observes, speaking  of the fifty cases of reported cure by Baker Brown,
 " When, therefore,  we find Fricke's operation, as  modified by Malgaigne,
 who carried his incisions much deeper,  and removed a  considerable extent
 of mucous membrane at the orifice of the vagina, in order to include a still
 larger surface in the suture, abandoned on account of its not being followed
 by permanent success, we hesitate  to pronounce an opinion on the alleged
 successful result  of almost every one of fifty cases in which the modified
 operation was performed  by one surgeon."  I have operated a number of
 times for the cure of this  lesion, combining reduction of the caliber  of the
 vagina with restoration and elongation of the perineum, leaving the os and
 vaginal portion of the cervix intact.  For a time, varying from six months
 to two years, they have been partially successful, but the uterus eventually
 made its appearance at the outlet, and  finally escaped.   This I attributed
 to the removal of  too little tissue from the vagina, and recommended to
 others and  determined myself to be more radical in the operation  in the
 future.
     I found, however, that the fault was not' in removing too little from the
 vagina, but  in not removing the vaginal portion of the cervix.  I now make
 its removal the primary step in the  operation, following  it by reducing the
 dimensions of the vagina, and finally restoring the perineum.  Since I have
 adopted this course, the results, so far as I have been able to ascertain, have
 been entirely successful, and the experience of my friend, Dr. G. Thomas,
 of New York, coincides with my own, he having adopted the  same method.
I amputate  the cervix and allow the parts to recover before reducing the 
78
procidentia; it is safer, being less likely to be followed by acute inflam-
mation  of the  body or peritoneum, which sometimes follows  the  simple
reduction without any other interference with the parts.
     I reduce the procidentia, when extreme, by seizing the entire mass in
my left hand, with  which I exert steady compression, for the purpose of
reducing the amount of blood.in  the organs; then, pressing the fingers of
the right hand immediately in front of the anus, commence  to invert the
protruded membranes at that  point, as these yield to the  pressure assisting
their return by a gentle pushing of the uterus upward and backward.
     Reduction by this  plan'is readdy performed if  there are no firm adhe-
sions binding the uterus down.

                      PROLAPSUS UTERI.
                                Case 1.

Prolapsus Uteri, first stage—Relaxation of vaginal walls—Profuse Leucorrhoza
                    —Cervical Endometritis.—Cured.

     Mrs. R----, aged twenty-five; has been married  seven years, but
never became pregnant.  Complains  of pain in the  back, aching  in the
groins, frequent disposition to urinate, costive bowels, and profuse leucor-
rhcea.   She states that she has been troubled with  this discharge since her
girlhood, but that it hag been worse since  she was  married.   Intercourse
with her husband gives her great  pain, and when she sits upon a hard seat
it hurts her, appearing to push something upward that is  tender.  Appetite
capricious;  whatever she eats disagrees with her; tongue  coated; pulse 94.
    Examination.—Vagina lax; uterus retroverted, and within two  inches
of ostium vaginale;  cervix hypertrophied; os patulous and eroded, its  cavity
filled with  tenacious mucus, tinged with blood;  pressure of  the finger in
the posterior cul-de-sac gives pain,  as also lifting the uterus up on the  finger.
     Treatment.—For the first two weeks the treatment, consisting of hot-
water injections to  the uterus, morning and evening, for fifteen to twenty
minutes at a time, followed by the introduction of a pledget of raw cotton
soaked in glycerine, passed up to the posterior cid-de-sac.  The belladonna-
treatment for the bowels brought away large masses of  scyballae, some of
winch  had  undoubtedly been impacted for  months.  During  this time no 
79
 application was made to the cervical canal, it being considered better to
 reduce the inflammation first.  This was followed by the application of pure
 carbolic acid to the mucous membrane of the cervix every four or five days.
 After each application a  suppository was passed up to the uterus, containing
 two grains of the watery extract of opium, the following fonuula being used
 in its preparation:
                            B. Butyrii cocose, fij.
                              Aq. ext. opii, gr. xij.
                              M. ft. suppos., No.  vj.
      Absolute rest in the recumbent position was strictly enjoined.
      As a tonic the sirup of the phosphates of iron, quinia, and strychnine
 was given in teaspoonful-doses after each meal.
      The cervical inflammation readily  yielded to  this treatment.   At the
 expiration of three months it was reduced to one-half the size it presented at
 the time she came under my charge.  The secretion of the cervical canal
 was normal.   The vagina had partially regained its tone, but the uterus was
 still retro verted, owing to the hypertrophy of its posterior wall.
     The warm-water  injections were continued, but the  one administered
 in the  evening was thrown  into  the rectum instead of the vagina, about
 three-parts of a pint being used.  It was allowed  to remain and be gradually
 absorbed, the rectum being tolerant of its presence.  The water having been
 thrown into  the bowels  brought  it into  more immediate contact with the
 body of the uterus than per vagi nam.
     A weak cm-rent of electricity was directed through the vagina and uterus
 daily, for about  five minutes at a time.   This was  gradually increased in
 strength, and the time prolonged to ten and, finally, fifteen minutes.
     At the expiration of six months the uterus had ascended to its  normal
position.  It  measured two and three-fourths inches from os to fundus and
the whole organ appeared healthy.   The vagina  had entirely recovered its
tone; the bowels were regular, a movement being had daily; appetite and
digestion good.
     The patient was dismissed, cured, with instructions to  take no cathartic
medicine at  any time, but,  if the bowels were not moved, to take a tepid-
water enema, never permitting a* day to pass witliout securing a movement. 
80
                               Case 2.

     Mrs. S----, aged thirty-two;  has been married thirteen years; been
pregnant five times, but aborted on each occasion  between the fourth and
fifth month.   She first menstruated at eleven years  of age, and was regular
up to the time of her marriage; but, for three years before that event, her
discharge had been excessive, lasting for seven and eight days, and saturat-
ing six to eight napkins daily.  Since  her  marriage she  has menstruated
every  two  weeks,  never having more than  one week's exemption  except
when pregnant.  Intercourse with her husband always caused haemorrhage,
and, from the first, was attended  with  pain, which increased  rather than
diminished.   She  suffered from constipation, and its attendants, headache
and nausea.
     Examination.—The uterus was low  down, the os within an inch of the
vaginal outlet;  the cervix hard and nodular; os patulous, but not eroded;
vagina relaxed and irritable; the parts were bathed in a muco-purulent dis-
charge.  The probe, passed into  the  uterine cavity, showed the distance
from os externum to fundus to be four  and one-half inches.  Although used
with great care it caused considerable  pain, and, when withdrawn, was fol-
lowed by blood.
     The enlargement appeared general, and was  due to subinvolution of
the organ.
     The treatment in this case was the same as  in Case 1, with the  excep-
tion that chromic acid was substituted for carbolic acid, and the  galvanic
current used less frequently.
     Her first pregnancy occurred when 'the uterus was in  an unhealthy
condition, and not capable of passing  through the different  stages of pro-
gressive metamorphosis ;♦ hence her first abortion.  From this she  probably
did not fully  recover, and, again becoming pregnant while the uterus was
in this condition, she again aborted, and so on until the time when she
sought medical aid.
     This patient was under treatment four months only, at the end of which
time she was  dismissed, cured. 
81
                                Case 3.

Prolapsus Uteri, second stage—Partial Reetoeele and  Cystocele, with Loss  of
                               Perineum.
     Mrs. B----, aged thirty-seven; married at seventeen;  mother of four
children, youngest twenty months old;  has had repeated miscarriages,  all
of which she produced herself by the use of a steel sound.
     She complains of general abdominal tenderness;  pain in left groin;  con-
stant desire to micturate;  bowels moderately regular, but a movement
always painful;  inability to stand; profuse leucorrhoea;  menstruation irreg-
ular and excessive; appetite and digestion good, but feels nervous and irri-
table.  A very little cause will produce a  violent display of temper,  which,
she says, is not natural to her.
     Examination.—Uterus visible at the  vulva, with a fold of membrane
anteriorly  and  posteriorly  accompanying  it;  os   patulous, eroded,  and
hypertrophied, measuring two inches in diameter.  It  felt as hard as bone.  A
sound, passed into the bladder, made its appearance at the vulva, if turned
in that direction; the finger, introduced into the rectum, followed the  pos-
terior fold of membrane  downward; perineum rent to  the  anus, but the
rupture not involving the sphincter.
     Treatment.—Hot-water irrigation to the uterus, morning and evening,
followed by applications of  glycerine; bowels kept regular  by the  use of
tepid injections; rest, in the recumbent position, constituted the treatment
for  the first six weeks, and it succeeded in  giving entire relief from pain and
tenderness.  But, although the uterus had been retained in position  by the
pledgets of cotton, and the patient kept on her  back or side during the whole
time, there was no diminution  in the size or  hardness of the cervix, and
it was determined to amputate the enlarged and hardened portion.   This
was done by the flap-operation, the  parts united by silver sutures, a small
piece of lead being left in the remains of the cervical  canal to keep it  patent.
The parts united kindly.
     A small section was next removed from the vaginal walls  anteriorly
and posteriorly, the operation being the same as reported under the head of
cvstocele.
     Two months after the  operation of elytrorrhaphy,  the  perineum was
restored, with  the usual success.
     Patient dismissed, cured.
       11 
82
                               Case 4,
    Mrs. E. H----, aged fifty-seven; mother of thirteen children; has had
prolapsus uteri for thirteen years;  wears a pad and napkin to keep it within
the vagina;  bowels always costive; otherwise enjoys good health.
    She complained of the usual  symptoms accompanying this lesion, and
examination showed prolapsus in the third  degree.  Uterus  hypertrophied,
and cervix inflamed;  the anterior wall of the vagina much thickened, and
hung loosely like a curtain in the cavity when the uterus was returned and
kept in place by the retractor.  Injection of the bladder did not affect this
pouch of membrane, proving that it was a simple hypertrophy and prolapse
of the anterior wall, and not a cystocele.
    The same  plan of treatment  was  adopted for the reduction of the
inflammation and  hypertrophy of the  womb as  in Cases  1 and  2, and,
to a limited extent, proved successful.  The patient being compelled to  leave
for her home in Arkansas, I was induced to operate upon the vagina earlier
than otherwise would have been advisable.
     I removed the whole of  the redundant tissue, which was very loosely
connected with the bladder, uniting the edges in  the usual manner.   The
parts healed readily, and the patient left for home, apparently cured.
     Two years afterward I heard from her; she  was as badly off  as ever,
the uterus being down, and, upon the least exertion, escaping externally.
     The error in treatment in this case was two-fold: first, the body  of the
uterus should have been more reduced  before operating upon the vaginal
walls; and, secondly, the vaginal portion of the  cervix should have been
removed.   As it was, the uterus  was too heavy  for its sole  support, the
vagina, to retain it in its normal position.
                              Case 5.

         Prolapsus uteri and Vaginoe, complete, two months1 duration.

     Mrs. R, H----, aged twenty-seven; married one  year; three months
since gave birth to twins; five  days after her confinement got  up and went
down two flights of stairs; experienced no ill effects from it at  the time, but
noticed, some three weeks afterward, a tumor projecting between the  labia;
the lochial discharge ceased on the tenth day. 
83
     Complains of abdominal tenderness, and  constant desire to micturate;
pain in the back and loins;  continued nausea.
     Diagnosis.—Subinvolution of the uterus, due to nervous  shock;  pro-
lapsus,  due  to inability of the vagina to support the increased weight, the
prolapse of the vagina being a necessary accompaniment.
     Patient  was placed in bed, hips elevated,  the uterus  returned, and
retained with the cotton pledget, soaked with the following:
                         ft Glycerine, (Price's,)  §ij.
                           Aq. ext. opii, gr. xij.
About  half an ounce was  used in each application.  This treatment was
continued for one week,  the  cotton  having  been changed  every  twelve
hours.  At the expiration of this time the hot-wrater  applications were com-
menced, and continued for eleven weeks, when involution was found to be
progressing satisfactorily.   The glycerine-treatment was continued  during
the whole period during which the hot-water was applied.
     The vagina remaining lax, the galvanic current was used daily, and the
subcutaneous injection of strychnine  thrown into the vaginal walls.  This
last remedy acted like a charm; the vagina regained its tone ;  the absorb-
ents of the  uterus appeared stimulated  to  increased activity; and, at the
expiration of seventeen weeks, my patient was perfectly cured, without any
surgical operation.
     Had this woman continued without treatment for one  year, this result
could not have been obtained, as the tissues of the part would have degen-
erated beyond recovery; at least, such appeared probable.
                                Case 6.

                        Prolapsus uteri, complete.

     Mrs. S. R----, aged forty-four; mother of two  children, the  younger
seven years  of age.   Both her labors were extremely short, not lasting over
half an  hour;  but her convalescence, in each case, was  protracted.  Soon
after the birth of her first child, which occurred  when she was thirty-two
years of age, she began to complain of pains in the back and pelvis, and was
unable to stand for any length of time without great  inconvenience.  When
bathing herself she found the uterus very low down,  and, for  several years,
wore  a  ball-pessary, which she removed and  replaced herself.   After the 
84
birth of her last child all the symptoms became aggravated, and the uterus
finally protruded from the  vulva, dragging with it  the  vagina.   It was
returned by her attending physician, and a large ring-pessary introduced,
which had not been removed for four years.
     Her general condition was bad; body emaciated and anaemic;  pulse
small, and 118 per minute ;  appetite poor, and digestion imperfect;  bowels
loose.
     Examination.—The os was visible at the vaginal entrance, patulous and
ulcerated;  the cervix was enormously hypertrophied, soft and pulpy, and
of a dar>k  purple color.   The weight of the cervix had drawn into the ring
the upper part  of the vagina and  a portion  of the body of the uterus, in
which position they had become tightly wedged and partially strangulated;
the ring was buried in the tissues.
     Treatment.—The point of a pair of strong nippers was introduced under
the ring, which,  with some difficulty, was divided and removed.   Hot water
and glycerine were freely used until the congestion and tenderness of the
parts were relieved.  The cervix, remaining enlarged but soft, was reduced
by the application of potassa fusa.  Chalybeate tonics, stimulants, cod-liver
oil, and nourishing diet were  freely  given.  After five months' persistent
treatment the uterus was sufficiently reduced in size, and the patient's health
in a  condition that warranted an  attempt  at radical  cure.  Two sections
were removed from the vagina in the same manner as before reported; the
parts healed kindly, and the patient left, apparently cured.  I have not seen
or heard from this patient since she left the city, and cannot say, therefore,
whether or not the apparent cure was complete.

                               Case  7.

                Complete Prolapsus and Ruptured Perineum.

     Mrs. E. G----, aged thirty-five ; has been married twenty years ; first
menstruated at  eleven; mother of six children; first child was  born when
she was seventeen.  It was delivered with forceps, and the perineum became
lacerated down  to the anus.  No attempt has been made  at restoration.
Complains of the usual symptoms  accompanying  this lesion when compli-
cated with prolapsus.
    Examination.—Perineum w:as ruptured, and the anterior portion of the
sphincter ani fissured and ulcerated.  The uterus was external to the  labia, 
85
and the posterior wall of the vagina prolapsed.   The cervix uteri was hard,
the os patulous, and filled with bloody mucus.   The sound marked four and
one-fourth inches from os to fundus.
    The same preliminary treatment was adopted in  this case as in those
previously reported.  The uterus was retained in situ by pledgets of cotton
and glycerine, and, at the, expiration of seven weeks from the commencement
of treatment, the os was amputated.  When the stump healed, the sound
measured but two and one-half inches.   A section was next taken from the
posterior wall of  the vagina, measuring three  and one-half inches in its
broadest diameter.   The  parts healed kindly, the union, at the expiration
of three weeks, being firm.
    The perineum was restored in the usual  manner, and, seven  months
from the commencement of treatment, the patient left,  cured.
    This woman has since borne two children.  I attended her at the birth
of each.  There was no difficulty in the labors ; they progressed and termi-
nated normally.   Her convalescence occupied about the usual  term.   The
involution of the uterus was perfect.  The  perineum remained  intact, and
the vagina appeared fully competent to hold the uterus in place.

                               Case 8.

                           Partial Prolapsus.

    Mrs. A. I----, aged fifty-five; unmarried;  admitted to hospital Novem-
ber 17, 1870.  Complains of continual pain in the back, profuse leucorrhoea,
and chronic constipation; frequently allows herself to go for two, and even
three  weeks, without a movement  from the bowels.   The patient was of
phlegmatic temperament,  fat and indolent.
    Examination.----Os  uteri within an inch of the vulva; vagina large,
and tissues lax; the uterus not much larger than normal, and  apparently
healthy.
    It was evident that the displacement in this case was due to the enor-
mous accumulations of fecal matter which were constantly pressing the ute-
rus down, the vagina, from its relaxed condition, being unable to sustain it.
The indications were to overcome  the  habit of constipation, suppress the
hypersecretion from the mucous membrane of the vagina, and give tone to
its muscular tissue. 
86
    The first indication was met by the belladonna-treatment,  (reported
under  the  appropriate  head;)  the second  by  the  application of simple
glycerine, which perfectly depletes the  capillaries of the excess of serum;
and the last by the use of the galvanic battery.
    This  was  a  case  which,  under ordinary practice, would have  been
treated by  astringent injections and a pessary.   This treatment would have
increased  rather than  relieved the difficulty,  and, if  persisted  in, would
eventually have made the case incurable.
    By the course pursued the woman was perfectly cured, without an oper-
ation, and, should the bowels be kept in regular condition, and moderate exer-
cise taken,  she  will have no return of her trouble.
                                Case 9.

                    Prolapsus Uteri,  complete.—Cure.

     Sarah S----, aged forty-four; has been married twenty-three years;
mother of three children, the youngest seven years of age.  She states that
she experienced no pain of any moment during her labors, which lasted but
a few minutes ; has been in the habit of getting about* on the fourth or fifth
day.   For the last eight years she has suffered great pain in the  back and
loins ; has a discharge from the vagina, which excoriates the thighs and ren-
ders locomotion difficult.
     Examination.—Uterus much enlarged;  the cervix engorged and tender;
the lining membrane of cervix and body in a state of chronic inflammation.
When the  patient stood in an erect position the uterus was external to the
vulva.
     The indications were to reduce the inflammation.  With its subsidence
the uterus  would become reduced in  size, and the vagina have an oppor-
tunity of recovering its tone.
     The usual treatment was adopted—chromic acid being  used in the
place of carbolic acid—and, at the expiration of seven months, the womb
measured but three and one-fourth inches, and was in a healthy condition.
     The posterior wall of the vagina being still very lax and hypertrophied,
tho redundant tissue was excised.  The parts united by first intention  and
the patient left, eight months after the commencement of treatment, cured. 
87
                                Case 10.

              Prolapsus Uteri, complete, with Cystocele,—Cure.
     Mrs. P----, aged thirty-three;  admitted  to  Columbia Hospital, Janu-
ary 24, 1870; by occupation  is a feeder to a printing-press ;  has been in
the habit of standing  for hours  at  the  press when she desired, to empty
the bladder  or bowels, it happening  at  the  time  to be inconvenient for
her to leave.  One  week after the birth of  her last child (who  is three
years of age) she went to her work, and stood  for several hours.   Since
then she has suffered from back-ache, leucorrhoea, and general ill-health ;
within the last six months micturition has been difficult and painful; and
she has  been compelled  to wear a  napkin to keep the uterus within the
vagina.
     Examination showed complete prolapsus  uteri, cystocele, and  cervical
endometritis.  Rest  and topical applications in a few  months restored the
uterus to a healthy condition, and, on May 17, 1870, the operation for radi-
cal cure  of the cystocele was performed.
     May 30.—The  sutures were removed, union found to be perfect, and,
on June 12th, she was dismissed, perfectly well.
                               Case 11.
                        Prolapsus  Uteri, complete,
     Eliza B----, aged twenty-seven; mother of one child, two  years of
age.  The prolapsus began two  months after the  birth of child, and the
uterus gradually descended, until it now appeai-s between the  labia, drag-
ging  the anterior  wall  of the  vagina  with  it.  The uterus was little
enlarged, and its  enlargement evidently due to interference with the circu-
lation by its malposition.  Rest and the hot douche soon reduced it.
    January 24,  1871.—Operation for cure of the cystocele.
    February 18.—Sutures removed.
    March 4.—Discharged, cured.

                               Case 12.

       Prolapsus  Uteri, complete, with  Cystocele  and  Reetoeele.—Cure.

    Mrs. W----, aged forty-nine; mother of nine  children; has suffered
from prolapsus of the womb ever since the birth of her first child.   For the 
88
 last five years her womb and the entire vagina have been outside the body.
 Repeated efforts were made to return the tumor, but they were unsuccessful.
      The subacute endometritis which existed in this case was first reduced,
 then the cervix amputated, and, when the stump became firmly healed, a large
 section of the vagina anteriorly and posteriorly was removed.   The parts
 united by first intention, forming a strong column anteriorly and posteriorly
 for the support of the uterus.
      August 12.—The patient was dismissed, cured.
      I had occasion  to  see  this  patient, while suffering  from an attack of
 pneumonia, in June, 1872.   She had had no return of her trouble.  The
 uterus was well up in the pelvis, and the vagina close and in a healthy con-
 dition.

                               Case 13.

                    Partial Prolapsus, with Reetoeele.

      Mrs. N. N----, aged thirty-two ;  mother of one child, six years of age ;
 has had five miscarriages since the birth of her child.   Her habit, from "irl-
 hood, has been to allow one or two weeks to pass without a movement from
 the bowels, and the effort, on these occasions, was so severe that she would
 frequently faint from exhaustion.
     Examination,—The uterus was but little enlarged; its lining membrane
 inflamed and  very tender.   The rectum was distended into  an enormous
 pouch,  which pushed  the  labia apart  when the bowel was empty,  and
 when filled, formed a tumor as large as a child's head.   The prolapsus in
 this case was dependent upon the reetoeele.
     The  indication  was  to overcome   the habit of constipation before
 attempting any  operation.   This was done by the belladonna-treatment,
 and, as soon  as  the  endometritis became reduced, the usual operation was
 performed.
     The operation was successful, and  the patient. left, four  months after
 admission, cured.
                              Case 14.
        Complete Prolapsus  Uteri, with Eversion of the  Vagina, &c.
    Mrs. C. D----; aged forty-seven;  admitted August 23,1872; mother of
eleven children, the youngest of whom was  eight years of ao-e.   With  the 
89
birth of her fourth child the perineum was ruptured to the anus.  She stated
that she had  suffered but little inconvenience from the accident until after
the birth of her last child.   The reason of the absence of prolapsus at an
earlier period in this case may be explained in the language of the patient
herself: "I was in the family-way all the time; my last seven children were
born in nine years and two months."   Shortly after the birth of her  last
child, the  uterus  commenced  descending, and finally protruded from  the
vulva,  dragging with it the vagina, bladder, and anterior wall of the rectum.
For more than four years she has carried the mass in a bag, supported by
a belt passed around the waist; it had  not been returned  into the pelvic
cavity during this time.
     She  suffered from vesical irritation and  constipation, the irritation of
the bladder being due to the retention of urine.
     Examination,—A tumor as large as an adult head was hanging between
the thighs, of a dusky-red color, and covered with a tissue unlike skin or
mucous membrane.   It consisted of the entire vaginal walls, with the blad-
der, rectum, and uterus.  The cervix as well as the body was enormously
enlarged,  the os patulous, permitting two fingers to pass readily into  the
uterine cavity.
     A sound, introduced into the urethra, passed directly downward in front
of the  tumor, and the finger, passed into the rectum, showed  the anterior
wall to occupy the  same position posteriorly as the bladder  did anteriorly.
The indications were to return the mass,  if possible, and reduce the hyper-
trophy, before operating for radical cure.
     The  tumor was seized between both hands, and firm pressure made
continuously for about fifteen minutes for the purpose of unloading the dis-
tended blood-vessels, and, as far as possible, reducing the size of the uterus.
     After prolonged manipulation the reduction was accomplished, and a
large pledget of cotton soaked in glycerine passed into  the  vagina, for  the
double purpose of retaining the  uterus in situ, and depleting the vessels of
the cervix.
     October 8.—It having been found impossible to reduce the size or hard-
ness of the cervix, it was decided to amputate it, which was done as high up
as possible, a strong pair of blunt-pointed scissors being used for the pur-
       12 
90
pose; the haemorrhage was trifling.   The flaps were brought  together with
silver wire.
     The  cervix weighed twenty-two drachms.   Its appearance and exact
size is represented in Plate  7, Fig. 2.
     The  stump united partly by primary union and partly by granulation.
December 2d I performed the  operation of elytrorrhaphy,  removing  an
elliptical section six and  one-half inches long by four  inches wide from the
anterior and posterior walls; the dissection laid the rectum and bladder bare.
     Fig.  1, Plate 7, shows  the appearance of the parts after the cervix had
been amputated, the uterus having been drawn down to facilitate the dissec-
tion of the vaginal membrane.
    A margin of at  least half an inch of the vaginal  tissues was dissected
off around the parts that had been removed, and the  raw surface  everted.
The everted portions were then carefully approximated and retained in posi-
tion, the  lower part by clamps with  silver wire and shot, the upper edges
by the interrupted wire suture.   The clamps and wires were adjusted after
the uterus had been returned.
    The next and last operation was the restoration of the perineum, which
was performed in the usual manner, and attended by the same success which
has always accompanied these cases.
    It is seldom that  one patient has to submit to  so much surgery as this
poor woman,  and particularly in so short a time, but, from first to last, there
was no evidence of the slightest constitutional disturbance, her pulse remain-
ing below eighty per minute,  skin cool, and appetite good.  She slept well
and complained of no pain; not one grain of opium, or its equivalent, was
administered.
    January 10.—Patient dismissed cured.

    There have been fifty-seven cases of prolapsus uteri treated, about one-
third of which were complicated with reetoeele and cystocele; and the experi-
ence obtained in the treatment of these cases convinces me that, to effect a
radical cme when the cervix is hypertrophied—the enlargement consisting of
connective tissue, and irreducible by topical applications—it is necessary to 
Plate  VIII.
From a photograph of the patient three weeks after amputation of the cervix.
Fig. 2.
From a photograph of the cervix after amputation—exact size; weight twenty-two drachms.
9993150 
 
91
amputate  the whole of its vaginal  portion, otherwise the vagina will yield,
in time, to the disproportionate weight, and the uterus again escape exter-
nally.  In the  hands of competent men, the operation  is fraught with no
special danger.   The pain attending it is very slight; the parts always heal
kindly; and the function of the organ remains unimpaired.
     In but three of the fifty-seven cases have pessaries been used.  Two
were patients whose advanced age forbade any interference, both  of them
being nearly eighty years of  age;  the third refused to submit to any oper-
ation.  Hodge's pessaries were used in these cases.
     In the article under the  head of "Cancer"  I  refer specially to these
hypertrophied conditions of the cervix, accompanied, as they always are, by
endometritis, as being one of the  principal, if not the principal  cause of
malignant disease of the uterus.  This opinion, I believe, will be sustained
by the history of patients afflicted with this terrible malady.

                            Uterine Tumors.
     The  nomenclature of uterine  tumors has changed  with our increased
knowledge of their minute anatomical structure, and the simple term fibrous
is now little used; myo-fibroma and myoma have taken  its place, the latter
term carrying us back to the  "fleshy tubercles" of John Hunter.
     Of the pathology of these growths much has yet to be learned, and, for
this knowledge, we must look to such men as Rindfleisch, Strieker, Virchow,
and  Billroth.   The active practitioner has time for little more than to glean
from the labors of such men.   It is not much he can contribute beyond the
record of  facts, which may assist in substantiating  or disproving new theo-
ries,  or  occasionally,  by well-timed hints, give direction to  the  thoughts
and investigations of others.
     The  cases  I have the  honor to  report  under this  head  embrace
almost every variety of tumor that has been described by authors, situated
either in or on the uterus, and an abundant opportunity has been offered for
testing every form of  treatment that has been recommended for  removal,
either by  extirpation or absorption.
     Some of the cases reported were treated  outside the hospital, having
occurred  among the out-door patients, who could be attended at their own
homes, and are here  recorded as adding to the statistical value of special
forms of treatment. 
92
     Interstitial, Sub-peritoneal, and Sub-mucous Tumors  of the Uterus.

    Mrs. F----, aged forty-seven ; colored; admitted to hospital, Septem-
ber 17, 1867 ;  mother of five children, the youngest seven  years of age.
Since the birth of her last child she has suffered from pains in the back and
groins, costive bowels, frequent and  difficult micturition, and, during the
last year, from repeated haemorrhages, which have been exhaustive in char-
acter.
    Her general  appearance was that of a woman at full term, but unusu-
ally large.   She measured  fifty-nine inches around the abdomen  at the
umbilicus;  and,  to balance herself when standing or wralking, the head and
shoulders wTere thrown backward.  Her features were pinched, and the face
had an  anxious  expression;  pulse 120, soft and compressible;  respiration
hurried;  tongue slightly furred;  appetite poor;  and nights restless.
    Physical examination.—The abdomen was occupied by a large tumor,
extending from the pubes to within two inches of the sternum.   Its outline
was smooth and oval.  Careful palpation  gave evidence of fluid.  The iliac
fossa, on either  side,  wras  packed  with intensely hard and immovable
tumors about the size of  small  oranges.  The finger, passed into the vag-
ina, was arrested by hard masses, which felt like bony growths, completely
filling the space  between the pubes  and sacrum.  The whole  mass was
firmly wedged in the pelvis, no motion being imparted to the  lower growths
when the main tumor was lifted or moved from side to side.
    The diagnosis was myo-fibroma of the uterus; the prognosis  unfav-
orable, but  it was determined that  every effort  should  be  made to pro-
long the life of the patient with  the hope that if she lived through the cli-
macteric period  any further development of the tumors would cease, and
they might degenerate and become atrophied.
    The immediate indications were to arrest the haemorrhages, and reduce
the size of the principal growth by drawing off the fluid.
    September 21.—A large-sized trochar was passed-into the tumor immedi-
ately below the  umbilicus, and a little  over three pints of bloody serum
withdrawn.  No  constitutional  disturbance followed the operation, but it
gave marked relief to respiration.
    October 8.—Patient attacked with violent haemorrhage, which was con-
trolled by injecting the cavity of the uterus with  a strong solution of per-
chloride of iron. 
93
     December 17 and 28.—Returns of the haemorrhage, but in both instances
it was readily controlled by the same means.
     March 8, 9, and 10, 1868.—A slight bloody discharge, which required no
treatment.
     From the last date to the present time  there has been no  sanguineous
discharge from the uterine  passage;  the size of the patient has diminished,
measuring now but forty-seven inches around  the  umbilicus, and her gen-
eral health and strength are good.   She has been under continual observation
the whole time, having been engaged since her convalescence  as nurse in the
colored ward of the hospital.
     The treatment in this case has been to  meet the immediate indications,
and sustain the patient  until  the functional activity of the  uterine  system
ceased, hoping and expecting that, with its cessation, the  growth  of  the
tumors would be arrested.  The result has not  disappointed the expectation.

                   Sub-mucous Fibroma of the Uterus.

     M.  R----, aged thirty-seven;  colored; mother of four children;  has
always enjoyed good health.  She  seeks  advice  on account of haemor-
rhages from the uterus, occuring every two or three weeks,  which she has
been informed were due to "change of life."  She suffers no  pain  or any
inconvenience beyond the debility attendant upon the loss of blood.
     A digital examination showed the uterus to be three times as large as
natural, intensely hard,  but movable.   The os and cervix were  normal in
appearance; the mammae gave no evidence  of pregnancy, and the woman's
history rendered such a condition improbable.  Nevertheless, it was consid-
ered advisable to keep her under observation for some time before making
an exploration of the cavity of the uterus.
     June 7, 1867.—Ten days after the first examination, the  patient was
attacked by a very severe flooding,  which  was  arrested by plugging  the
vagina.  Upon the removal of the plug, two  days afterward, a sound was
carefully introduced, and the cavity of the uterus, from os to fundus, found
to measure six and one-fourth inches.   The withdrawal of the sound was
followed by a gush of blood, but further haemorrhage was arrested by inject-
ing the uterus with the tincture of perchloride of iron, diluted with an equal
part of water.   The patient was ordered thirty  drops of the tincture of iron
every four  hours, and rest in the recumbent  position. 
94
     June 28.—-A small-sized carbolized sponge-tent was  introduced into
the cervical canal,  and pushed beyond the internal os, which offered no
obstruction to its passage.  A suppository containing half a grain of mor-
phine was placed in the rectum.
     June 29.—The  tent was removed, and a larger one introduced.
     June 30.—Patient suffered some  little  pain during the  night; pulse 90,
and irritable.  The  tent was removed, and a  larger size introduced.   One
grain of opium ordered to be taken every four hours.
     July  1.—Tent removed, cervix well dilated.   The left hand was placed
upon the fundus,  and the uterus pressed well down, when the second  finger
of the right hand, having been passed into the cavity of the uterus, discov-
ered a sub-mucous tumor  about the  size  of an  orange  and very hard.   It
was determined to  cut through the mucous membrane and  sub-mucous
investing  capsule, and endeavor  to enucleate  the mass.   A round, pointed
scalpel was guarded up to within half an inch of the point, and carried up to
the fundus uteri.  The womb  having been kept steady by the downward
pressure of the hand, as the scalpel was withdrawn, it was made to divide
the capsule completely.   A steel sound was next passed between the capsule
and the tumor, and  made to separate  the tissues for some distance on  either
side of the  incision;  the  vagina was plugged,  and a full  dose of  opium
administered.
     July  2,  10 a. m.—Has  had considerable pain during the night, and is
now vomiting; pulse 120, hard  and irritable; tongue slightly  furred; no
tenderness over the abdomen on pressure, except in the region of the bladder,
which was full.  Urine drawn by catheter, and cracked ice ordered to allay
the irritability of the stomach ; tampon allowed to remain, and three  drops
of Fleming's tincture of aconite with twenty of laudanum to be given  every
four hours.
     July 2, 8 p. m.—Has passed a restless day;  pulse still high and irrita-
ble; temperature 101; she complains  of the vaginal plug causing her  much
chscomfort; plug  removed, and vagina washed out with  a solution of car-
bolic acid.  Twenty drops of Magendie's  solution of morphine to be  given
at 10 p. m.
    July 3, 11 a.  m.—Patient complains of no pain, but is  still restless and
pulse high; the uterus a little tender  on pressure.  From this date to July
10th, the womb was washed out daily with a tepid solution ©f carbolic acid, 
95
(five grains to the ounce,) and a suppository containing half a grain of mor-
phine introduced into the rectum at night.
    July 11.—Patient was  placed  upon her left side in the ordinary posi-
tion for uterine examination, the speculum being held firmly by an assistant
The os was as fully dilated as on the 1st instant, and the exposed portion of
the tumor, which was readily felt with the finger, seized with a volsella, and
drawn forcibly downward; an ordinary male sound was passed in, and much
the larger portion of the tumor separated from its attachments.
    The patient was not aetherized, and the operation gave her no acute
pain;  little blood was lost,
    July 12,  9 a. m.—Pulse  100;  patient very restless  and uneasy; says
she has continual bearing-down pains in her back and  along the thighs;
there  has been no haemorrhage during the night.  Bowels to be  moved by
an enema, and a morphine suppository to be introduced at noon.
    10 p. m.—Has had a very severe chill; eyes unnaturally bright; head
aches; pulse 130; respiration  hurried;  temperature 1021.   Irrigated uterus
with a warm solution of carbolic acid for twenty minutes,  and ordered one
grain  of  quinine and half a grain of the  watery extract  of opium to be
given every two hours.
    July 13,  8 a. m.—Pulse 127; respiration still hurried; temperature 103;
has passed no  water; mind wandering; great restlessness;  water drawn by
catheter.   The uterus again irrigated,  and,  after the water had drained off,
applied pure  carbolic  acid  to  every portion of the uterine tissue that had
been  separated from the tumor; the  application was made by  a flexible
silver sound charged with raw cotton.   The administration  of the quinine
and opium to be continued, with the addition of a drachm  of brandy every
hour,  and beef-tea ad libitum.
    4 p. m.—But little  improvement, except  in temperature, which was
reduced to 102£; treatment to be continued.
    10 p. m.—Temperature 102; pulse 123; patient less restless, but com-
plains of more pain.
    July 14,  9 a. m.—Has slept for four hours; she appears  much brighter
and less  restless;  pulse  114; temperature 100J; uterus  again irrigated;
treatment continued.
    10 p. m.—Patient has much improved; pulse 104; temperature 100.
    July 15,  11 a,  m.—Improvement continuing; quinine* and opium to be
given every four hours. 
96
     The improvement continuing  to the 20th, all  constitutional treatment
was then discontinued.
     August 2.—It was decided  to separate what  attachment still remained
between the tumor and the uterus.  The patient having been placed in posi-
tion, the tumor was seized as before, but, upon passing the sound, it was found
that the enucleation  had been perfected, and the  tumor was free in  the
uterine cavity.    A firm hold was taken of the  mass by a strong volsella,
and steady traction made.  Little resistance was  offered by the uterus, and,
in a short time, the tumor was withdrawn.  The haemorrhage was slight, and
no unpleasant symptoms followed.   As a prophylactic, one grain of quinine
and one of opium were given every four hours, for  two days, when further
attendance was discontinued.
     The tumor was examined at the Army Medical Museum, and found to
consist entirely of connective tissue.  Plate  8 represents its microscopical
structure.
                       Myo-Fibroma of the Uterus.
     II. L----; aged thirty-eight; colored; has never been married; general
health always good until within the last year, during which she has suffered
from repeated haemorrhages, continuing, with more or less severity, for three
and four days.  These repeated losses of blood have somewhat reduced her
strength, although she is still a powerful woman, of large frame, and very
muscular.
     She now complains of a bearing-down pain,  and aching about the loins
and along the thighs, profuse leucorrhoea, and irritability of the bladder.
     Examination.—Conjoined manipulation revealed the uterus about three
times its natural size, greatly retro verted;  the  sound passed into the cavity
of the organ  readily, measuring nearly six inches;  blood followed its with-
drawal.
    A small-sized sponge-tent was introduced, the patient placed in bed, and
a morphine suppository passed into the rectum.
    March 15.—Patient has suffered no pain since  the introduction of the
tent.  This was removed, replaced by  a  larger  size, and  the  suppository
repeated.
    March 16.—She has had a severe chill during the night, and complains
of headache  ancf sharp pains  in the  abdomen;  the removal  of  the tent 
Plate IX.
Microscopical appearance of sub-mucous myo-fibroma of the uterus removed from Mrs. M. R. 
 
97
  caused much pain.  A full dose of morphine was administered by the mouth,
  and an anodyne suppository placed in the  rectum; the abdomen was cov-
  ered with a hot hop-poultice.
      March 17, 10 a. m.—Has had another chill, which lasted longer than
  the first; pulse 128;  respiration hurried; tongue covered with a heavy coat-
  ing; knees drawn up;  abdomen tender; temperature 102.   It became evi-
  dent that the woman suffered from metro-peritonitis, and Magendie's solution
.  of morphine was  ordered to be  given every hour  until pain ceased, unless
  its administration should be  contra-indicated by the condition of the respi-
  ration, which was not to be allowed to fall below ten per minute.   Brandy
  and beef-essence were ordered to be given at regular intervals, and the hop-
  poultice continued.
      8 p. m.—Patient much easier, being completely under the influence of
  the narcotic; pulse 130; respiration 13; temperature 103£.
     March 18, 8 a. m.—No improvement in her general condition; her res-
 pirations had been reduced to  twelve per minute, but the pulse had increased
 to  140, and the temperature to 104;  abdomen  tympanitic;  no complaint of
 pain.  The morphine was ordered to be reduced, and one grain of quinine
 and a teaspoonful of brandy to be given every hour.
     March 19, 9 J a. m.—Pulse 140; temperature a  little over 104;  mind
 wandering; patient rapidly failing.
     11 p. m.—No improvement.  She died at  2 a. m. on the 20th.
     Sectio cadaveris thirty-eight  hours  after death,—Body  not  emaciated;
rigor mortis not well marked; head not examined.   Thorax—adhesion of left
pleura, evidently of long standing; lungs generally healthy, but some solid-
ification of the  lower lobe  of  left lung.   Heart healthy,  as also abdomen
and liver; left kidney nearly twice the normal size, and intensely congested.
     There were about seven ounces  of sero-purulent fluid in the peritoneal
cavity.   The uterus was adherent posteriorly, and,  upon its  removal,
found to weigh  eight ounces and five  drachms.  A tumor, myo-fibroma, was
imbedded in its posterior wall.  In making  the section through the uterus
the knife  was followed by greenish-yellow, stinking pus;  the tissue was
unusually soft.
     Commentary.—The metro-peritonitis which destroyed this patient was
undoubtedly caused by the sponge-tents.  It was the first  instance which
had occurred in my own practice where any serious  consequences followed 
98
 their use, but unfortunately not the last, as more than  one of the following
 cases will show.  The intense inflammation excited in this instance was not
 occasioned by the admission of air into the  uterine cavity, for every care
 was taken to prevent that accident.  How much of the unfortunate termina-
 tion may have been due to the pre-existing disease of the kidney cannot be
 estimated.
     But  however much  the  general  condition of the patient may have
 assisted in bringing about the fatal issue, it cannot be denied that the sponge-
 tents proved to be the exciting cause.  They are indispensable  in the treat-
 ment of uterine diseases, but  are by no means the simple  agents they are
 generally supposed to be.  Like other potent remedies, they should be used
 with great care and circumspection.
          Myo-Fibroma of the Uterus, complicated with Pregnancy.
     August 17, 1869.—M. S---—; aged thirty-two; colored; mother  of two
 children, the younger of whom was seven years of age.  About one year after
 the birth of her last child she noticed a hard tumor on the left side  of the abdo-
 men, which increased in size from year to year, while others had made their
 appearance  on the right  side.   She had suffered little inconvenience from
 them; her menstrual periods had been  regular until the last three months,
 and the discharge normal; she had experienced no  haemorrhages.
     She sought advice principally on account of the stoppage of her monthly
 periods, which was attributed to a cold taken about three months previously
     Examination showed a  mass of sub-peritoneal  tumors surroundino-
 the uterus, which appeared imbedded in them.  It  was difficult  to estimate
 the size of this organ, but as near as could be  ascertained it was as large as
 at the sixth month of pregnancy, and very hard.   It was well advanced in
 the cavity of the  abdomen,  the finger with difficulty reaching the os.
     The nipples gave  unmistakable signs  of  pregnancy, and, from the his-
 tory of the case as given by herself, it was decided that she had progressed
 to a period between the third and fourth months of gestation.
     The question arose as to what was best to do in the premises.  If her
pregnancy should be allowed  to continue, the tumors would increase with
the functional activity of the uterus, and it was highly improbable indeed
impossible, that she could go her full time and give birth to a livino- child 
99
After mature deliberation it was decided to puncture the membrane and
induce premature delivery.
     Instead of puncturing, a piece of catgut about nine inches long, and as
thick as fine pack-thread,  was moistened and passed into the uterus, to the
lower portion of which was attached a piece of strong thread which was left
hanging  out of the vagina, to secure its  easy removal in the event of pro-
voking too violent contractions.
     Strong labor-pains commenced in about eighteen hours,  and continued
over two hours, when she was delivered of a foetus  with  the membranes
entire.
     Recovery was  rapid,  no unpleasant symptom occuring during her con-
valescence.
     After complete recovery she was placed upon full doses of the iodide
of potassium, pushed to tolerance, and  continued  for six  months  without
appreciable diminution in the size of the growths.   Bromide of potassium
and iodine  were faithfully tried with the same  effect.  The increase of the
tumors has continued slowly but surely.
     Operative interference in this case was out of the question;" nothing
short of  the removal of  the. uterus would have been  of any use, and the
symptoms  up to this time have not been sufficiently urgent to justify so
formidable  an operation.
     The probabilities are, that the tumors will  steadily increase until the
climacteric  period, when  it is hoped that further growth will be arrested,
and  the}' will undergo  calcareous degeneration  or gradual atrophy, as in
the first  case  reported under this head.   If,  on the contrary, they should
become sufficiently large to jeopardize the patient's life, by mechanical inter-
ference with the abdominal and thoracic organs, the whole mass will be re-
moved unhesitatingly as a dernier resort.

Fibrous Tumor attached to  the Fundus of the Uterus  mistaken for  Diversion.

     MarthaM----; aged fifty-seven; admitted to Columbia Hospital June 18,
1871; mother of eleven children; was sent to the hospital by a physician in the
country, who diagnosed the case as one of irreducible inversion of the uterus.
The patient stated that, at the birth of her last child, which was seven years
of age, she suffered from a severe flooding that nearly cost her her life, fob 
100
lowed by an  almost  continuous haemorrhage for several  days, eventually
controlled with much difficulty.   From that time she noticed a tumor occu-
pying the entrance to the vagina, which, when pushed up, came down again
immediately,  and occasionally, when in  a stooping position, would project
externally, and remain in that  state until returned; several pessaries  had
been introduced, but she was unable to retain them on account of the severe
pain they occasioned.   She suffered from pain in the loins, difficult micturi-
tion, and costive bowels.   The vulva and inside of thighs were  constantly
bathed with an ichorous discharge, which chafed the parts and caused much
discomfort.
     A careful examination showed the vagina filled by a  moderately solid
body, pear-shaped, and covered by a mucous membrane, which, upon exam-
ination under the microscope, proved to be decidual in character.
     The patient having been placed in position, the vagina was exposed by
Sims's speculum, the tumor drawn downward, and an attempt unsuccessfully
made to introduce a sound into the uterus.  A digital examination was made
per  rectum,  but the  uterus  could not  be discovered.  The  finger while
in the rectum came in contact with the point of  the sound in the anterior
cul-de-sac.  The sound, passed into the bladder  and  pressed  backward,
came in contact with the finger in the rectum, and the spot where the uterus
should have been was marked by a depression answering to the  abdominal
ring.
     The differential diagnosis between fibroid tumor and  inversion of the
uterus seemed perfect—manipulation failed to  reveal any uterine body in
situ.  The probe was arrested at the neck.
     From the statement of the patient the tumor immediately followed par-
turition, and was accompanied by severe and protracted haemorrhage.  Every
symptom of inversion was present; there seemed nothing wanted to render
the diagnosis  clear, and the opinion of the medical gentleman who sent her
to the hospital was confirmed.
     The patient having been fully aetherized, an attempt was made to reduce
the inversion, but it was found impossible, and it became a question .which of
the two alternatives to adopt, to leave it unreduced, or to remove  it with the
ecraseur.  As she was still the subject of frequent exhaustive haemorrhages,
and  experienced great personal  inconvenience from the  presence of the 
 
Plate  X.
Fig.  i.
Fibrous or connective-tissue tumor removed from the fundus  of the
          uterus.  Exact size.  Photographed on wood.
Fig.  2.
Curved ecraseur, used for the removal of uterine tumors. 
101
tumor, and the offensive  and acrid  discharge to which it gave rise, it was
decided, with the consent of the patient, to remove it.
     The danger attending the operation was full}' explained to the woman,
and  the choice given  her  of palliative treatment  or the  removal.   She
decided to take the risk of the operation for radical cure.
     Patient being fully  aetherized,  two stout, curved needles were passed
through the top of the pedicle to prevent the. surrounding tissue being drawn
into  the chain of the Ecraseur.   The chain was then carefully adjusted and
tightened;  it was allowed  to  cut but very slowly,  fifteen  minutes being
occupied in cutting  through the mass.   Upon its removal, to the astonish-
ment of all, it was found to be a fibrous tumor  that had been attached to
the fundus of the uterus.
     The uterus was so  atrophied  that there was but a  mere trace  of it,
measuring  less than one inch from  os externum to fundus; its walls  were
extremely thin, and rectal and recto-vesical manipulation failed to discover
its existence.   Figure 1,  plate 10, shows the appearance of the tumor subse-
quent to removal, being the exact size after six hours' immersion  in alcohol.
     The error in diagnosis in this  case could not be avoided;  every care
was  taken to prevent it.  The mistake was evidently  due to  the atrophied
condition of the  uterus, which was  caused by the supply of blood having
been mainly consumed by  the tumor.  This tumor undoubtedly was ex-
truded with the child,  and  its  presence, preventing complete  contraction of
the uterine walls, was the cause of the flooding.
     Only a few  drops of blood were  lost  in the operation.  The patient
recovered rapidly, and left the hospital in about two weeks.

              Large Sub-muco Fibrous Tumor of the  Uterus.

     Mrs. A. I----; aged forty-two; mother of four children,  the youngest
being seventeen years  of age.  For eighteen years  she  has suffered from
severe headache,  constipation of the bowels," and all the  general symptoms
accompanying chronic  dyspepsia; her menstrual  periods have been regular,
but more or less painful;  for two years past she  has suffered  from monor-
rhagia, and, between the menstrual periods,  from profuse  leucorrhoea, the
discharge being always discolored with blood.  The general appearance of
the patient  was that of  a  person well nourished,  but with an  expression of
countenance indicative of pain and  anxiety. 
102
    Examination made July 18, 1870.—Abdomen much enlarged;  the womb
hard and about the size of a gravid uterus at full  term;  cervix obliterated;
the os fully dilated and occupied by a smooth,  round tumor, feeling like a
foetal head.  The sound passed in front of the tumor, but posteriorly there
was no sulcus;  a whalebone probe, armed with a button, was passed in to
the extent of eleven inches before reaching the fundus.   A thorough exam-
ination satisfied me that the tumor was sub-mucous,  and composed mainly
of connective tissue, and entirely  separable from the body  of the uterus.
I recommended that the mucous and sub-mucous tissues covering the tumor
should be divided and separated from it by a strong steel sound, trusting to
the contractions of the uterus for its complete enucleation.
    The patient declined submitting to any surgical interference, and went
to New York,  where she  consulted Dr. Gr. Thomas, who  confirmed  my
diagnosis, and recommended the treatment which I had proposed.
    Upon her return to the city she again came  under my care, but con-
cluded not to submit to any operation, and the only  treatment pursued  has
been to meet the indications, arresting haemorrhage, and soothing pain when
severe.   The tumor has grown but little during  the last year, and but little
haemorrhage has occurred.  In the absence of an operation for removal,  the
only hope in this case is,  that with the change of life all further growth will
cease, and the  tumor undergo some retrograde metamorphosis by which it
will become atrophied.

Fibroid or Connective  Tissues-Tumor attached to the Fundus of the Uterus—
                          Death from Tetanus.

    M. S----; aged twenty-three; white; admitted January 13, 1868; mar-
ried when nineteen years of age; has given birth to two  children, the youngest
of whom is eleven years of age.  Her general health has been bad, and, living
in a malarious region, she has suffered, in spring and fall, from protracted at-
tacks of intermittent fever.  For the two preceding years her menstrual periods
have been irregular, sometimes returning but once in three or four months-
and there has been a constant sanguineo-purulent discharge from the vagina.
She complains of pain in the back and loins;  the slightest exertion produces
vertigo and nausea.   Her general appearance is unhealthy;  skin  of a dirty 
103
waxen hue; lips almost colorless, and face bloated;  pulse feeble and rapid;
hands cold; tongue and mucous membrane of mouth pale.
     Examination.—The vagina was relaxed, uterus low down, and os patu-
lous, through which the sound passed readily, to the extent of four and three-
quarter inches.  A small polypus could be  seen about half an inch within
the cervical canal.  The  cause of  the  enlargement being obscure, it was
decided to dilate the canal.   A medium-sized sponge-tent was  introduced
without difficulty, and a suppository, containing half a grain  of morphine,
ordered to be placed in  the rectum  if the patient should experience much
pain.
     January 14, 11 a. m.—She suffered severely during the night; the sup-
pository was used as  directed, and forty drops of  Magendie's solution  of
morphia administered,  but with little effect.  The tent was removed  with
some difficulty, having been held firmly by the internal  os,  beyond and
below which the sponge had fully expanded.  The part, however, embraced
by that portion of the  cervical canal was  scarcely larger than before the
introduction of the tent.
     7 p. m.—Patient very restless;  complained of pain in the back, extend-
ing to the neck; headache and chilliness.   Hot bottles were placed to the
feet, and a full dose of  opium administered, with orders to repeat  it during
the night if needed.
     January 15, 6 a, m.—Complained of oppression about the epigastrium
and stiffness in the back of the neck; had not slept since the tent was intro-
duced.   Thirty drops of Magendie's solution to be administered hypoderm-
ically.
     11a. m.—The morphine had produced no effect.  There was  difficulty
in opening the mouth and in swallowing;  respiration labored;  pulse  100;
temperature 104.   Ice was ordered to  be applied to  the spine, and the  dose
of morphine to be repeated.
     6 p. m.—Muscles  of  the jaws  firmly  contracted;  breathing  labored;
face  anxious.  She experienced difficulty in turning upon her side, requiring
the assistance of the  nurse.   Extract of cannabis indica (Squibbs) in half-
grain doses ordered to be given every two hours, and the ice application to
be continued.
     11 p. m.—Has had two  spasms  since  nine o'clock, the last  one very
severe;  treatment to  be continued. 
104
     January 16, 9 a. m.—Patient much worse; the spasms  had been very
frequent during the night, and  of increased violence.  Opisthotonos well
marked; pulse  118; thermometer 105^.
     10 p. m.—The spasms had been unremitting; all the other symptoms
aggravated; no change in the treatment advised;  prognosis,  grave.
     January 17, 11 a. m.—Patient failing rapidly;  with difficulty kept in
bed  during spasm; the opisthotonos very extreme; deglutition impossible.
She  died at 3 p. m.
     Sectio cadaveris forty-three hours after death.—Thoracic organs healthy.
Abdomen:  spleen  large, soft, and of  a pale bronze color; liver  pale, but
otherwise healthy.  Uterus  three times its normal size, but no  evidences
of inflammation in the organ, or any  of the tissues connected with it.  Its
cavity was  occupied by a tumor attached to the fundus,  which readily
shelled  out when the investing capsule was divided.   The internal os was
surrounded by  fibres as unyielding as cartilage.
     Commentary.—The traumatic tetanus from which this woman died was
caused by the irritation produced in the effort to dilate the  cervical canal.
Had the fibres of the internal os  been divided before the introduction of the
tent, the probabilities would have been in favor of her recovery without
tetanic  symptoms.
     The accident in this  case,  as in others, which  have unfortunately
occurred in my practice as well as in that of my professional  brethren,
has induced me, in all cases where the employment of a sea-tangle or sponge-
tent is indicated, first to divide the fibres around the internal os.   Since the
adoption of this plan I  have had no trouble following their use.
     The treatment pursued  in  this  case  after the alarming symptoms of
tetanus supervened was regarded as the most eligible  under the circum-  *
stances, combining as it did the  two  remedies from which the best results
have been usually obtained.
     Professor D. W. Yandell, of Louisville, published in the  Practitioner an
analysis of a report on tetanus, by Dr.  R. 0. Cowling, showing  the relative
merit of different  methods of treatment.  The following is  a summarv of
that  analysis, which embraces  acute and chronic  cases.  The value  of the
percentage must be-considered in relation to the number of cases reported as
having been submitted  to the different methods of treatment.  Acute is the 
105
term applied when the symptoms occurred within nine days after the injury,
and chronic when they were not developed until after that time:
     "Calabar-bean  was given  in thirty-nine  cases  with thirty-nine per
cent, of recoveries.   Of these reported cases, but one was of acute tetanus;
five  others were  cases which recovered before the expiration  of fourteen
days.  Per contra, there were ten deaths from chronic tetanus.
     "Indian hemp used in twenty-five  cases, with sixty-four per cent,  of
recoveries, of which three  cases were acute, and six recovered before the
symptoms lasted  fourteen days.
     "Chloroform relieved  seventy per  cent, of thirty-five  cases, nine  of
which were acute, and eight recovered before fourteen days.  Three chronic
cases died, and two after the symptoms lasted fourteen days.
     ".ZEther: sixty per cent, of fifteen cases recovered; five acute;  seven
inside of fourteen days; one chronic case died.
     "Opium: fifty-seven per cent,   of  one hundred and sixty-five  cases
recovered; twenty-two acute; twenty-nine before the fourteenth day. Twen-
ty-six chronic cases were lost, and four after the disease had continued four-
teen days.
     "Tobacco relieved fifty per cent,  of forty-one cases;  six acute; six
before fourteen days of the  disease.   Four chronic  cases died, and one after
fourteen days.
     "Quinine:  seventy-three  per cent, of fifteen  cases recovered;  one
acute; three before fourteen days.  Three chronic  cases ended  fatally, and
one after fourteen days' duration.
     "Aconite: eight per cent,  of fourteen  cases  recovered, none acute:
none recovered before fourteen days.  Death in one chronic case.
     "Stimulants: eighty per cent,  of  thirty-three  cases recovered; four
acute; six within fourteen days.   Six chronic cases died, and three after
fourteen days.
     "Mercury:  fifty-seven  per cent,  of seventy-five  cases got well, twelve
before fourteen  days.   Seventeen chronic  cases were lost,  and  two after
fourteen days.
     "Bleeding: fifty-five per cent, of  fifty-eight cases recovered; nine acute;
ten before the fourteenth day.  Seven chronic cases were lost, and two alter
fourteen days.
      11 
106
      "Cold  affusion:  seventy-three per  cent, of  eleven  cases  recovered;
 three acute; three before fourteen days.  Two chronic cases died.
      "Ice-bags: seventy-seven per cent, of nine cases recovered;  one acute;
 two in less than fourteen days.
      "Amputation: sixty per cent, of seventeen cases recovered; four acute;
 four in less than fifteen days.   Three chronic cases died, and one after four-
 teen days.
      "Division of nerve relieved seventy-five per cent, of three cases; one
 acute;  one before the fourteenth day.   One chronic case died.
      "Purgatives: sixty-six per cent, of seventy-four cases recovered; thir-
 teen acute; twelve before fourteen days.  Ten chronic cases died, and three
 after fourteen days.
      "Turpentine  relieved seventy  per cent, of sixteen cases;  six  acute;
 four before fourteen days.  Five chronic cases died, and two  after fourteen
 days."
      In commenting upon this analysis, Professor Hammond says:
      "Among the conclusions  arrived  at by Dr. Yandell from these data
 are:  That recoveries from traumatic tetanus have been usually in  cases in
 which the disease occurs subsequent to  nine days after  the injury; that
 when the symptoms last fourteen days, recovery is the rule, and death the
 exception, apparently  independent of the treatment; that chloroform, up to
 this time, has yielded the largest percentage of cases  in acute tetanus; that
 the true test of a remedy for tetanus is its influence  on the  history of the
 disease.   Does it cure cases in which the  disease has set in previous to the
 ninth day?  Does it fail in cases  whose duration exceeds fourteen  days?
 and that no agent tried  by these tests  has  yet established its claims as a
 true remedy for tetanus."
                        Intra-murcd Myo Fibroma.

     Mrs. C. R----; aged forty-two; married; has never borne children.  She
 menstruated at eleven  years of age, and became a wife at thirteen.   From
 her history, as given by  herself, she was fully developed at the time of her
 marriage.   She enjoyed good  health until her thirty-fifth year, when her
 menstrual periods became irregular, returning every ten days  or two weeks
and attended by severe menorrhagia.  About one year after this she noticed
a tumor the size of an orange in the lower part of her abdomen, not painful, 
107
but nevertheless  giving rise to  much anxiety.   From  that time until my
advice was solicited, the tumor had steadily increased in size.
    The general  appearance of the patient was anaemic  and emaciated, her
abdomen as large as a woman's at the  full term of pregnancy;  the veins
of the left leg- were  varicose.
    Examination.—The cavity of the pelvis was occupied by a large tumor,
regular in outline, in size and shape like the gravid uterus; it extended from
the pubes to within two inches of the ensiform cartilage,  and laterally to the
same distance from the rim of the pelvis.
    Palpation gave evidence of fluid in the most prominent  part of the
tumor.
    Digital examination of vagina and rectum,—The  roof of the vagina was
hard and unyielding;  the  cervix small and pushed  over to the right side;
the rectum less  obstructed  than usual under such conditions.  Simpson's
sound passed into the uterus readily for about four inches, its direction being
backward  with a strong curve.   It was withdrawn, and one  of Thomas's
sounds introduced,  (a thin piece  of whalebone with  a rounded top the size
of a buckshot,) which passed up to  the  extent of ten and one-half inches.
The diagnosis was  myo-fibroma, developed interstitially in the fundus and
anterior wall of the uterus, a portion having undergone cystic degeneration.
    The trochar  was introduced into the most prominent part of the tumor,
and twenty-one ounces of bloody serum withdrawn.
    It was decided to  keep the patient under observation and meet indica-
tions as they might occur.   As the menses returned every two weeks, each
succeeding period was anticipated by an injection of the diluted tincture of
the perchloride of iron  into the uterine cavity.  Bromide  of potassium, to the
point  of toleration, combined with the syrup  of 'the bromide  of  iron, was
given for twelve months with the most marked benefit.
    The tumor did not increase; the patient improved  in strength, gained
flesh, and was cheerful; and her menstrual periods diminished in frequency
and duration until March, 1872,  when they ceased altogether.
    Commentary.—Myoma or myo-fibroma of the  uterus, developed inter-
stitially, rarely warrants  surgical interference.   Cases  may possibly occur
which justify such a procedure, but  the statistics are most decidedly in favor
of non-interference beyond mere palliative  measures—such  as  arrest  of 
108
haemorrhage by the local application of astringents, tapping where practica-
ble to relieve pressure, and keeping the patient as nearly at par as possible.
     The bromide of potassium was given in this  case as a sedative (which I
believe  it to be) to the uterine system, and not with the hope that it would
cause absorption of any portion of the already organized matter.  Its effect
in conjunction with the astringent injections fully realized the expectation.
                          Sub-mucous Fibroma.
     Mrs. I. R----;  admitted as out-door patient February 7, 1871; colored;
aged thirty-six; married;  has had seven children.  She enjoyed good health
until two years ago, -since which time she has suffered from a sanguineo-
purulent discharge from the vagina, pain in the back and loins, and nausea.
     Examination per vagi nam.—Os patulous and eroded; the cervical canal
filled with  thick, chocolate-colored, offensive discharge.  The sound passed
in five and three-quarter inches, and, although  used with great  care, gave
considerable pain.    The finger introduced into the posterior cul-de-sac came
in contact  with a firm, well-defined tumor, apparently occupying  the poste-
rior wall of the uterus, and imbedded in the  lower part.  Conjoined mani-
pulation revealed the correctness of the digital examination.
     A medium-sized sponge-tent was readily introduced past the internal os,
and allowed to remain twenty-four hours.
     February 8.—Os moderately well dilated; tent removed, and  one  of
larger size introduced, and a morphine suppository placed in the  rectum as
a precautionary measure.
     February 9.—Tent removed;  its withdrawal followed by considerable
quantity of offensive matter; no constitutional disturbance whatever.  The
finger passed readily into fhe uterus and came in contact with a well-defined
sub-mucous tumor in the  posterior wall.   A free incision was made  throuo-h
the mucous membrane and intervening tissue down to the tumor;  but, after
repeated efforts, it was found impossible  to  separate the growth from  the
layers of tissue investing it.  It was undoubtedly a myo-fibroma, the fibres
of which were intimately interlaced with  those of the  proper tissue of the
uterus, and an attempt  at enucleation, as in Case No. 2, it was  presumed
would result disastrously.  It was determined to increase the depth of the
incision, and introduce into the wound a piece of raw cotton soaked in pure
carbolic acid.   The incision was increased  to one inch in  depth,  and  the 
109
opening filled with carbolized cotton.  A suppository containing one grain
of morphine was introduced into the rectum.
     February 10.—Patient feels well; slept all night; has a little soreness
over the pubes.
     February 11.—Pulse 100; severe pain in the back and loins;  nausea
and headache.  One grain of the watery extract of opium to be given every
four hours.
     February 12.—Pulse 120; respiration hurried; she complains of severe
pain in the abdomen and back; temperature 98; opium to be  continued.
     February 13.—Pulse 114;  respiration easy;  less pain; temperature 98.
The speculum was introduced, and the os found  almost as open as on the
9th instant; a copious sanguino-purulent discharge was flowing from it.
     The piece of cotton was removed easily, and the cavity of  the uterus
syringed out with tepid  water and  carbolic acid.
     From this time onward the tumor slowly melted away.   The discharge
was  excessive and very offensive; the uterine injections were continued,
daily,  and the patient's strength sustained  by nourishing  diet,  bark, and
iron.
     On the 8th of April she left the city for California.  The tumor at that
time had become reduced to less than one-third the size it was when operated
upon,  and the  probabilities  are that it eventually  disappeared, but,  not
having heard from her  since  she left, nothing positive can be said about it.

                  Large Intra-miiral Tumor of Uterus.

     Mrs.  A. S----; admitted June  7, 1871; aged  forty-nine; German;
married; mother of four children, the youngest eight years of age.  Her
recovery from each labor was rapid and perfect; her general health  has
always been  good.   She ceased to menstruate at forty-five years of age,
since which time she has noticed a tumor in her abdomen, which has in-
creased rapidly within the  last two years,  and is now as large as the gravid
uterus  at  the sixth month.   She has suffered from  no haemorrhages, but
complains of some pain in the back,  and weariness upon the slightest exer-
tion.  Her bowels are regular, and all the functions appear to be  performed
normally.
     Examination per vagi nam.—Os  patulous;  sound measures nine and one- 
110
quarter inches.   It could be readily felt tluough the abdominal walls when
pressed forward, showing the mass of the tumor to be in the posterior wall.
     Surgical interference in this case appeared unwarrantable, but it was a
fair case for a trial of the effect of medication.  She was  ordered the one-
sixteenth of a grain  of the bichloride of mercury, and five  grains  of the
iodide  of potassium, to be  taken  three times daily; the abdomen to be sup-
ported by an India-rubber belt.
     No disturbance of digestion resulted from the use of the iodide, and it
was  continued uninterruptedly for more than six months, but with no appar-
ent diminution  in  the size  of the growth.  It was then  discontinued, and
forty grains of the bromide  of potassium given three times daily.   This was
borne well, and continued as long as she remained in the  city, or until the
following May, when she left  for Grermany.
     At the time of leaving she appeared in perfect health, the tumor being
about the same size as when she first  came under my care.
     Commentary.—The  prognosis in  this case was not as favorable as it
would have been had the woman been  younger, and the tumor made its
appearance before the  climacteric period.   It was the first case that had
come under  my observation  where a tumor of such large size had been
developed after the cessation  of the functional activity of the uterine sys-
tem.   I doubt very much if  the  medication exerted  any special influence
upon its growth, and am disposed to  believe that in  the  reported cases of
the disappearance of fibroid tumors of the uterus under the use of mercury,
iodine, or bromine, there has  been an error of diagnosis, and that the en-
largement was not due to a new growth, but to a hypertrophy of the mus-
cular tissue of the uterus, which is undoubtedly amenable to medication.
                    Large, Soft Polypus of  the Uterus.

     Mrs. C. McC----; admitted  March 14, 1870; aged forty; mother of
five  children, the youngest fifteen  years of age.  She  complained of pain in
the back, and profuse leucorrhoea; had  suffered within the last year from
several severe haemorrhages, which lasted from four to five days.
     Examination showed the  uterus to be as large as a full-sized foetal head;
manipulation gave no pain.   The  sound measured only three and one-half
inches, and did not come in contact with the fundus uteri, but with a yield-
ing body, which was diagnosed as a soft polypus. 
Ill
    The os being small, a sea-tangle-tent was first  introduced.  This was
removed in twenty-four  hours, and replaced by a  medium-sized sponge-
tent, which was allowed to remain the same  length  of  time.  Six hours
before its removal considerable pain was experienced by the patient, which
she described as being similar to labor-pains.   Upon the removal  of the
tent the os was found well dilated, and. much shortened, and  a  soft body
could be distinctly felt pressing down, not unlike the foetal membranes.
    The pains continuing, one teaspoonful of the saturated tincture of ergot
was administered every half-hour,  until decided  uterine contractions were
established, which lasted  more than twenty-four hours, and then suddenly
ceased.
    Upon  examination, the vagina was found full of a  soft friable mass, but
so firmly packed  that the finger could with difficulty pass around  it.  It
was broken down with the placental forceps, and brought away by piece-
meal, until  its attachment to the uterus was reached.   The pedicle was found
to be broad and  much firmer than the bulk of  the tumor; it was firmly
seized by a volsella, and encircled with a  chain-ecraseur.  Its separation
occupied twenty-seven minutes.   The entire mass weighed nineteen ounces.
    The part to which the tumor had been attached was smeared with pure
carbolic acid, and two grains of opium administered.
    There  having been no haemorrhage during the removal of the tumor, it
was considered unnecessary  to insert  a tampon into the vagina, but the
nurse was instructed to watch the patient closely, and "notify the house-
surgeon" if any bleeding should be discovered.
    A rapid recovery was made;  no complication  occurring  to  interfere
with convalescence. .

                           Glandular Polypi,

    S. R----;  admitted  June 17, 1871; unmarried; seamstress; has never
enjoyed good health, having suffered since she was fifteen years of age from
menorrhagia, almost continuous headache, pains in the back, and leucorrhoea.
When quite young she was employed in a factory at Lowell, and from her
statement was hard-worked, poorly fed, and badly housed.
    Upon examination the vagina was found relaxed; the os uteri patulous,
eroded, and filled  with dark tenacious mucus.   The  cervix yielded to im- 
112
mediate  dilatation, and two  glandular polypi were  seen attached to the
lower portion of the canal.
     Her general  condition being one of extreme  debility, it was  thought
best to place  her upon constitutional treatment before interfering with the
uterine ailments.   She was  placed upon  generous diet  and tonics;  iron,
quinine,   and strychnine having .been  administered.  Her recovery was
slow, but perfect.
     October 10.—The condition of the uterus much the same as when the
patient was admitted.  A sponge-tent  was introduced, and, upon removal,
replaced by one of a larger size; the object being to  destroy the polypi by
pressure.   This was accomplished  perfectly,  and the patient dismissed,
November 7th, cured.
     There have  been  ninety-seven patients in the Institution for  various
forms of uterine tumors.  About  eighty per cent, of those  generally classi-
fied as fibroid growths, which include myo-fibroma, myoma, and connective-
tissue growths, have occurred in colored  women.
     The experience obtained from this limited number of cases leads to the
following conclusions:
     First. When the growths are sub-serous or interstitial, operative inter-
ference is inadvisable,  unless they  reach  such proportions that by their
mechanical interference with the pelvic organs life is jeopardized.
     Secondly. That after the  climacteric period has been passed, further in-
crease in size is  the exception,  and atrophy by absorption or retrograde
metamorphosis the rule.
     Thirdly. When the tumors are sub-mucous, and but loosely connected
with the normal tissue of the uterus, they can be safely removed, if the patient
is properly prepared, and the operation carefully conducted.
     Fourthly. Absorption of the tumor cannot be accomplished by alteratives
or any known system of medication; and when tumors disappear during a
course of treatment of this character, it is a  coincidence,  and not owino- to
the effect of the drug or drugs administered.
    Fifthly. That the large majority of cases reported as cured by the per-
sistent administration of mercury, iodine,  bromine, or medicinal  waters were
in reality not  adventitious growths, but  simple hypertrophy of the proper
tissues of the uterus. 
113
                       Subinvolution of the Uterus.
     A hospital devoted specially to the treatment of diseases peculiar to
women must necessarily receive  a large number of patients suffering from
subinvolution  of  the  uterus, a condition to  which the poorer classes  are
peculiarly liable.
     The uterus in its unhnpregnated condition measures three inches, and
weighs but a few  drachms.   In the  short period of  a  natm-al  pregnancy it
has increased to several pounds in weight, and may be sufficiently enlarged
to contain two or more children.   After delivery this mass of tissue under-
goes retrograde metamorphosis or fatty degeneration, and, if this physiolog-
ical process is  uninterrupted, it returns to nearly the same size it was before
impregnation.   Many circumstances are likely to occur, however, to interfere
with this process  of involution, most frequent of which is metritis, acute or
sub-acute, and insufficient contraction following the expulsion of the child.
Either of these may be excited by a  general toxaemic condition of the
blood, dependent upon the presence of more effete matter than the emunctories
can eliminate;  too early exertion after delivery; coition before  the complete
restoration  of  the uterus;  depriving the patient of sufficient  nourishment
during the first ten days following delivery; excessive haemorrhage or  any
one of the many accidents likely to  occur during parturition.
                       Subinvolution of the Uterus.

                               Case 1.
     Mrs. R. Z----;  admitted  October 14,  1866; aged thirty-five; mother
of eight children,  the youngest seven months old.   The eight children were
born in ten years and two months,  and all were single births.  Her labors
have always been rapid, three  or four violent pains  expelling the child and
placenta.  She had never suffered from after-pains, and usually was up and
attending to her household matters in six or seven days; but, since the birth
of the last  child,  she had been unable  to  move around with  any comfort
She  complained of debility, nausea, want of appetite; suffered from bear-
ing-down pains, pains in the back, and profuse leucorrhoea.
     Upon  examination the uterus  could be felt  above the  pubes, much
enlarged.   By digital examination per vaginam, the os was found patulous,
readily admitting the end of the index-finger; the cervix was large, but soft;
the sound measured six and one-quarter inches from os to fundus.   Its intro-
     15 
114
duction, although unobstructed, gave considerable pain.   The body of the
uterus was abnormally soft.   Speculum examination: os eroded; the upper
part of the vagina covered with ill-conditioned pus, which was flowing from
the cavity of  the uterus.  The diagnosis was subinvolution, with  chronic
endometritis.
     Treatment.—The child was weaned immediately, and the patient placed
upon  extra diet, with four ounces of sherry-wine daily.   The  hot  douche
was applied to the uterus morning and evening, followed by the  introduc-
tion of a pledget of raw cotton soaked with glycerine.   An  application of
pure carbolic acid was  made weekly to the lining membrane of the uterus,
and one-thirtieth of a grain of strychnine with five grains of the citrate of
quinine and iron administered after each meal.
    Under this treatment she gained rapidly, and at the expiration of tluee
months the uterus had become  reduced to one-half its  excess, and the  dis-
charge had  entirely ceased.   The same treatment was continued, with the
addition of electricity.
    April 17,  1867.—The patient was  discharged.  The  uterus had nearly
regained its normal size,  and her general  health was excellent.
     Commentary.—The want of involution in this  case was owing to  excess-
ive fecundation and insufficient food and  rest after parturition.   The neces-
sary sequence of this combination was atony of the uterine muscular fibres.
The endometritis was caused by the atony permitting the retention of blood
within the sinuses, and thus interfering with the circulation.
    Cases of this nature  cannot be treated successfully unless the patient is
in comfortable circumstances, or can have the advantage of a well-regulated
hospital.   The hygienic treatment is as essential as,the specific  medication.
            Subinvolution of the  Uterus.—Amputcdion of Cervix.
                               Case  2.
    Mrs. H. B----; admitted October 18, 1866;  aged twenty-seven;  Ger-
man by birth; mother  of two children, the younger seventeen months of
age, and still musing.  Patient complains of pain in the loins and between
the shoulders, leucorrhoea, constipation, and loss of appetite.  For  the last
six months her eyes have pained her at night, and she has experienced diffi-
culty  in reading ordinary print.  Her nights are restless.
    Examination.—Uterus low  down;  cervix large  and hard; os patulous;
the whole organ much  enlarged and very tender.  The vagina was relaxed, 
115
and incapable of affording any support to  the  uterus; perineum ruptured.
The retina of both eyes congested.
     Treatment.—The child was taken from the breast, and both mammae were
covered with belladonna plaster to arrest the secretion of milk.   To regu-
late the bowels,  a suppository containing one grain of the English extract
of belladonna was introduced into  the  rectum at night, followed in the
morning by an injection of three pints of tepid water.   No medical attention
was directed to the uterus for two weeks, it having been considered advisa-
ble to  allow the  patient rest  before commencing any special treatment.
    November 4.—Four leeches  were  applied to the posterior cul-de-sac,
followed by the hot-water douche, and the interior of the uterus was swabbed
out with a solution  of the nitrate of  silver,  (twenty grains to the ounce.)
    The hot-water douche was continued, having been used twice daily, and
the nitrate of silver application made to the uterine mucous membrane weekly.
One drachm of the sirup of the phosphate of iron, quinine, and strychnine
was taken after each meal.
    The recovery in this case was slow, the body of the uterus yielding
more  readily than the cervix, which remained  indurated, and was finally
amputated; no flap having been formed, the stump was allowed to heal by
granulation.
    February 8, 1867.—Perineum restored.
    March 15.—Patient dismissed cured.
            Subinvolution of the Uterus.—Amputcdion of Cervix
                                Case 3.
    Mrs. C. C----;  admitted  October 28,  1866; aged thirty-one; Ameri-
can by birth; married when sixteen years of age; mother of seven children,
the youngest of whom was four years  of age.   Since the birth of her last
child she has had six miscarriages, each one occurring between the  second
and third month.
    She complained of  pain low  down in the back,  extreme debility, leu-
corrhoea, menorrhagia, headache, and indisposition for exertion of any kind.
    The uterus was  found low down, and twice or thrice  its natural  size.
Cervix much enlarged, and os patulous,  giving exit to  an offensive discharge
of a brownish-yellow color.  The posterior lip  was hard and nodulated.  The
sound passed in four and one-half inches.
    Treatment.—Rest in the recumbent  position, chalybeate tonics and nour-
isliing diet.  Locally, chromic  acid was applied to the interior of the uterus 
116
 once a week, and a pledget of cotton soaked in glycerine (Price's) inserted
 into the vagina daily.
      Under this treatment the body of the uterus became reduced  in size,
 the patient gained strength, and the leucorrhoea diminished, but the cervix
 remained large, and the hardness increased rather than diminished.
      January 5.—The whole vaginal portion of the cervix was amputated by
 flap-incisions, and the flaps brought together with  silver wire; they united
 by first intention, and the patient was dismissed February 17,  1867, cured.
      Cases of this  description  are most likely  to invite  malignant disease.
 Had this woman continued without surgical treatment, the probabilities are
 that  she would ultimately have been  attacked with  corroding ulcer or
 epithelioma of the cervix.
           Subinvolution of  Uterus and Abscess in the posterior wall.
                                 Case 4.
      Mrs. F. J----; admitted November 4, 1866; aged twenty-nine; Ameri-
 can by birth; mother of one child, seven years of age.   Since  the birth of
 her child,  she has been pregnant a number of times, but on each occasion
 procured an abortion about the end of the second month, this having been
 accomplished by the  insertion of a piece of whalebone into the  uterine cav-
 ity.  On the last occasion, which occurred seven  months previously,  she
 lost a large amount of blood,  and, at each  menstrual period since, the dis-
 charge has been excessive, lasting for ten or twelve days.
      She complained  of severe pain during  coitus; sitting down caused suf-
 fering, the sensation  being that of something tender having been pushed
 up.  Her bowels were costive, appetite poor, and digestion imperfect.   The
 bladder was irritable, not tolerating more  than one ounce of  urine.  She
 had had several chills within  the week preceding her admission, followed
 by fever.
     Examination.—Uterus large; os patulous and eroded; cervix hypertro-
 phied, but  soft.  The finger, having been pressed into  the posterior cul-de-
 sac, came  in contact  with  a soft, fluctuating tumor, which appeared  to be
 developed in the posterior wall of the uterus.  Pressure gave extreme pain
 and caused nausea.  The uterus measured five and three-quarter inches- its
lining membrane was  in a state of chronic inflammation.
    An exploring-needle, having been introduced into the tumor, revealed
the presence  of  pus.  A free incision was  then made, which gave exit  to
about three ounces of greenish-colored matter. 
117
    This  treatment was followed by the  hot douche, and after that the
insertion of an opium suppository into the  rectum every six hours.  At the
expiration of a week much less tenderness existed, and it was thought advis-
able to make an attempt to reduce the endometritis.   A stick of solid nitrate
of silver was passed into the uterine cavity and brought in contact  with
every part of its lining membrane.
    For several days following the use of the silver there was an increase
of pain, as also an increase  in  the quantity of the discharge.  It was not,
therefore,  again employed, chromic acid having been substituted.
    The  hot-water irrigations  of the uterus were  continued for  several
weeks, and glycerine applied in the intervals between the injections.  Iron,
quinia, and strychnine were administered internally.
    Recovery was slow; she had suffered several relapses.   It was not until
August, 1867, that she became  sufficiently recovered to leave for her home
in Massachusetts.
    I heard  from this patient  in.May, 1869.  She  was then six months
advanced  in pregnancy, and enjoying good health.  I have  had no commu-
nication from her since.
            Subinvolution of the Uterus, with Secondary Syphilis.
                                Case 5.
    Mrs.  0. S—:—;  admitted  March  12,  1867;  aged thirty;  married;
mother of three children,  all of whom are dead.   The youngest, if living,
would have been fifteen months old.  She was  married four years before
she became pregnant, and during that time  enjoyed excellent health; but
soon after she became enceinte, she noticed an eruption over her body, accom-
panied by persistent headache,  and fever toward  evening.
    This  she supposed was part of the inconveniences to which women in
her condition were subjected, and paid but little  attention to it, until her
throat became so sore that she was compelled to seek advice.  Under treat-
ment the  eruption disappeared,  and her general health improved.
    She repeatedly has had  attacks  of sore throat and ozaena, and latterly
complains of pains in her bones at  night, and constant supra-orbital pain,
sleeplessness, and loss of appetite.
    Her  recovery from the birth of her first two  children appears  to have
been  moderately good, but  from the last she has never recovered.  Her
appearance was that of a woman far  advanced in  consumption; her  general
expression haggard in the extreme,  the  countenance giving unmistakable 
118
 evidence  of  extreme suffering.   Her lower limbs were  covered with an
 eruption of rupia.
     The  uterus was large,  measuring over five inches;  os patulous,  the
 forefinger passing  in readily; the posterior  lip partly covered by  a sus-
 picious ulcer; cervix swollen and tender.
     There was little to be gained by local treatment beyond the application
 of soothing remedies, until an improvement was made in the general condi-
 tion of the patient.
     The  following treatment was pursued:
                     IjL Tincturae ciuchonse co., 1 iv.
                        Hydrarg. bichlorid., gr. j.
                        Potass, iodidi, 3 ij.
                            M.
     One  dessert-spoonful of this mixture to be taken three times daily, and
 the patient placed upon generous diet; glycerine and opium to be applied
 to the uterus every morning,  and the hot-water douche used at night.
     The  alterative course of treatment was pursued with much benefit for
 six weeks, when it was discontinued, and the ammonia-tartrate of iron sub-
 stituted, it being given  in ten-grain doses.   The iron appeared to irritate
 the bowels, and had to be abandoned, and the first prescription was  again
 given, omitting  the mercury.  After the first  two weeks her improvement
 was rapid, and at the expiration of three months she exhibited no symptoms
 of syphilitic disease.  The ulcer  on the posterior lip of the os  uteri disap-
 peared under the glycerine treatment;  the uterus diminished in size as the
 patient increased in strength.
     Pure carbolic acid was applied five times to the uterine mucous mem-
 brane, its application on neither occasion giving pain.
     She was dismissed so much improved that it was believed a few weeks'
 residence  in the country would complete the cure.
     Commentary.—It appears from  a careful  examination of this  woman's
 case that she had never suffered from  a primary sore.   Her husband, who
 appeared  honest in  his statement, informed me that the attack of syphilis
 from which he had suffered was contracted three years before his marriage-
 that he had submitted to a regular course of treatment and been pronounced
 cured.   Before his marriage he consulted the same physician Avho had treated
him, and was assured that it was safe for him to marry.  He had occasionally
 what he called rheumatic pains in his bones, for which he had taken the 
119
iodide of potassium, and they had disappeared under that treatment.   There
was no other symptom about him which indicated previous taint.
                       Subinvolution of the Uterus.
                               Case  6.
     Mrs.  C. O'H----;  admitted February  17, 1867; aged twenty-two;
American; married  at sixteen years  of age; has  had two children, the
younger of whom is four months old.   Her health was bad during the whole
time that she was pregnant with the  last child.  Immediately preceding
delivery she was  attacked with remittent foyer, from which she has not fully
recovered.  She  complains of pain in the loins, extending down  the thighs,
irritability of the bladder, and profuse  leucorrhoea.
     Examination.—Uterus enlarged, measuring over five inches; os patu-
lous and eroded; the entire mucous membrane of cervix and body in a state
of chronic inflammation.   The uterine  leucorrhoea was  characteristic of the
diseased condition.
     Treatment.—Constitutional: iron, quinine, and strychnine.   Local: the
application of pure carbolic acid to the interior of the uterus every eight or
ten days, and the insertion daily of a  pledget of raw cotton  saturated with
pure glycerine.  After each application of the carbolic  acid a morphine
suppository was  introduced  into the rectum.  Patient dismissed June 4th,
cured.
     There have  been  one hundred and seven cases of subinvolution of the
uterus treated in the  Institution.   The general plan of treatment pursued
has been similar to  that adopted in  the preceding  cases, viz, perfect rest,
generous diet, accompanied with stimulants, or not, as  indicated.  Locally,
soothing applications to the uterus until pain should be  relieved, and  the
use of carbolic or chromic acid to the inflamed membrane.   Where enlarge-
ment of the  organ remained from atony of the  muscular fibre, after all the
symptoms of inflammation had  disappeared, a current of  electricity Avas
passed through the uterus daily.
     In seven of the cases leeches were applied to the cervix on account of
the existence of a higher grade  of  inflammation than  is usually present in
this form of disease.   Their application gave marked relief.
     The general results have been most satisfactory.  Of the one hundred
and seven cases treated,  ninety-four were perfectly restored  to health.   Six
left  the  hospital before  the  cure  was completed, and were not afterward 
120
heard from.   Two died, during treatment, from Bright's disease of the kid-
neys, and one from valvular disease of the heart.  Four, after being under
treatment nearly six months, left without having been benefited, the uterus
being harder, and the pains more severe than upon admission.   Three  of
these patients  have since been re-admitted, suffering from carcinoma uteri;
the fourth went to Ireland and has not been heard from.
     Such favorable results cannot be obtained in private practice, as patients
are not so completely under control.  Perfect rest can rarely be secured.
The topical applications are less likely to be effectually or regularly made;
and, what is a  still more serious drawback, the complete abstinence from
marital intercourse, so essential to recovery, cannot be enforced.

                            Carcinoma  Uteri.
     The fearful malignancy of this affection, its increasing frequency in this
country, its certainly fatal termination when once  fully established, in spite
of the best  selected remedies and the  most accomplished medical and surgi-
cal attention, the pain which accompanies it, exceeding in intensity all that
can be imagined as most horrible, attended by circumstances which  render
its unfortunate victim loathsome to herself and disgusting to those whom the
ties of the strongest affection gather round  her, combine to render the study
of its pathology and causes one of unusual interest.
     The thoughtful practitioner, when confronted with a disease so frequent
and so utterly hopeless, in which he finds himself powerless,  not only in
arresting its fatal  progress, but sometimes even in mitigating the horrible
agonies to which it gives rise, necessarily asks himself: If I cannot cure this
disease, can I not prevent it?
     The importance of the subject will justify me in going somewhat into
detail, with-the hope  that I may succeed in directing the attention of my
professional brethren  to this question:  Is carcinoma uteri preventable?
     The conclusion to which I have  arrived as  the result of  a moderately
large experience is, that, in the large majority of cases, the surgeon, can, by
judicious treatment, remove the exciting cause of the disease, and thus pre-
vent an  attack when the uterus is the organ threatened.  It is true,  it must
sometimes be heroic, but not always necessarily  so.
     I am aware that I run the risk of being considered rash in making such a
statement, but I am confident that facts will bear me out, and that by a careful 
121
study of the pathology of carcinoma, with an analysis  of the previous con-
dition of patients who suffer from the disease, the conclusion will be reached,
that  cancer rarely, if ever, attacks the uterus uninvited; and when all cir-
cumstances are considered, the surprise will be that so  many women escape
its ravages, rather than at the number who fall its victims.
     It attacks at  the invitation of oft-repeated irritations, congestions, and
inflammations, superinduced too often by willful violation  of  the  plainest
physiological laws.   It comes not in consequence of a pre-existing heredi-
tary taint transmitted from mother to daughter.   It  is not primarily a con-
stitutional  disease, and in by far the larger number  of cases it  does  not
destroy life by a general blood-poisoning, but by the  exhaustion attendant
upon the discharges  and continuous pain to which the patient  is subjected.
     Of the true pathology of cancer but little was known prior to 1865.
With its symptoms the ancients were well acquainted,  and from the minute
description of its ravages given by some of them it is evident that they were
in the habit of making post-mortem examinations of its victims.
     That we may compare our present  treatment of the disease with that
employed by Celsus, Scribonius, Largus, Aetius, Archigenes, Leonidas, and
others, it  may not be out of place to make the following  quotations from
Paulus iEo-ineta, who has collected  and condensed  pretty much all that
was known or had been written on the subject up to his time:
     "Of cancers in  the womb, some are attended with ulceration, and some
are without it. In those cases in which the part is not ulcerated, a tumor is
found about the mouth of the womb, hard, unequal, callous, of a feculent
 color, and red, but  sometimes  also somewhat livid; and they have violent
pains in the  groins and abdomen, the low^er part of the belly and the loins,
which are exasperated by handling and complicated applications.   When
 the  cancer is  ulcerated, in addition  to  the  pains,  hardness, and swelling,
there are phagedenic  and unequal ulcers to be seen, which, for the most
 part, are  foul, callous, white,  and having  ugly  scabs on them;  but some
 appear clean, some feculent, or livid, or red, or bloody.  The discharge from
 them is always a thin ichor, watery, black or tawny,  and fetid; but blood also
 is sometimes discharged along with the other symptoms of an inflamed uterus
 already mentioned.   Wherefore the complaint is incurable, as Hippocrates
 has pronounced, but ma}' be alleviated by hip-baths from fenugreek and
 mallows, and bv cataplasms of a like nature.   And the exacerbations of the
 complaint may be much alleviated by common mallows or marsh-mallows,
       16 
122
 softened by boiling in honeyed water, and pounded with a little rose-oil, and
 applied; and by a cataplasm of dried figs and melilots, rue,  frankincense
 and navew bruised carefully with oil, and also by that from dates boiled in
 must, containing also the yelk of eggs  and fine flour;  or that from poppies
 with coriander, knot-grass, or endive.   These things are to be applied during
 the violence of the pains, after which a cerate may be applied from rose-oil,
 or myrtle-oil, or the oil from the flowers of wild vines, or that of apples with
 dates boiled in  must.   But one particularly recommended is  that from the
 sediment found in copper-vessels, which, being burned, is reduced to a powder,
 and mixed with the cerate of roses until  it acquires  the consistence of a
 plaster.  These are the external applications.  But oil applied internally is
 soothing to the parts, and when they become ulcerated  the milk of a woman
 may be injected, and the tepid juice of plantain. But if they bleed, the infusion
 of knot-grass  with a little  rosemary proves soothing, and so also do pessa-
 ries, medicated with saffron, woman's milk,  and the juice of poppies, and the
 sordes of unwashed wool.  But the  following is one of the best applications:
 Of washed Italian litharge, oz. vj;  of male frankincense, of the  sordes of
 unwashed  wool, of fresh axunge, of newly-made butter,  of Tuscan wax, of
 each oz. ij;  of rose-oil, oz. iv.  Triturate the litharge with the juice of endive,
 and add to the other things when melted.   Food of easy distribution, and
 wholesome, may be given, and some watery wine, avoiding  acrid food and
 repletion, for they are apt to be troubled with indigestion.
     "The uterus becomes  scirrhous, sometimes all at once, without any pre-
 ceding complaint, but most frequently after having been preceded  by inflamma-
 tion, which  has neither been resolved nor converted into an abscess.   The disease
 called scleroma  is a species of scirrhus, most frequently forming  about the
 neck of the womb, and having  also  some swelling, but less resisting, and
 attended with moderate pain.  These are accompanied with  displacement
 to the opposite parts, swelling powerfully resisting in proportion to the pain,
 with heaviness  and difficulty of motion,  not of the  limbs only,  but of
 the whole  body,  and aversion to  exertion.   When not properly cured a
 dropsical cachexia  supervenes.  In the commencement we  must have re-
 course to venesection, or purging  with the  hiera of Archigenes; then to
 cataplasms of dried figs, grease of wool, nitre, wormwood, and cupping with
scarifications;  and to  the  soothing ointments, viz,  the  polyarchium, that
from seeds, and that from bay-berries; to hip-baths prepared with the decoc-
tion of  dried figs, mugwort, pennyroyal, and marsh-mallows;  to pessaries 
123
of turpentine, galbanum, myrrh, iris, and the grease  of wool; to dropaces
and the use of the  natural baths, viz, the nitrous and bituminous.  When
the strength permits, a course of hellebore may be tried.    *    *    *    *
     "Cancer occurs in every part of the body, for it takes place in the eyes
and uterus, and most other parts, but is  more particularly frequent in  the
breasts  of  women, because, owing to their laxity, they readily admit  the
thick humours which  occasion it; for cancers  are formed by black bile
overheated, and, if particularly acrid, it is attended with ulceration.  On this
account they are  darker than phlegmons, without being  attended with  the
same degree of heat.  The veins are filled and stretched around like the feet
of the animal called cancer, (crab,) and hence  the disease has got its appel-
lation.  But some say that  it is so called because it adheres to any part
which it seizes upon in an  obstinate manner like the crab.  Owing to the
thickness of the humour which  occasions it, cancer is an incurable disease,
for it can neither  be repelled nor discussed—not yielding to purging of the
whole body, resisting the milder applications, and being exasperated by the
stronger ones.
     "It may be possible, however, to prevent incipient cancer from increas-
ing,  by evacuating  the melancholic humour before it becomes fixed in  the
part.  We  may evacuate first, if nothing prohibit, by venesection, and after-
ward by purging at  the commencement with the simpler purgatives, such
as giving dodder of thyme to  the amount of oz. iv, in whey or honeyed
water, and  afterward hiera, containing black hellebore.  The juice of strych-
nos may be applied to the ulcerated parts without exciting pain, a linen rag
being folded and  wetted in it and laid on; but externally to  this we must
apply soft wool, which also has been soaked in the juice, and care must be
taken that  they do not become dry, by frequently pouring on some of the
juice.
     "In all carcinomatous ulcers  of  a  chronic nature^ one may use  the
preparation from  pompholyx; and  those remedies which were mentioned in
the Third Book for Cancers in the  Womb may be applied with advantage."
     Archigcnes, for carcinomatous and malignant idcers, recommends the levi-
gation of equal parts of burnt river-crabs and  calamine, and to sprinkle or
apply the ashes of crabs with cerate, or to apply the seed of hedge-mustard
triturated with honey.
     Hippocrates gives a long account of cancer of the womb, which, when
fairly formed, he  pronounces to be utterly incurable.   He directs us, how- 
124
e^ er, to try the effect of fumigating the womb by introducing into it a pipe
attached to a pot.   Steams from garlic and the fat of seals are to be applied
in this manner.
     Aretceus describes the ulcerated  cancer, and  that kind in .which there
is no ulceration.  He calls them chronic and fatal diseases.
     Holy Abbas pronounces  the disease to be incurable,  but  directs us to
soothe the sufferings of the patient by various  anodyne preparations.   For
this purpose he gives direction for the formation of several suppositories and
injections,  the principal ingredients of which are linseed, chamomile, fenu-
greek, coriander, beets, poppies, and the like.
     Alsaharavius indorses and approves of anodyne applications.
     Phases enjoins abstinence from everything of an acrid nature, and such
articles as  engender black bile.
     Celsus describes  carcinoma  as  an immovable and unequal  tumor,
attended with swelling of the veins, which are pale or livid.  His account
of the treatment is  so important that it  deserves  to be  given in his  own
words:  "Quidam usi sunt medicamentis adurentibus; quidam ferro adusse-
runt; quidam scalpello exciderunt: neque ulla unquam medicina profuit; sed
adusta, protinus  concitata sunt, et increverunt  donee occiderent;  excisa,
etiam post inductam cicatricem,  tamen reverterunt, et causam mortis attule-
runt: cum  interim  plerique  nullam vim  adhibendo, qua tollere id  malum
tentent, sed imponendo tantum lenia  medicamenta quae  quasi blandiantur,
quo  minus ad  ultimam senectutem perveniant, non prohibeantur."   In
another  place, however,  he  recommends compositions containing arsenic,
copperas, cantharides, galls, etc.   He makes a distinction between the cacoe-
thes, or malignant tumor, and the  true carcinoma, but says that the differ-
ence between them is to be recognized only "tempore et experimento."  He
marks the  gradations of malignant disease  with singular precision:  first,
there is cacoethes; then, carcinoma without ulceration;  and, last, there is the
fungated ulcer.  In doubtful cases he directs us, first, to apply caustics or
heating medicines;  and, if the disease is alleviated, to proceed to the  scalpel
or burning, according to  circumstances;  but  if it  is exacerbated, we are to
conclude that it is  of a  carcinomatous nature, and must abstain from all
acrid and vehement applications.
     Scribonius Largus recommends for all malignant ulcers, even such as
are cancerous, an application  consisting of arsenic, p. vj; of squama aeris,
p. iij; of elaterium,  p. j;  of burnt paper, p. iij. 
125
     Aetius gives  from Archigenes  and  Leonidas  an interesting account
 of the  disease, which he divides  into  ulcerated cancer and cancer with-
 out  ulceration.  He  describes the disease  in the  female  breast  as con-
 sisting  of a large  tumor, which is unequal and resisting, extending its roots
 far,  and being attended with varicose veins;  its color is either cineritious,
 verging to redness or livid; it appears  soft, but is in reality very hard;  is
 accompanied with a pungent pain, and gives rise to malignant phlegmons
 in the armpits.  The  pains shoot to the claviole and scapula.  An ulcerated
 cancer, he says, goes on corroding and  spreading deeper, nor can it  be
 stopped;  it discharges a sanies of an  abominable smell, and is aggravated
 by medicines and handling.
     The disease  he  considers as generally incurable.  He  recommends
 purging with hiera and the theric, Mithridatic antidote, etc.   Apparently, in
 order to mitigate the  violence of the pains, he directs us to make  an appli-
 cation containing  equal portions  of plantain, poppy-heads, the seed of the
 wort, and other things of the like kind.  For ulcerated cancer he recom-
 mends  emollient epithemes,  such  as the  one containing litharge,  axunge,
 white wax, oil, and the yelks of eggs.
     Oribasius and Actuarius  supply nothing of importance that is  not to be
 found in Paul of ^Egina.
     Nonnus, according to Sprengel, is  the only ancient author who attrib-
 utes cancerous ulcerations to acrimony of the bile.  But Nonnus merely
 copies the wrords of Paul of iEgina.
     The Arabians agree with the Greeks  in representing  the disease as
 being produced by black bile.  They were, no doubt, led to form this opin-
 ion from remarking that the blood in the part is thick and black, which they
 considered owing  to  its not  being properly purged of its  recrementitious
 sediment.  The moderns deride this theory, but they have substituted noth-
 ing  satisfactory in its stead.  Van Swieten thinks more favorably of the
 ancient doctrines.   Avicenna speaks highly of a milk diet.   Serapion like-
 wise approves of milk deprived of its butter, and  of a vegetable diet.  He
 speaks of no other treatment as being likely to prove remediable, with  the
 exception of excision and the cautery.  Haly Abbas rather approves of
 excision when the  disease is seated in a part which admits of this operation.
 However, like Galen, he disapproves of tying the  arteries.   The character-
 istic symptoms of the disease, he says,  are a stony hardness and distension.
T4ie account given by Alsaharavius  is nothing different.  Rhases has little 
126
 confidence in excision.   After  ulceration has taken place he approves of
 using a  cooling application, containing ceruse, tutty, rose-oil, the juice of
 nightshade, and some other such things of a cold nature.   He  mentions a
 case of cancer of the breast, in which the whole mamma was extirpated, but
 the disease returned on  the  other side.   One of his authorities, Antyllus,
 describes the cancerous sore as having  a  tendency to  spread  inward, its
 edges being thick, large, and  everted, and the discharge thin  and acrid.
 When the disease cannot be completely extirpated, he forbids us to meddle
 with it.   Theodoricus and all the earlier  modern writers on medicine call
 cancer by the name of apostema melancholicum, and recommend the same
 treatment for it as the Greeks and Arabians.
     It will be seen by the  foregoing extracts from the old writers on cancer
 that they were almost as familiar with its  symptoms and  the indications for
 its treatment as we are to-day.  They employed such means  as they pos-
 sessed to allay pain during its exacerbations and destroy the fetor of the
 discharges.   In what appeared to them suitable cases, they did not hesitate
 to use the knife, actual  cautery, or caustics for the  removal of the disease.
 The general result of the treatment pursued eighteen hundred years ago
 was the  same as now, and  the reason no advance has been  made has been
 on account of the absence  of knowledge of its pathology.
     With the modern  aids of science we  have, however, made vast strides
 in this direction, and if we  can not cure the disease, we may reasonably hope
 to learn  sufficient of its causes to be enabled to prevent its attack.
     The investigations  of Virchow, Billroth,  Rindfleisch, Koester,  and
 Thiersch have shed so much light upon this subject that the pathological
 anatomy of cancer is beginning to be understood as well as that of pneu-
 monia, and the mystery which has hitherto  surrounded this fearful malady
 is being  dispelled.  We find that its growth is governed by the  same laws
 which regulate every other growth in the body; and instead of searching in
 the blood for some subtle poison giving rise to the local manifestation
 of the disease, we must look for its origin in some local irritation by which
the nutrition  of the part is perverted.
    The following extract  from Rokitansky's Pathological Anatomy, while
of little value in so far as the pathology of the disease is concerned, contains
so admirable a description of the destruction produced  in the contiguous
tissues and  in some points agrees  so fully with what I  have  been in the 
127
habit of teaching concerning its  origin, etc., that I have thought well to
introduce it:
     " Carcinoma,—Next in  frequency to fibroid growths is the occurrence
of cancer.  It always attacks the cervix in the first instance, and especially
that portion which projects into the vagina; the primary occurrence of  car-
cinoma at the fundus uteri is so extremely rare that the above observation
may be considered as an absolute rule.   It is contrasted in this respect with
fibroid and tubercular disease  of  the uterus, and it presents a similar con-
trast in reference to its extension and ulcerative destruction.
     "According to our observations, fibrous cancer very rarely affects the
uterus; the most common form is the medullary, either by itself or com-
plicated with the former.
     "Opportunities  very rarely present themselves  of  investigating  the
early stages of cancer in the dead subject; according to a few observations,
fibrous carcinoma,  when closely  examined,  appears  to consist of dense
whitish, retiform fibres, differing from  the  normal texture of the  vaginal
portion of the uterus in which  they are found,  and  in their  very minute
meshes a pale reddish-yellow or grayish translucent substance is deposited.
     "This morbid growth is inserted into the uterine tissue without well-
marked boundaries;  it occupies  a various extent,  and from accumulating at
certain points, gives  rise to  the irregular nodulated character and the well-
known induration which accompanies the enlargement of the cervix.
     '' Medullary cancer in the first instance appears as an infiltration of a white
lardaceo-cartilaginous or lax encephaloid  matter,  in which the  uterine fibre
disappears;  as the deposit increases, the vaginal portion assumes an uneven
nodulated character  and  appears  hard and elastic to the  touch.   Cancer
of the uterus  very rarely presents itself in  the shape  of isolated globular
growths.
     "As the cancerous  degeneration  proceeds, and especially on the com-
mencement of the stage of metamorphosis, with its consequent new forma-
tions, particularly if they belong to the medullary  variety, the lower segment
of the uterus  undergoes  a very considerable  and rapid enlargement.  At
last we find a  callous, loose, spongy ulcer developed in the usual manner,
which discharges a  very fetid,  greenish-brown,  sanious  and  sanguineous
fluid,  and as it  extends  generally causes a progressive infiltration of can-
cerous matter.   The  tumefaction of the cervix  and the  fungoid excrescences 
128
not unfrequently close up the orifice, and the consequent enlargement of the
womb will be the larger the more copious the secretion of the mucus.
     "Cancerous degeneration of the uterus is generally confined, in a very
remarkable and distinct manner, to the vaginal portion;  still there are fre-
quent exceptions to this rule, as the disorganization is sometimes found to
extend with great rapidity to the body, and even to the fundus of the uterus;
this is particularly the case if the os  tincae has already been attacked by
ulceration.
     "The disease may  spread downwards and involve the vagina, thus
establishing vaginal  cancer.   It may extend in other directions, and thus
give rise to  cancerous degeneration of the rectum, the bladder, the pelvic,
cellular, and adipose tissues, and the periosteum; the uterus thus becomes
fixed in the pelvis, and at  last we find  the peritoneum attacked, cancerous
growths being formed upon it  and its tissue, or perforating it, especially in
the shape of medullary masses.
     "Cancerous ulceration spreads in the same direction; in rare cases we
find the greater part of the uterus, and  even its fundus, destroyed.   The
destructive process, when attacking the vagina, sometimes predominates on
the anterior,  sometimes on the posterior surface;  sometimes it attacks both
equally, and may extend downwards almost to the external orifice.  It also
involves the degenerated parietes of the rectum  and of the bladder, and
generally produces extensive communications between their cavities and the
original cancerous sinus,  (ulcerous cloacae.)  It finally extends, in the shape
of sinuous passages, through the remainder of the cancerous mass that fills
the pelvic cavity, to the pelvic bones.
     "In this manner a large cavity with fungoid parietes is at last  estab-
lished, which occupies the  greater part of the uterus and the vagina, and
opens into the cavities of the rectum and the bladder;  above it is  closed in
by the fundus uteri and the adherent rectum and the cervix vaginae, as also
by the  caecum  and small intestine, which are agglutinated to these parts,
and at last it penetrates into the cavity of the peritoneum or the intestines.
The contents of the cavity are cancerous ichor, mixed up  with faecal matter,
urine, and portions of gangrenous tissue.
     "The temporary and tumultuous periods of development presented by
the peritoneal inflammations of the pelvic and hypogastric regions, which
accompany  and characterize  the metamorphic and ulcerative stages, and 
129
 which not unfrequently extend from the original layer over the entire peri-
 toneum, and are important occurrences in the progress of cancerous disease.
     " Uterine cancer is, in most cases, a primary disease, and generally remains
 for a long time, if nottliroughoid, the sole carcinomatous affection of the organism.
 However, it is sometimes developed concurrently with or consecutively to
 mammary and ovarian cancer;  or it is accompanied by degenerations of
 the adjoining tissues above mentioned, and of the lymphatic glands, which
 must be explained upon the theory of  propagation by contact; or again, it
 is associated with  cancer  of the peritoneum  of the liver, the  stomach, and
 the breasts, with cancer of the bones, with mollities ossium, ovarian cancer,
 and universal cancerous deposit, as a consequence of the resulting cancerous
 dyscrasia.
     "Uterine  cancer most frequently occurs between the fortieth  and
 fiftieth  year;  still there are many cases on record  in  which it appeared
 between the thirtieth and fortieth years, and even earlier.   The cases of
 spontaneous recovery from  uterine cancer are of extreme rarity, but they
 do occur;  the carcinoma and the  cancerous  ulceration are  then limited to
 the cervix, the internal orifice forming  the boundary; the loss of substance
 heals with a funnel-shaped cicatrix."  (Rokitansky.)
     Rindfleisch remarks:
     "By carcinoma we understand a new formation destroying the organs
 of the body, after extirpation, commonly recurring and undergoing metastasis,
 therefore malignant.  These properties certainly pertain, also, to certain his-
 tioid tumors;  and it were  exceedingly desirable if there  were  a positive
 anatomical characteristic by which we  could  recognize carcinoma as  such,
 and could distinguish it from other destructive and malignant new forma-
 tions.   We have now become accustomed, and to-day we yet hold fast this
 custom, of regarding a certain peculiarity of structure, the so-called alveolar
 structure, as  a necessary  requisite for  the diagnosis—cancer.  By this we
 wish to say that we seek for the substance of the carcinomatous  degenera-
 tion  in  a  deposition in foci  of cells advancing in fixed directions, which
 necessarily tends to this that we must grant to the parenchyma of the organ
 in process  of destruction which remains between these  cellular depots the
 form of a framework, a trabecular, or net work, (stroma,) whose meshes
 (alveoli) are determined by  the form and size of the deposited aggregations
of cells.
          17 
130
     "It is manifest that this structure is particularly fitted to lodge largo
amounts of free cells, which we must regard as the most effective stimulus
as well for the local growth  of a  tumor  as for the  infection  of  the  entire
organism.   The seeming arbitrariness with which we proclaim the alveolar
structure  as the  anatomical  criterion of cancer  consequently receives  its
justification."     *     *     *      *******
     "The greater number by far of carcinomas proceed primarily either
from  the  epithelial-clad surfaces of the  body, from the skin  and mucous
membranes, or from the secerning glands.  They depend upon an abnormal
growth of the epithelial tissue.  We may say that an ingrowing  of  epithe-
lium into the sub-epithelial layer of connective tissue of membranes or into
the interstitial  connective tissue  of glands forms the fundamental process
in these carcinomas.
     "The nature and manner of  the ingrowing are extraordinarily various.
The whole impression made by a carcinomatous destruction—for example,
the observation of a vertical section by a low magnifying-power—appears to
justify the opinion that in them the question  is about  a diseased imitation
of those histological processes which precede the development of glands with
excretory ducts;  namely, here, as there,  we see aggregations  of epithelial
cells, which proceed from the under surface  of the epithelium in the form
of cones or  strands,  and insinuate themselves between the separating fila-
ments of the connective tissue. Active processes of division also show them-
selves in the elements constituting the cell-aggregations, so that  in both of
these principal points an undeniable uniformity with glandular  growth  is
present.
     "Nevertheless, the view that the carcinoma formation  consists in a sub-
ordinate  and  irregular imitation  of the physiological glandular  growth
(heteroddnie of the French)  has but a very contracted justification.
     "For the  carcinomas of glands with open outlets, of course, we may
even indicate with emphasis  that all imaginable  transitions between glan-
dular hypertrophy and the glandular carcinoma  are to be found.  We of
the latest time have learned to know these intermediate forms more funda-
mentally, and have invented the name adenoma, to designate a tumor which
is  neither  simple hypertrophy nor carcinoma.  This is at least the most
comprehensive  conception.   Several authors certainly move  the idea  of
adenoma up and down upon the scale mentioned, in tliat  they now assign 
131
it more  to hypertrophy, now more to  carcinoma; that, however, a motion
up and down of this kind is possible just proves the existence of the scale.
     "The general comprehension, however, of  carcinomas, which proceed
from the epidermis or the epithelium of mucous membranes, is much more
difficult; namely, here also exists an unmistakable correlation of the hyper-
plastic and  carcinomatous conditions.   It  is, for example,  a  well-known
experience  that those  circumscribed  hypertrophies of the skin which we
term warts and papillomas have the capacity of going over into epithelial
carcinoma.  This transition is brought about purely anatomically  in the
following manner:  The  papillar hypertrophy  conditions a more or less
great alteration of the  level of that plane in which the epithelium and con-
nective  tissue come into contact,   The steeply-raised lateral surfaces of the
enlarged or newly-produced  papillae bound deep,  cleft-like  depressions
between the papillae.
     "The epithelial covering  of the papillae is, at the same time, an epithe-
lial lining of the interpapillary clefts, and as long as this relation remains
constant by a sufficient desquamation of the older epithelial cells, the hyper-
plastic character of the tumor is preserved.
     "It is, however, manifest that a sufficing desquamation is so much the
less possible, the more the papillae  elongate, and especially the richer their
dendritic ramification proves to be.  The lateral pressure which the points
of the papilla^, widely branched but united to a narrow basis, exert, simul-
taneously closes from above the interpapillary clefts, and causes in them a
gradually increasing accumulation of epithelial  cells.  The epithelium in
the deeper parts of the tumor no longer appears as a lining, but as a solid
plugging of the interpapillary clefts.  As such it now begins to push forward
against  various points  of the connective-tissue substratum.  Oval epithelial
cones appear, which first protrude from the  under surface of the epidermis
into the cutis, then penetrate deeper and deeper.
     "By this the carcinomatous• condition is given.   We cannot of course
avoid comparing these cones with the epithelial cones in the glandular for-
mation : we  also observe, as was said, lively processes of division in the con-
stituent  cells, although, until proof to the contrary has been shown, I am
convinced that  their growth chiefly depends  upon a peripheric apposition of
young cells, like the growth of normal epithelium, and find this representa-
tion just as plausible as perhaps the enlargement of retention-cysts by the 
132
secretion from their walls.   The processes of division in the interior of the
epithelial cones indicate a secondary growth, and may indeed contribute
the greater part to the thickening  of the epithelial cones; to their  elonga-
tion, however, and their forward progress upon which the peculiar destruc-
tion of organs still depends, they do not contribute.  I content myself, in
these preliminary remarks, to have  pointed out  that the  laws of normal
growth  are correctly maintained  even in these extreme and most danger-
ous excesses."
     Billroth says:
     "The common clinical definition of carcinoma should be controlled by
the anatomical structure of these tumors.  In  accordance with this,  I only
call those tumors true carcinomata which have a formation similar to that
of true epithelial glands, (not the  lymphatic glands,) and whose cells  are
mostly actual derivatives from true epithelium.  I am  convinced that this
view will constantly have  more adherents,  and  that thus  the  differences
about  the anatomical definition of  'carcinoma'  will constantly diminish.
Those investigators who, during  the last few  years, with all the modern
aids, have worked without prejudice on this portion of the study of tumors,
recognize the great importance of epithelial proliferation in those  tumors
that we  call cancer; still most of them  seek for a compromise between the
different histogenetic views, and wish still to admit, in a modified form, the
development of  true glandular and epithelial cells from  connective  tissue,
(heterology proper, Rindfleisch, Volkmann, Klebs, Liicke;) only Thiersch
and, recently, Waldeyer maintain, as I  do, the  strict boundary between
epithelial and connective-tissue cells.  Waldeyer  defines carcinoma as an
atypical epithelial neoplasm.  But we must here state that in cancer-tumors,
besides the epitheliums, there are usually numerous young small round cells
which, infiltrated in the connective-tissue portion  of the  tumors, form an
important part of it.  This small-celled connective-tissue infiltration,  which
exists in varying quantities wherever epithelial proliferations grow into the
tissue,  appears to be  caused by a  sort of reaction, and  to be the result of
the penetration of the epithelial new formations into the  tissue according to
the number of infiltrated cells and their future fate, as well as the decree of
vascularity, just as in inflammation it sometimes leads to softening, to atro-
phy, and cicatricial thickening of the tissue.  In some cases this small-celled
infiltration is  so  considerable  as almost  entirely to hide the epithelial new 
133
formation, from which it may be very difficult to distinguish if the latter be
small.   We may then be in doubt if it should not be regarded as entirely
independent, and occasionally, perhaps, as the sole constituent of cancerous
tumors.  Formerly I myself thought it necessary to agree to this, and even
supposed that this component of carcinoma possessed a spontaneous power
of infection;  but further observations  with neiv aids have made it appear to me
more probable that, even in the smallest cancerous  nodides, epithelial elements
always gave the first start for development.  This has been confirmed by Wal-
deyer.11
     Frey remarks:
     "The carcinomata, or cancerous tumors, those  enigmatical and most
dangerous new formations of the body, are imbedded, at least in the normal
connective-tissue  textures, and show, in conformity therewith, a frame-work
consisting of a connective-tissue intercellular substance.  In the sometimes
larger, sometimes smaller spaces of this frame-work lie imbedded cells which
may, in certain cases, resemble those of pavement epithelium, but generally,
however, they present a character which does not thoroughly correspond to
that of any of the normal cells, although they may have taken their origin
from glandular or epithelial cells.  These 'cancer-cells' are capable of an
unlimited, exuberant multiplication.   It is customary to distinguish between
certain forms of carcinoma.  A tumor  is generally called scirrhous (Faserkrebs)
when there are only small collections of cells imbedded in a firmly inter-
woven connective-tissue frame-work, so that the tumor possesses throughout
the character of hardness and firmness.   Inversely, one speaks of medullary
carcinoma where  large aggregations of cells occur in spaces of considerable
size, the whole having a softer consistence, and the groups  of  cells forming
masses of a butter-and-cream-like nature.  If the cells have the appearance
(but not the group-like arrangement) of pavement epithelial cells, we have
one form  of epithelial cancer,  while the  others have cylindrical cells, in
both cases certainly descendants from the epithelial and glandular cells.  If
the substance of the frame-work presents a strongly-marked fungous (alveo-
lar) structure, and in the numerous spaces lie cells which are undergoing
the'colloid transformation, we have the alveolar  or colloid cancer  of  the
pathological  anatomists.   It is well  known that sharp boundaries between
these various forms of carcinoma do not exist; that they frequently pass into
each other; and that in one and the  same tumor some localities may be more
of one  character, and others more of another. 
134
     Doctor J. J. Woodward, the accomplished microscopist of the United
 States Army Medical Museum, has recently published a monograph on can-
 cer, in which he  describes and furnishes illustrations of two cases of  carci-
 noma; one multiple cancer consecutive to the ablation of a primary carcinoma
 of the female breast,  and the other primary mammary tumor of similar
 structure.
     The succinct and masterly manner in which he has handled the pathology
 of malignant growths, and by which he embraces, within a brief  compass,
 the most modern views upon the subject, saves the profession  the labor of
 exploring lengthy essays, some of which are difficult to comprehend.
     I consider this last production of Doctor Woodward so valuable  that I
 have copied the greater part of it.
     "Koester has been led to the opinion that carcinomatous growths very
 frequently have  their origin in a proliferation of the endothelium of the
 lympathics of the parts involved, and that this transformation plays proba-
 bly a great part in the development of most cancers  and sarcomas.  His
 work, so far as published,  is confined to  the  examination of epithelial
 cancer of the  skin and  alveolar colloid of the stomach, (alveolarer Gal-
 lertkrebs des Magens,) and he has postponed for future parts  the detailed
 examination  of other varieties.  His views  have  been  received with  much
 favor in  various quarters; I may especially mention Rindfleisch as having
 given prominence to them in the last edition of his text-book.   I shall have
 occasion to refer further to the views of Koester in the sequel.   *    *    *
     "No. 955, Medical Section: The left mammary gland, which is trans-
 formed into an oval, flat, somewhat nodulated scirrhous tumor, three  and  a
 half inches long by two  and a half  broad,  and about  an inch  thick in the
 center.
     "In thin sections of  this tumor, individual lacteal alveoli and ducts,
 stuffed with  large  cells  derived  evidently  from  the glandular  epithelium,
 were but sparsely scattered, and  the greater portion of the gland was re-
 placed by a peculiar scirrhous tissue, in which its scanty atrophied remains
 were imbedded.  This peculiar tissue consisted of a firm,  delicately  fibril-
 lated connective-tissue stroma, containing numerous small cells and many fine
 elastic fibres,  and of a plexus of irregular,  varicose, nucleated  cylinders of
protoplasm, corresponding in many respects to the 'cell-cylinders'  of Koes-
ter, which intimately interlaced with  the connective-tissue stroma, filling all 
135
 its meshes except those occupied by the vessels and the atrophied remainder
 of the gland.  These nucleated cylinders did not appear to be composed of
 separate cells.  They seemed rather to consist of a granular protoplasm, in
 which  innumerable nuclei,  1-2500th to l-2000th of  an  inch in long dia-
 meter,  or even larger, were imbedded side by side, without any evidence of
 limiting cell-walls separating the protoplasm surrounding each nucleus from
 that belonging to its neighbors.  On scraping or teasing the sections, more-
 over, the nuclei escaped abundantly into the 'juice' in a quite naked con-
 dition.   Very often, however,  some of the nuclei appeared in the 'juice'
 thus obtained surrounded by a more or  less irregular mass of protoplasm,
 resembling thus  'the typical cancer-cells' of the older writers.
     "The nucleated cylinders usually varied from the 1-1000th to the 1-500th
 of an inch in diameter, but in some parts attained still greater dimensions.
 In places where the section passed transversely through the cylinders, they
 appeared as  round or somewhat oval masses of protoplasm, stuffed  with
 nuclei,  which might readily pass for the 'mother-cells'of the books.   In
 glycerine and balsam preparations, the protoplasm of the cylinders was often
 shrunk away from the connective-tissue stroma, the margin of which, being
 clear and transparent, might  almost be taken  for a  limiting membrane.
 The nuclei of the cylinders were transparent or but slightly granular when
 fresh, and usually contained a single large nucleolus.   In the balsam-mount-
 ed sections they appeared more decidedly granular.   Elongated nuclei with
 two nucleoli and other indications of commencing division were but rarely
 observed.  The nuclei of the connective-tissue stroma were generally rather
 longer than those  of the cylinders, but much narrower.  Occasionally their
 position was  occupied by little rows of two, four,  or more nuclei,  which
 might be supposed to be the  progeny of the  connective-tissue nuclei.   Such
 rows were generally surrounded by a small quantity of protoplasm.  Sec-
 tions taken from the peripheral portions of the tumor generally presented a
 certain amount of more or less altered adipose tissue.   The quantity of the
 matrix between the fat-cells was much increased, so that instead of the indi-
 vidual cells of each fat-lobule being apparently in contact, they were separated
 to a greater or less extent (often the l-2000th of an inch or more) by a deli-
 catch' fibrillated matrix,  in which were imbedded many oval nuclei,  which
were both larger and more  numerous than normal.  The connective-tissue
septae between the individual fat-lobules  were also greatly thickened, and 
136
in many places contained cell-cylinders quite like those of the body of the
growth.   (See Microscopical Section, Nos. 4615—4631.J
     '' No. 958, Medical Section:  A portion of the right lobe of the liver.  The
liver was nearly normal in size, but presented in section numerous  little
hard whitish nodules, varying from the size of a pin-head to that of a pea,
or even smaller.  These were invariably situated in the course of the portal
vessels, i. e., in the  interlobular  spaces.  In structure they closely approxi-
mated the  scirrhous tissue of  the breast-tumor as  above  described;  simply
the meshes of the plexus of nucleated cylinders were less elongated, and in
the sections, therefore,  these more frequently appeared  as  round or oval
forms, (the cylinders having been cut more or less obliquely,) and less fre-
quently as continuous cylinders of some length, such as were common in
the breast-sections.   Hence, on  superficial observation, the sections of these
cancer-nodules of the liver appeared at first sight as a nucleated connective-
tissue stroma, in which numerous large, round, oval, or elliptical mother-cells,
containing numerous nuclei, were imbedded.  On carefully focussing, how-
ever,  it was easy to perceive that these apparently separate  masses  of pro-.
toplasm formed, in fact, portions of a complete net-work of nucleated cylinders,
which had been divided by the   section.  As in the case of the mammary
tumor, the cylinders appeared to consist of  a mass of granular protoplasm,
with numerous  nuclei imbedded, actual  cell-walls  being nowhere  distin-
guishable.
     "Nowhere did it appear that the hepatic  cells had contributed by their
multiplications to the formation of the cancer-nodules; on the contrary, the
actual structure seemed quite clearly to contradict  any such inference.   For
some little distance around each little  cancer-nodule the cut  ends of single
nucleated  cylinders were frequently  observed imbedded  in  the  very sub-
stances of  the hepatic acini.  They always occupied, however,  the vascular
spaces or the meshes of the network of hepatic  cells, and these  appeared
quite normal, except in the immediate vicinity of the cancer-nodules, where
the chains  of hepatic cells were  often flattened somewhat,  as  though by the
pressure  of the growth.   At the margins of the growths, in many places,
nearly all  the meshes formed by the  compressed  hepatic  cell-chains were
occupied by the nucleated cell-cylinders of the cancer, the atrophied secret-
ing tissue of the liver here taking a position corresponding  to that of the
connective-tissue stroma of the more  central portion of the cancer-nodules. 
137
The cancer-nodules  then  would appear to  have grown by a continuous
extension of their nucleated cylinders into the adjacent hepatic parenchyma,
the secreting cells of which seem to perish by atrophy without contributing
to the substance of the growth.  (See  Microscopical Section,  Nos. 2389-
2393.)
     "No. 960, Medical Section:  The uterus and  its appendages.   Each
ovary is  transformed into an oval somewhat nodulated scirrhous mass, an
inch and three-quarters in long diameter.  In sections no trace of Graafian
follicles or ovules could be discerned.   The scirrhous mass everywhere con-
sisted of a tissue very similar to that above described in the breast.  Simply
the meshes of  the nucleated cylinders were longer, so that when the section
passed parallel to them they could sometimes be traced running parallel to
each other for some distance; moreover, the connective-tissue  stroma was
more conspicuously fibrillated  than in any of the other growths.   (See
Microscopical  Section, Nos. 2449-2467.)
     "No. 956, Medical Section: The heart.
     "No. 957, Medical Section:  A  portion  of the  pericardium.  On the
surface of the  heart and of the parietal pericardium  were a number of  flat,
white thickenings, which were at first supposed to be carcinomatous.   They
proved on  section to be composed of an imperfectly fibrillated matrix, in
which numerous small corpuscles were imbedded, and probably are to be
referred to some previous inflammatory process, and not to the carcinoma-
tous disease.   (See Microscopical Section, Nos. 4690-4693.)
     "On reviewing this case we cannot fail to be struck first with the great
similarity of the  minute structure of all the morbid growths, although seated
in quite diverse organs.  Everywhere the normal tissue characteristic of the
part .affected  appeared to be  replaced by the morbid product, which  was
everywhere similar in texture.
     "This  similarity of texture has long since been frequently observed in
multiple carcinomatous growths, and is the anatomical basis of the doctrine
of a cancerous dyscrasis  regarded as the constitutional  cause of the local
affections.  It  will readily be understood that if we could believe in a special
modification of the blood giving rise to peculiar organizable exudations we
should expect  the tissues thence derived to be everywhere characterized by
some common  structural features, the  consequence of their common origin.
Such a view as  that of Koester, however, would equally well explain the
       IS 
138
 circumstance referred to;  for, if the  nucleated  cylinders are everywhere
 transformed lymphatics, they must be  expected to have very many features
 in  common, combined with some minor differences  in the  caliber of the
 cylinders—the size of their meshes, etc.—consequent upon the local varia-
 tions in the character of the finer lymphatic nets.
     "Koester describes the net-work of cylinders in epithelial cancer as 'cell-
 cylinders,' and was able, by silver imbibition, to map out cell-walls, and to
 trace the continuity of the cancer-cylinders, with normal lymphatics lined
 by their characteristic epithelium.   At the time the foregoing  case was in-
 vestigated his monograph had not yet reached me; since reading it I have
 caused  sections of several other carcinomatous tumors to be  treated with
 silver, by Dr. E. M. Schaeffer, one  of the  assistants at the Museum.   In
 several  instances results were obtained approximating those described by
 Koester, but they have not yet been sufficiently complete to justify me in
 forming a definite opinion.  I hope to make this matter the subject of a future
 report.   In the mean time, however, I can not but admit the close corre-
 spondence between the outlines of the plexus of nucleated cylinders and the
 net-work obtained when the lymphatic capillaries are injected.  And I may
 add that the  general features  of the morbid growths above  described, viz,
 a net-work of nucleated cylinders interlacing with a connective-tissue stroma,
 are to be observed in quite a number of the sections of carcinomatous growths
 preserved in the Museum.  In none of these cases, however, have I, as yet,
 been able to satisfy myself with Koester of the existence of a lumen in  the
 central part of the nucleated cylinders, nor am I convinced that the normal
 lymphatic capillaries lined by an epithelium are alone capable  of being
 transformed into the cancer-cylinders.  Much more probable  does it appear
 to me that all the lymphatic spaces of  the connective tissue  are susceptible
 of this  transformation, which  would at once account for the voluminous
 character of  the pathological net-work.   The presence or absence of cell-
 walls in the protoplasm through which the nuclei of  the cancer-cylinders
 are distributed does  not  appear to  me  an essential  point.  Marked cell-
 walls can be  observed in the cylinders of several epithelial cancers in  the
 Museum collection.  On the other hand, Koester himself mentions that at
times he found cylinders in which the nuclei were imbedded in a  granular
protoplasm, in which no cell-walls could be observed.
     "In the present state of our knowledge we may perhaps regard the cell- 
139
wall as an  indication  of a  comparatively  advanced stage in the history of
the individual cell, which at first consists of a nucleus surrounded by a mass
of protoplasm.   There seems, then, no difficulty in agreeing with Koester
to regard such nucleated cylinders as  I  have described  above as composed
of cells too young to be possessed of  walls,  and placed in such close jux-
taposition that no line of demarkation can be  observed between the proto-
plasm of the several elements.
     "As to the mode in which  the  cells of  these cancer-cylinders arise,
however, I find greater difficulties.  I  am not satisfied, either by my own
examinations or by the study of Koester s paper, that they  can be justly
considered the progeny of  the  lymphatic  endothelium.  A view  which
should regard  them as transformed white corpuscles  accumulated in the
lymphatic passages appears to  me, if anything, a more  probable interpre-
tation.  This would harmonize with the general absence of any demonstrable
lumen, as well as of  demonstrable cell-walls  for the separate elements,  at
least in the earlier period of the history of individual cylinders;  it would
also harmonize with the close  agreement generally  observed between the
elements of the youngest cylinders, i. e., those in the most peripheral parts
of the growth, and ordinary granulation-tissue.
     "I am not willing, however,  to commit myself very  warmly at present
to the advocacy of any detailed views as to the  mode of origin of the cancer-
cylinders.  I desire simply to call attention to the probability, now almost
a certainty, that they  are conditioned in their  genesis till further facts have
been accumulated.
     "In the case which has been described,  the primary growth was not
received by me for investigation.   I have, therefore, added a short account
of a primary tumor of the breast,  in which the  structure was very similar  to
that observed in the  secondary  cancer of  the breast  in the case above
described.
     "No. 5905, Surgical Section, is a scirrhous tumor of the female breast
by a surgical operation in the spring of  1870.   No particulars are recorded,
and the subsequent history of the patient has not been reported.  A section
through the piece shows that the mammary gland is represented by a small,
somewhat pyramidal mass, the apex  of which terminates in the retracted
nipple.  The borders  of the  mass extend irregularly into  the surrounding
adipose tissue, which constitutes the bulk  of the  specimen.   The case rep- 
140
resents that very common variety of scirrhus in which the mammary gland
is transformed into a small irregular cancerous mass, while the  surrounding
adipose tissue remains normal in  bulk,  or  even may actually increase in
quantity   Nos. 3489,  3490,  and  Nos.  4616-4623, Microscopical  Series,
are sections of this tumor.
     "In these  sections, as in the secondary mammary tumor in the former
case, more or less modified gland-lobules were but rarely encountered,  and
the greater part of the carcinomatous tissue appeared to consist simply of a
net-work  of  nucleated  cylinders imbedded in a connective-tissue stroma.
In -this  case,  however, the cancerous mass was imbedded in a more bulky
mass  of adipose tissue, the peripheral parts of which were ■ quite normal.
The separate fat-cells were much larger than in the first case, being from
0.002 to 0.004 inch in diameter, while in the first case the limits were 0.001 to
0.002 inch.   This would appear to  depend simply upon the  degree of ema-
ciation, which existed in the first case at the time of death.   At all  events,
the anatomy of that part of the adipose tissue which adjoined the morbid
growth was  essentially the same in both cases.  Extension of the cancer-
cylinders into the connective-tissue septae between  the fat-lobules and the
development of a more  or less abundant nucleated matrix between the indi-
vidual fat-cells  of those lobules nearest the scirrhous tissue  were character-
istic conditions in both  cases.
     "The first of the plates which illustrate this paper represents  a portion
of preparation, No. 3489, Microscopical  Section, which  is taken  from  this
second case,  magnified  400 diameters.  It exhibits a side-view of  a part of
the net-work of nucleated cylinders.  The granular character of the  pro-
toplasm, the  imbedded nuclei, and  the manner in which  the nucleated  cyl-
inders interlace with the connective-tissue stroma are faithfully represented.
The nuclei of the connective-tissue  stroma  are  not  so obvious, but few of
them lying in the optical plane selected for representation.
     "The second plate  represents  a portion of one of the  liver-nodules in
the first case.   It is  copied from preparation No. 2393,  Microscopical  Sec-
tion, magnified 400 diameters.   The section divides several of the  nucleated
cylinders in  a direction nearly perpendicular to their  course, and they appear
hence, as above described, not unlike so many multi-nucleated or mother-
cells.
     " Both  photographs were  made from carmine-stained preparations, 
141
mounted in balsam, and in both, therefore, the nucleated cylinders appear
slnunk away from the connective-tissue stroma in which the}' are imbedded.
     "In conclusion, I must  refer briefly to  another interpretation of the
nature and origin  of such  nucleated  or  cell cylinders as I  have above
described, which has been received with great favor for some few years.
     "Thiersch, in his work on Epithelial Cancer, explains the cell-cylinders
in that form of carcinoma, especially of the  skin, as outgrowths from the
lower layer of the epidermis and from the epithelium of the glandular appar-
atus.   Such an  interpretation implies, of course, the possibility of demon-
strating that the cell-cylinders are continuous with the epithelial structures
from which they are supposed  to have budded forth.  Such a continuity
Thiersch believes  himself to have observed in  many of his sections.   He
admits, however, that it is often  impossible to make it out, and explains this
by supposing the connection to have originally existed, but subsequently to
have disappeared, pointing, in justification of  the hypothesis, to  the history
of the normal development of the embryo as affording many examples  of
epithelial formations, which proceed originally from the epithelium of the
surface, but become disconnected with it at a later period of their growth.
Thiersch did not fail to  observe  the fact of the frequent anastomoses of the
cell-cylinders, which he has very well figured in  Fig. 1,  Tab. IX, but this
circumstance did not shake his confidence  in  the view he had propounded.
     "Billroth maintains similar  views to those of  Thiersch, not merely for
cancer of the skin, but also for mammary cancers, and, in fact, for cancer
generally.   In the last edition of his lectures he mentions the view of Koes-
ter as  'enticing,' but thinks that  'all his evidence in favor of this view is not
tenable.'
     "I would call attention,  however, to the fact that the manner in which
the cell-cylinders  anastomose in at least many  mammary cancers points
rather  to  the  lymphatics than to the mammary-gland tissue.  Moreover,
when  a  mammary cancer  returns  after extirpation,  or when secondary
growths develop in distant organs, as in the case reported in this paper, the
new formations are generally constructed upon the same  structural plan as
the original growth.  To reconcile these facts with Billroth's views, we must
resort  to far more  complicated  and improbable  hypotheses than those  of
Koester.
    "Billroth was well  acquainted with the anastomosing cell-cylinders in 
142
 certain forms of mammary cancer.  He describes such growths as the 'tubu-
 lar form.'  According to him, mammary cancer, in general, almost always
 begins 'with a coincident enlargement of the small, round, epithelial cells in
 the acini, and with small-celled infiltration of the  connective tissue around
 them.'  He admits that it is 'difficult to  make  out the further fate of the
 glandular  acini,' yet he has  no doubt that in the tubular form 'the acini
 do not maintain their form, but grow into the connective tissue as very thin
 cell-cylinders, while it becomes infiltrated with cells.'  I mention with inter-
 est that Fig. 144, page 643,  of his work, (loc. cit.,) agrees precisely, so far
 as a  wood-cut can represent  the microscopical appearances  of a morbid
 growth, with portions of some of the sections of the two cancerous breasts
 described in this paper.  In it, as in them, certain figures, which undoubt-
 edly represent more or less modified gland acini  and ducts, lie side by side
 with the cell-cylinders, which are variously shaped in accordance with their
 relation to the plane of the section.   Both are imbedded in the same con-
 nective-tissue stroma, but in his figure, as in the Museum preparations, no
 anatomical connection between the  two  is  shown.  They are  separated
 always by connective tissue.  Nevertheless, I am not prepared to deny that
 transformations of  the true gland-tissue of the parts involved play a certain
 role' in producing the texture of cancerous growths.   But just how far they
 are atrophied and perish, how far at times a formative activity may lead to
 their transformation, are matters as to which it is difficult at present to form
 a judgment, and  to which I hope  to return  at some future time.  Mean-
 while I cannot avoid calling attention to two more of Billroth's wood-cuts,
 Fig. 148, page 648, and Fig. 150, page 651,  (loc. cit.,) the first  representing
 the 'extension of cancerous tumor into the fatty tissue about a lymphatic
 gland,' the second  'cellular infiltration of the fatty tissue in the periphery
 of a hard cancer of the breast.'  Either figure might have been drawn from
 the altered fat in the sections of the two breasts described in this paper, and
 the appearances are such that, as Billroth well remarks,  'we can  scarcely
 avoid thinking that in these cases, also, white blood-cells escaping from the
 vessels cause the cellular infiltration.'  With this suggestion I heartily agree,
but the real and difficult point in the analysis of cancerous tumors, as of so
many pathological transformations,  is to define with precision the exact part
which  the emigration of white blood-cells plays in the process,  how far it is 
143
the principal, how far merely the accessory alteration.   This report is offered
as a preliminary contribution to the study of this question, now become so
important in reforming our pathological doctrines.  I may mention  in con-
clusion that the microscopical sections referred to were all made by Dr. E.
M. Schaeffer, and that they  are permanently preserved in the Microscopical
Section of the Museum, where they may be  examined by any one interested
in the subject."
    The  great mistake  which appears to  have been  made by the older
authorities in  relation to the pathology of cancer has been in investigating
it as a special disease, without due regard to the particular organ or part of
the body in which it may have been developed.
    This error is now being corrected, and we are beginning to learn some-
thing of the true nature of this formidable disease.
    A diligent examination of the  investigations of others, and the  careful
analysis of a comparatively large number of  cases which have come under
my own  observation, induce me to believe—
    First. That cancer is not constitutional in its origin, but the result of a
slowly transpiring interstitial inflammation,  dependent upon local irritation.
    Secondly.  That there is no specific cancer-cell, the cells found in the
connective-tissue stroma being altered epithelial cells or the white corspuscles
of the blood,  their different  appearances in different forms of cancer being
dependent upon the stage of the disease and the  organ in which it is devel-
oped.
     Thirdly.  That the probability of secondary cancer occurring after the
ablation of a primary tumor depends upon  the richness of the part in lym-
phatics and the stage of the  disease.
    Frequency of the disease.—The  absence  of a proper system of registra-
tion in this country precludes the possibility of furnishing reliable statistics
of this disease.  Indeed, the tables  of mortality of  England are not  strictly
correct, although the approximation to exact results is sufficiently close to
render them exceedingly valuable.
    The  entire number  of deaths  from  cancer reported as occurring in
England,  Ireland, and  Scotland, from 1851  to 1871, was  124,740.   Of
these, 31,816  were males and  92,924 females; the excess, 61,108,  of the
females over the males being attributed to cancer of the uterus or mammae. 
144
In proportion to population, the death rate from cancer in Paris is largely
in excess of London, and this, I think, can readily be explained by a con-
sideration of its causes.
     In the large  cities, as compared with  the  rural districts, the rate  of
death from malignant disease is much higher.   M. Tanchou computes the
deaths from cancer in  the arrondissements of Sceaux and St. Denis at 1.63
per cent, of the total mortality of the suburbs, while intra-muros, or in Paris
proper, the estimate is 2.54 per cent., showing that this disease is much more
frequent in the capital than its environs.
     In England the frequency of  cancer in the  counties, as compared with
London, is in the proportion of 1 to  1.4406.   The remarkable agreement in
these proportional numbers, deduced from two independent registers, would
seem to justify the conclusion  that  city life is favorable to the production
of cancer.
     In the  Department of the Seine, the mean  of ten years from 1830 to
1840 of deaths from cancer was 0.75501 to every 1,000 living.  In England
and Wales the mean for the same time was 0.18954 for every 1,000 living.
     After making every allowance for the difference in the system of regis-
tration in the two countries,  we shall find the mortality from cancer in the
department of the Seine to be  nearly four times greater than it is in En-
gland  and Wales.
     In America it is impossible to  ascertain the relative proportion of cancer
to other fatal diseases;  but, from all the available data, I am satisfied that.
the proportion is very largely in excess of that of Great Britain or France;
and that, within the last ten  years,  the numbers afflicted with this disease
have increased out of proportion to the increase in the population.
     No  calculation as to the  general frequency  of the disease can be made
from the reports of hospitals set apart for the special treatment of females,
but a very correct estimate  can be  obtained of its proportion to all other
diseases to which women alone are subjected.
     The general law governing disease appears to exercise little influence
on cancer.   Concentration of population and imperfect hygienic surround-
ings do not increase its frequency.
     In 470 deaths from cancer occurring in thirty-one of  the  Unions or 
145
parishes in London between July, 1837, and December,  1838, we find the
following anomalies:
Thirty-one unions.	Population in 1838.	Deaths from cancer.		
		Males.	Females.	Total.
A. 10, most unhealthy___ B. 11, medium salubrity.. C. 10, healthiest..........	517,288 505,746 787,785	14 36 46	82 103 189	96 139 235
				
    From this it would seem that the mortality from this cause increases
with the salubrity of the locality;  a result which is rendered  more startling
by comparing it with the calculations of Mr. Farr, of the annual mortality
from all diseases, from typhoid fever, and from phthisis in the same districts,
as exhibited in the following table:
Districts.	No. of square yards to one person.	Annual general rate of mortal-ity per 1,000 living.	Annual rate of mortality per 1,000 from—		
			Typhoid fever.	Phthisis.	Cancer.
A. B. c.	57 78 219	33. 21 28.39 21.63	3.24 2.05 1.07	4.78 4.51 3.54	0.124 0.183 0.199
     If cancer was the result of a general blood-poisoning, if a pre-existing
cachexia was  necessary for its development, we should naturally look for
an increased number of cases among the lower classes, who inhabit poorly-
ventilated houses in  unhealthy portions of large cities, as we find all other
blood-diseases fearfully increased among that class of the population, but
the reverse is the case.
     Temperament,—Persons of lymphatic temperament are much more prone
to this disease than those of sanguine or sanguineo-nervous.  Of  167 cases,
coming  under my own observation, 123 were of lymphatic temperament,
and 44 of sanguine or sanguineo-nervous.
         19 
146
    Age.—In Europe, of 1,000 cases of carcinoma uteri and mammae, in
which the statistics were collected—
                    32 were between 20 and 30 years.
107 <	30 <	35
126 <	' 35 '	40
189 l	< " 40 '	45
280 '	' " 45 '	50
162 <	' " 50 <	60
84 «	60 '	65
20 '	1 above 65	
     More than half of the entire number occurred between the ages of thirty-
 five and fifty.   In this country, so far as my limited observation has extended,
 the larger number of cases occur between the ages of thirty-five and forty-
 five.   Of the 167 cases referred to above none were under 30—
                    11 were between  30 and 35 years.
                    44   "     "     35  "  40   "
                    77   "     "     40  "  45   "
                    23   "     "     45  "  50   "
                    12   "   above   50          "
     According to Mr. Paget's  tables, the larger  number of cases of cancer
 occur between the ages of forty-five and fifty.  In  this country, women
 develop, mature, and fail earlier by at least five  years than English women.
 This anticipation  of five years in the decadence of American as compared
 with English women reconciles the difference  in  the two tables.  Of the
 2,781  cases, the statistics  of which were collected and reported by M. Le
 Eoy d'fitiolles, as occurring in France, 1,227 were above forty, and 1,061
 above  sixty, leaving 493 below forty.   (London Lancet, June 3, 1843.)
     Menstruation.—Whether scanty, profuse and  painful, painful, postpon-
 ing, irregular, or anticipating, appears to have no special connection with the
 development of cancer.
     Fecundity.—It has been asserted  by many authorities, though ample
proof to the contrary has long since been adduced, that single women, and
those who were sterile, were most liable to be attacked by cancer.  The
truth is the direct reverse of this statement.
    Out of 134 cases of carcinoma uteri reported  by  Dr. West, but 3 were
single women, and only 8 were sterile; in other words,  there was  but 1 sterile 
                                 147

marriage in 16.3 of the cancer-patients.  In St. Bartholomew's Hospital the
average is 1 sterile marriage in every 8^5.
     The further we extend this inquiry the stronger becomes the evidence
that extraordinary fecundity predisposes to cancer.
     After deducting the 3 single and 8 sterile cases  from the above 134
cases, w© have 123 women whose marriages  had been fruitful, they having
been pregnant  844 times; 685 of the pregnancies  terminated  at full term
and 158 prematurely, the average being 6.8 pregnancies to each woman,
with 5.5 children born at full period, and 1.2  miscarriages.
     The average number of children born to each married woman in Eng-
land is 4.
     The following table shows the number of pregnancies to each of these
123 women, the number of children born to each, and  the number of abor-
tions, and, as will be seen, there were only two  out of the whole number
whose pregnancies resulted in nothing but abortion:
Number of	Pregnancies	Number of	Children	Number of	Abortions
women.	to each.	women.	to each.	women.	to each.
13	1	14	• 1	28	1
13	2	13	2	17	2
10	3	15	3	8	3
4	4	8	4	4	4 •
9	5	14	5	6	5
13	6	12	6	1	7
13	7	12	7	1	8
* 7	8	8	8	1	11
8	9	7	9	..	..
6	10	7	10	..	..
9	11	2	11	..	..
6	12	3	12	..	..
5	13	2	13	..	..
2	14	2	14	..	..
	16	1	17	..	..
	18	1	18	..	..
	19	..	..	..	..
	20	..	..	..	..
	24	--	--	--	--
123		121		66	--
    In 14  of the 123 cases  referred to by West, the symptoms of cancer
were discovered almost immediately after the termination of pregnancy, or
at least within  a  sufficiently short period to connect the disease with the
changes occurring in the puerperal state.
    In the 167 of my own cases of cancer of the uterus and mammae referred 
148
to in the following table,  and of which I have retained full  notes, all had
been married or borne children.
Number of patients.	Number of pregnancies to each.	Number of children to each.	Number of abortions.	Total number of children.	Total number of abortions.
17	2	2		34	
15	3	3	..	45	..
5	3	2	1	10	5
7	3	..	3	..	21
23	4	4	..	92	..
13	4	3	1	39	13
5	4	1	3	5	15
1	4	..	4	..	4
3	5	5		15	..
11	5	3	2	33	22
7	6	4	2	28	14
1	6	1	5	1	5
3	6		6	..	18
3	7	7	..	21	..
8	7	4	3	32	24
4	7	2	5	8	20
2	8	8	..	16	..
10	8	5	3	50	30
3	8	2	6	6	18
1	9	6	3	6	3
1	10	8	2	8	2
24	Sterile.				
     From the above table it will be seen that among the 167 women there
 were 663 pregnancies, 449 children at full term, and 214 abortions.  With
 33 more patients than West reports,  there were 180 less pregnancies, and
 56 more abortions.  Upon  reflection we  must ask ourselves the question,
 "Are English women naturally more prolific than American, and is the crime
 of abortion more prevalent in this country?"
     These tables do not strengthen the theory of the constitutional origin
 of carcinoma uteri, but rather show that it is the result of imperfect or per-
 verted nutrition  of the part, consequent upon the often-repeated changes in
 its tissue which occur during the puerperal state; and that those women who
 have  undergone these changes most frequently are the more liable to  its
 attack.
    Hereditary influence.—Until quite recently, authorities were agreed upon
the constitutional origin of cancer, and so generally was this opinion received
among the profession and laity that the strongest objections have been raised 
149
against marrying into a family where one of its members had died of cancer;
it being regarded as almost certain that the  disease would be transmitted.
Many a woman's life  has been made wretched by the constant fear that in
herself would be developed eventually the fearful malady from which her
motlier suffered.  Let us carefully examine  the  ground  upon which this
universal belief has  rested, by  appeal to the cancer records.
     Of 160 cases of  cancer of all parts collected by Paget,* 26 presented,
as he terms it, "the history of hereditary cancerous taint," or 1 in 6.1.  In
102 cases, referred to  by Lebert,f the same fact was ascertained in reference
to 14, or 1 in 7.2.   In 8 out of 49 cases of cancer of the womb, referred to
by West, the following was the history:  in 1, the father had  died of cancer of
the throat; in 2, the  mother;  in 4, the sister had  died  of cancer of the
womb;  and in 1, the  sister had died of cancer of the breast.   In 21 of the
cases to which I refer, some one of  the members of the family had died of
cancer, or  at least it was so supposed; but 6 of  these 21  were believed to
have died of cancer of some internal organ, but  no  post-mortem  examina-
tion had been made, leaving room for considerable doubt.   If we take the
whole  number of these cases, and  they constitute a fair  average,  we shall
find that, out of the 478, there  existed what has been  termed hereditary taint
in 69, or 14.5 per cent.  Could we find 478 patients afflicted with any disease
as common as cancer, for instance, "pneumonia,"  which  no one  suspects
of being hereditary,  and  not  discover as many as  69 out  of the number
whose  parents or near relations  had "pneumonia"  before them?  Are we
on that account to aver that the  disease is hereditary, and the result of a
constitutional taint?  By no means; and yet on this  slender basis rests the
whole  theory of the hereditary character of cancer.   M. Le Roy d'Etiolles
collected with much care and accuracy the history of 2,781 cases of cancer
occurring  in France,  and  reports  that 54 per cent, of the whole number
occurred in the breast and uterus, and that only 1  in 278 presented a history
that would permit of a supposed hereditary transmission.   (London Lancet,
June 3, 1843.)
     Causes.—Whatever tends to excite a slow interstitial inflammation of
the cervix uteri at the time of  life when the tissues are more prone to retro-
grade than progressive metamorphosis.
     Acute inflammation  allowed to degenerate into a sub-acute or chronic
form.
*0p cit., vol. ii, p. b'.iS.
t Op cit., p. 134. 
150
     Repeated parturition, inducing imperfect involution, which terminates in
 a slow grade of inflammation.
     Abortion, especially when often repeated, is one of the principal excit-
 ing causes.  In my judgment, the percentage of deaths from cancer in cities
 in excess of the rural districts is mainly due to the habit among some fash-
 ionable women of  procuring  criminal abortions whenever they find them-
 selves pregnant, not desiring to increase their families or have their pleasures
 interrupted by maternal duties.
     My own experience has been the reverse of that of Dr.  Gaillard Thomas,
 who says he has never found a case remotely sustaining the position that
 chronic inflammation was an exciting cause.
     I have seen very few  cases where the history did not unmistakably
 point to this condition as the exciting cause of the disease.
     The  older writers were not far wrong when  they described cancer of
 the uterus as a disease slow  in progress, continuing in its first quiescent stage
 of scirrhus not only for months but for years, and then,  excited by one knows
 not what cause to activity, passing into the state of ulcerated carcinoma, and
 thus at its close quickly destroying the patient.
     They confounded the  pre-existing state of chronic inflammation and
 induration of the  cervix with its sequelae, "cancer."
     Paul of ^Egina, in referring to carcinoma uteri, remarks: "The uterus
 becomes scirrhous sometimes all at once without any preceding complaint,
 but most frequently after having been preceded by inflammation, which has neither
 been resolved nor converted into an abscess.11
    Riudfleisch, who writes twelve centuries after, and is to-day one of  the
 highest authorities,  remarks: "According to my comprehension, the  question
 in  hard, glandular carcinoma is about a slowly  transpiring interstitial  in-
 flammation,  whose  cellular products  are  converted into  epithelial structures
 instead of pus or connective tissue.11
    The relation of chronic metritis to malignant disease of the uterus has
been  traced by some  observers so directly that there would scarcely seem
to be a doubt that ihe minor is frequently transformed into the major disease.
    Dr. E. Noeggerath, in a paper read before the New York Academy of
Medicine, and published in the American Journal of Obstetrics, vol. 11, p.
5*05, relates a number of cases where he had amputated the  cervix for can-
cerous disease supervening upon chronic metritis. 
151
     Astruc claims that a large majority of cases of carcinoma uteri are the
 result of abortion.
     Re'camier, Lisfranc, and still later Ashwell, Montgomery, Duparcque,
 Blatin, and Xivet, express their  belief that  scirrhus results from  chronic
 inflammation of the parenchyma, and in this they simply indorse the opin-
 ion of Galen, Pierry, Andral, Paul of iEgina, Broussais, Breschet, Bouil-
 laud, and many others.
     Treatment—'Curative, Palliative, and Prophylactic,—When the disease is
 fairly  established  in  the neck of the uterus,  or  in  any external portion of
 the body, complete removal by some one or other of the following means is
 the only chance for saving the life of the patient: Excision by the  knife or
 eVraseur;  destruction by  some  powerful caustic,  by the actual cautery,
 or by compression;  and  the probabilities of success  will depend upon
 the stage  of  the  disease,  and the  constitution  and temperament  of the
 patient.
     If we are to rely upon statistics, the success attending the removal of
 cancerous growths is  so small that little  inducement is held out to the sur-
 geon to undertake the operation; nor must it be  supposed that the long list
 of failures is due to any want of skill or good judgment on the part of the
 operator when once the operation has been decided  upon.  I fear, however,
 that extreme caution  sometimes induces my professional brethren to delay
 surgical interference until the symptoms of the disease are so strongly pro-
 nounced that  the  case becomes hopeless.  Removal by excision  to be suc-
 cessful must be performed early, at a time when the knife can get behind
 the  disease,  which means, according to the  modern pathological views,
 "before the altered epithelial cells, or white blood corpuscles, have  escaped*
 into the lymphatics and gotten beyond our reach, and by their  aggregation
 and multiplication in contiguous parts given rise to secondary disease."  That
 this takes place much earlier in some patients than in others, the history of
 reported cases furnishes abundant evidence.
     We find in  some  instances when  the tumor has been removed in  the
 early stage of the  disease, that a secondary growth has appeared within a
few weeks afterward,  and, in others, when an operation has been performed
as a mere palliative measure, there has been n© return of the disease, either
at its original site or in any distant organ.  As remarked in an early part
of this  article,  we have improved little in the treatment of cancer within the 
152
last eighteen hundred years.  As a  mere matter of interest I will refer to
some of the oldest authorities on this subject.
    Claudius Galenus, or Galen, A. D. 170: "Cancer is only curable at its
commencement; when it has attained any considerable magnitude, it admits
of no remedy without a surgical operation.  Cancer of the womb, it is neither
expedient or possible to operate upon."     *     *     *     *     *
    "If ever you attempt to cure  cancer by an operation, begin by purg-
ing the melancholic humor, and, having cut away the whole affected part so
that not a root  of it be left, permit the blood to be  discharged, and do not
speedily restrain it,  but squeeze the surrounding veins so as to force out the
thick part of the blood, and then cure  the wound like other ulcers."
    Hippocrates, B.  C.  460,  forbids  the  surgeon  from  interfering  with
occult cancers,  that is to say, with such  as have not ulcerated, remarking,
"that if healed  the patient soon dies,"  whereas,  "if let alone, he may live a
long time."  (Aph., vi, 38.)
    Aetius, A.  D., 500, the  first Christian  physician whose writings have
come down to us, gives the following description of the operation on a can-
cerous mamma: "Laying the patient in a supine position, I make an incis-
ion into  the mammae above  the cancer, and immediately apply a cautery
until an eschar be produced to  stop the bleeding; I then make another in-
cision, dip into  the substance of  the mammae,  and again burn the  parts, and
so proceed, first cutting and then burning;  in this way there is no danger
of haemorrhage.  After the amputation has been completed, I again burn the
parts until they are quite dry."
     Haly Abbas recommends extirpation by the scalpel when the cancer is
seated in the  extremities  or in the mammae, and advises to allow the part to
bleed for some  time to wash out any of the melancholic humor, but does not
advise the application of the hot iron.
     Albucasis  says he never saw a  case  of cancer cured by extirpation,
unless it was small and recently formed;  but when the mamma is removed,
if there is a redundancy of flesh, he makes two lunated incisions, and removes
the intermediate skin with the gland, and when  the haemorrhage has ceased
brings the two  edges together with sutures.
     Soranus, A. D. 53, recorhmends the extirpation of  the cancerous breast
when not adherent to the ribs, but when adherent  considers the operation
unjustifiable.    He  remarks that in  scirrhus there is little danger  from
haemorrhage. 
153
     In cancer of the uterus, our  remedies are 'mostly palliative, as we are
seldom called upon to see the patient sufficiently early to permit of an}' truly
remedial measures.
     If the disease is confined to the vaginal portion of the cervix, and the
contiguous tissues are not implicated, the indications are to remove the neck
as high up as possible, without endangering the peritoneal cavity.
     The following is the method I adopt:  The patient being placed on her
left side, and the parts exposed by the duck-bill speculum, the cervix is seized
by a strong volsella, and sufficient traction  made  to bring it fairly within
reach; it is  then severed by a pair of strong blunt-pointed scissors, cutting
from the periphery toward the center, first on the right, and then on the left
side.   There  is less haemorrhage in the use of the scissors than the knife ;
what little bleeding occurs  is  easily arrested by penciling the raw  surface
with a crystal of the persulphate of iron.
     There is considerable danger in the use of the Ecraseur, the tightening
chain being apt to  draw in  more  tissue than was intended to be removed;
it has,  in some instances, torn through into the peritoneal cavity.
     Dr. Sims  mentions a case in which this accident occurred to him when
operating in the presence  of Dr. V. Mott.
     When the disease has advanced too far  to permit of amputation of the
cervix, our treatment will necessarily be confined to palliative measures, for
the purpose of retarding the ulceration, relieving the pain, and  destroying
the fetor of the discharges.
     I have found pure bromine more effective than any other caustic in arrest-
ing rapidly destructive ulceration.  It appears to permeate the tissues more
thoroughly than any other with the operations of which I am acquainted; it
requires to be used with great care, not only with respect to the patient, but
to the operator—care to the patient in order to protect the sound parts from
its corrosive action—and care  on the  part of the operator to avoid inhaling
its fumes,  which produce severe bronchitis.
     To destroy the fetor of the  discharges I  use bromo-chloralum; carbolic
acid is equally effective, but it has an unpleasant odor, and is on that account
objectionable.  To relieve pain I have found nothing so efficient as morphine.
In the  earl}' stages, conium  has answered  well, but in severe paroxysms it is
not sufficiently powerful.
     With all the resources of modern surgery, and the entire armament of the
       20 
154
materia medica, our best efforts fail in arresting the disease when once estab-
lished in the uterus, and  scarcely are we able to mitigate the sufferings of
its unfortunate victims or retard the fatal issue.  Hence it behooves us to
endeavor to prevent what we are compelled to  admit cannot be cured.  If
chronic inflammation of the cervix in some constitutions results in carcinoma,
will it not be good practice to amputate the cervix whenever the disease is
found  intractable  to  ordinary remediable measures?   Why not  give  the
patient the security which this operation affords?
     It may be argued that we have no evidence that she would suffer from
malignant disease.  True, we have no absolute evidence that such would be
the sequela;  but the probabilities are  strongly in its favor, and even were
nothing more to be dreaded than a continuation of the existing disease, am-
putation of the diseased part would be the best treatment that could be pur-
sued, for quite a large majority of these cases of chronic  cervical metritis are
incurable by any other means.  They yield apparently for a time,  but only
to return with increased obstinacy.   (See Cervical Metritis.)
     The operation itself is  devoid  of any special danger,  and,  contrary to
what might be expected, the function of the organ remains unimpaired.   I
have delivered three women at full term from whom I had previously removed
the cervix uteri,and the only appreciable effect which I noticed was a short-
ening of the labor.
     Lisfranc  successfully  amputated the cervix ninety-nine times.  It is
now a  common operation with  every gynaecologist, and with a little care
always successful.
     It must not be understood that I recommend amputation of the cervix
uteri for chronic inflammation as an operation to be  resorted to in the early
stages of that disease, but only when all other means of resolving the inflam-
mation and induration have failed.  I then resort to it  as a curative and
prophylactic measure.
                          Cancer of the Uterus.
                                Case  1.
     Mrs. S. L----; aged  thirty-seven;  admitted to hospital January  12,
1867, by request of Dr.  F.  Howard; American by birth; has been married
twice;  pregnant eight times; has given birth to three children, the youngest
being seven years of age.   Her abortions had not been the  result of acci-
dent, but of design. 
155
     The history  of the case,  as  detailed by  herself, was as follows: "I
 enjoyed perfect health until after the birth of my first child, from which I
 did not recover for several months, having been attacked on the fourth day
 after its birth with child-bed  fever.   My next five pregnancies I stopped
 between the second and third months by the use of a catheter.   I suffered
 little from their effects, at least, noticed but little  difference in my feelings,
 for I was never well, always having pain in my back  and some discharge
 from the womb.  Intercourse with my husband was painful, and sometimes
 almost  intolerable.  Being  told that my health might  improve  if I had
 another  child, I consented to go the full term, and my last child was the
 result.  I was, however,  disappointed, for I  experienced no benefit, but, on
 the  contrary, felt weaker than before.  I tried to  nurse  my child, but was
 unable to do so.
     "The last year I have been perfectly helpless, and my agonies beyond
 description.   When night  came I prayed for morning, and when  morning
 came I prayed for night.  During the past few months I have had repeated
 haemorrhages,  which generally continued until I lost consciousness."
     The patient was brought to the hospital apparently in  a dying condi-
 tion ; her appearance characteristic  of her  disease.  She was. thin to ema-
 ciation; complexion waxy; pulse 140; constant nausea, vomiting whatever
 was taken into  the stomach; colliquative diarrhoea and sweats.  About six
 hours after her admission she was attacked with a violent haemorrhage, which
 was controlled by  a tampon introduced into the vagina.  Brandy and mor-
 phine were freely administered per rectum.
     January 14.—The  tampon was  removed  and a  careful examination
 of the uterus  made.  The vaginal portion  of the  cervix was completely
 destroyed, the vaginal mucous membrane terminating in a chasm,  which
 opened into  the uterus, and was sufficiently large to permit the finger to pass
 easily into its cavity, which was irregular and hard, presenting the charac-
 teristics of cancer.
     The vaginal mucous membrane appeared free from the  disease, the line
 of demarkation being distinct.  The ulceration in this case had passed upward
into the body of the uterus, which was rapidly undergoing destruction.
     Before her admission she had taken large quantities of morphine, as
much as three  grains having been administered in six hours during severe
paroxysms, with little apparent effect. 
156
     The condition of the patient was  utterly hopeless;  she had become so
accustomed to narcotics that they were almost useless as a means of allay-
ing pain;  her passages were involuntary, the constant nausea prevented any
nourishment being administered, the cheeks and fauces were  covered with
an aphthous deposit, and  the  breath  partook of the general fetor  of  the
discharges.   Death was evidently approaching in its most revolting form.
     A case so desperate justified the trial of any means that could be sug-
gested to  alleviate the  more distressing symptoms, and, after consultation
with Dr. F. Howard, whose patient she was, it was determined to try the effect
of the local  application of bromine, as suggested by M.  Landolfi.  In  this
case pure bromine was used instead  of the paste recommended, for which
the following is the formula:
                          Chloride of bromine, 3iij;
                          Chloride of zinc, 3ij ;
                          Chloride of antimony, 3j ;
                          Chloride of gold, 3j;
to which,  when thoroughly mixed, add enough liquorice to form a paste.
     The  woman, being too  low for the administration of any anaesthetic,
was placed on her back and the uterus exposed by an ordinary glass specu-
lum, it being preferred in  this  case to  the duck-bill, as  it protected more
perfectly the sound parts from  the corrosive  action  of the caustic.   Small
pieces of sponge were passed into the uterus until it was packed full; a hard-
rubber syringe being charged with pure bromine, and the long nozzle insin-
uated through the pieces of sponge up to the fundus, the piston was slowly
pressed down, permitting the bromine to flow  out in drops, which were
instantly absorbed by the sponge.   A piece of dry  sponge was placed over
the opening into the uterus to absorb any of the bromine which might escape
with the  discharges, and around this cotton soaked in castor-oil was packed
to protect the mucous membrane of the vagina.
    No increased pain was experienced from the application, and for some
days no apparent benefit resulted.  The patient was sustained by injections
of beef-essence,  milk-punch, and brandy.   A morphine suppository was
introduced every six hours.  The tampon was removed on the second day,
and for several succeeding days a large number of sloughs were thrown  off
with the debris of the sponge; no unpleasant odor accompanied the  dis-
charges, which proved a great relief to the patient and attendants.
    February 7.—Fourteen days after the application of the bromine.   There 
157
was a very decided improvement in the condition of the patient; the bowels
were under better control, and less nausea existed;  she retained a little milk
and lime-water.   The pain was still severe, but she described it as being of
a different character.
     The bromine was again applied in the same manner as before, and with
the  same precautions for the protection of the sound parts.   The tampon
was removed on the second day, and no discharge of any kind was observed
for at least forty-eight hours, after which time the sloughs commenced com-
ing away, and continued to do  so for ten days  or  more.  During this time
the patient was slowly but surely improving.  All nourishment and stimu-
lants were given by the mouth, and retained.  Morphine suppositories were
continued.  The uterus was washed out several times daily with warm water
and glycerine.
     March 3.—Considerable haemorrhage followed the uterine injection, but
it was readily controlled by the local application of tincture of perchloride
of iron.   Citrate  of iron and quinine was exhibited internally.  From this
time  until April 16th the general improvement continued; there had been
no  return of the haemorrhage, and but  little pain.  A careful examination
showed the cavity of the uterus to be smooth, and, as far as could be ascer-
tained, free from suspicious tissue,  but it was thought better to re-apply the
bromine thoroughly to its entire surface.  The duck-bill speculum was used
on this occasion to expose the part, and unfortunately  some of the bromine
came in contact with the vaginal walls and caused quite  an acute inflamma-
tion, which, however, was  easily arrested by the  application of glycerine
and Goulard's extract of lead.  Acute pain followed the  use of the bromine
on this occasion, and for some days my patient was much worse, and all that
had been gained seemed on the verge of being lost,
     The  thin  shell of  uterine tissue  was not  sufficient to protect  the
peritoneum from  the action of the caustics, and peritonitis resulted.  The
pulse went up to 140, and the patient fell into  a  semi-comatose condition.
From this condition  she rallied, the pain subsided, her pulse  came down to
110, her appetite returned,  and she became quite cheerful.
     May  24.—The  change that had taken place  in this  case was  no less
surprising than gratifying.   She was able  to walk about the room, quite
free from  pain  or  discharge of any kind, her appetite and digestion good,
and she was rapidly gaining strength. 
158
      June 3.—Upon examination the uterine  walls  were found extremely
  thin, but apparently healthy; there was no abnormal discharge from the
  vagina, and the health of the patient had become restored.   She was advised
  to continue some preparation of iron for a few months.
      June 4.—Discharged.
      I occasionally visited  this lady for several months.  She was keeping
  house, did her own marketing, and superintended her domestic concerns.
  She assured me that she was in better health than she had been for years.
      About  eight months after leaving the hospital she went with her hus-
  band to reside in New Jersey, where she died twelve months afterward from
  pneumonia,  as stated by her attending physician.
      I have  no comment to  offer  on this remarkable case; the facts must
  speak for themselves, and be taken for what they are worth.

                             Carcinoma ideri.
                                Case  2.
      R- S----J  aged thirty-six;  admitted January 7, 1867; American  by
  birth; married when she was eighteen years of age;  had  never borne chil-
  dren, or been pregnant.  She  had suffered for several years from all the
  symptoms of uterine disease, but had not submitted to an examination.   She
  complained  of intense  lancinating  pain in the region of the womb,  more
 severe at times, constant pain in the loins and hips, and painful micturition;
 offensive  discharge from the vagina,  excoriating the thighs and labia.
     Examination.—Posterior lip of os uteri destroyed;  anterior lip hard and
 nodulated; the body of the uterus large and intensely hard, but not fixed in
 the pelvis; the broad ligaments thickened.
     There was nothing to be gained by amputating the cervix, as the disease
 had advanced far beyond its boundary.  All  that  could be hoped for was
 to relieve pain by the destruction of as  much of the diseased tissue as was
 within reach.                                                  . •
     January 12.—The galvano-cautery was applied freely to every accessi-
 ble part, and a suppository,  containing one grain of morphine, introduced
into the rectum.
    January  13.—She had suffered considerably during the night, but was
easier.
    Injections of tepid water, with Labaraque's  solution, were administered 
159
two or three times daily, followed by morphine suppositories.  The sloughs
resulting from the cautery separated slowly, and it was not until the tenth
of February that the parts were in a condition to admit of further interfer-
ence.   The os was then found sufficiently patulous  to admit of the intro-
duction of small pieces of sponge into  the uterine  cavity,  and it was deter-
mined to apply the bromine, as was done in Case 1 with such good results.
The application caused no additional pain, but failed to give the relief hoped
for.   The sloughs came away slowly, and  the  discharges were excessive,
but not foetid.
    March 8.—The cavity of  the uterus was smooth, the ulcer on the ante-
rior lip  and that remaining from the destruction of the posterior lip looked
healthy.
    The patient,  being  anxious  to leave for her  home, was discharged
March  12.   She died July 7,  1867.
     Commentary.—The bromine was not applied in this case with any hope
of curing the  disease, but to  destroy  as much of the cancerous growth as
was within reach,  hoping thereby to lessen the pain and alter the character
of the discharges.   In the first it failed; in the second it accomplished what
was desired.

                             Carcinoma uteri.

                                Case  3.

    Mrs. G----;  aged forty-one;  admitted  March 1,  1867;  has been preg-
nant  seven times; given birth to three children at full term, and had four
miscarriages.   She complains  of a dull aching pain in the back, from which
she has suffered for more than five years; does not think it any worse now
than formerly;  within the last three  months she has had several haemor-
rhages,  and noticed an alteration in the character of the vaginal discharges,
which had become watery and offensive.
    Examination,—Cervix uteri entirely destroyed; uterus of stony hard-
ness and fixed in the pelvis; neither bladder nor rectum apparently involved.
From the general  appearance  of the patient, no suspicion  would have been
entertained that she was the victim of a malignant disease.   She was plump,
well nourished, of a healthy complexion, and cheerful.
    After being informed of the nature of her complaint, she continued as 
160
cheerful as before, but refused to permit of any remedial or palliative treat-
ment, not even consenting to the administration of a grain of opium.
     There was no apparent change in  the condition of this woman up to
April 26, when she was attacked with haemorrhage from  the stomach and
vomiting, which was arrested by the application of ice.
     April 27, 10 a. m,:—Sinking rapidly;  she died  at 11 p. m.   During the
last six hours  of life her cries were most distressing, being similar in char-
acter to the hydrocephalic cry of children.

                            Carcinoma uteri.

                                Case  4.
     L. I----; aged thirty-nine;  admitted June 16, 1867; married at nine-
teen ; first child born when she was twenty.  Second pregnancy resulted in
miscarriage, and second child was born  sixteen  months after the first.   The
next pregnancy occurred when the second child was four months old, and
she  aborted at the third month.   Again she became pregnant and aborted
about the same time; twelve months afterward, became pregnant again and
continued the full term.   From the birth of this child she fully recovered,
and enjoyed perfect health more than eight years, when she became preg-
nant with her last child, of which she was delivered at full term.   From the
birth of this child her recovery was very slow, she not leaving her bed for
more than five weeks.
     She went abroad for the first time when her infant was nine weeks old.
In getting out of a car, in which she had been riding, her foot slipped, and
she  came suddenly down,  giving herself a severe shock, and causing great
pain in the lower part of the abdomen.
     Acute metritis  followed,  and  she  was confined to her bed for  four
months.   From this sickness she never fully recovered, complaining of con-
stant pain in  the back, painful micturition and defecation, continuous dis-
charge from the vagina, and pain during coitus.
     Examination,—Cervix large, hard, and nodulated; body of  uterus large
and hard; pressure  in the posterior cul-de-sac causing, great pain; uterus
immovable.
     The discharge was light-colored,  muco-purulent, and inoffensive.
     The treatment was merely palliative and sustaining, as injections of 
161
antiseptic lotions, iron and quinine internally, and suppositories of morphine
to allay pain.  As no cure could be promised, she left the Institution to return
to her home on August 3.
     This lady fell into the hands of some quack, who promised to cure her,
and under whose treatment she died March 23, 1868.
     Commentary.—The rational conclusion  in this case is, that the metritis
from which  this patient  suffered after the  birth of her last child, and six
years prior to her admission into the hospital, was never completely subdued,
but remained in a chronic form, and terminated in the attack  of cancer.
When the existence of the disease was discovered, it had advanced too far
to admit  of  any surgical  interference.
                  Carcinoma uteri—Amputcdion of cervix.
                               Case 5.
     F. E----;  aged thirty-seven; admitted July 17, 1867;  American by
birth; temperament phlegmatic; was  married at  fifteen; is the  mother of
seven children,  and  has  never miscarried.   Her  general health has  been
good until the last two years, since which time she  has  suffered  from pain
in the  back, loins, and breasts, vaginal discharge, and a feeling of general
malaise.
     Examination disclosed the cervix large, hard, and  nodulated;  os patu-
lous for three-quarters of an inch;  the internal os and uterine cavity appar-
ently normal.
     The body of the uterus being uninvolved, and the upper part of the
cervix apparently free from disease, it  seemed to be a proper case for ampu-
tation,  and its removal was accordingly advised.
     It being inconvenient for  the woman to remain  at the  hospital, the
operation was performed  at her own house.
     The patient having been placed on her  left side, the parts were exposed
by the duck-bill speculum; the cervix  seized by a volsella, drawn down and
severed close to the reflection  of  vaginal  membrane.   No provision was
made for flaps, but the stump left to heal by granulation.
     All her distressing symptoms were relieved in the course of a few weeks,
and she became eventually restored to perfect health.
     A microscopical examination of a portion of the tissue removed proved
it to be a case  of epithelioma. 
162
     I delivered this woman of a child at full term, in February, 1872.  The
labor was normal, the recovery rapid, and no evidence existed of any return
of the disease.
                            Carcinoma uteri.
                                Case 6.
     Mrs. T----; aged forty-four; admitted May 12, 1867;  American  by
birth; temperament phlegmatic;  married at nineteen.   She enjoyed  good
health until thirty  years of age, when, uterine disease being manifest, she
consulted a physician, under whose  care she  recovered, and  shortly  after
became pregnant for the first time.
     A miscarriage  occurred at the sixth  month, brought on by a fall down
the cellar-steps of her house.
     This accident  was succeeded by slow but apparently sound recovery.
She again became pregnant, and aborted at the third  month  without any
apparent cause.
     Three more pregnancies and a like number of abortions followed.  Her
recovery from the last left her with a feeling of uneasiness in the pelvis and
pain  in the back, which increased, and for which she again consulted her
physician, under whose care she remained for more than two years,  with
slight evidence  of  improvement.  Her general health  declining, she was
advised to return to her native State, California.  This  she did, remaining
there more than a year, with much apparent advantage, having grown  stout
and strong.
     April 3, 1867.—She returned to her home in Washington, the  only
annoyance from which  she then suffered  was an offensive watery discharge
from  the vagina, which had been of some months' duration, but unaccom-
panied with pain.
     Examination.—Uterus  large, hard,  and  fixed  in  the pelvis;  cervix
enlarged and the posterior lip of os destroyed; the ulceration had invaded
the anterior lip.
     The hospital accommodations not permitting her husband to be  with
her, she was unwilling to remain, and left the institution May 25.
     I was informed by her  husband that she continued in the same condi-
tion for about three months after leaving the hospital, suffering no pain, but
he thought,  perhaps, a  little weaker.   On  July 8,  she  was seized  with a
violent convulsion, passed into a comatose condition, and died July 11. 
163
     The interesting features in this case were, first, the closely traceable
origin of the disease to the metritis resulting from the frequent miscarriages;
and secondlv, the entire absence of pain throughout the whole course of the
malady; her sudden death rather pointing to some cerebral disease (possibly
emboli) as its immediate cause, than to any of the ordinary lesions discover-
able in these cases.
     Is it not  more  than  probable that the cancerous  disease in this  case
would have been prevented by an early amputation of the cervix, a removal
of the part undergoing slow interstitial inflammation, before that inflamma-
tion had traveled upward and attacked the bod}' of the uterus?

                            Carcinoma  uteri.

                                Case  7.

     Mrs. F----; aged fifty-five; admitted November  24, 1867; American
by birth;  sanguine temperament; mother  of four children, the  youngest
eighteen years of age; has been a widow fourteen years.   Since  the  birth
of her last child  she has been  suffering  from uterine  disease;  has been
treated on several occasions for ulceration of the cervix.  AVI file under treat-
ment she would improve, but  shortly after the  discontinuance of the local
applications her condition would be as  bad  as before - their commencement.
     For the  last ten months she had suffered intensely from lancinating
pains in the lower part of her abdomen;  profuse watery discharge from the
vagina, of very offensive odor,  excoriating  the thighs  and labia; had had
no haemorrhages.
     Examination,—The vaginal portion  of the cervix was  completely de-
stroyed, the ulceration spreading over the posterior cul-de-sac.  The uterus
was free, but enlarged and hard, its cavity lined with  friable cancerous tis-
sue which bled at the slightest touch.
     It was determined to give this woman the benefit of a thorough applica-
tion of the bromine, which was applied in  the same manner as  in  Case 1,
and repeated ever}' ten days for about two months.  No improvement was
observed;  the  pain was not lessened  or the  discharge diminished.   The
ulceration continued to extend,  eating  through into the rectum, and finally
into the peritoneal cavity.
     Large doses of morphine were administered  to check  the peritonitis; 
164
for a time it was kept subdued, but  eventually became unmanageable, and
the patient succumbed March 14,  1868.
    This was another instance in  which the disease was traceable to a pre-
existing sub-acute inflammation of the cervix, and the patient might proba-
bly have been saved by its early amputation.
    The grandmother of this woman died of cancer of the breast;  her
father and mother both lived to a  good old age.
                            Carcinoma uteri.
                                Case 8.
                                                              »
    Mrs. S. S----; aged thirty-nine; admitted September 11, 1868; Ameri-
can; temperament lymphatic; mother of three children, the youngest four
years of age.   Her general health has been good until the last year;  she
has suffered since her marriage from pain in the back, and leucorrhoea;  her
labors have been short, but her convalescence  has always  been slow, and,
with the last child, imperfect.
    Her general appearance indicated suffering;  she was pale and emaci-
ated;  complained of constant nausea; severe pain in the back and rectum,
and intense weariness; leucorrhoeal discharge abundant and offensive;  for
several weeks before admission she had been troubled with diarrhoea.
    Examination.—Cervix uteri destroyed by ulceration which had extended
into the  body; uterus not fixed  in the pelvis; vaginal mucous membrane
not involved.
    Bromine was applied four times, at intervals  of ten days, which  alle-
viated the pain, reduced the amount of discharge,  and destroyed all  the
unpleasant odor; but the  disease steadily progressed, and  the ulceration
extended to the bladder, forming a vesico-vaginal fistula.
    The patient being aware of the hopelessness of her case was unwilling
to remain in the hospital, and  returned to her home, where she died June
7, 1869.
    After July 1, 1869, no detailed history was kept of cases of carcinoma
uteri.   The general plan of treatment jmrsued in all cases was the same as
in those reported, viz, bromine to retard the specific ulceration and alter the
character of the discharges, morphine or conium to allay pain, and injections
of bromo-chloralum as an antiseptic.
    The general result has been unfortunately fatal.  Case 1 is not to be 
165
considered an exception to the rule, for I have no doubt the patient died of
malignant disease of some internal organ, although her attending physician
reported her death the result of pneumonia.

                           Carcinoma Mammae.

                               Case 1.

     L. R----; aged forty-one; admitted August 7,  1866;  American by
birth; temperament bilious-lpnphatic;  mother of six children;  has enjoyed
good health  from childhood.   She complains of a tumor in her left breast,
which is increasing in size, and occasionally the seat of sharp pain running
up to the  shoulder.   Her family history, as far back as  she could trace it,
was  clear from malignant disease.
     Examination.—Both breasts were large, the left gland being the seat of
a hard nodular tumor, painful upon pressure, and situated in the upper part
of the breast; the nipple retracted  and axillary glands enlarged; the skin
was  not adherent or discolored.
     August 9.—Patient having  been fully aetherized, an elliptical incision
was  made, including the nipple, and the entire gland removed.  The axillary
glands, although  enlarged, were not removed, as the enlargement was be-
lieved to arise from the irritation in the breast, and not from any malignant
deposit,   No ligatures were  used, the vessels  being controlled by torsion.
The  edges were united by silver  sutures and covered  with  lint  soaked in
carbolized glycerine, over which a compress  was placed, and retained in
position  by  a many-tailed  bandage, so  arranged as to  secure gentle but
regular pressure over every portion of  the flaps.
     August 13.—Dressings removed and every part found to be united; the
sutures were allowed to remain, and the pressure still continued.
     August  16.—Sutures removed, and the parts  supported  by adhesive
strips.
     August 27.—Patient discharged.
     This patient was seen on  the  10th day of February, 1872; there had
been no return of the disease at that time, and  she appeared to  be in perfect
health.
     The  tumor was examined at the United States  Army Medical Museum
and  found to be  scirrhous. 
166
                           Carcinoma Mamma'.
                                Case  2.
     Mrs. K. M----; aged thirty; admitted August 13, 1866; Irish by birth;
 temperament  sanguineo-nervous;  married when nineteen years  of  age;
 motlier of two  children.    Her health has always  been good;  does not
 recollect ever  having been sick a day.   When nursing her last child, who is
 three years of age, she noticed a small tumor  in her right breast, not pain-
 ful, and after weaning  her child it was forgotten.
     About six months before her admission she was  accidentally struck in
 the breast by  her husband's elbow.  She complained of severe pain at the
 time, which soon passed off.   A few weeks after this occurrence she ob-
 served  a  tumor, the size of a walnut, in the same part of the breast where
 she had previously noticed  the small tumor when nursing.  This had  in-
 creased rapidly, and was the seat of severe lancinating pain.
     Examination,—The right breast was enlarged, nipple retracted, and the
 skin for two inches above and below the nipple  adherent  and discolored;
 the  entire gland appeared  a  mass of  disease, but was not adherent to the
 deep tissue, and the axillary glands were not enlarged.
     August 15.—The  entire gland was removed, with as much of the skin
 as appeared involved in the disease;  no ligatures were used; the parts were
 retained in apposition by silver sutures, a dressing of carbolized glycerine
 having been applied on lint, and compresses over all.
     August 19.—Sutures removed;  union by first intention  was found to
 have taken place in every part.  No constitutional treatment was considered
 necessary in this case.
     September 20.—Patient  discharged,  perfectly well.
     This woman was  kept  under observation for three years and  seven
 months, at the end of which time there was no symptom  indicating any re-
 turn of the disease.

                       Carcinoma of both Mammae.

                                Case  3.
     Mrs.  A. E----;   aged  thirty-seven; admitted  November  11, 1866;
American; phlegmatic  temperament; mother of four children, the youngest
two years  of  age.   Her general  health has  been good, but for the last 
167
eight months she has suffered  intense pain in both  breasts.   The  pain
commenced before she had weaned her youngest  child, and the tumor in
the left breast appeared soon after her last confinement,
     The  general  appearance of  the woman was healthy.  She was  very-
large, weighing over two hundred pounds; her breasts were enormous in
size, the nipple of the right  one retracted, and the skin for some distance
around it  adherent and purple in color.   The nipple of the left one was not
retracted,  and the skin less discolored, but there was a deep, ragged ulcer,
about the size of a silver  dollar,  situated to the right of and a little above
the nipple; the axillary glands on the left side enlarged, but those on the
right apparently uninvolved.
     The  serious nature of the disease was fully explained to the patient, as
also the probability  of its return if the breasts were reinoved; at the same
time she  was  informed that  the only hope of  a cure was by extirpation of
both glands.   After consultation with her friends she decided to submit to
the operation.
     December 8.—Patient was fully aetherized, clinical  class present,   The
right breast was first removed; the redundancy of tissue afforded abundance
of skin for flaps after the removal of all that portion  which  appeared in-
volved with the gland; the pulse  remained  good and respiration was easy.
The operation was continued, and the left breast  and axillary glands were
removed.  The haemorrhage proved trifling, the divided arteries having been
secured by torsion; no ligatures were used on either side.
     The  flaps were adjusted, and carbolized glycerine was applied as a
dressing;  compresses were so arranged that every part of the raw surfaces
came in apposition.  The patient was ordered  one grain of opium every
four hours, and nourishing diet.
     December 9.—Had passed  a comfortable  night;  pulse seventy-eight;
soft and full; tongue moist;  complains of soreness, but no special pain.
     December  10, 11, and 12.—Patient easy; no constitutional disturbance
whatever.
     December  15.—Sutures removed, and every part found  to be united.
She complained of numbness in left arm and  hand, which had been  pro-
duced by  the violence done to the axillary plexus during  the manipulation
for the removal of the glands of that part.
     Gentle compression was continued for the following three weeks, at the 
168
 expiration of which time she was sufficiently recovered to require no further
 attendance.
     January 11,1867.—Patient discharged, with orders to report herself for
 observation every three or four months; which was done until the latter part
 of 1870, when  she  left  the city, since which time she has not been heard
 from.
     The tumors weighed  five  pounds, two and one-half ounces.   They
 were examined microscopically at the United States Army Medical Museum,
 and found to be  malignant.
                        Carcinoma of right mamma.
                                Case 4.
     Mrs. M. K----; aged forty-three; admitted  March  13,  1867;  Irish
 by birth; temperament nervo-bilious; mother of eight children; has  had no
 miscarriages; has nursed all her children,  and enjoyed good  health  until
 within the last two or three months.  Her mother is living, in perfect health,
 and, as far as she knows, there has been no member of the family afflicted
 with malignant disease.
     She complains of pain in the mamma and under the right shoulder.  A
 small tumor was first discovered in the breast  about  three years ago.  In
 a few months  several  others  made their  appearance,  having  gradually
 increased in size, but caused no pain until recently.
     Examination,—The   entire  gland  had  degenerated into  a mass  of
 intensely hard  nodules; it  was  not  adherent to  the deep  tissues, nor was
 the skin  implicated or nipple retracted; the axillary glands were not enlarged.
 It appeared one of the most favorable  cases for complete  extirpation that
 had been admitted into the hospital.
     March 15.—Patient  was aetherized,  the clinical  class present.  The
 gland, with every portion of suspected tissue, was reinoved; one large ves-
 sel had to be ligated, torsion failing to  arrest  the haemorrhage.   The  liga-
 ture was applied  in the following manner:  A needle threaded with a piece
 of stout  silk was  passed through the skin, carried round the artery and out
 again near the  point of  entrance, thus  including the vessel in a loop; the
two ends were then tied on  the outside over a piece of lint rolled up into a
little compress the size of a  quill.  The flaps were adjusted with silver-wire
sutures, and compresses applied as in the previous cases. 
169
     March 19.—Dressings removed, and the ligature cut and withdrawn.
     March 23.—Sutures removed and union found to  be perfect;  a  light
compress and adhesive strips were applied and retained for about ten days,
when the patient was discharged.
     May 16.—Patient re-admitted.   The skin covering the part from which
the gland had been removed, was filled with hard  nodules, two cancerous
masses were  sprouting  from the  cicatrix, and  the axillary glands  were
enlarged.  The patient  was troubled with a severe cough, was very rest-
less, pulse  rapid, and skin hot.
     She grew rapidly worse, and died May 28.
     Sectio cadaveris.  Thorax,—The cavity of the pleura contained on the
left  side about seven ounces of  sero-purulent  matter, some old adhesions
remained in the upper part.   Lungs, on  both sides, studded with cancerous
deposit; heart, health}'.   Abdomen.—Liver normal in size, color, and  con-
sistency.  Left kidney atrophied, but containing no evidence of cancerous
disease.  Peritoneum  covered with  small hard masses which were believed
to be cancerous in character, but, through carelessness, the piece removed
was lost, and, therefore,  not submitted to  a  microscopical examination.
Uterus  and appendages healthy.
     Commentary.—The  gland was removed before there was  any breaking
down of the  abnormal growth; there was no reason to suspect a general
contamination of the system;  indeed,  considerable doubt existed, at the
time of the operation, whether it was not a case  of fibroid glandular degen-
eration, non-malignant.   There was no family history to point to any sup-
posed hereditary  taint, and  yet in a woman  of previous perfect health we
have a rapidly fatal, acute, malignant disease developed all  over the sys-
tem in  a few  months.   Is not the supposition irresistibly strong that  some
of the cells (epithelial or  white blood-corpuscles) so  rapidly developed in
the  gland escaped into the  lymphatic vessels with which  the mammae are
so rich, and were thus conveyed to the different portions of the body, where
their growth and proliferation gave rise to just so many new centers of dis-
ease.
       22 
170
Carcinoma  of both  breasts  and cancerous  tumor of the sternum  successfully
                               removed.
                               Case 5.
    In  the latter part of July, 1868, I was requested by Dr. J. A. Ritchie
to see a patient of his, Sister----,  one of the  nuns of the Convent of the
Visitation,  Georgetown,  who was  suffering from  extensive  carcinomatous
disease.
    Upon  examination, I found the left breast enlarged, hard, and nodular,
adherent to the deep tissues, nipple retracted, axillary glands enlarged.  It
was the seat of sharp, lancinating pains, which passed into the  shoulder
and down the inside of the  arm.
    The upper portion  of the sternum was occupied by a tumor, hard,
irregular, and strongly adherent, but not painful, except when disturbed.
    The right mamma  had lost its characteristic  shape, and was a mere
mass of degenerating cancerous tissue, the skin mottled and adherent to the
tumor  in  every  part; the portion below the  nipple had  ulcerated, the
axillary glands were enlarged, and the whole of the diseased mass was the
seat of  constant and severe pain.
     From the physiognomy of the patient no suspicion would have arisen
that she was a victim of  malignant disease.   While her  expression was
careworn and anxious, there was an  entire  absence of the usual cancerous
complexion.   This, indeed, presented the only favorable symptom in her
case.
     A  more  unfavorable subject for operative interference could not well be
selected.   According  to the recognized  authorities, the  patient was past
surgical aid.
     If  anything could be gained by an operation, it must be radical, the syn-
chronous removal of both breasts  and the sternal  tumor.   Risk of death
from flie shock of so extensive an operation was imminent.   Escaping that,
there would  be great danger of  exhaustive suppuration, and,  should the
patient  recover fully from  the operation, a  return of the disease within a
few months seemed more than probable.  All that could be said in its favor
was the bare possibility that she might  form an exception to the  rule, and
the disease remain in abeyance for  some years.   It was also  certain that
witliout prompt surgical interference death under its most horrible  and
agonizing form would inevitably occur within a few months at farthest. 
• 171
     It was decided to state the case fairly to the patient, to tell her frankly all
 that was to be feared and the little that  could be hoped for from an opera-
 tion; and, without advising, let her  form her own  decision, after consulta-
 tion with  her friends.   She very promptly decided  to take the chances
 offered by an operation, which was performed on August 4, 1868, Doctors
 J. A.  and L. W. Ritchie  and F. A. Ashford assisting.  Patient was fully
 aetherized, a  full dose of whisky having been administered fifteen minutes
 previously.
     The  left breast  and axillary glands were extirpated first;  the arteries
 were controlled by torsion with one exception; the ligature in that case was
 brought out through the skin at the point of ligation.
     The   sternal tumor  was  next  removed.   The  haemorrhage  proved
 troublesome, but no ligatures were used.
     The pulse and respirations continuing regular, and little blood having
 been lost, it was decided to proceed, and remove the right breast and axillary
 glands.
     The whole mass was adherent to  the ribs; all that portion of the pectoral
 muscles beneath  the gland was involved in the  disease, and removed with
 the breast.  The wound made by the operation was elliptical, nine inches
 long and seven inches wide at the broadest part of  the ellipse.   This large
 surface had to be left to heal by granulation.
     The  aether was now discontinued, the patient  having been under its
 influence  twenty-three  minutes.   When re-action became fully established
 the flaps of the left side and central wound were  brought together by silver
 sutures.   On the right side the surface was  dressed with charpie soaked in
 glycerine  and carbolic acid, five grains of the latter  to the ounce of glycer-
 ine, and strong traction  made above and below by strips of adhesive plaster.
     Dr. Ritchie,  being  the attending  physician, took the general charge of
the case  from  this time onward.   The  parts were  dressed every morning
with the carbolized glycerine, until the  eighth da}', when the sutures from
the left breast and sternum were reinoved, every portion having united by
first intention;  healthy  granulations were springing up in ever}' part of the
wound on the right side.  The following ointment was  substituted for the
               ©                     ©
glycerine  as a dressing:
                     J>. Ungt. hyd. oxidi rubri, f ss.
                        Ungt. simplicis, f ss.
                        Tulv. myrrhre, gr. x.
                        Acidi carbolici, gr. v.
                            M. 
172 .
     Tonics and stimulants were pushed to the point of toleration.
     The patient steadily progressed toward complete  recovery;  the cavity
of the open wound was soon filled up to the level of the surrounding tissue,
and cicatrization rapidly followed.
     More than four years have elapsed since the operation was performed;
there is no evidence of any return of the disease in the parts from which it
was removed, or in any other part.   Dr. Ritchie assures me, and the patient
confirms the assertion, that  she is in better health at the present time than
at any previous period during the last twelve years.  She is bright, cheer-
ful,  enjoys life, and is actively engaged in teaching in the academy attached
to the order, and has a fair prospect of continuing her life of usefulness for
many years.
     The diagnosis of malignant  disease was fully confirmed by a micro-
scopical examination made at the Army Medical Museum by Dr. Woodward.
     I do not wish to be understood as claiming this case to be cured, but I
do claim to have given the patient years of life and fair health, with a reason-
able prospect of continuance.
     It is too commonly the custom to deny the victims  of this  loathsome
disease the  possible benefit of surgical interference, upon the plea that the
disease will surely return, and that an operation may hasten the final issue.
This, although probable, is not certain, and the records of the hospital of
which I have  charge are  sufficiently encouraging  to warrant  a different
course of practice:
     The above case does not properly belong to the hospital  report,  but it  •
is inserted on  account of  its peculiar  interest, affording, as it  does, the
strongest  possible  argument  for surgical  interference even in  the most
desperate cases.

       Encephaloid degeneration of an adenoid tumor  of the left mamma.

                                Case 6.
     Mrs. M. T----; aged  thirty-nine;  admitted  July 3, 1867;  tempera-
ment sanguineo-bilious;  mother of  one child; has had three miscarriages;
was  unable to nurse her  baby on account of sore  nipples.  She  complains
of sharp paroxysmal pains  in the  left  breast, increasing in frequency and
severity for two months prior to admission. 
Microscopical appearance of tumor  removed from the sternum, (case 5, page 170.)  Photo-
  graphed on wood from a section prepared at the United  States Army Medical Museum. 
 
173
     Her breasts were large and fleshy, and in the left one, about one  inch
above the nipple, careful examination discovered  a  small lump which was
painful upon pressure.   It was difficult to distinguish it from the mammary
tissue, its exaggerated consistence being hardly sufficient to mark its outline,
but the tissue around it appeared less supple than  the remaining part of the
gland, or the corresponding part on the sound side.
     There was nothing  sufficiently well marked about the  case to make a
satisfactory diagnosis.  It might be a slight innocent hypertrophy;  simple
inflammatory induration; or scirrhus in its  early stage of development, the
shooting, lancinating pain making the  latter the more probable.   It was
decided to await further development, and the patient was requested to
report herself occasionally as an out-door patient, more for observation than
treatment.
     The tumor increased rapidly in size and hardness,  and but little doubt
being entertained of its  malignant character, it was decided that it should
be removed.
     September 14.—The entire gland was removed and the usual dressings
applied.
     September 18.—Dressings removed and  union  found perfect.
     The  sutures were  removed on  the eighth  day and adhesive strips
applied for support; no ligatures had been used.
     Upon examination of the tumor  under  the microscope it was found to
be what Velpeau describes as an  " adenoid tumor with bosses of encephaloid
matter."
     This woman left the city shortly after her discharge from the hospital,
but her daughter, who is a resident here, informs  me that her mother  has
had no return  of the disease.

                        Scirrhus of left mamma.
                               Case  7.
     M. K----;  aged forty mine;  admitted October  23, 1867;  spinster;
American;  of  sanguineo-nervous temperament;  complains of  pain  in  left
breast, extending up to  the  shoulder  and  down the arm.  She has never
enjoyed good health, always suffering from  dyspepsia, which she ascribes to
want of exercise, being a dressmaker.
     The lei't breast was  the seat of  a hard tumor as large as a lien's  egg, 
174
 adherent to the skin, which was discolored, being of a purple hue, nipple
 not retracted.
     Upon consultation with Dr. Ritchie, her  attending physician, it was
 decided to remove the entire gland, and the operation was performed Octo-
 ber 26.  The wound closed by first intention, not a drop of pus forming in
 any part,
     November 19.—Patient discharged.
     The tumor was examined at the  United States Army Medical Museum
 and found to be scirrhous.
     This woman has remained  under Dr. Ritchie's  charge ever since,'and
 he informs me that there had been no return of the disease up to June 30,
 1872, nearly five years since the operation for removal.

                         Scirrhus of left mamma,
                                Case 8.
     Mrs. R. J----; aged forty-one; admitted March 8, 1868; American
 by birth, but of German parentage; temperament bilio-lymphatic;  mother
 of eight children, all of whom she nursed; has had two miscarriages.  Her
 general health has been poor for the last three or four years.
     The left breast was larger than the right, the entire gland being in a
 state of  cancerous degeneration, and the axillary glands enlarged also.
     March 15.—An attempt was  made to aetherize the patient, but it was
 found impossible on account of the irritation produced by the aether on the
 mucous  membrane of the bronchi, and  chloroform had to be  employed to
 produce anaesthesia.  A  straight incision was  made  from the  axilla to the
 breast, terminating in an  ellipse which included the nipple.  The removal of
 the tumor  was quickly effected, but the dissection of the glands from the
 axilla was  tedious.  Just as the  last hardened  mass  of these was removed
 and the arm brought down to the side of the patient,  she stopped breathing.
 Her mouth was forced  open, the tongue seized  and drawn forward, and
 artificial respiration resorted to, which was continued for twenty-two minutes
 before a natural breath was  drawn by the patient.
     When she had fully recovered, the  flaps were adjusted and the  wound
 dressed  as in the previous cases.
    The sutures were removed on the eighth day and union found  perfect
in every part.   Discharged Ma}' 7. 
175
     There had been  up return of the disease in this  patient up to April,
 1871, since which time she has not been seen.
     The microscopical examination of the tumor verified the diagnosis.

        Carcinoma of mamma and Extra-capsular  Fracture of femur.

     M.  M.----; aged forty-one; admitted  August 18, 1867; mother of
 three children; has had no miscarriages; always been healthy; has never
 had occasion to employ a physician in her life, having been attended by a
 woman in her labors, which she describes as periods of rest for a few days.
 She was brought to the Institution on account of an accident.  In stepping
 on to a car she twisted her foot, and found herself unable to stand.  Upon
 examination  it was discovered that the  neck of the femur had been frac-
 tured, (extra-capsular.)
     When the nurse  undressed the  patient previous to placing her on a
 fracture-bed, it was observed that she had carcinoma of the  left mamma far
 advanced in the ulcerative stage, with enlarged axillary glands.   The ulcer-
 ation, which  was deep, measured two and one-quarter inches  by two and
 seven-eighths.
     Her general condition was decidedly good.
     The existence of the cancerous disease  made the prospect of union of
 the fractured bone very doubtful, but,  upon consultation  with Dr.  J. K.
 Barnes, the Surgeon-General, it was  determined  to treat the case as if no
 cancerous disease of the breast existed.
     The patient was placed under aether, and the fracture adjusted, a modi-
 fication of  De Sault's splint having been applied.  This had shortly to be
 removed on  account of the ulceration produced by the perineal belt. »In
 its place sand-bags were laid on each side of the limb, and  extension made
 bv adhesive strips and a four-pound weight.   Contrary to all expectations,
 perfect union was  obtained, and by the  middle  of December she was able
 to move  about the ward moderately well, assisted by crutches.
     The amputation of  the breast was not considered advisable, but it was
 deemed a good case for a trial of the virtues of bromine.
     September  5.—Bromine  (pure) was applied to every  portion of the
 ulceration,  and the ulcer dressed twice  daily with a solution  of bromine,
 one part bromine to twenty of alcohol.   Under this  treatment  the enlarge-
ment of  the glands disappeared, the ulcer lost its characteristic appearance 
176
and diminished in size, healthy  granulations sprajig up, and  everything
looked promising.  The patient suffered no special pain,  but complained of
soreness only; her appetite appeared good, and digestion and assimilation
perfect.
     She was sufficiently recovered at Christmas to be discharged and treated
as  an out-door patient.  Of the ultimate  fate of this woman I am unac-
quainted, she  having left the city some months after her  discharge from the
hospital.
     Twenty-four operations have taken place in this hospital for cancer of
the breast.  One by Dr. Thomas Miller of this city, one by my assistant,
Dr. F. A. Ashford, and twenty-two by myself.
     Twenty-three fully recovered from the operation, and one died from
surgical fever on the fourth day.
     In twenty-two of the  cases, perfect union was established between the
fourth and sixth days, not a drop of pus having been formed in any part of
the wounds.
     In two cases, there was secondary haemorrhage, which necessitated the
opening of the wound to secure the bleeding vessels.
     In seven  cases, there had been no return of the disease for a number of
years.
     In two, it returned within four months, and in seven, within one year
from  the date  of the primary operation.
     The result in the remaining nine cases cannot be  given, as the patients
were  not heard from after they left the hospital.
     It will  be observed that, with two exceptions, we have succeeded in
obtaining union by first intention in all the cases of mammary cancer oper-
ated upon in this institution. This result was chiefly owing to the care exer-
cised  in the after-treatment, especially in the arrangement of the compresses,
which were so adjusted that every part was kept in apposition, but no por-
tion submitted to undue pressure.
    The  general result has  been extremely gratifying, and affords  the
strongest possible argument in favor of extirpation by the knife.
    No question can be raised as to the nature of the tumors  removed, for
every one of them was submitted to a microscopical examination, and found
to possess the  anatomical arrangement peculiar to malignant growths.   The
theoretical reasonings adduced by the antagonists of the operation will have 
177
no weight when tested by actual experience.  It is  quite true that  some
surgeons have been peculiarly unfortunate, and their reports are well calcu-
lated to discourage operative interference;, according to them the disease will
always return after removal, and the operation only accelerates its  progress
and fatal termination.
    This  was the opinion of  Boyer, who, out of one hundred operations,
could enumerate but four in which there was no return of the disease.
    Scarpa states that he has met with but three cases of success.
    MacFarlane, out of one hundred and eighteen cases, could not point to
a single case  in which there was no return.
    Mayo had ninety-five returns out of one hundred  cases.
    I cannot but believe that these statements were made up from imperfect
information and not from careful observation.
    In  Europe, when a patient finds herself afflicted with a tumor, she first
consults a surgeon,  and does not  apply to a physician until a later period.
Those who have been operated upon and cured have no occasion  to  go to
physicians at all, but those in whom the disease returns end by seeking ad-
vice from everybody.  If a physician only sees those who have been  the
subjects of unsuccessful operation, or in whom the disease has advanced to a
stage where an operation is performed only as a palliative measure, he may
easily be led to the  conclusion that an operation is useless.
    Surgeons are naturally called upon to examine tumors of the breast in
all possible conditions.  They see them at the  commencement, and are able
to follow them to their termination, and they alone possess  the necessary
data for the solution of this  problem.  If they possess an equal amount of
talent, judgment, experience, and good faith as physicians, they must be better
able to  decide whether the operation of extirpation of  the breast for cancer
holds  out any hope  of effecting, a  cure.
    In  seven of the twenty-two cases  operated upon  by myself, there  has
been no return of the disease,  so far as could be ascertained, up to the time
of writing this report.  One survived the operation five  years and six.months,
two five years, one four years and  six months, one three years and  seven
months, and  two over three years.  Three of these cases were extremely un-
favorable subjects, and the operation was performed as a palliative measure
onh',  not with any  idea of effecting a cure.  No report has  been  made of
      23 
178
•
cases operated upon within two years in which the disease has not returned.
Of these there are eight in my private practice alone.
    Neither of the  above cases may be cured,  but that  does not  militate
against the operation.   In all probability not one of them would have been
living to-day if the disease had been allowed to run its course uninterruptedly.
If it should return in either of them, and the patient's strength will admit, I
shall remove the secondary growth, for which procedure there is abundance
of warrant.
    Dr. Arnott reports a remarkable case which occurred in his own prac-
tice: Sarah Hillier;  aged forty-seven;  a married woman; the mother of four
children; healthy and of spare habit; applied to him in  December, 1846,
for  the removal of a tumor which had been  perceived in her left breast four
weeks previously.   Her attention had been called to the part by a sensation
like the sting of a flea, and influenced by the  example of what had  befallen
other members of her family who had suffered from cancer, she determined
to have the swelling taken away with as little delay as possible.  He acceded
to her request and removed the whole  mamma.   The tumor was about the
size of the last joint of the thumb, and situated around the nipple, which,
however, was not in the least retracted.  She left the hospital in less  than
three weeks, with the wound cicatrized.  The  mass which had been removed
was an example of genuine scirrhus.   In 1850 she was  seen again, when
the cicatrix was found to be perfect and the axillary glands were in healthy
condition.  In April,  1856, nearly ten years after the primary operation, she
once more consulted Dr. Arnott, having a return of the disease in the cica-
trix, and some swelling of the axillary glands.   She had only discovered this
three months before, having in the interval between  the previous operation
and the present time enjoyed perfectly good health.   At the axillary border
of  the cicatrix was a  hard tumor, of about the size of a small pigeon's egg,
adherent to the integument.   In the axilla and above the clavicle, were some
enlarged, but not indurated glands, having no apparent communication with
the tumor.
     On the 3d of April, this  lump, together with four axillary glands, was
extirpated  by M. Shaw, who took  charge  of the patient, and both to the
naked eye  and under the microscope the whole  was found to be made up of
well-marked, somewhat soft scirrhus.
    The mother of this patient died of open ulcerated cancer of the breast, 
                                 179

which had  not been operated upon, and out of a family of six sisters, only
one had escaped the disease.
     Previous to 1846, when the disease commenced in this patient, she had
lost her mother and two sisters from cancer, for which they had undergone
no operation ;  another sister had been operated upon for similar disease  in
1844, and remained well until 1855, a period of eleven years, when she had
to submit to a fresh operation, but continued well after the second.
     Thus the disease was kept in abeyance in two of the sisters for a period
respectively of ten and eleven years by the primary operation, and how long
by the secondary is uncertain.
     Velpeau reports a number of cases where  he removed cancerous tumors
from the  breast a second and even -a third  time, several years intervening
between  the return of the disease, but no return taking place after the last
removal. 
180
       DISEASES OF THE VAGINA AND  CERVIX UTERI.

     To understand fully the importance of prompt and efficient treatment
 in acute or chronic inflammatory diseases of the cervix uteri and vagina, it is
 necessary that we shall be thoroughly acquainted with the minute anatomy
 of the parts.   Tyler Smith has given the best description of their anatomy
 extant; it is concise and comprehensive, and for convenience of reference in
 cases reported I make the following extract:
   " The os uteri  and the external or vaginal portion of the os and cervix uteri.
     "Like the mucous membrane  in other parts of the body, the mucous
 covering of the  os and cervix uteri  consists of 1, epithelium; 2, primary or
 basement membrane; and 3, fibrous tissue, blood-vessels and nerves.  There
 are, however, numerous points of special character belonging to the mucous
 membrane in this situation;  and for convenience of description the mucous
 membrane of the os and cervix uteri may be divided into two tracts, one
 comprising the surface of the os uteri and external portion of the cervix, the
 other being the  mucous lining of the canal or cavity of the cervix.  In the
 first place I proceed to describe the mucous membrane of  the os uteri and
 external portion of the cervix, or that which lies between the junction of the
 cervix with the vagina, and  the margin  at which the mucous membrane of
 the os uteri becomes continuous with the mucous lining of the  canal of the
 cervix.
     "The layer of epithelium found in this situation is tesselated or squa-
 mous, and is  so arranged as  to form a membrane of considerable thickness.
 On the free surface it is comparatively  smooth, but its attached surface is
 rough and excavated from  the projection of the villi or  papillae into the
 epithelial layer.   After maceration in water for a few days, or  when incip-
 ient decomposition  has taken place, it  can readily be detached from the
 papillae, and raised from the surface  of the mucous membrane.  It closely
 resembles the epithelial covering of  the vagina, with which it is continuous.
 See Fig. 1, plate 12.
     "Immediately beneath the layer of epithelium the basement membrane is
found, covering  numerous villi or papillae, which stud the whole surface of
the  mucous membrane.  These villi are sufficiently large in some specimens 
Plate XII.
Fig. i.
Pavement epithelium covering the os uteri, 240 diameters.
Fig. 2.
Papillae or villi of the os and cervix uteri, 23 diameters. 
 
181
to be seen by the naked eye, when a thin section is held up to the light.  The
villi of the os uteri are generally single, but occasionally two or tluee villi
are united together upon a single pedicle.  When the villi are partially or
entirely denuded of their epithelial and sub-epithelial coverings by macera-
tion, or decomposition after death, or in certain  diseased  conditions,  an
uneven appearance is given to the os uteri.   The  extremities of the villi,
from which the covering of scaly epithelium has been removed by macera-
tion, present  a very characteristic appearance when seen by a  low power
They form an irregular fringe standing out from the surface  upon which
they are placed.  See Fig. 2, plate 12.
     ''Much  information as to the nature of these villi  may be gained by
examining them with different powers of the microscope.  When a thin por-
tion is sliced  from  the surface of the os uteri,  and examined with a higher
power than that used in the preceding examination, the points  of the villi
appear nipple-shaped, and the whole surface is studded with wavy eminences
formed by the villi.   Around the.bases of the projections, and immediately
upon them, the epithelial scales  are  more numerous and crowded than in
the interspaces.  The shape of the scales in  the crowded parts becomes
narrower and more acutely pointed.   In the center of the point of each villus
a depression is seen,  suggesting the probability that the extremities of the
villi may be more specially engaged  than the other parts in the production
of the mucus of the  os  uteri and the vaginal  portion of the cervix.  This
arrangement of the villi and their epithelial envelope considerably increases
the extent of the epithelial surface.
     "The surface of the os uteri is generally described by authors as contain-
ing numerous mucous follicles.  A variety of diseases are referred to morbid
  ©                                   j
changes in these follicles,  and  they have been  made to  play an important
part in the pathology  of leucorrhoea by many authors; but under the micro-
scope, it is difficult to make out any distinct follicular structure.   On look-
ing with a low power at  a section  taken  from the os uteri, an appearance
very similar  to that presented by mucous follicles  is observed; but on a
closer examination it is found that the dark spots, which appear like mucous
crypts, are really elevations with central depressions.  See Fig. 1, plate 13.
Some of the dark spots will be  seen to contain red points, which are ter-
minations of the blood-vessels of the villi.   In other parts of the same speci-
men, the  blood-vessels can often be  seen  with great  distinctness.   The 
182
appearances which might be mistaken for mucous follicles seem, in fact, to
be nothing else than the villi, more or less obscured by their epithelial cover-
ing.   In examining different parts of the same specimen, we may detect that
what  appear at first to  be depressions are evidently slight elevations;  and
that the points which seemed to be the site of follicles are really the termin-
ations of villi.
    "Another source of error  has arisen from the  occasional presence of
Nabothean ovules, as they are termed, in  the situation of the villi.   The
villi have  been mistaken for mucous  crypts, and the ovula Nabothi  have
been supposed to be the same crypts obstructed and  distended with mucus.
    "When  a few of the villi  are examined by a high power, in a recent
specimen,  each villus is  found to contain a looped blood-vessel, which may
be seen passing to the end of the villus, and returning  to its base, where it
inosculates with the blood-vessels of the neighboring villi.  These villi are
everywhere covered by a thick layer of pavement  epithelium, which  also
fills up the intervals between them, rendering the external surface compara-
tively smooth, as seen  by the naked  eye.   In Fig. 2 plate 13. the outlines
of several villi,  the vascular loops of the villi, and the layer of epithelium
covering  the villi, are  represented.
     "The thick layer of epithelium,  and the villi with their looped vessels,
appear to be the  principal anatomical  features of the mucous  memjbrane of
the os uteri  and external portion  of the cervix;  and it will be seen in the
sequel that both  villi  and  epithelium play an important part in the patho-
logical changes which occur in the lower segment of the uterus.
            " Villi of the lower part of the canal of the cervix uteri.
     "On passing within the os uteri, to examine the mucous membrane lin-
ing the  cervical canal, a small tract of smooth surface is generally found be-
tween the margin of the lips of the os uteri  and the commencement of the
penniform rugae.   Sometimes,  however, there is only a slight rim between
the os uteri and  the lower rugae;  and occasionally the rugae extend so low
down that they may be  seen at the os uteri itself.   When the smooth surface
now spoken of exists, as it does in most specimens to some extent, the mucous
membrane appears to the naked eye more  delicate and vascular than the
mucous membrane of the external portion of the  os  uteri.   But whether
rugose or  smooth, the mucous membrane of this portion of the cervix  con- 
Plate XIII.
Fig.  i.
Extremities of villi of the os uteri, showing their central depressions, 220 diameters.
Fig. 2.
Villi of the os uteri covered by pavement epithelium, and containing looped
                    blood-vessels, 220 diameters. 
 
183
 sists of the same elements, "except that wherever rugae are present mucous
 follicles are found-in great abundance.   When examined by the microscope,
 the mucous membrane  immediately within the os uteri is found to be com-
 posed of cylinder epithelium arranged upon villi, somewhat after the manner
 of the epithelium covering the villi of the intestinal canal, of basement mem-
 brane, and of sub-mucous tissue.  See Fig. 1, plate 14: The villi in this sit-
 uation are three or four times larger than the villi of the external portion of
 the os uteri.   Like the  villi of the os uteri, the villi of the canal of the cervix
 are occasionally compound, consisting of two or tluee or even four villi aris-
 ing from  a single  stalk.   They contain looped blood-vessels, and, in some
 specimens, two or tluee of the vascular loops may be seen in  a single villus
 where the villi are of large size.  They are  covered, as well  as the spaces
 between  them, with cylinder epithelium, dentated in shape,  and arranged
 with  great regularity.  At  the bases of the villi, their blood-vessels inoscu-
 late  freely, as in  the case of the villi upon  the external surface of the  os
 uteri.
       *       *         *       *       *     .  *       *       *
     "M.  Jobert was of opinion that the upper  part of the cervix uteri is
 supplied with nerves, which pass from thence to the vagina, leaving  the os
 and cervix uteri destitute of nerves.   In this way he explained the absence
 of pain upon the application of escharotics and the actual cautery to the os
 uteri.  Dr. F. Kilian doubted the correctness of this view of M. Jobert,  and
 this doubt led him to the examination of the structure of  the  os and cervix
 uteri.  Dr. F. Kilian assumed that, as papillae are the organs  of sensibility,
 there must be sensibility and consequently  nervous filaments wherever
 papillae  are present;  and finding papillae in the mucous membrane of the os
 and cervix, he concluded  that there must be nerves of sensation in this part
 of the body.   He  could not, however, demonstrate their presence with  the
microscope.  The  fact that the os uteri  is, in ordinary conditions, compara-
tively insensible to pain, he met by supposing that its nerves  are fitted to
receive  pleasurable  sensations, and  that the nerves of the cervix uteri  are
not under ordinary circumstances susceptible of painful impressions.
     "It becomes a question of much interest to decide what are really  the
functions performed  by the villi of the  vagina  and  the os and cervix uteri.
In the lower part of the vagina, the  papillae are no doubt sensitive in func-
tion, and  deserve  the term applied  to  them by Dr. F. Kilian; but in  the 
184
 upper part of the vagina, the mucous  surface is, in the healthy condition,
 possessed of little  sensibility either to  pleasure or pain; yet the papilhe or
 villi  are very abundant.  The 'villi are present  in  very great abundance
 upon the os uteri and the external portion of the cervix, though the os uteri
 is, in the majority of cases, insensible to the touch.  It is only when the os
 or cervix uteri is distended by instruments, or when the cervical canal is in-
 flamed or  constricted, that pain is caused  in ordinary cases.  The villi are
 largest and more highly developed within the os uteri, where  sensation is
 more blunted than in any part of the vagina or on the os uteri.   For these
 reasons, I  am inclined  to believe that the villi of the os and cervix uteri,
 particularly the villi of the cervical canal, are little concerned in sensation.
 From the liberal supply of blood possessed by the villi, I suspect they are
 concerned in the secretion of the fluid plasma which the external .portion of
 the os and cervix and the upper part of the vagina pour out, and which forms
 the vehicle in which the epithelial debris is suspended; or they may be in-
 tended for the formation of the thick layer of epithelium covering these parts,
 and which is in constant process of renewal and disintegration.    *      *
 The papillae of the os and cervix may be almost entirely vascular.  But the
 probabilities are that some of them are vascular, others sensitive, like the
 papillae of the skin, in which some contain vascular loops and no nerve-tubes,
 others contain nerve-tubes but no vascular loops.  The practical  results are,
 however, little affected by these questions.  The os and cervix uteri are un-
 doubtedly  covered by epithelium, which may be abraded, and it undoubtedly
 contains papillae  or villi,  which, when denuded or  hypertrophied, may pre-
 sent all the appearances of granulations, and have  probably been mistaken
 for them.  The large vascular loops contained in the villi of the os uteri,
 and particularly of the lower part of the canal of  the cervix, also afford the
 explanation of the sanguineous  discharges from the  os and cervix uteri, so
 frequently  met Avith in cases of leucorrhoea.
     "Underneath the  villi, both  in the  lower part of the cervical canal and
 upon the external surface of the os and cervix uteri, a dense fibrous and vas-
 cular tissue is  found,  mixed  with nerve-fibres and  involuntary muscular
fibres and nuclei, the muscular fibres becoming more plentiful on  descending
deeply into the structure of the walls of the cervix.  In the villi themselves
are numerous oil-globules, many of them of large  size, as well as an abun- 
185
dance of granular cells; these elements are situated between the looped blood-
vessels and the basement membrane.
   "the glandular steuctuees of  the canal  of the cervix uteri.

     "The descriptions  hitherto given of the canal  of the cervix uteri,  in
anatomical works, have been very meager and insufficient; certainly not at
all commensurate with its importance both in a physiological  and patho-
logical point of view.   Obstetricians have rivaled systematic anatomists in
the brevity with which they have dismissed this  subject.   In recent times,
the os uteri and the external portion of the cervix have so far eclipsed the
cervical canal in importance that the latter is scarcely referred to by writers
on leucorrhoea.
     "One of the best accounts with which I am acquainted in any English
work is contained in the last edition of Dr.  Quain's 'Elements of Anatomy.'
I quote from this description the passage relating to  the glandular structure
of the cervix:
     "'That portion of the (uterine) cavity which corresponds  to the neck
resembles a tube slightly flattened before and  behind;  it is somewhat
dilated in the  middle, and opens inferiorly into the vagina  by the os tincae.
Its inner  surface is marked by two longitudinal  ridges or columns, which
run, one on the  anterior, the other  on the posterior wall, and from both of
which rugae are directed obliquely upward on each side, so as to present
an appearance  which  has  been  named arbor  vital tderinus,   also palmce
plicate.
     "'The mucous membrane which  lines the uterus is thin,  and closely
adherent to the  subjacent substance, especially in the body of the organ.
It is  continued  from the vagina  into the Fallopian tubes.   Between the
rugae of the cervix, already described, it is  provided  with numerous mucous
follicles and glands.'
     "This, it  must be confessed, is very brief; but,  although the subject is
treated of in ahnost every  systematic treatise on midwifery, it is seldom
that  any further description is met with.   No obstetrician has, so far as I
am aware, described the cavity of the cervix more minutely  than Professor
Paul  Dubois, in  the first volume of the great work he is still engaged upon,
Traite de  VArt des Accouchements, the first part of  which was published a
few years ago.  His description is as follows:
       24 
186
     "'The cavity of the cervix represents a small elongated canal, flattened
 and fusiform,  dilated toward its  center,  and becoming  narrower at the
 extremities.  Its two walls, one of which is anterior and the other posterior,
 present each, at the median  line, a longitudinal eminence or crest, which
 appears  to be the  continuation of the less marked ridges existing in the
 walls  of the cavity of the fundus.  From  each of these  crests, numerous
 folds are given off laterally;  these are thick, regularly arranged one above
 another, and less united at the center than at the extremities.   They take a
 somewhat oblique  direction  upward and outward, toward the lateral walls
 of the canal, where they terminate at another vertical but less apparent line.
 Thus  arranged, these folds  seem to  be formed between  the  two vertical
 crests, like oblique  steps of  a ladder,  and are a little concave above.  The
 meeting of these branches, which somewhat resemble a fern-leaf, has been
 termed the arbor vitce.
     "'Between these folds rather deep grooves are seen, which are occupied
 by a greater number of mucous follicles.   The excreting orifices of these
 glands are  frequently obliterated by accidental causes,  and  the  mucus
 accumulating in their cavities, they acquire a remarkable development.   In
 this state they  were taken, by an ancient anatomist, Naboth, for  human
 ovules; and even at  the  present day, though their real structure  is  well
 known, they are still frequently designated as the ovules of Naboth.'"
     " Sir Charles Clarke, whose work on the 'Diseases of Females' has never
 been excelled, described the  cervix uteri in three or  four sentences.   He
 entertained a correct idea of the structure and functions of this part of the
 body,  though he was  far  from seeing its  importance  in  the pathology of
 leucorrhceal disorders.   He states:
     "'The cervix of the uterus is beset with a  number of glands.  These
 glands are more readily discernible in women who have died pregnant; and
 in some  bodies they are probably much more  numerous than in  others.
     *******      The cervix of
 the uterus is a glandular  part; its secreting organization can be demon-
 strated.  It is subject to the diseases of glands in other parts of the body,
 and in all probability will be particularly liable to take on disease in habits
which  are  prone to other  glandular complaints, namely,  in weak  habits.
The  majority of cases of disease in the breast,  and in the testicle, arise in
such persons.'" 
187
     In volumes xvii  and  xviii of  the  Archives Generates de Jledecine,
 (fourth series,) M. Charles Robin has published an historical memoir on the
 anatomy  and pathology of the mucous membrane of the uterus, in which
 he  gives a minute account of the mucous surface of  the cervical canal and
 its mucous follicles.  M. Robin states that mucous glands are present in the
 cervix, from the limit  separating the cavity of the fundus from the cervix,
 down to the os  tincae.  The orifices  of these glands are said to be visible
 on  the rugae of  the arbor vitae, as well  as in the grooves between them, but
 to be most  numerous in the intervals between  them.   He observes that the
 microscope  reveals many more than can be seen with the naked eye.  The
 glands themselves are described, not as  simple mucous follicles, but as small
 cylindrical  tubes  terminating  in a round  cul-de-sac, the  tubes and  their
 terminal cul-de-sac being compared  in shape to  a bottle or vial.
     11 Rugae of the cervical canal,—A careful examination of the canal of the
 cervix uteri itself, will, however, show  that even  the most careful of these
 descriptions are imperfect.   When the cavity  of  the cervix  belonging to a
 virgin uterus is laid open by a  longitudinal incision, so as to  expose the
 whole of  the cervical canal, the internal  surface is generally found to con-
 tain four columns of rugae, or folds of mucous membrane, the rugae being
 arranged  in an  oblique, curved, or transverse direction.   Between these
 columns of  rugae four longitudinal grooves or ridges are usually seen.   In
 some specimens, grooves, in others, ridges are present.  Of these, the two
 grooves or  ridges in the median line,  anteriorly and posteriorly, are the
 most distinct.   The other longitudinal markings  are situated, one on each
 side, between the anterior and posterior  walls of the cervix, beginning below
 at the angles dividing the anterior  and posterior lips  of the os uteri.  The
 canal of the uterus is flattened in shape, and two of the rugous columns are
 arranged  on the anterior surface, corresponding to the anterior lip, and the
 other two upon  the posterior lip; the posterior half of the cervix being the
 largest of the two,  and containing the  greatest number of rugae.   The
 sulcus or  division between the posterior rugous columns is also generally
 more strongly marked than the sulcus dividing the anterior rugous columns.
 The rugae of each column, as seen by the eye alone, vary from about ten to
fifteen in  number.   In the intervals between the columns numerous small
longitudinal folds  may be  seen, but these are  less distinct  than the trans-
verse rugae.   In the healthv  state,  the  transverse  ruga?,  with the fossa' 
188
between them, are covered with a viscid and transparent mucus;  and when
this is brushed  away, a  reticulated  appearance,  caused by  numbers of
secondary rugae, is visible in the mucous membrane beneath.   The second-
ary rugae run in  various directions,  without much regularity.   In some
parts of the fossae the mucous crypts  are  deeper than usual, and here and
there  minute openings are seen at the bottom of the pits, into which fine
bristles may be passed to the distance  of the twelfth of an inch or more.
Besides the four rugous columns and the furrows between them, which are
found in the well-developed  cervix, other rugae of irregular shape are seen,
particularly at the upper and lower portions of the cervix, where the regu-
lar, transverse, or oblique rugae become indistinct.  The cervical rugae have
been compared to a tree, a feather, or a fern-leaf; but when  the  whole
cervix belonging to the uterus which has never been  impregnated  is dis-
played, it is not unlike an open book in miniature, printed in double columns.
     "Although the columnar arrangement now described is generally met
with in the  cervix uteri in women who have not borne children, specimens
of virgin uteri are sometimes seen in which the cervix presents a  cribriform
appearance, instead of the arrangement of transverse rugae, with fossae be-
tween them; or there may be a less number of rugous  columns  than four,
from the absence of some of the  longitudinal sulci, or  ridges.   When the
follicles are arranged in a cribriform  manner, they enter more deeply into
the structure of the cervix, and are collected together in pouches instead of
furrows.   I have seen one Or two instances in which the follicular structure
of the  cervix extended down to the os  uteri, and the rugae, instead of being
arranged transversely, were found in the form of radiating laminae round the
os uteri.   In some specimens, the  rugae of the whole cervix  are arranged
closely together, as thin laminae, with  deep divisions between them.
     "In the virgin state, the arrangements of the mucous membrane above
described occur  with tolerable regularity; but after pregnancy and child-
bearing, they become, to some extent, confused and irregular, though the
follicular  structure remains.   The less  regular disposition of the cervix in
muciparous women is not to be wondered at,  when we consider the changes
which  occur from the development of the cervix in pregnancy, and the great
dilatation of this part of the uterus during the passage of the child in parturi-
tion.   Probably it is owing to the great extent of the  reduplication of the
mucous membrane of the cervix that laceration of the mucous surface of the 
189
cervix does not occur more frequently during labor.  In pregnant women, or
in cases where the cervix uteri is unusually developed,  as in long-standing
leucorrhoea, polypus, prolapsus, or procidentia, the rugae, or folds are con-
siderably increased in  size,  or they are unfolded to a considerable  extent.
Probably all the rugae  of the cervix disappear during labor from the unfold-
ing of the rugae, just in the same way as the columnar rugarum and the trans-
verse rugae of the vagina are obliterated from the same cause.  In one case
of polypus of the uterus which  I examined after death, where the tumor was
contained in the fundus uteri, but in which the cervix had shared in the in-
creased growth of the  organ, the rugae and follicles of  the  cervix were in-
creased in size.  In another case, in which a  large polypoid growth occu-
pied the cervix uteri, the cervical canal was  thinned out to a great  extent,
and the situation in which the rugae are usually found was perfectly smooth,
from the gradual unfolding of the mucous membrane.  In the young child,
the cervix uteri bears a greater proportion to the rest of the organ than in
middle life,  and the arbor vitae is seen very distinctly.   In old age the whole
of the  structures of the cervix and fundus  uteri shrink to a great extent.
     "The foregoing is a description of the mucous surface of the  cervix
uteri, such as it appears on a careful examination with the naked eye alone.
In all anatomical works,  mucous follicles and  lacunae are mentioned  as be-
ing numerous in the canal of  the cervix  uteri and between the penniform
rugae;  but the subject  is, as I have already observed, generally dismissed in
a few words, and I am not aware that any exact description of the cavity of
the cervix uteri and the arrangements of the mucous membrane, as they may
be seen  even without the aid of a lens, has been hitherto  given.   Names
too often hide the real  significance of things, and the terms, penniform rugae,
glandidae Nabothi, palmae  plicatae, and arbor vitae uterinus, would seem in this
instance to have been received  in lieu of more accurate descriptions.
     "Glandular follicles  of the  cervical caned.—If the above be true of the
cervix uteri  as it may be examined by the naked eye, we have been still
more  ignorant of the  anatomical arrangement of its mucous membrane as
seen by the microscope.   If we take a section of a virgin cervix uteri, con-
taining one of the longitudinal columns only, and magnify it nine diame-
ters, we obtain a clear insight  into the glandular structiue of the cervical
canal.   The transverse ridges now stand  out with great prominence.  Be-
sides  the primary rugae,  each  fossa is seen to be  subdivided by smaller 
190
rugae,  from which curved septa, still more minute, take their origin, divid-
ing the principal fossae into a  great number of crypts, arranged like a fine
piece of net-work.  In  each of the  fossae between the primary  rugae, as
many  as  from forty to  fifty  crypts or laminae may be seen.  A cervix of
moderate size would show between  the  transverse rugae  of  the  four  col-
umns alone, with this low magnifying power, from two to three  thousand
follicular pits.   But, besides the fossae between the rugae, the-spaces between
the rugous columns, and the longitudinal sulci themselves, are all seen to be
covered by multitudes of mucous follicles.   Small plicae are everywhere
visible, and these are evidently only a repetition of the columnar rugae, on a
lesser scale.   This is particularly the case with respect to the larger extremi-
ties of the transverse rugae, all of which  are  closely studded  with mucous
pits.  See Fig. 2, plate 14.
     "If a portion of the cervical mucous membrane be magnified still further
to the  extent' of eighteen  diameters,  so as to take only two or three of the
primary ridges and fossae into the  field, it will be seen that the rugae them-
selves,  and even the secondary septa, are covered in the greater part  of their
length  with mucous follicles.   The crypts in the furrows are still  further
divided and subdivided, so as  to double or treble the number of follicles and
laminae seen with the lower power.   In a portion of the cervix, comprising
only tluee rugae, and their two interspaces, upwards of five hundred mucous
follicles were easily counted,  so that it is  within the limits  of moderation to
say that a well-developed virgin cervix uteri must contain at least  ten thou-
sand mucous follicles; indeed, even this number is probably greatly exceeded.
See Fig. 1 plate 15.
     "When a longitudinal section is made through the middle of one of the
rugous  columns, and viewed laterally, fossae are found to  extend obliquely
and deeply into the substance of the  cervix, sometimes to the extent of the
sixth of an inch or more; and occasionally mucous openings pass into the
center of the walls of the cervix, and may be seen filled with the tenacious
mucus proper to the cervical canal.  These irregular cavities are sometimes
obstructed, and contain masses of inspissated mucus, the openings leading to
the cervical mucous surface having become closed.
    "Besides the anatomical arrangements already described, the superficial
surface  of this part of the mucous membrane of the cervical canal  is further
increased by the presence of villi similar to those found in the  lower part of 
Plate XIV.
Fig.  i.
Villi of canal of the cervix uteri, covered by cylindrical epithelium, and
           containing looped blood-vessels, ioo diameters.
Fig. 2.
One of the four longitudinal columns of rugae from the virgin cervix, 9 diameters. 
 
191
the cervix.  The villi extend to the glandular surface of the canal, and are
found in considerable  numbers on the larger ruga1, and other  parts of the
mucous membrane in this situation.   Thus the entire organization and dis-
posal of the mucous membrane lining the canal of the cervix uteri are such as
to afford a very large extent of glandular surface for the purposes of secre-
tion.   In effect, the cervix uteri  is an open  gland, and it performs, as Avill
hereafter be shown, all the functions fulfilled by glands in other situations.
     "Another purpose served by the reduplications of the mucous mem-
brane of the cervix uteri I have already alluded to, namely, the dilatation
of the cervix uteri during labor, without laceration.   In pregnancy, the cer-
vix uteri is enlarged and unfolded considerably by the processes of growth,
and in this enlargement the rugae take part; but nevertheless, at the time of
parturition, a large amount of distension takes place during the passage of
the foetus.  Without some such, pro vision as that offered by the  rugae of the
cervix, laceration of the mucous membrane would be a frequent occurrence.
During pregnancy the  rugae are enlarged and  loosened; but when the os
uteri  is fully dilated in labor, the mucous membrane of the cervix may be
felt perfectly smooth, no doubt from the unfolding of the rugous mucous
membrane.   In this, as I have already said, the rugous arrangement of the
mucous membrane of the cervix uteri  may be compared to  the rugous
arrangement  of the mucous membrane of the vagina.
     "I may here refer to a point  which should not be lost sight of, bearing,
as it does, upon the pathology and treatment of the disorders of the  os and
cervix uteri, namely, the great similarity which exists between the skin and
the mucous membrane of the vagina, and of the external portion of the os
and cervix uteri.   The  resemblances of  the mucous  membrane  in these
situations are certainly much nearer to the cutaneous structures than to the
mucous membranes of more internal parts.   This  is particularly the  case
with  respect  to the dense epithelial layer of the vagina and os uteri;  and
the villi of the os uteri are perhaps more nearly allied to the papillae of the
skin than to  the villi of the intestinal mucous membrane.   The surface of
the vagina, and the  external portion of the os and  cervix, like  that  of the
skin, is constantly acid;  while  within the cervical  canal the surface is as
constantly  alkaline.  These analogies are strongly  confirmed  by what  is
observed of the pathological lesions to which these parts are liable, and by
the effects of therapeutical applications.  Several of  the common skin affec- 
192
 tions are closely imitated on the vaginal surface and the vaginal portion of
 the  cervix uteri, and  give way to treatment adapted for genuine skin dis-
 eases.  It is also well known that when inversion  of the vagina occurs, as
 in procidentia uteri, the  secretion of vaginal mucus is  suspended, and  the
 epithelial layer of the  vagina becomes hard, and similar to epidermis.
      "The epithelium found upon the follicular surface of the canal of  the
 cervix is cylindrical or dentated, like the epithelium just within the os.   It
 is also ciliated low down in  the cervix, but not at its very lowest  part, and
 the ciliated character is continued into the cavity of the fundus uteri.  The
 villi  found in the upper portion  of the  cervix  are covered by dentated
 epithelium, just as is the  case with the villi of the lowest part of the cervix.
 Mixed with the epithelium of the follicular surface of the cervix,  a  consid-
 erable number of caudate corpuscles are frequently found, each  having a
 distinct  central nucleus.  These  are probably nothing more than  altered
 epithelial particles. The epithelium of the os uteri and external portion of
 the cervix is, like  that of the vagina, constantly squamous; the epithelium,
 just within the os uteri, is  cylindrical,  but not ciliated.   Various opinions
 have been held respecting  the point at  which the squamous epithelium
 becomes changed for the cylindrical, and also respecting the point at which
 cilia  are  first found.   The above is the  result, however, of the examination
 of many uteri, made as  early as possible after death, so as to anticipate the
 alteration  of the cilia  and epithelium by post-mortem changes.  The situa-
 tion in which cilia  are first found in ascending the utero-vaginal tract varies
 a little in different subjects, but, I  believe it will be found that the transition
 from squamous to  dentated  epithelium constantly occurs just at the margin
 of the os uteri.      *******
     "It will be seen  that from the nymphae to the entrance of the  fundus
 uteri, the glandular structures are arranged at two principal stations, namely,
 at the ostium vaginae, or the  cervix vaginae, as it might be  called, and at the
 cervix uteri.   There is no apparatus for any considerable mucous  secretion
 in the space between these two points."
     The  vaginal   canal  is formed of  three layers, first, the internal  or
 mucous;  secondly, the middle or erectile; thirdly, the external or contractile
 sheath.
     The mucous membrane  is studded with villi or papillae, some  of which
have  two or  three club-shaped terminations growing from a  single stem. 
Plate XV.
Fig.  i.
Fig.  2.
Side view of one of the columns of rugae
        and fossae, 6 diameters.
  Two of the  transverse rugae, with one perfect
fossa  between them, from  the virgin  cervix,  18
diameters.
Fig-  3-
  Sebaceous follicles, after  a drawing  from a preparation by Dr. Hassall.  The dark
bodies are the sebaceous glands, the white spaces are the depressions in which the
papillae have been received; 18 diameters. 
 
193
Around the entrance thev are very numerous, and abundantly supplied with
capillary vessels; thev diminish in numbers; and their vascular supply less-
ens on passing upward toward the cervix uteri.
     In that portion of the mucous membrane forming the cul-de-sac there
are but very few follicles or glands.
     At the ostium vaginae, just within the carunculae myrtiformis, are situ-
ated two large glands, commonly called  the  vulvo-vaginal glands, or the
analogues of Cowper's glands, their purposes being to supply  the vaginal
entrance with  an oily fluid.
     In addition to the vulvo-vaginal glands, the vulva is thickly  studded
with sebaceous follicles or fat-glands.   The secretion  from these follicles is
thick and tenacious, of a white color, strongly acid, and possessing a pene-
trating odor.   See Fig. 3 plate 15.
     The whole mucous membrane of the vulva and vagina is covered with
a layer of squamous epithelium;  its mucous secretion  is strongly acid, as is
the secretion  from all surfaces covered  with squamous epithelium.  The
secretion from the mucous membrane of the cervix uteri is alkaline, it being
covered by cylindrical epithelium.
     A  piece of blue litmus brought into contact with the secretion  of  the
vagina becomes reddened, but its color is restored if pressed into  the cervical
canal.
       25 
194
    CHRONIC CERVICAL  METRITIS AND ENDOMETRITIS.

     The  subject of corporeal metritis and endometritis has been so fully
considered by my assistant in his report of cases treated in the out-door de-
partment of the hospital, that I shall not refer to it, but confine myself to in-
flammation of the cervix, which, from its exposed position and complex glan-
dular construction, is peculiarly prone to disease.
     By chronic cervical endometritis, I understand a low grade of inflamma-
tion confined to the mucous membrane lining the cervical canal, between
the os externum and internum, and covered by columnar epithelium.  It does
not include inflammation affecting the vaginal surface, which is entirely differ-
ent in its character.
     It is by  far the most common of  all the  maladies to which the genital
system of the female is liable.   It is the starting-point of some of the most
serious and rebellious of uterine disorders.
     Causes.—Laceration from parturition, abortion, too frequent indulgence
in marital intercourse; particularly when that function is imperfectly per-
formed, which is very apt to be the case with men whose  lives are devoted
to hard study, or who, from any cause, have  exhausted their  nerve-power
before marriage.*
     "Such persons marry; anxiety for children, or some other complex
feeling,  leads them  to over-frequent  attempts at  sexual intercourse.  The
act is incompletely performed; nervous apprehension  leads to  still more
frequent attempts, and its more incomplete performance, and, unless by good
fortune pregnancy has taken place very soon  after marriage, a condition of
permanent congestion of the cervix uteri is induced, and the wife becomes
as inapt for conception as the husband for procreation.
     "Inflammation of this gland may  occur, however, from a generally  de-
praved condition of the system, independent of any local irritation.   I have
frequently met with it in unmarried women of  whose chastity there could
be no question.
     "It is not a disease self-limiting in character.   Unless proper treatment
is adopted, the inflammation, *at first confined to the lining membrane of the
cervical canal, spreads to the parenchyma.  If this occurs during the func-
tional life  of the uterus the probable result will be hypertrophy and indura-
                                * West. 
195
 tion; but if the climacteric period is about to occur or has  passed, the more
 probable termination will be epithelioma."
      Symptoms.—In the early  stage of the disease the symptoms are not
 well marked; indeed it may exist for a length of time without the  patient
 being conscious of any local trouble.  There may be a general feeling of
 malaise, and indisposition for exertion, particularly when walking or stand-
 ing, but acute pain is not one of the symptoms  present at the commence-
 ment of the disease, or indeed at any period of its existence.  Leucorrhoea,
 frequently profuse, is always present; at first it has the appearance of boiled
 starch, but this soon changes to a somewhat thinner purifomi matter.  The
 secretion from the cervical canal being alkaline, its passage over the mucous
 membrane of the vagina, whose  normal  secretion is acid, causes irritation,
 accompanied  by an increase in the quantity and an alteration in the charac-
 ter of the vaginal mucus.   This mixing with  the secretion from the  cervix
 causes its puriform or sanguineo-puriform appearance.   Sometimes the dis-
 charge is sufficiently ichorous to  excoriate the labia and inside of the thighs.
 The patient's whole nervous system becomes implicated from sympathy with
 the  local affection.  The digestive  function  is among the first to  suffer;
 nausea, loss of appetite, and constipation being the common attendants.  The
 blood becomes impoverished as the result of impaired nutrition,  and,  as
 Thomas observes,  "she will become  nervous, irascible, moody, and hysteri-
 cal."   Complications rapidly develop themselves, the most common of which
 is cervical metritis.  With this  there is always  pain, more or less  acute,
 during sexual intercourse, pain in the back, and painful and excessive men-
 struation, in addition to the symptoms already enumerated.
     Cervical  endometritis may exist independent of  cervical  metritis, but
 cervical metritis rarely exists uncomplicated with  endometritis.
     Physical  signs.—-If the  disease is  confined  to the  upper part of the
 cervical  canal, there may be no  enlargement  of the os, or abrasion of the
 mucous membrane around it, to indicate the existing trouble, but there will
 be seen hanging from the os a ropy, tenacious mucus, like the white of an
 vgg, sometimes a little yellow, but rarely tinged with blood, which it will be
 found difficult to remove, as it adheres firmly to the depressions between the
 rugae.   If the  disease implicates the whole of the canal, the os will be patu-
 lous and the vaginal portion of the epithelium covering its margin destroyed,
laying bare the papillae, presenting to the unpracticed eye the appearance of 
196
ulceration.  If the inflammation has spread to the parenchyma, there will
necessarily be hypertrophy in addition to the foregoing pathological condi-
tion.  If the disease is confined to the cervix, the passage of the uterine probe
will meet with obstruction at the os internum; if the body of the uterus has
become involved, no obstruction will be offered to the passage of the sound,
but it will cause great pain.
     Treatment,—If the disease  is simple endometritis, the  first care  must
be to place the patient under the best possible hygienic influence.  The con-
dition of the alimentary canal must be carefully watched, all depressing in-
fluences removed, and the largest amount of fresh air obtained with the least
possible  exertion.   Her food should be  nourishing, easy of digestion, but
not stimulating, and marital intercourse strictly forbidden.  If necessary, an
infusion of some vegetable bitter may be administered to increase the appe-
tite, and a preparation  of iron to enrich the blood.
     Locally.—The first step will be to dilate the canal sufficiently to admit
of the thorough application of alteratives.  This is best effected  by the car-
bolized sponge-tent. One  of small diameter should be selected; it'should
taper towards the  point, and only be  introduced as far as the os internum,
never being  permitted to pass through it.  If this precaution  be taken no
unpleasant complications will follow.  It is the violence done to  the fibres of
the internal os that occasions the acute inflammation which sometimes occurs
after their use.
     The os having been well dilated the mucus must be  carefully removed
and a solution of nitrate of silver (20 grains to the oz.) applied to every por-
tion of the membrane.  If the mucus has not all been removed, the alterative
will  not  reach the glands  situated in  the sulci between  the rugae.  Some
practitioners  prefer chromic acid, and others carbolic acid, as an alterative;
either is good.   The importance is not so much in the choice of caustics as
in the thoroughness of  their application.  After the caustic has been applied,
a pledget of raw cotton, soaked in glycerine containing two or three grains
of the watery extract  of opium, should be passed into the posterior cul-de-
sac.  The pledget should  be removed in a few hours.
     This course of treatment will have to be pursued  in some cases for
several months before  a  cure will be effected.   The erosion around the os
requires no treatment;  it is dependent for its existence  upon the cervical in-
flammation, and as soon as the  parent  disease  is disposed  of, its offspring
will disappear.  To use  Dr.  Emmet's apt illustration, the erosions around 
197
the os uteri are like the excoriations upon the lips of children who are suffer-
ing from ozaena.  Cure the ozaena, and the excoriation will take care of itself.
If, however, the inflammation has existed sufficiently long, and been severe
enough to affect the parenchyma and produce a general  cervicitis, we have
a much more difficult disease to combat.
     The general treatment will be the same  as in endometritis.  The lo-
cal treatment, in addition to that recommended for endometritis, will  con-
sist in the abstraction of blood by leeches from the posterior cul-de-sac, the
daily use of the hot douche, and such other remedies as the exigencies of the
case ma}' suggest, the  indications  being to allay the pain, and reduce the
hypertrophy which is always present.
     As each case has its  own particular history and indications, the general
method of treatment will be best illustrated by a report in detail of a few of
the cases treated in the hospital.
     I  have  met with no instance of inflammation of the parenchyma of the
cervix  uncomplicated with endometritis, and the report is therefore confined
to endometritis and general cervicitis.
                      Chronic cervical endometritis.
                               Case 1.
     A. T----; aged thirty-two; admitted July 2, 1866; married at nine-
teen; has never been pregnant; her health not good for the last two or tluee
years.   She complains  of pain in the back and  hips, and profuse leucorrhoea,
which discolors her clothing and excoriates the nates and inside of the thighs.
     Examination.—Os  patulous  and filled  with a tenacious, ropy mucus;
the investing mucous membrane abraded; papillae enlarged, and to the inex-
perienced eye  presenting the appearance of ulceration.  The introduction of
the sound caused no pain; the os internum not patulous.
     Treatment.—Hot douche  morning and evening, continued for  fifteen
minutes.  A small-sized sponge-tent introduced to dilate the cervical canal,
and removed at the end of twenty-four hours;  its  presence gave no pain.
A solution of nitrate of silver, (20 grains to the oz.) was applied every fourth
dav, the application followed by the introduction of a pledget of raw cotton
saturated with glycerine.  Her bowels were kept open by the occasional use
of a belladonna suppository, followed by  an enema of tepid water.  As a
tonic one drachm of the sirup of the phosphates of iron, quinine, and strych-
nine was given after each meal. 
198
     The  patient's recovery was slow, nearly four  months having elapsed
before she was sufficiently improved to leave the hospital.  She  remained
several months afterward under treatment as an out-door patient.
     She  became pregnant for the first time  in the spring of  1869, and hi
January,  1870, gave birth to a healthy male child.   Her recovery was good
and involution of the uterus perfect.

                       Chronic cervical endometritis.
                                Case 2.
     F. K----; aged twenty-three;  admitted  August 25, 1866, single; has
been employed in a printing-office as feeder to a cylinder press.  Her occu-
pation kept her upon her feet for ten and sometimes as many as fifteen hours
out of the twenty-four.  Her health has been  failing for two years, and she
has now become  so weak as to be  unable to follow her occupation.  She
complains of a severe pain in the loins and hips, leucorrhoea so profuse as to
necessitate the use of a napkin constantly; her monthly periods are regular
and painless, but the discharge excessive.  She has constant pain in the top
and back part of the head, her appetite is capricious,  digestion imperfect,
and the bowels are  obstinately constipated.
     Tongue furred, the edges marked by the teeth; breath offensive; pulse
118 and weak.
     Digital examination.—Vagina relaxed, cervix long but normal in posi-
tion.   The posterior cul-de-sac was  occfupied  by a tumor  easily raised and
not tender; rectum filled with scybalae.   The speculum revealed the os patu-
lous and the mucous membrane around it eroded.  The discharge from the
cervix was less tenacious than usual in  such cases, approaching more nearly
to pus.  The  sound was passed with some difficulty, disclosing a complete
retroflexion of the uterus.   It was easily replaced, but, upon the withdrawal
of the sound, the  fundus fell back again into the posterior cul-de-sac,
    Diagnosis.—Chronic cervical  endometritis,  with  retroflexion of the
uterus, due to atony of the muscular fibres of its lower segment.
    The uterine  disease in this case was secondary.  The primary trouble
was  a depressed  condition of the vital powers, brought  on  by  excessive
fatigue.  The nervous system failing under  undue taxation, the  digestive
function necessarily became disordered.  The  uterus being an erectile organ,
suffered in common with the rest of the system from enervation, its retro- 
199
flexion not being due to any hypertrophy of the posterior wall, but to the
want of  power in the lower  segment to sustain the fundus in its normal
position.
     The general treatment pursued in this case was the same as in case No.
1, but locally the  hot douche was omitted.   The  uterus  was partially re-
tained in position by a pledget of cotton saturated with glycerine, placed in
the posterior cul-de-sac.
     The patient gained  strength rapidly, and the discharge lessened.   By
the latter part of October the cervical disease became scarcely recognizable,
but  there was no improvement in the position of the uterus, and it was
determined  to try the effect of a current of  electricity, directed through its
muscular fibres, daily.
     The hospital being full, she was discharged as an in-door patient, and I
arranged with her to call at my office for the continuation of treatment.
     One pole of the battery was passed up the rectum to the fundus uteri,
and the other applied to the os, the application lasting on  each occasion ten
minutes.   These applications  were continued for  a little more  than three
months with moderate regularity.
     The effect was  all that could have been desired.  The cure was com-
plete.
     It is seldom I have met with a case where the result of treatment has
been so gratifying as in this instance.  She  entered the hospital completely
broken down in health, and dejected in spirits, physically a miserable speci-
men  of a woman.  At the end of six months she had  regained her health
and spirits, her local trouble completely cured, and she was enabled to com-
mence life anew with the consciousness of ability to gain a livelihood.
                            Chronic cervicitis.
     Miss C----;  aged  thirty;  admitted as out-door patient February 8,
1867.  General health good;  complains of inability to walk, pain  in the
back and loins,  constant disposition  to micturate,  pain  upon sitting down,
the feeling being as if something tender was being  pushed upward; pro-
fuse and  offensive leucorrhoea.
     Examination.—Vagina relaxed and  capacious.   At  the entrance  the
fino-er encountered what was supposed  to  be a foreign  body, but,  upon
further investigation, was discovered to be an enormously enlarged and elon-
gated  cervix, measuring  two and one-half inches in length;  the upper por- 
200
 Hon was very tender, owing to the inflammation produced and maintained
 by the  constant violence done  to the organ by the ordinary movements of
 the  body.  The indication was first  to reduce the inflammation, and then
 remove  the whole vaginal portion of the cervix.
     Three leeches  were applied to  the  posterior cul-de-sac, and the hot
 douche  used twice daily, followed, on each occasion, by the introduction of
 a suppository containing one grain of morphine.
     Under this  treatment, with absolute  rest, the inflammation subsided,
 and in  six weeks was  sufficiently reduced to permit of the operation for
 removal with safety.
     March 8.—The patient was placed in position on  her left side and the
 cervix seized by a volsella  and drawn downward; the upper portion, close
 to the vaginal reflection, was transfixed by a strong curved bistoury, and
 the removal effected by the flap operation.
     The flaps were retained  in apposition by the clamped suture for the
 deep portions, and the interrupted suture superficially.   The object in using
 the  clamps was  to  prevent haemorrhage, which they perfectly control.   A
 piece of catgut was  placed in the cervical canal to keep it open.   The parts
 united by first intention; no  constitutional disturbance followed the opera-
 tion, and the cure was complete.

       Chronic cervical endometritis, with hypertrophy and induration.
                        Amputation of the  cervix.
                                Case 4.
     Mrs. 0. L----; aged forty; admitted as out-door patient May 9, 1869.
Mother of five children, the youngest  four years of age.   Since the birth of
her last  child she has suffered  from aching in the back, leucorrhoea, pain
upon sexual intercourse, and after a movement from the bowels.   She has
been twice under treatment, once for a period of five months and at another
time for  six months.  She  improved  each time,  but as  soon  as the local
applications were discontinued became as bad  as before.   Menstruation
occurred  twice monthly, and  was profuse,  but not painful; her appetite
was poor, and digestion imperfect,  Her general appearance indicated suf-
fering, being anaemic and feeble; pulse ninety-six and irritable.
    Examination,—Os patulous,  large  enough to admit the end of the index 
201
 finger;  cervix hypertrophied, and the portions around the os of stony hard-
 ness.  It was a case to  invite malignant disease, if it had not already com-
 menced, and the amputation of the cervix was recommended without wait-
 ing for  any preliminary treatment.
     May 11.—The entire vaginal portion of the cervix was reinoved.  The
 amputation being performed with scissors, no flaps were formed, the stump
 being allowed to heal by granulation.
     No complication occurred during the after-treatment  of this patient;
 she fully recovered, and at the present time is enjoying good health.

     The  number of cases that have been  admitted  into the hospital for
 disease  of the  cervix uteri are nearly double those admitted for any other
 disease  of the  uterus.  The general symptoms, treatment, and results have
 been pretty uniform.   The great difficulty experienced has been in detain-
 ing  the patients long enough to effect a cure, most of  them having families
 from whom it was difficult, and  in some cases impossible for them to remain
 absent.  As soon  as improvement begins they wish  to return home, and
 promise to continue attendance  as out-door patients, but this promise is sel-
 dom kept.  They frequently apply for re-admission months afterward, worse
 off than when first presenting themselves for treatment; and in several cases
 what appeared to be a simple inflammatory  hypertrophy and induration of
 the cervix when first treated, has been found to develop unmistakable malig-
 nant disease.
     I have reported but four  of these cases, which are typical of all.  The
 details of the others would be mere repetition and serve no good purpose.
     I have amputated the cervix in a large number of cases in hospital and
private  practice, and in no instance  has  the amputation been followed by
an}' complication.  (See Dr. Ashford's report in Appendix.)
      26 
202
REMOVAL   OF   THE   HANDLE  OF  A  CROCHET-NEEDLE
                  (IRON) FROM THE BLADDER.
     L. S----;  aged twenty-eight; admitted to Columbia Hospital January
14, 1872.  This patient had been under the care jof Dr. Ma grader, of this
city, who had made several attempts to remove from the bladder what ap-
peared to be  a large  calculus.   He had dilated the urethra and  succeeded
in crushing and removing several fragments.
     Upon her admission I  recognized her as a patient who had been in the
institution two years before, and who had left only partially relieved of the
trouble for which she was then admitted.
     At the time of her  first admission she complained of extreme prostra-
tion, loss of appetite and inability to sleep, and was frequently the subject
of severe hysterical  paroxysms;  her  bowels were costive; her  menstrual
discharges irregular and,scanty;  bladder and vagina irritable; leucorrhoea
profuse.   The urethra was patulous and congested, the clitoris  hypertro-
phied, and there was unmistakable  evidence  of  long-continued irritation
about the vulva.
     I was satisfied. the woman was  a victim of masturbation, and  all  the
treatment she received while in  the hospital was directed in accordance with
that theory;  such as large and continued doses of the bromide  of potash,
and the frequent use of a warm sitz-bath, followed by the local application
of  sedatives.   A  strict  surveillance was  kept over this. patient, and on
several occasions she gave  absolute evidence of the practice of this vice.
     Medication  failing  to  cure and  moral suasion to control her, she was
dismissed from the hospital as incorrigible and incurable.
     With the previous  knowledge of this woman's habits, I was prepared,
upon her second admission, to suspect something more than a simple calcu-
lus in the bladder; and, upon introducing the sound, and finding a body
measuring between three and four inches in length, I was satisfied that  my
suspicions were correct, and that there had  been some foreign body intro-
duced into the bladder through the urethra, forming a nidus upon which a
mass of incrustation had formed.
     A careful exploration  showed the walls of the bladder to  be much
thickened and contracted; upon injecting it with tepid water to ascertain its 
Iron handle of a crotchet-needle incrusted with the salts of the urine.   Removed from the
      bladder of a female by an incision through the vaginal walls.   See page 202. 
 
203
capacity, not more than thirteen drachms could be forced in; its walls ap-
peared covered  in  every part with incrustations.   The  foreign body was
imposed  immediately over the  entrance  to the bladder, and transversely.
Urine dribbled from her continually, and she  suffered  from severe pain in
the supra-pubic region.
     From the contracted and inelastic condition of the bladder it was feared
that any  attempt to change the axis of the foreign body, so that it could be
removed  by the  urethra, would result in a rupture of the bladder and death
of the patient, and it was decided to remove it by an incision made in the
viscus through the vagina.
     Patient being  fully aetherized was placed upon the operating  table,
there being present most of the consulting board of physicians and the full
clinical class.  A free incision was made through the vagina into the blad-
der, the walls of which were  enormously thickened.  Upon introducing the
finger tluough the opening the  mass could be felt firmly wedged.   A pair
of forceps was passed through the urethra, the foreign  body firmly seized,
and, by forcibly depressing the posterior wall of the bladder with the fin-
ger, which was  introduced into its cavity, its point was  liberated and the
mass withdrawn.  Removing a portion of the incrustation the nidus was
found to be the iron handle of a  crochet-needle, around which had been
wound and knotted some common  hempen cord, evidently for  the purpose
of. making its surface more irritating.   See Plate 16.
     Upon sweeping the finger around the bladder the whole  surface was
found to be incrusted,  hard, and unyielding,  and felt  like  the inside of a
rough stone vessel.
     The fistulous opening was allowed  to remain, the  parts being in no
condition for union,  and to afford a  better opportunity for treating the
bladder.
     A stream of  slightly acidulated water was injected daily through the
urethra, passing out through  the vagina, each time carrying with it a quan-
tity of the incrusted  salts from the walls of the bladder.   An injection of
glycerine and carbolic acid followed the tepid water.
     This plan of  treatment locally, and bromide of iron internally, were
continued for several weeks,  when the fistulous  opening was closed in the
usual maimer.
     On  the third day after the closure of the fistula, the nurse informed me 
204
that she feared the operation would be a failure, as the woman was contin-
ually abusing herself with the catheter that was left in the bladder.
    An examination showed the part to have  been torn open, two of the
wires torn out, and the edges bleeding.
    On the  ninth  day the  balance of the wires were taken out and about
half the fistula was closed.
     One  month was allowed  to elapse  before any further attempt  at  a
closure of the opening was made, when the operation was repeated and the
patient kept under the closest surveillance day  and night.  The wires were
removed on the tenth day after the operation, and union found to be perfect.
    The parts were examined frequently during the following three days,
the hydrostatic test applied, and the bladder found tight.  On the morning
of the  fourteenth day after the  last operation the nurse detected the patient
using the  long nozzle of  the enema-pipe  in her  urethra, and it was found
that she had  forced it through the newly united parts and again created  a
fistulous opening.
     Thoroughly disgusted and disheartened with the case I dismissed her,
telling her, however, that when prepared to behave herself decently I would
make  another effort for her cure.
     The pages of this report are not the proper place  to enter into a dis-
cussion as to the means to be employed to check the fe'arful vice of self-
pollution.  That it exists to a most alarming extent there is no doubt.  Nor
must it be supposed that  it is a habit of modern date or  in any way due to
the luxurious habits of  civilized life.  As far back  as we can trace the
records of our profession we shall find reports  of similar cases, a large ma-
jority of them proving fatal to the unfortunate victims.  Our insane asylums
can tell the tale of  its fearful prevalence.
     It is a great social evil, to  be met and grappled with by those who have
the task of educating our youth.  The province of the physician is to cure
or alleviate the diseases to which • it gives  rise, and they are a legion.  The
principal of these are phthisis, mania, and  heart-disease.  It is high  time
that medical authorities  put aside the morbid sentimentalism which  has
hitherto prevented a free discussion of the  ailments which this practice gives
rise to.  The Lancet, of  1870,  suggests, in a series of leading articles, that
all medical and surgical authorities should fearlessly discuss this abominable
vice and its attending physical evils with the same freedom they would any 
205
kindred class  of nervous affections.   Acton, Ritchie, and  Esquirol have
already done so; let others  follow, until the  penalties of this vicious habit
are sufficiently well known to prevent its practice.  •
     Often the medical man is misled by the  statements of the patient, and
the long range of sympathetic diseases to which the  practice gives rise are
ascribed to any but the right cause; and even in  spite of  the most positive
evidence,  such men as Velpeau, with a faith in human nature irreconcilable
with his experience, when speaking of foreign bodies in the bladders of
females, makes the following remark:
     "A woman tormented with attacks of the colic was not cured, accord-
ing to  Van-der-Wiel, until she had discharged through her urinary passage
a ball  she had swallowed.  And among the examples of calculi of the blad-
der which have exhibited for their nucleus points of spindles, ears of wheat,
&c, it is probable that they reached there tluough the migrating process.
     "These substances having arrived in the stomach  or  intestines get en-
tangled in some of the folds of the mucous membrane, and gradually escap-
ing outside of them, continue to march in this or that direction according to
the disposition of the  parts."
     In 1857 I was sent for to see a young lady in New York, a patient of
Dr. Edwards,  who was suffering the most intense agony in  the region of the
bladder;  her  urine, which was passed  every few minutes, was mixed with
blood.   The  urethra was patulous, admitting  the little finger  readily;  a
probe  passed into the  bladder came in contact with several pieces of hard
substance, giving a clear, distinct sound when struck, but feeling too smooth
for stone.   For some  time the  patient denied having introduced anything
through the urethra, but finally admitted that she had been in the habit of
using a small  female  syringe,  (glass,) and on the day on which I saw her
had pressed too hard upon the piston  and fractured the lower part of the
syringe, the pieces remaining in the bladder.
     It was impossible to extract them by the urethra without lacerating the
part.   The surest and safest plan was to cut into the bladder through the
vagina, remove the pieces, and close the parts immediately with the silver
sutures;  this was done, and the patient recovered without any unpleasant
symptoms.
     On another occasion a young girl of fifteen had been using a long hair-
pin, which was drawn from her fingers  into the bladder, but fortunately it 
206
was too long to pass entirely in, and the two  ends remained within the
urethra.   It was with some difficulty removed.
     These are by no • means uncommon cases.  Old as well  as modern
authors report abundance of them.  The surgeon, it must be noted, is only
called upon when the foreign body is in the bladder to remove it,  The
gynaecologist is constantly called upon to treat cases where there has been
no  accidental loss of the article used, but where the patient is suffering from
a long train of nervous disorders produced by this vicious habit.
     Morgagni, in his  work published in 1768, reports the following cases,
which are full of interest:
     "A country girl,  almost of the same age with that formerly spoken of
by  me in the Ephemerides, for she died in her fourteenth  year, having done
the same thing as the  former, sixteen months before, deservedly suffered the
same misfortune.   For,  having  introduced a brass hair-bodkin, notwith-
standing it was bent in the middle, very high into the urethra, she perceived
that it was suddenly  snatched out of her  fingers, and entirely hid within
the bladder.
     " Being  restrained by shame, she not only then, but  even almost quite
to the time of her  death, was  silent as to the true  cause of the pains and
uneasinesses which she felt, and  particularly in making water; which were
so many and so great that a tumor having, at length, arisen in the  hypogas-
trium and the nearest  part of the ilium, a pus was discharged by two foram-
ina that it had made for itself; one larger and one  smaller; the  former of
which wras in the left  ilium, and  the latter  on the  right  side, in  that part
which is properly called, with Laurentius, the  'fines hypogastric'
     " Being thus affected she was received into the  hospital at  Padua, a
month or two before death.   It was  there easily observed that, together
with pus, urine was poured  out through each of the foramina, but more
through  the  left, under  which was a cavity  of pretty  considerable size,
wherewith the right foramen also communicated.
     "As, in this cavity, the probe met with something hard, I was  asked
what I supposed this could be.   I  immediately called to mind what had re-
sisted the probe when it was introduced through  the fistula,  which had
opened itself in one of the  ilia, and had  discharged urine with the pus, in
the  former girl.  And when  I heard  that  this girl was  also tortured with
pains of the bladder in making water, and that she discharged only a small 
207
 quantity of urine, and that purulent, I answered that it was necessary to
 inquire whether she had introduced a needle or anything,  else of the like
 kind into the urethra.  The girl denied it, till the left foramen being en-
 larged  by a slight section of the  common  integuments, the point of the
 bodkin, and the greater part of its length, were evidently seen within the
 cavity by everybody.  Then, what she could no  longer hide,  she too late
 confessed.  For even the bodkin  could not be extracted, by reason of a
 calculus that was formed upon it; which calculus, though it was easy to
 perceive it by introducing the probe through the passage of the urethra, or
 through that cavity, yet it was impossible to move, even the most slightly,
 without great pain.
     "And the same calculus prevented their injecting anything into the
 urethra, to assuage the pains, by blocking up the passage.   To these symp-
 toms were added a very great wasting of flesh;  the  quantity  of pus was
 increased every  day;  and the putrid smell and  the fever  became  very
 violent.
     "These symptoms were followed by a loathing of  all food;  a vomiting,
 and discharge by stool, of  a yellow liquid  matter; a dejection of strength,
 and weakness of pulse, till death at length put the wished-for end to so many
 miseries and complaints, among which complaints there  had never been
 heard any of a pain in her loins by those who examined her  upon that head.
     "The carcass, which seemed to be a skeleton covered with skin, was
 dissected in the open air,  and in a very large place, on account of the time of
 the year being very hot;  for it was the beginning of July in the year 1738.
     "I, first of all, ordered the probe to be passed through the right foramen
 into the cavity of the ulcer, and the whole sinus to be laid open—this was
 betwixt the muscles of the abdomen  and the integuments—nor was there
 any communication, in any part, but with that cavity.
     "The cavity was, in length and in  breadth, three inches; extending itself
from the  left ilium toward the linea  alba, having a thin posterior paries,
which the remains of the muscles  and the  peritoneum  made up, and by
which it was separated from the cavity of the belly; but  in the same paries,
which was open on the right side,  it  communicated with the fundus of the
bladder; and there a great part of the  bodkin was prominent into the cavity
of the bladder.
     "The abdomen was then cut into in such a manner that  the incision did 
208
not reach to the bladder; which, although the cavity was small, had coalesced
pretty high, that is, above the os pubis, with the internal surface of the ab-
domen, in that part only where it lay open into the cavity of the ulcer; so
that nothing could be discharged into the general cavity of the abdomen,
wherein there really was not the least extravasated fluid.
     "And even the lower border of the omentum, which had scarcely any
remaining  fat,  in  most places, was closely connected to the neighboring
peritoneum of the bladder.
     "These appearances being seen, and the bones of the pubes being drawn
asunder, the whole bladder was disclosed to view; and itself, together with
the urethra, was  laid open;  the coats of these cavities  were found to be
thickened, but so  contracted, that besides the calculus they could scarcely
contain anything.
     "The internal coats of these parts, which were unequal, and ulcerated
in many places, adhered  to the stone here and there;  and were, like the
cavity of the ulcer, in many places gangrenous  also.
     "The calculus was a  little more than two inches long, being somewhat
thicker than a man's thumb, and in its shape resembling an egg, the vertex
of which was  turned upward as the point of the needle was also, with all
that part which went to the angle whereof I spoke in  the beginning, being
almost parallel to the calculus, and disjoined from it by the interval of an
inch;  the remaining part  of the needle was also on the  outside of the cal-
culus, as far as could be conjectured, almost universally; the head only, with
some of the neighboring portion of it, being very firmly infixed to the mid-
dle and left side of the calculus; that is, covered over with the calculous con-
cretion; which portion is, on that surface, and at both of its extremities, very
unequal; on the opposite surface almost smooth and somewhat white, except
where it was tinged of a  yellowish color, as the whole left part is;  which
■circumstances I describe as I now see  them;  for at that time it  was bloody
in some places, and in others of a dirty brown color.
     "At that time, also, tlie calculus being examined, as it is connected with
the needle, by medical weights, was found to be a few grains lighter than
seven  drachms; but now  it is a few grains heavier than five drachms  and
two scruples.
     "Most of the other parts of the belly were in a preternatural state.  Their
appearances were as follows: 
209
     "Some of the intestines were a little livid, and somewhat turgid with
that yellow humor which was last of all discharged; the liver was whitish;
the spleen was  pretty livid, and a little larger than it generally is.  But
the ureters, and the kidneys themselves, were  in a very bad condition in-
deed; for these canals were dilated, and full of  pus, of the same  kind with
that which was found in the cavity of the ulcer in considerable quantity;
for it was very liquid,  and of a yellowish  color, inclining to white;  or, in
other words, it was a pus  mixed with urine.  And the kidneys were pre-
ternaturally enlarged,  especially the right, which was also very  hard, and
internally hollowed into small cells, that were in great number, and so dis-
tended with the same kind of pus as the pelvis was also, that it rushed out,
to a considerable height, upon dissection.
     "The adipose and proper coats of the left kidney being  joined to each
other, tliickened, and indurated, confined the same kind of pus betwixt them-
selves, with which the surface of the kidney, that was eroded in some places,
overflowed; as the internal parts did also in several places.
     "But the very filthy odor which exhaled from the kidneys and the blad-
der forbade us going on to open the thorax; no  mark of disease in that part
having appeared.
     "The dissection being thus finished, you will readily conceive, from what
I shall here subjoin, somewhat  more at large, what I then immediately said,
according to my custom,  to the many  men of  eminence, and others, both
medical and chirurgical practitioners, and students, who heard me.
     "What reason could induce this girl, and so many others, to thrust the
heads of needles, or bodkins, into the urethra, is not so much to be inquired
after in the lacunae of the fallacious humor, inasmuch as they open  in other
parts, and even on the outside of the urethra,  unless  you, perhaps, suppose
that those canals also, which I described within the urethra  of women, be-
long to this class also, as in the exquisite sense  of the membrane wherewith
it  is internally invested.   For unless they applied the friction very high up
in the urethra, it could not happen,  that, by a sudden and strong contraction
of the lower part of the bladder, the needle should be snatched out of their
fingers, and be  quite buried in that cavity; especially when the needle is
pretty long.
     "For from  the bladder, and its sphincter, 1 account for this misfortune,
agreeably to the opinion of Molinetti; and not  from a certain  power of the
       27 
210
uterus, as they say, which, even if it had this power of drawing downwards
itself, would not, however, draw what was thus acted upon, into the blad-
der.   In some cases the needles have fallen out, of themselves, after having
been taken in; as happened to two girls that are spoken of by Vallisneri, to
one when she was asleep, and to the other when she was making water; I
suppose, because in these they had only entered the bladder in part; that is
to say, the crooked needle easily  remaining with one part  in the  urethra,
while the other was retained in the bladder for a month.
     "On this part, however, no calculous matter had been formed; as is also
said not to have happened to a needle that  was thrust in  by a fourth, and
discharged after fifteen days, at the time of  making water;  which needle it
is probable had been obstructed, in  its  passage through  the urethra, at its
lowest and acute part, from this symptom,  that she only complained of a
sense of pricking about the neck of the bladder.
     "But although these things that  I have said about the  point of the
needle, or bodkin, being fixed  in the urethra, will be more illustrated  by
what will be hinted afterward, yet I  shall not deny that needles, which have
been received quite into the cavity of the bladder, may nevertheless be so
turned therein, as, in like manner, to be discharged by the meatus urinarius.
But that  to those two, whereof I spoke last, no  calculus adhered, within
fifteen days, and even within the space of a  whole month, there must have
been more than one reason, as we have known this matter to adhere to others
in much less space of time.
     "For the urine, in all persons,  is not equally impregnated with particles
fit to recede therefrom, and generate a calculus; and some retain their urine
longer than others do;  and the matter, or surface,  of different needles is dif-
ferent.  Thus  Vallisneri  has supposed  that a silver needle, or  bodkin, Avas
taken out from the bladder, without the addition of any calculous concretion,
merely for this reason,  that it was silver; which conjecture, however, will be
much more credible, if it shall, at  any time, be confirmed by other experi-
ments.
     "Thus a concretion  seems more likely to adhere to a pretty rough sur-
face than to a  very polished one; and hence, perhaps, we are to account for
this circumstance, that  one part of the needle is, for the most part, covered
with a calculous matter, while the other is left quite naked. Of the two girls,
therefore, whose bodies I examined after death, in  the former the head of the 
211
needle, or pin, had perforated the bladder, and  in this other the point; be-
cause, in the former, the  concretion more easily gathered round the lower,
and perhaps rougher part, and in the latter  more  easih' about the opposite
extremity.
     "But out of those women who have had a needle, which had been thrust
into the bladder, and a calculus of  a considerable size formed upon it, none,
that I remember to have  read of, carried it for a very long time, yet had the
needle extracted  afterward, and was saved, except that Venetian woman
whose case is published by Molinetti (under whom she was cured in 1649)
with a figure of the needle, and  the calculus added thereto, which he used
to show  in this anatomical theater, where Moinichenius, in  his  epistle to
Thomas Bartholin, asserts that it was seen by him; for Bartholin himself, an
author in other respects very learned, has through carelessness asserted this,
he could not be witness to the calculus, which  was extracted after  he had
departed from Padua,  and even  from Italy.
     "And this calculus is the same which is spoken of by the same Moiniche-
nius, in his observations; and this I have hinted at, because, in  the latter
part of the annotation to  the observation of Vallisneri, both of which I  have
often referred to, it does not seem to be  acknowledged for the same, which
Vallisneri had  said was wont  to be shown in this theater, and is now pre-
served in his museum;  for as to his saying that it was taken from a Paduan,
instead of a Venetian  woman, that I suppose  was the cause of the error,
which would have been easily avoided if Molinetti had been read, in whose
book he seems not to know that  it is described;  and I also say that Lanzo-
nus seems to have been ignorant of it, as he would, otherwise, in  his scho-
lium to that observation  of Moinichenius, have been less  surprised 'that a
bodkin of bone should have lain buried so long in the bladder, without any
injury  to the  bladder itself,  and  even  without any inconvenience  to the
girl.'
    "This, the words even of Moinichenius, and much more those of Moli-
netti, did not suffer him  to suppose, not only when speaking of  what she
suffered in the extraction, but also  when describing what she endured,  both
before and afterwards.
    "Yet if the bladder of this girl was much  less hurt by the needle  than
the bladders of those whom I have written  of,  this probably happened be-
cause the point of the needle stuck longer in the urethra than in the bladder: 
212
and was, at length, pushed out of this passage  by the weight of the calculus
forcing downwards from above, as Molinetti found it,
     "These calamities, and even death itself, may be prevented, by the per-
son who, being timely warned of the case, can  extract the needle before the
accretion of any calculous matter;  and this with such dexterity that the
bladder, as far  as it is possible  to avoid it, may not  be injured.  And this
has been done  with success, not  only by others spoken of in the works of
Vallisneri, but also by two of my friends in particular, whom I have com-
mended to you already; I mean  Marianus and  Vulpius.
     "The former of these gentlemen, as he told me in a letter sent to me in
the beginning of December, in the year 1720, took out a needle from the
bladder of a country-girl, who already made bloody urine, after having in-
dustriously brought it from a transverse to a direct position.  And it was a
hair-bodkin made of bone.  But that which  I saw  extracted  by Vulpius,
from a certain girl of this city,  was made of brass.   And he had  extracted
it, a few weeks before I received the letter from Mariani, with the  use of no
other instrument than a very smooth iron wire, one  extremity of  which he
had so incurvated into the shape of a small hook, and almost into  the shape
of a ring, that it could  not hurt the bladder, and yet could lay hold of the
pin, and would not suffer the head of it to slip  when once laid hold of.
     "However, if the  case is not known till much  later, and a calculus is
already gathered around the needle,  and this calculus is not of such a kind
as to  allow of  its being easily drawn out through  the urethra, it will be
necessary, before the woman be  subjected to the tortures of a very difficult
extraction, to make diligent inquiry, not only whether the bladder, which it
is natural to all to suspect, but whether the ureters also, and particularly
the kidneys themselves, (which suspicion arises from our dissections,) have
already contracted so much disorder, that if even the needle and the calcu-
lus are taken away the woman must die nevertheless.
     "And the conjecture of the kidneys being disordered will not be taken so
much from the pains of the loins,  (which we have seen may be absent,) or, as
it probably happened in the girl  now in question, may be obscured by the
much more cruel tortures of the bladder, according to the aphorism of Hip-
pocrates, as from the suppression of urine in the bladder, which has  some-
times preceded, continued for a long time, and been more than once repeated,
or from the very frequent retention to avoid those severe pains,  or from too 
213
small a discharge; in estimating which, however, we must take care lest we
are at any time deceived by the continued dripping of urine, calling to mind
that, with this stillicidium, a retention thereof may be joined,  and that in a
very great quantity, as I shall show when I speak on the subject of lameness,
although this has  already been sufficiently shown even by other letters.
And indeed the Sepulcluetum will present us with a history,  in which you
will read that the neck of the bladder was found so lax from paralysis, as
'easily to admit the finger;' for which reason the urine came away  before
death, without the patient's feeling it, yet the bladder, 'though almost twice
as large as it naturally is, was entirely filled nevertheless.'  And how much
the  retained urine  had enlarged the ureters, you have learned from those
letters, and how much it had, also,  dilated the cavity of the kidneys, and
had injured the substance thereof, or in one of them at least.
     "And if these things happen from a part of the urine being retained,
how much more will they happen from a long and repeated  suppression of
the whole of it within the bladder, or from a frequent retention both  of
urine and of pus ?   At least you have many examples of this  kind, in the
Sepulchretum, from a suppression, among which are those of Rumlerus and
Ballonius, the latter of whom saw a very enlarged state of the ureters, and
the former these canals full of urine, and the  kidneys of so large a  size, in
a child, as they could scarcely have had in an adult.
     "And  for this  reason the celebrated Fantonus, with justice, supposed
 that where more urine is drawn off by the catheter than the bladder seems
 to contain, 'it may partly flow down from  the distended ureters also, and
 sometimes  even partly from  the enlarged kidneys.'   That is to say, when
 the bladder can now contain no more; whatever urine is continually secreted
 in the kidnevs first distends  the ureters, and  after that the kidneys them-
 selves also.  Xor did this escape Aretaeus.  'Where the urine is suppressed,'
 savs he, (meaning in the bladder,)  'the superior parts also, that is, the kid-
 nevs, are  filled, and the urinary ducts,  which the Greeks call  ureters, are
 distended.'   And as these circumstances happen where there is  not  said to
 have been any calculus before in the bladder,  and where there is  none at
 present, as may be read in the examples proposed, and in like manner in
 that which is related by the authors of the Commercium Liberarium, or in
 the acts of the Cajsarean Academy, or in the Acta Helvetica;  for the  dis-
 charge of the urine from the  bladder being hindered by the abscess  thereof, 
214
or by the coarctation of the passage through the prostate, or the influx into
the bladder  being prevented by the very great diminution of its capacity,
'an enlarged state of the kidneys and of the ureters,' or, at least, a dilatation
of them so as to 'exceed the thickness of the little finger,  or even equal that
of the largest,' immediately occurred to the eye.   As these things, therefore,
happen, even without calculi, they certainly ought not to have been imputed
only to  the obstruction of calculi in the ureters, which resist the descent of
the urine by a man in other respects very inexperienced.  Nor ought it to
have been argued, from the  circumstance of a certain person having only
one calculus in the  bladder, but both his ureters  dilated, that this calculus
had necessarily been made up by the coalition of two,  one of which had
been  obstructed in one ureter, and the other in the other.
     "But as those things that I have mentioned happen even where the blad-
der may be  extended to a very great capacity, you, without doubt, perceive
how much more easily they must of course  happen if the bladder is either
contracted into itself, as in one of the examples referred to, or has its cavity
occupied by some foreign body internally, and leaves but little  space for
the urine within, and sometimes  scarcely any, whether  an  ischuria or a
strangury only be the consequence.
     "Thus  you have, in the Sepulchretum, an observation of Silvius, after
an ischuria  of the ureters 'frequently admitting  a man's thumb, and  con-
taining  urine within them quite to the  kidneys themselves,'  as he says, not
in the second, but in the first book of his Praxis  Medica, chapter the fifty-
sixth; and you have, also, that which is described as communicated to Rio-
lanus, of the kidneys being 'larger than usual by one-half, filled, and tur-
gid with serum;' and  'of the ureters being very large, and  so  distended
as to  be capable of admitting the little finger with ease.'
     "And you will read  in the same place that  Cattierus found, after the
strangury, 'the kidneys distended and turgid with urine,  (from which parts,
when cut into, it flowed  out copiously,) and the ureters very wide;' and
these were  found to be 'very large' by Fantonus, whom I have  already
quoted, even after a dysuria from a cause of the same kind; and in pro-
portion  as the dysuria, like that,  is more severe,  it generally has the more
violent  strangury joined therewith.
     "As, therefore, in  the two  girls whose bodies were examined by me,
there had been a very severe dysuria, and the bladder was very much con- 
215
tracted, and  almost wholly occupied with the calculus, it is  not  surprising
that the urine, before it could pass out a little  more freely from thence,
through a passage made by the needle, should stagnate in such a quantity
in the ureters and kidnevs as to dilate, and  even to vitiate them,  especially
when mixed with the pus which flowed from the ulcerated coats of the
bladder.
     "A young country-girl, having had a bone-bodkin, which she used for
her hair, drawn into the bladder in the same manner as those already spoken
of, although  it created  pains  and many uneasinesses, they did not, never-
theless, extort a confession of the fact before that, a calculus having formed
itself around the  needle, she was affected with intolerable tortures.
     "Then, at length, the situation thereof being examined, the point of the
needle was found to be  prominent within the cavity of the vagina, the ure-
thra being perforated  near to the lower part of that cavity.
     "It seemed to Mariani that, if the urethra were cut into a little in a lon-
gitudinal direction, this  point might be drawn into the urethra; and, by this
means, the needle and  the calculus being placed in a  direct situation, it
might be tried whether by scaling away this calculus, which was, perhaps,
of a fragile nature, gradually and dexterously, it Mere possible to reduce it
to such a state of thinness as to suffer it to be taken  away with the needle.
     "But as others were of a contrary opinion, it  happened that nothing at
all Mas attempted, but that the  girl Mas deserted, and given  up to her mis-
erable lot.
     "In process  of time the calculus, and the pain  also, Mere increased; and
the M'hole orifice  of the bladder being noMr almost stopped up, but a small
quantity of urine, and that very ill-smelling, was discharged   And a fever
also coming on, an end was, at  length, put to her miserable life.
     "The belly being opened,  pus Mas seen in the pelvis thereof, and was
supposed to  have been poured out from the kidneys, Mrhich M'ere suppu-
rated.  In the bladder, which Mras corrupted with a  sphacelus, was a calculus
of the figure of a pear,  for the  more it  descended from the head, and the
upper part of the needle, the more Mas it extenuated.
     "When it Mas taken away from the bladder, to which it adhered in some
parts, it left scales agglutinated to that part;  and yet, when put in the scale,
together with the needle, Mas then equal to eighteen drachms;  but after-
Mard, when this account Mas sent to me,  it weighed no more  than fourteen. 
216
     "The person who, as I have said above, had successfully extracted the
needle from another girl, before a  stone had been formed upon it, did not
despair but this also might be taken out, even when the calculus M'as begun,
and increased  to a considerable size, if, the point of the needle being re-
duced into the  urethra, and held fast with a forceps, he endeavored previ-
ously to extenuate the calculus, if it were possible, before he drew it out,
in imitation of  Benivenius, who diminished it in the urethra of a virgin, in
some measure,  previously to  its  extraction;  or  if this did not  succeed
according to his wish, then to imitate Molinetti, who had taken care to  have
it extracted by force, at all events;  and it is probable that something might
even then have been of service.
     "But after the calculus  had been so much augmented in its size, and
with this every disorder had increased, who is there that could hope for any
advantage %  And if the  calculus had  been  so much  thinner, and the pas-
sage, though which the cavity of the urethra communicated Mith the  cav-
ity of the vagina, had been so much  larger,  as they must both  of  them
have been in a case of  this  kind, which, being sent from Italy, you read of
in the history of the Royal Academy of Sciences at Paris,  perhaps this also
would have fallen out into the vagina, in the same manner as that did.
     "But I should believe, even in  that case also, that the passage had  been
from the upper part of the urethra, rather than from  the  bladder into the
vagina, since we read  that an afflux of urine,  through the vagina, did not
succeed, but only an incontinence of urine.
     "For whether the needle is not wholly snatched away from the fingers,
into the bladder, in many persons, as I conjectured above ; or, if you please,
whether, after it is wholly carried into the bladder, it is again pushed  back
into the urethra, by the contraction of the bladder;  although the former of
these suppositions seems to me the  more probable, since the point that was
held in the fingers,  and not the head, or, at  least, in the examples of Moli-
netti and Mariani, and in as many as I shall  immediately produce, M'as cer-
tainly turned toMrard the urethra; nothing can more easily happen than that,
the head being pushed forward, by  the posterior part of the bladder, in con-
sequence  of  the  annexed vagina,  then libidinously turgid,  being, in like
manner, forced forward, the point  of the crooked needle  is driven back-
ward, and by this means  fixes itself into the posterior part of the urethra,
especially if it is very sharp;  and  at length, being driven by the frequent
contractions of the bladder, perforates that part. 
217
     "And as this happened in a young country-girl, who applied to our sur-
geons at the time of my writing this letter, so it would also have happened
in a young virgin of fourteen years of age, the case of M'hom was related
to me by a surgeon, whose preceptor in anatomy I had been, not long after
the death of the other, whose dissection I have described to you.
     "The  girl was in a sitting posture M'hen she did the same thing as the
other, and had thrust the head of the bodkin, which M'as almost as thick as
the uretlua itself, very high into this meatus:  and being terrified by  the
sudden  appearance of her mother,  at once let go the bodkin, and found it
drawn up very high, at the same time.
     "Almost four days she bore the pains and uneasinesses in  silence;  on
the fifth day she told her  mother  the  affair, and her mother told it to  the
surgeon of M'hom I have spoken; who, supposing from the seat of the prick-
ing, of M'hich the patient chiefly  complained, that the lower  part  of  the
needle  stuck fixed about the middle of the urethra, and fearing lest, if any
instrument were introduced into the urethra, to extract this inherent bod}-, it
should  be entirely pushed on into the bladder, he, with  the consent, and
even at the request both of the mother and daughter, introduced first one
finger, and then another, into the vagina, and by this means so far moved
the needle downward, with no less industry than success, that the point
began to appear at the orifice of the urethra, and could he laid hold of with
the forceps.
     "Thus, with the loss of two drops of blood only, and without any incon-
venience remaining behind, the needle, which he brought  to me, Mas taken
out.  This needle, or bodkin, Mras, or, at least, seemed to be, of  tin,  and
M'as of that kind M'hich women use for their hair, being  four inches long,
and having a very sharp point;  and the surgeon had observed that a little
tartarous matter had already begun to  adhere to it in several places, M'hich
matter  Mas, afterward, very improperly rubbed off.
     "I would not have you be chagrined to find that what has been asserted
by some persons  seems to be confirmed by the number of examples I have
added; I  mean that the  women,  to whom  these  things happen, ' are,  the
greatest part of them, Italians.'  I could wish all our country-women knew
Iiom' many of their sex have been untimely carried off by  the most excruci-
ating tortures from this cause.
     ''But how can country-girls, of the lower class, and such as even their 
218
tender years render unexperienced, be  acquainted with these things ?   Yet
such instances ought not to be passed over in silence, that physicians, being
admonished by the frequency of them, may, if any girl begins to complain
of a difficulty of making water, inquire very narrowly into every circum-
stance ;  and, by a cautious dexterity, force out the truth, while it is as yet
possible to administer relief.
     "However, neither these instances are common to  all parts of Italy,
(or, at least, not to some of them, where  I have been  for a considerable
time,) nor are  all foreign countries free therefrom;  which examples it is by
no means necessary for me to take notice of here, with an odious diligence ;
some of them you will learn, if you ask me now,  from  reading Vallisneri,
others from Platner; and, finally, some you will meet with in the reading
of other authors.
     "Nor do I doubt but more examples would be extant, if as many bodies
were dissected in every other place as they are in  Italy; or, if shame did
not  oblige most women  to conceal the true  cause of their disease.   For
others, as even among the women of this region a country-girl was about to
do, and as some, according to Alghisni and Vallisneri, have done,  conceal the
whole affair with the most obstinate silence;  it therefore happens that the
needle,  of which nobody has any suspicion, is buried together with them.
     "And some girls pretend to have swallowed it,  in order that physicians,
notwithstanding they find it either in the living or the dead body, may be
deceived by such an assertion.
     "There was a time when such deceptions took place even in Italy; as
by that Venetian virgin spoken of by Alexander Benedictus, about the latter
end  of the fifteenth century, who had  a large  calculus formed upon a very
long bodkin, such as women use in their hair; for notwithstanding this author
has  rejected the opinions of those who supposed the needle to have passed
through  the veins, from the  stomach to the liver, from thence to the heart,
and  from this  viscus to the kidneys, and so on to the bladder; yet, he him-
self  thought ' that by its point it had gradually, and in a long course of
time, penetrated through the intestines, and made a passage for itself to the
bladder;' although he is  much to be  commended  for having discarded the
opinion, M'hich, to my great astonishment, was embraced by others, even a
long time after, and is not easily to be imitated in proposing another, which
had a much greater number of followers. 
219
     "Nor is the question here of any slender needle, but of thick ones, and
very often  of  those which  have a  large head at one extremity, and at the
other not a very sharp  point;  and always  (I mean in those shame-faced
virgins M'ho say that they  had been swallowed  by  them) purposeh', as it
were, going to the bladder, and not attended with those previous and con-
comitant symptoms and pains which a circumstance and passage of this kind
required.
     "Wherefore this kind of credulity is now more rare ; or, at least, among
the more learned Italians;  the retention of which, in some other countries,
I see pretty clear marks of, even in some excellent books.
     "It remained to take  notice  not  only  of the needle, but of the  case
wherein they  are  kept, having passed the same way, since that  excellent
man Benevoli says that he had extracted one from the bladder of a Tuscan
girl.
     "Here, again, you will perhaps be displeased that a vice almost incred-
ible should be  imputed to an Italian girl.  But  read, I  beg of you, the
annotations that are made to  article one thousand tluee hundred and fifty-
nine of Platner's Institutiones  Chirurgiae, and you  will see  whether she was
the first that had attempted this thing."
              Stone in the bladder.—Removed by vaginal section,

     A. M----; aged forty-seven;  admitted October  17,1871; American by
birth;  single.   I was requested to see this patient by  Dr. Ritchie, of George-
town, before her admission to  the hospital,  She complained of intense pain
at the meatus  urinarius whenever  she passed Mrater,  constant distress in the
supra-pubic region, and all the long train of symptoms attending the pres-
ence of a foreign body in the  bladder.
     The sound readily detected a  stone, which Mas too large to be reinoved
with safety through  the  urethra, as the requisite dilatation would probably
have been  followed by paralysis of the sphincter, and incontinence of urine.
     The patient was desirous of having the operation performed at  her
]louse, M'hich Mas assented to, on condition of her  removal to the hospital
as soon as  sufficiently recovered, for the purpose  of undergoing treatment
rendered necessary on account of  the diseased condition of the bladder.
     September 20.—Patient was aetherized and placed on her left side, after
which, a staff having been introduced, an incision one and one-half inches 
.  220
long mus made through the vaginal wall, and the stone easily found  and
withdrawn.
     The parts were closed, as in ordinary vesico-vaginal fistula, by ten sil-
ver-Mire sutures, and a self-retaining catheter left in bladder.   The sutures
Mere removed on the tenth day, when  union was found perfect.
     The stone was composed of lithic acid and oxalate of lime, and meas-
ured, in its'greatest diameter, one and  one-eighth inches.
     The distress endured for  several years wTas only partially relieved by
the operation, and on October 17 she was admitted into the hospital.
     Examination of the urine disclosed the presence of blood and pus in
large quantities.
     The treatment adopted was the administration, three times daily, of an
emulsion of almonds  containing twenty grains  of  the bromide of potash
and twenty drops of the balsam of copaiba.  The bladder was washed out
every morning with tepid Mater, followed by an injection  of glycerine,  one
part, Mater, tluee parts, and carbolic acid, five grains to the ounce.  A mor-
phine suppository M'as introduced into  the vagina after each injection.   The
capacity of the bladder, at first  small,  gradually increased.
     Under this treatment she slowly improved, and on January 23, 1872,
was discharged, with instructions  to  report bi-weekly for the  purpose of
continuing the injections.  These were kept up until June of the same year,
M'hen further attendance was dispensed with.
     Thanks to Marion Sims, the operation for removal of stone in the blad-
der of the  female has ceased to be formidable or dangerous.
     It  may be objected that a stone  of  this size,  and even much larger,
could be removed through the urethra after dilatation.  This is quite true,
but to dilate the  urethra effectually frequently requires a long time, and is
productive of  great pain.   A much stronger objection is to be found in the
consequent incontinence of urine.
     The operation  performed in this case  is safe, simple, and not likely to
be folloM'ed by complications.
                           Urethral caruncles.
     There are two different kinds of  urethral caruncles, alike  in  appear-
ance, but differing anatomically.  Both are  highly vascular, bleeding with
the slightest touch, the mere passage of the urine over them being sufficient
to rupture  some of  the capillaries.   One  form is exquisitely sensitive, the 
221
other possessed of little sensation.   The irritable  caruncle has a rich distri-
bution of nervous filaments in it, which, according  to some observers, ter-
minate in bulbous expansions, not like the  tactile  corpuscles in which the
tactile nerves of the skin  are supposed to terminate, but more  resembling
neuromas in their construction.
     The ramification of the blood-vessels in them have precisely the ap-
pearance of the vasa vorticosa.  The majority of the vessels are much
larger than capillaries, but their walls are equally simple in structure, which
accounts for the readiness with M'hich they are  ruptured.  Wedl  regards
these bodies as "dendritic, papillary, new formations of connective tissue."
Their size varies from that of a pin's head to a cherry.   They generally
arise from  the mucous membrane of the urethra,  near its orifice.  Their
attachment is by a broad base, but sometimes tiiey are pediculated.   Those
attached by a pedicle are  seldom sensitive.
     If we except fissure  of the anus, there  is no disease of so trifling a
magnitude productive of so much intense  suffering as an irritable caruncle.
I have knoMm women, who would bear the pains of child-birth without a
murmur, shrink from the necessity  of urinating, and put  it off until the
bladder became over-distended, and when finally compelled to  pass water,
their groans revealed the excruciating agony they endured.
     Professor Simpson reports  the  case of a shepherd's wife who had one
of these  sensitive caruncles at the orifice of the urethra, and whenever she
was obliged to pass water, was in the habit of going some distance from her
cottage, in order that she might moan and scream  unheard, so intense and
intolerable was the suffering M'hich at such times she experienced.
     No  age or condition is exempt.   I have seen these  caruncles in young
girls  before  puberty, and in old women over seventy; in the single and
married;  but I have never seen  one in a patient of purely  phlegmatic tem-
perament.
     The diagnosis is easy if the examination  be  made with care.   Digital
examination is useless; it must be made by the eye, and frequently the lips
of the meatus must be separated before you discover the caruncle, although,
in the majority of cases, it is situated on  the edge of the  lower lip of the
meatus.
     The prognosis of  permanent relief is by no means favorable,  as they 
222
are essentially  recurrent, repeatedly returning  after the most  careful and
thorough removal.
     The treatment will depend upon the nature of the caruncles.  If not
painful or inconvenient, leave them alone.   I frequently observe them in pa-
tients who  are unconscious of their presence.  If sensitive,  remove  them.
The method I adopt is to pass a tenaculum under their base,  taking care to
introduce and bring the point out in sound tissue, and then  with a pair of
curved scissors cut the tenaculum out and with it the tumor.   Fuming nitric
acid is then applied to every portion of the raw surface, followed by a solu-
tion of the  carbonate of soda to neutralize the excess of acid.
     For two days before and for one Mreek after  the operation, the patient
should be placed upon the copaiba  mixture, in order to render  the  urine
bland and unirritating.
     Ligatures, as a means  of removal, are inadmissible, as their application
produces much more pain and are less efficient  than the knife or scissors, it
being impossible to include the whole of the diseased structure  by this pro-
cess.
     Nineteen cases have been treated in the hospital, and in all the removal
was effected in the manner here recommended.  In several, the disease re-
turned in a few months, and was again removed,  but the larger portion did
not re-appear.  I have no doubt the disease returned in these also, and pre-
sume advice was sought from some other  sources, owing to  dissatisfaction
with the necessarily unsuccessful treatment pursued in  the hospital. 
223
           EXTIRPATION OF THE PAROTID  GLAND.

     Mrs. C. S----;  aged thirty-two ; mother of two children, has hereto-
fore enjoyed perfect health.  She seeks advice on account of a large tumor
which occupies the site of the right parotid gland.  It is painful, unsightly,
and inconvenient.  She first noticed it about five years  since, and for three
vears it increased but little in size; its growth, hoMever, within the last
six months has been very rapid, the pain increasing with the size.
     The tumor  Mras  as  large as an  orange, independent  of the  portion
which dipped back  under the jaw, and extended as high as the  anterior
portion of the zygomatic process; it was of medium consistency and lobu-
lated.  The first impression Mas that it might be a carcinomatous  degene-
ration of the gland, but the healthy appearance  of the patient, her age, the
length of time in which she had suffered with the disease,  the  healthy con-
dition of the skin, and the neighboring glands being uninvolved, made it
improbable, and  it was decided to be a fibroid  degeneration of  the  gland,
and its removal recommended.
     January 2, 1872, assisted by Doctors R. Reyburn, N. Young, F. A. Ash-
ford, and H. McBlair, I removed the entire  gland with its capsule. "Patient,
being fully aetherized, was placed in a semi-recumbent position, the head
Mell  elevated.    A semi-lunar incision was made  from the zygomatic process
downward and backward behind the  angle of  the jaw, passing over the
center of the tumor, the flaps were dissected off and the upper part of the
mass exposed. The  separation was  made  from above downward, the  size
and shape of  the tumor rendering that course  preferable to working from
below upward.
     The detachment of the upper portion of the tumor Mas readily effected,
but the dissection of the  lower and deeper portions was  tedious and diffi-
cult,   The styloid process Mas imbedded in the lobes, Miiich dipped back-
ward, completely encircling it.  The  stylo-glossus and stylo-pharyngeus
muscles Mere  so unusually thin as to be scarcely discernible, and were with
difficulty preserved.
     The arteries tied  during  the operation were the temporal, transverse
facial, occipital,  internal maxillary,  lingual, facial,  and  external carotid.
When  the  mass  had been  removed, the  appearance of  the wound  Mas
frightful.   At the side lay the common carotid, the jugular vein, and pneu- 
                                  224

mogastric nerve; at the  bottom were the attenuated styloid muscles, par-
tially covering  the  pharnygeal opening.  A portion of the  aponeurotic
sheath of the vessels had been sacrificed with the tumor.
     The danger most to be feared Mras suppuration  and  burrowing of pus
in the deep tissues of the neck.   This could only be avoided by the careful
adjustment of compresses,  so as to bring every part of the wound in appo-
sition.
     The'patient was allowed to recover  fully from the aether, and reaction
to be well established before the flaps were  adjusted; the compresses  were
made of raw cotton, soaked in carbolized glycerine, and so arranged that all
portions of the tissues were in contact.
     The jaws were firmly  bandaged, it being intended to permit no move-
ment of them for several days.
     10 p. m.—Patient comfortable ; pulse eighty-four, soft and  regular.
     January 3,  10 a. m.—Has passed a good  night, having  slept  from
eleven until six in the morning ; complains  of the jaws feeling stiff, but no
special pain ; pulse eighty.
     January 4, noon.—No  undue heat about the wound; everything pro-
gressing well; patient sitting up.
     January 7.—Sutures removed; every portion had united by first inten-
tion.
     January 15.—Ligature loose from facial artery.
     January 19.—Ligature loose from internal maxillary  artery.
     January 22.—Ligature loose from carotid artery.
     The  recover}- of this  patient was rapid  and perfect.  The deformity
from the paralysis occasioned by the division of the branches of  the facial
nerve was much less than is usually stated to  occur, and a few months after
the effect of the  operation was not noticeable.
     There had  been no return of any disease in the part from which the
gland was removed up to July, 1872; the patient at that time  appeared in
perfect health.
     Plate 16 is a transfer  from a photograph of the tumor, taken the day
after its removal, and is the exact size.   A careful  examination  of  the mass
proved it to be the parotid gland in a state of fibrous degeneration.   This,
with its capsule, was reinoved entire.
     It has been questioned, by some authorities worthy of consideration, if 
Plate  XVI.
Parotid gland, removed from .Mrs. C. S., January 2, 1872.   Photographed on wood. 
 
225
it was  possible to remove the entire gland, and reported cases  have been
supposed to be merely tumors growing on,  in, or adherent to, the gland.
     Erichson says:  "Excision of the parotid gland is occasionally spoken
of, but is rarely, if ever, done.  I believe that  in most, if not all, the cases in
M'hich  it is stated that complete removal of the gland has been accomplished,
tumors overlaying and compressing it have been mistaken for it."
     Gross remarks: "Considering  the narrow space in which  the parotid
gland is situated and the complexity of the relations which it sustains to the
surrounding structures, is it  possible to extirpate it in the living subject?"
Considering the present state of the science of surgery, he says:  "I should
consider it great folly either to doubt its possibility or to deny its propriety.
That the operation is  difficult of  execution, requiring the  most accurate
knowledge of the anatomy of the  parts and the most consummate skill, is
certain; and unless the surgeon is fully possessed of these important qualities,
failure, if not disgrace, will be sure to attend his efforts."
     Allan Burns states that the operation is impracticable,  and  Coulson, of
London, denies the possibility of its performance.  There is no doubt, how-
ever, that the whole gland has  been removed repeatedly with success, but
the large majority of cases reported were undoubtedly not  removals of the
gland, but of tumors occupying its  site.
     The statistics of this operation  are not sufficiently good to offer much
inducement to surgeons to undertake it, but I believe the unfavorable reports
have been mainly due to the fact that, in the larger proportion of the cases
 reported upon, malignant disease has existed.
       Successful removal of a hypertrophied third lobe of the thyroid gland.

     K_ M----;  aged twenty-two;  admitted April 13, 1867.  The  patient
 complained of a tumor which was situated  immediately below  the thyroid
 cartilage, and had become a source of annoyance from  its large size  and
 pressure upon the trachea.
     The tumor was hard and globular in form; palpation gave  no evidence
 of fluid; and from its central position and the absence of any lateral enlarge-
 ment  it M-as not suspected to be a part of  the thyroid gland, but an adven-
 titious fibroid or fibro-cystic formation bound down  by the deep cervical
 fascia.  It Mas not apprehended that its  removal would be attended with
 any unusual difficulty.
        29 
226
    April 14, clinical class present.  Patient having been fully aetherized,
an incision Mas made, commencing at the lower border of the thyroid car-
tilage and continued downward for two and one-half inches, and the skin
reflected from either side to the fullest extent  admissible by the length of the
incision.   To expose the tumor fully it  was necessary to divide the sterno-
hyoid and sterno-thyroid muscles.
    As the dissection proceeded it became evident that an error in diagnosis
had been made, and  that the growth was an  hypertrophy of the  third lobe
or pyramid of the gland.   It was too late to retreat; the only proper course
was to proceed and remove the tumor.  The  incision was extended one inch,
to give room for further dissection, every step of which was followed by a
gush of blood, MThich M'as restrained with difficulty.
    When the base of the growth was reached it was found  to be adherent
to the upper rings of the  trachea and lower edge of the thyroid cartilage.
A needle,  armed with a double ligature,  was passed through the center of the
attached portion  and each half of the tumor firmly tied;  its connection
was then  severed.   After the  hemorrhage,  which  lasted two hours, had
ceased, the parts were washed with a  weak  solution of carbolic acid, the
edges of  the incision were brought in apposition and retained  by silver
sutures, and  the ends of the ligatures  brought out at the most dependent
portion.   Ice-water dressings were constantly applied.
    For two days the patient had considerable fever; pulse v^ent up to one
hundred and twenty; but under the use  of opium the fever subsided, and no
further constitutional symptoms were manifested.
    April 24, the sutures were removed and  every part was found  to have
united except at the point where the ligatures were brought out.   The liga-
tures were slow in separating, the last not coming away until May 19.
    May  28, the patient was discharged, cured.
    Commentary.—Although this tumor was  unsightly and occasioned con-
siderable annoyance by its pressure upon the trachea, the symptoms were
not sufficiently urgent to have justified the risk of go hazardous an operation
as the removal of part of the thyroid gland.
    The error in diagnosis occurred from the position of the tumor, which
was central, its well-defined outlines, and the absence of any enlargement
of the right or left lobes.   An hypertrophy of the pyramid of the  gland was
not thought of in forming  the diagnosis. 
227
     IMPACTED F^CES DIAGNOSED AS OVARIAN TUMOR,

     Miss C----; admitted April 24, 1869; aged twenty-two years; native
 of New York; for the last five years resident of Brooklyn; Mras sent to me
 last April for the purpose of having an abdominal tumor removed which had
 been  pronounced by her medical attendants "ovarian."
     The patient was of medium stature, sallow complexion, emaciated and
 very feeble ;  abdomen enlarged to about the ordinary size of a woman seven
 months advanced in pregnancy.
     Tongue heavily  coated, breath foetid,  pulse one hundred and  eighteen
 and feeble.   She  complained of continuous pain in the left side, extending
 down the thigh; subject to severe exacerbations, pain in the back, increased
 when lying upon her right side; micturition frequent but not painful; bowels
 troublesome,  the passages being M'atery and not completely under her con-
 trol.   She had not had a solid passage for several months.  Stomach was
 very irritable, rejecting food almost immediately, milk with lime-Mater be-
 ing the only nourishment that could be retained, and that required to be
 administered in small quantities.   Sleep disturbed by  unpleasant dreams;
 menstruation painful,  scanty, and irregular.
    Her aunt gave me the  following history of the  case prior to the time of
 her coming under my charge:
    She had been a robust, healthy girl up to the time of her present illness,
 which commenced two  years before.   In  March, 1869, she complained of
 pain in her left side, and, for the first time in her life, of headache. This con-
 tinuing, a physician was consulted,  Mrho relieved her for the time, but both
 pain in the head and side returned.   The pain increasing in severity, an ex-
 amination was  made,  and a tumor  the size of an orange discovered on the
 left side of the abdomen, which was painful upon pressure; if the pressure
 Mas continued, it produced  nausea.   It was decided that she was suffering
 from inflammation and enlargement of the left ovary.
    Vigorous treatment M'as  adopted, both constitutional  and  local, with
the view of reducing the inflammation and bringing about a  resolution of the
tumor, but all to no purpose;  the tumor steadily increased in size, and the
patient rapidly failed in  health.  The symptoms becoming alarming, a con- 
228
sultation was held, which resulted in the confirmation of the previous  diag-
nosis, "ovarian tumor;" and as all the  constitutional distress was  believed
to be dependent upon the local disease,  a surgical operation for its removal
was recommended, and for that purpose she was sent to this city, where her
aunt resided, and placed under my care.
     Her general appearance was that of a woman  suffering  severely from
"ovarian  disease"—anxious expression, pinched features, and prominent
enlargement of the abdomen.   A careful physical  examination showed the
tumor to be confined to the left side.   It was firm, resisting, and irregular
in outline; palpation revealed no fluid; the fingers readily passed between it
and the spleen, excluding enlargement of that organ as a possible condition.
     The tumor was on the wrong  side to  be due to enlargement of the
liver, and not sufficiently mobile  for a cyst in the omentum.  Pregnancy
was excluded by the history and position of the tumor; as also distension of
the bladder from accumulation of urine.
     The diagnosis  was narrowed down to fibrous tumor of the 'uterus,
mutilocular cystic degeneration of the ovary, or impacted faeces.
     Vaginal examination.—Fundus of uterus  pressed over to the right side;
sound  entered two and one-half inches, movable  antero-posteriorly; the
finger  introduced into the  rectum could get between the uterus and the
tumor, and upon moving the sound there appeared  to  be no  connection
between them.
     There being no enlargement  of the uterus, no  history of any hemor-
rhage,  and the tumor not  being movable, excluded the theory of fibrous
tumor of the uterus, pedunculate or  interstitial.
     Upon turning the patient  upon her right side, and percussing deep in
the left iliac fossa, no tympanitic  sound could be discovered indicating the
presence of intestine, nor could the  tumor be pressed over toward the right
side ; it was firmly bound down in the fossa.   The symptoms were all neg-
ative ;  no positive diagnosis could be made.   The tumor was too tender for
ovarian, nor was it sufficiently large to have produced such an amount of
interference with the functions of the abdominal organs as would cause the
severe  constitutional  disturbance  under which the patient  was suffering.
Her  age rendered malignant disease unlikely.  For these reasons I suspected
a mistake had been made in the previous diagnosis, and that the tumor was
not ovarian, but due to an enormous accumulation of impacted faeces. 
229
     An elastic tube was introduced into the rectum, but failed to pass the
upper portion ; it there met with a firm resistance, the least pressure giving
great pain.  There was  no faecal matter upon the tube when withdrawn.
A further examination revealed an impaction of scybalae in the whole track
of the colon.  I M'as now satisfied that the tumor was faecal, and so told her
friends.
     To remove this mass  by the  action of  cathartics was out of the ques-
tion.   Mechanical interference was equally inadmissible, and I determined
to adopt a plan of treatment which I had seen practiced by my friend Doc-
tor F. H. Baxter, United States Army, with the most signal success.
     This treatment is based upon the  following theory:  " Constipation is
due to excessive contraction of the circular muscular fibres at the top of the
rectum, and not to deficient power in the longitudinal fibres of the muscular
coat of the colon ; that  the obstruction is to be  overcome, not by increas-
ing the transmitting power of the longitudinal fibres, but  by diminishing the
contraction of the circular fibres, which are mainly under the control of the
sympathetic  nervous  system;  that atropia exercises a special influence
upon the sympathetic, and  if administered  in  sufficient  doses will  cause a
complete relaxation of the circular fibres, not only of the upper part of the
rectum, but of the whole intestinal track."
     I do not propose  to go into a defense of these propositions, but prefer
to report the treatment adopted in this case  with the results, and leave my
professional brethren to judge M'hether the theory is supported or disproved
by the facts.
     May 2.—The patient was confined to the  bed, and  her  abdomen cov-
ered M'ith a soft pad of muslin, (three thicknesses,)  soaked in an infusion of
stramonium leaves.  The pad was cut to fit in between the superior spinous
processes, and not allowed to go above the  umbilicus, its application  over
any part of the stomach being  sure to  excite vomiting.   A suppository was
introduced into the rectum for three consecutive nights, each one containing-
the eighteenth of a grain  of atropia, followed in the morning by an enema
of about one quart of Mater M'ith one ounce of sweet oil.  This had to be
thrown in carefully, about  half a pint at a time.
     For the first three  mornings the  enema  returned  without an}- solid
faecal matter,  the pain in  the  left side, at  the  point of termination  of the
transverse colon, being very severe.  I  applied a large cup over the part,
taking about two ounces of blood.  This succeeded in reducing the pain. 
                                  230
     The following  morning, May 6, I had the  satisfaction of seeing nine
lumps, which had passed with the enema.  They were  irregular in shape
and  partially covered with inspissated mucus.  They were very hard and
dry.
     The patient was exhausted, and complained of a burning sensation in
the rectum, which was relieved by an injection of pure  glycerine,  (one
ounce.)
     May  7.—Nothing  solid passed with the enema to-day.   Milk was
rejected as soon as taken into the stomach.
     May 8.—Pupil fully dilated.  Thirteen lumps passed in  the morning,
and seven in the evening, of the same size and character as  those passed on
the 6th; but two or three  were inclosed in capsules of tenacious  mucus.
Bladder very irritable ;  urine highly colored and offensive; nausea persistent;
pulse one  hundred  and twenty, and small.  Suppositories  and enema dis-
continued ; it Avas  evident  my patient could  not stand so  rapid a dislodg-
ment of the mass.  Alimentation by the stomach was suspended, and injec-
tions into the rectum of one ounce of beef-essence  every four hours substi-
tuted.  A suppository, containing half a grain of morphine, was placed in
the rectum at bed-time.
     May 11.—Pulse one hundred  and fourteen ; tongue very red  at the
edge ; great thirst;  less nausea; less pain.
     May 13.—Enema brought  away two  large lumps and  a  quantity of
ropy mucus.   Ordered the atropia-suppository to be again introduced.
     May 14.—No lumps passed.
     May 15.—Thirty-two lumps passed this morning.   The exhaustion fol-
lowing- this discharge  Mas so  great that for several  hours  the condition of
the patient was alarming.  Toward night she rallied and  took a little milk-
punch, which she retained.   Suppositories were  again suspended.
     May  16,  17, and 18.—The bowels  were   allowed  to remain  quiet.
There was  some improvement  in  the general  condition  of  the  patient.
Beef-tea injections were continued, and a little  milk-punch retained in the
stomach.  The M'hole surface  of the  body was washed daily with whisky
and M'ater and rubbed briskly.
     Mag  19.—Patient brighter; passed a good night; pupil about half
dilated. Atropia-suppository again introduced.
     May 20.—No faecal matter passed with the injection,  which gave great
pain. 
231
    May  21 and 22.—Suppository introduced each  night;  pupil  fully
dilated.   The patient was as much under the influence of belladonna as it
was safe to place her; but no lumps had passed since the 15th instant,  An
injection of one ounce of glycerine was thrown into the rectum at night and
retained.
    May 23.—Three lumps passed,  much larger than  anything I had ever
seen pass from the bowels;  some bloody serum  and mucus passed with
them; in the evening more than three pints,  by measurement, of large and
medium-sized lumps were voided, some of them covered by a material look-
ing like  parchment,  and  a  number of  long strings  of tenacious  mucus.
The tumor was much diminished in size, but  very  tender.
    From  this time  to  June 4, the same  plan of treatment was pursued,
occasional periods of rest being allowed for recovery from the  prostration
following the dislodgment of the lumps.  All appearance of the tumor had
now disappeared; but, upon a careful examination, it  was  found  that the
upper part of the descending, the transverse, and  ascending colon was yet
impacted, and it was not until July 10 that the whole intestinal track became
clear.
    The diet was carefully regulated  all through the treatment, the return
to solid food being very gradual.  Dry-rubbing with a pickled towel was
substituted during the later period of attendance for the whisky-and-water
baths.  From the middle  of July to the end of August, the patient took
three pills daily, each containing:
                       5- Quinise valerianatis, gr. ij ;
                         Ferri ferrocyanatis,  gr. j ;
                         Ext. gentianae, gr. j.
    On the 3d of September attendance was discontinued,  the patient still
feeble, but relieved of her disease.  Her convalescence  from that time to the
present (November 1, 1869,) has been rapid.  She has gained much flesh, her
bowels move regularly by the use of an enema, her appetite is good,  and her
food digests M'ithout trouble ; but, from the commencement of the treatment
up to date, there has  been but one attempt at menstruation.  That occurred
on the 10th of May.
    In tM^o  other cases, in which I have used the atropia to the same extent,
there has been an arrest of this function.
    I have pursued the same plan of treatment in  a number of cases of im- 
232
paction and chronic constipation during the last year.  It has been successful
in all.  In one case  the patient voided in six days more than two pecks of
hard scybalae, which  from its appearance must have  been impacted in the
track of  the colon for months.  No suspicion had been entertained that she
was suffering from constipation, as she had complained of diarrhoea for several
months.  Her abdomen was very large, but the enlargement uras supposed
to be due to pregnancy.  I saMr this woman Mith Dr.  Ritchie, who had seen
her but once before, and finding her not pregnant requested the consultation.
The result of the treatment was as astonishing to the doctor as to the patient. 
233
                      PELVIC CELLULITIS.

    In  1844,  Marchal de Calvi published in  France a  monograph on
" Intrapelvic Phlegmonous Abscesses," which was one  of the first modern
accounts of this disease.   It contained a faithful  description of its symptoms,
pathology, and treatment. This paper was criticised at length in the Medi-
co-Chirurgical Review, and the reviewer took especial pains to ridicule the
study of ancient authors on medical subjects, and to sneer at the knowledge
or supposed knowledge possessed by the early physicians of the science  of
medicine.
    So far as  this particular malady is concerned  the remarks were un-
merited.  Aetius,  Paulus Aegineta,  Archigenes, and Haly Abbas  describe
the symptoms, pathology, and treatment of the disease fully, under the head
of "Abscess  of the Uterus."  The  first and second  named authors, after
reciting the ordinary  symptoms preceding the  suppurative stage,  go on  to
remark that, when the  inflammation runs sufficiently high to form an abscess,
we have the pain  intensified, accompanied by irregular attacks of rigor, fol-
lowed by intense  fever and sweats, obstruction  of the urine and faeces, from
pressure upon the bladder and rectum by the  affected parts.  Sometimes,
they remark, there is swelling in the region of the  pubes, which gives a
sense of fluctuation upon palpation.   They direct the promotion of suppu-
ration by cataplasms of various herbs and the use of the hot bath, supposito-
ries of various narcotics to allay the pain, and the direction of steam into
the vagina to induce the matter to point in that part,
    They advise  delay in lancing until the inflammation is arrested, as new
abscesses might otherwise form and  more than one  opening have to be
made.  They also speak  of the pus being frequently evacuated into the rec-
tum, ulceration having taken place through  the walls of the intestines.
    We have  made but little advance, if any, on their treatment of this dis-
ease.   Their  description  of its symptoms is equally as  clear as that given
by modern authors.
     For the general symptoms, pathology, and treatment of " Pelvic Cellu-
litis," I must refer to the  standard works upon the diseases  of  women, one
of the best  of which is that of T. Gaillard Thomas.
    The following cases are reported as containing points of special interest,
       30 
234
the exciting cause in each  having been an  attempt to dilate the cervical
canal by a sponge-tent.
     I have taken  occasion in another portion  of this work to caution the
younger members of the profession against the indiscriminate use of uterine
tents, as they are capable of producing intense mischief.   When employed,
the effect must be  closely watched, and, as a matter of precaution, when it
is necessary to dilate the internal os, its fibers should be previously divided.

           Pelvic Cellulitis and deep Abscess in the Gluteal Region.
                                Case 1.
     Mrs.  A. S.----; aged twenty-four; admitted March 27, 1866 ; mother
of two children, the younger of whom was fourteen months old.   Her health
had always been  good, her labors easy and  convalescence  rapid.  She
weaned the baby when it was eleven months of age.  In February, believ-
ing herself to be again pregnant, she sought  the assistance of a professional
abortionist, with the view of getting rid of the child, who introduced a
sponge-tent into the cervical  canal and ordered  her to return the next day.
The following morning, February 17, she was suffering too severely to leave
her home, and her husband,  who was not aware of what she had done the
day before, sent for me.   I found her with a rapid pulse, hot skin, and
furred tongue, complaining of intense  pain in the region of the womb and
back, headache, and nausea.  She objected  to  a vaginal  examination.  I
ordered a full dose of opium, with five drops of Fleming's tincture, and a hop
poultice to be applied over the  abdomen.   In  the evening, finding no im-
provement, I  insisted upon an examination, which,  with much  apparent
reluctance, Mras granted.   The vagina was hot and tender, and the presence
of the tent was readily detected by the touch  and characteristic odor.   With
some difficulty I obtained from the patient the history of the case as given
above.  The removal of the tent was followed  by a gush of blood, but no
foetus or membranes appeared.   The opium  and aconite were ordered to be
repeated every four hours during the night.
     February 18.—Several large clots had passed during the night, but her
husband having thrown them away I was unable to ascertain their charac-
ter.   There Mas less pain in the  back, but otherwise no improvement in her
general condition ;  pulse one hundred and twenty-six; respiration hurried;
temperature one hundred and three ; and great tenderness over the  whole 
235
abdomen.  The opium and aconite were  continued, and six leeches applied
around the anus and perineum.
    February 19, 8 a. m.—No improvement, the pain having increased rather
than diminished.  The opium in two-grain doses was  ordered every two
hours, and a large blister to be applied over the lower part of the abdomen.
    7.30 p. m.—Patient was fully under  the influence of the opium, pulse
reduced to one hundred  and eighteen, temperature one hundred  and two.
I left one of my students with her all night, with instructions to regulate the
quantity of opium by the pulse  and respirations,  giving sufficient to keep
her quiet unless contra-indicated.
    February 20, 9  a. m,—Had passed a  comfortable night; pulse one hun-
dred and nineteen;  temperature  one hundred and two;  tongue moist; pain
in the abdomen less acute.
    February 21.—Patient directed my attention  to a tumor a  little to the
left of the median line, regular in outline,  and hard as a stone.  Its character
Mras at once recognized.
    From  this time until the date of her admission to the hospital the treat-
ment was soothing and supporting.  There Mrere occasional exacerbations of
pain, frequent rigors, followed by fever and copious sweats.   The tumor in-
creased in size and extended into the left  iliac  fossa.   The uterus was fixed
and pushed over to the right side, and the wall of the upper part of the va-
gina was hard and tense.
    On the date of her admission the tumor Mas as large as an adult's head.
There was  but little  uneasiness in the abdomen, the  principal seat of pain
being the left gluteal region.  She was emaciated, and her general appear-
ance gave unmistakable evidence of long-continued and severe suffering.
    March 29.—During the night the patient had several copious discharges
from the bowels,  which  the nurse  stated looked like pus.   Examination
failed to discover the tumor—it had evidently ruptured into the bowels.
    After the  discharge  of  the  pus, the  patient  ran down rapidly.   For
more than  two weeks the pulse remained at one hundred and thirty-six;
tongue dry and dark; lips and  cheeks covered with  aphthae; colliquative
sweats and diarrhoea.  Fortunately, her stomach not being irritable, she bore
stimulants  and nourishment well, and these, in  conjunction with the chalyb-
eate tonics were pushed to the point of toleration.
    The discharge per rectum gradually diminished, the pulse became less 
236
frequent, the diarrhoea was controlled, and the general condition of the patient
became encouraging.  The pain in the hip, however, had continued, and there
was a decided tumefaction above the joint, which increased in size daily, and,
upon palpation, gave an indistinct feeling of fluctuation.
    Dr. J. Riley present.—The abscess was punctured with a large trocar
and thirteen ounces of ill-conditioned pus drawn off.  A piece of spiral spring
made of silver wire was passed through the canula and left in the opening
to keep it patent.
    At the expiration of three weeks, the discharge  continuing in quantity
and very offensive, it was  decided to enlarge the opening and apply nitrate
of silver to the whole secreting  surface.  This was accordingly  done,  and,
upon  passing the finger into the cavity, it was found  to contain masses of
gangrenous tissue. These were removed, the cavity was washed  out  Mith
Labaraque's solution, and its walls were penciled over with the solid nitrate
of silver.  Compresses were applied above  and below  to secure  coaptation
of the surfaces.
     Convalescence progressed slowly, and it was not until the latter part of
November that the patient sufficiently recovered to leave the hospital.
     WJiat teas the cause of this secondary abscess?  The theory of the forma-
tion of secondary or metastatic abscesses, from the absorption of pus as pus,
and its conveyance into the general circulation, has but few adherents.   Its
advocates tell us  that  in these cases pus-corpuscles are found  in the blood,
but we now know that pus-corpuscles are only the altered Mrhite  corpuscles
of the blood, and the  increased quantity which is sometimes observable in
the circulating fluid of patients suffering from these secondary  deposits is
probably due to some derangement of the glandular  system.
     This temporary increase of  white  corpuscles, "leucocythosis" of Vir-
chow, is frequently seen during pregnancy, and indeed it exists  after every
meal, as the physiological result of the enlargement of the mesenteric glands.
     It was not due to thrombi  arising in any  of the  veins of the pelvis, for
in that case the detached portion of the thrombus would have been  arrested
at one of  the bifurcations of the pulmonary artery,  and embolism,  with in-
flammation and gangrene  of the lungs,  resulted.
    The following appears to me as the most  acceptable hypothesis in this
case:   The pressure upon the posterior branch of the internal iliac artery,
produced  by the infiltration of the cellular tissue, was sufficiently great to 
237
obliterate the cavitv of the vessel and permit .the formation of a clot or plug.
When the pressure was removed, the current of blood forced the  "embolus"
onward until  it was arrested  at the bifurcation  of the deep  branch of the
gluteal artery.   The supply of blood to the part beyond the obturated vessel
having been cut off, inflammation,  with infiltration of blood into  the tissues,
resulted, terminating in gangrene.

                             Pelvic cellulitis.

                               Case 2.

     Mrs. E. A----; aged twenty-five;  admitted August 4, 1869; married
when twenty years of age; has never been pregnant; has suffered from dys-
menorrhoea since she was fourteen.   The pain at her menstrual  period had
very much increased within the last two years, and latterly become so severe
that she was compelled to seek medical aid.
     Four weeks before her admission, a sponge-tent had been  introduced
into the cervical canal, her attending physician believing the dysmenorrhoea
and sterility to depend upon mechanical obstruction.  He informed me that
during the progress of the dilatation she suffered intense pain, which con-
tinued after the removal of  the tent, and, up to  the time of her  admission,
she had several rigors,  which were followed by fever.
     Examination,—Vagina hot and dry; cervix normal in size and position;
uterus fixed; posterior  cul-de-sac  occupied by  an intensely hard tumor,
which was immovable  and very tender.   Careful examination through the
abdominal walls revealed a hard mass behind and on either side of  the uterus,
in which that organ appeared imbedded.
     Treatment.—Eight leeches were applied to the cervix, and their appli-
cation followed by the hot-water douche to promote bleeding.  After the
bleeding had ceased, a  pledget of  cotton  soaked in Price's glycerine was
placed in the vagina, and this  application was continued daily.  A  supposi-
tory, containing two grains  of the watery extract of opium and  one of the
English extract of belladonna, Mas inserted into the rectum, and the abdomen
covered with a hot hop-poultice,  which was renewed every six hours.
     As soon as the acuteness of  the attack had subsided, the abdomen was
thoroughly blistered with the  aetherial tincture of iodine, which, as a vesi-
cant, I find more potent than the nitrate of silver, and free from the objec- 
238
tions attending the use of that common and  convenient counter-irritant, the
fly-blister.  The bowels were kept free  by the use of belladonna-supposi-
tories and injections of warm water.  As an alterative, and to promote the
absorption of the effused matter, ten grains of the iodide of potash were ad-
ministered in the infusion of gentian three times daily.  Her diet was nour-
ishing, and, when indicated, stimulants were administered.
     The  progress of the case was slow;  the inflammation spread from one
loculament to another, until almost every portion of the pelvic cellular tissue
had in turn been invaded.  For a large portion of the time that the  patient
was under treatment  her condition was critical, pulse  remaining above one
hundred and thirty  and  temperature one hundred and  two and one-half.
No abscess formed, however, the inflammation appearing to exhaust itself
before reaching the suppurative stage.
     It Mras nearly one year before all induration had disappeared and  the
uterus became freely movable, and fifteen months from  the date of the at-
tack before menstruation returned.

                             Pelvic cellulitis.
                                Case 3.

     E.I----;  aged twenty-five; unmarried; admitted July 24, 1870.  Her
first menstruation occured after  her eighteenth year, which was  scanty and
accompanied with great pain.  Eight months elapsed before it returned, since
which time it has been irregular.  The pain at each menstrual period has been
so severe  as to  confine her to bed and to necessitate the administration of ano-
dynes in  large  and frequent  doses.  Her general appearance was anaemic
and scrofulous.   She has been under medical  treatment for  the last two
years, both in New York and in Philadelphia, and, from her own statement,
appears to have been under the care of judicious and  scientific men, whose
best-directed efforts,  however, proved unsuccessful in  relieving her.
     Examination revealed a retroflexion of  the uterus with slight enlarge-
ment of the posterior wall.   The  uterine probe was  introduced with diffi
culty, the point of flexure resisting its passage, but in all other respects the
genito-urinary organs appeared normal.    The failure of previous treatment
in this case (which did not appear to have been directed with the view of
relieving the obstruction to the menstrual flow) suggested the propriety of 
239
an attempt to straighten the cervical canal, as recommended and practiced
by Dr. Marion Sims in similar cases.
     Her menstrual period was expected about August 7, and it was deter-
mined to introduce  a small-size sponge-tent to dilate the canal, a few days
in advance of the menstrual molimen, and watch its effect before using the
uterotome.
     August 4, a perfectly smooth carbolized sponge-tent about one-sixteenth
of an inch in diameter was carefully introduced, and the precaution adopted
of inserting an  opium-suppository  into the rectum  in  anticipation of any
possible trouble.
     Dilatation was accompanied by such severe pain that it was necessary
to remove the tent  in less than six  hours after its introduction; the patient
was  restless; pulse rose to one hundred and sixteen; skin hot and dry.   The
folloMing day she had a severe chill, followed by fever, the pain extending
over the whole  abdomen, which had become  tympanitic.  Metro-peritonitis
and  cellulitis supervened.  The peritonitis was controlled by large  doses
of opiuin, but the cellulitis ran on to the formation of a large abscess, which
pointed and was discharged through an opening in the anterior cul-de-sac.
     For several weeks the condition of the patient M-as extremely critical,
the exhausting discharge and her inability to retain nourishment rendering
her case almost  hopeless, and it was several months before she had gained
sufficient strength to travel to her home, in New Jersey.
     In March,  1872, she was still feeble; the discharge had entirely ceased,
but there had been no return of menstruation. 
240
                   DISEASES  OF THE RECTUM.
     Haemorrhoids.—It has  been estimated that  half the male population
 suffer from this disease; but, common as it is among men, it prevails more
 generally  among women.   It  is seldom  a woman who has borne children
 escapes an attack in a more or less severe form, nor is it difficult to account
 for the increased frequency of  the malady in women.  The  pressure of the
 enlarged uterus in  pregnancy prevents the return of blood from the pelvic
 organs and haemorrhoidal veins.  The same effect is produced by fibrous
 tumors, hypertrophies, and displacements of  the uterus, which are so many
 additional  causes to those existing in the male.
     Haemorrhoidal tumors, whether  external or  internal, are  essentially of
 the same  pathological character,  and are  characterized by an enlargement
 of the vessels of the rectum and an infiltration of  their connective tissue.
     External haemorrhoids are  composed of thickened integument,  covering
 one or more dilated veins, with a mass of infiltrated 'cellular tissue.   If the
 parts have not recently been inflamed they look like folds or  duplicatures of
 the integument surrounding, or partially surrounding, the anus; but, if in an
 irritable or inflamed condition,  they are hard  and tense, and the integumen-
 tary covering of a deep-red or purple color.  If split open, the central  por-
 tion will  be found to consist of  a clot of blood  surrounded by infiltrated
 cellular tissue, or, if the vein has ruptured, the  blood, instead of being clotted,
 will have become extravasated  into the surrounding tissue or formed for itself
 distinct cellular sheaths.   The  inflammation  may subside and the extrava-
 sated blood be absorbed,  or the extravasation may cause increased inflamma-
 tory action and the formation of an abscess.
     The suffering occasioned by  acute inflammation  of external piles is out
 of all proportion to the circumscribed extent  of the lesion.  If the disease
 has been allowed to go on unchecked for two  or three days the constitutional
 disturbance will be sufficient to prostrate the strongest man.
     Treatment.—In the  acute stage most authors agree  in  recommending
 the application of leeches.  I have seen little benefit resulting from their use.
 The indication is to relieve pain and reduce inflammation.  This, it appears
 to me, is best accomplished by freely opening the tumor, and turning out the
 clot of blood which it contains,  and then applying a hot poultice to promote
absorption, with which some anodyne and astringent may be incorporated. 
241
     I generally use the following ointment, spreading it thickly upon a piece
 of patent lint and applying the poultice over all:
                    fy Ungt. gallae co., §ss.
                       Aq. ext. opii, 3j.
                       Pulv. camph., gr. x.
                       Ext. plumbi diacetatis, gtt. xx.
                            M.
     A laxative should be administered, to keep the bowels free.   In summer
 I use an electuary of sulphur and cream  of tartar; in winter, a mixture con-
 sisting of two parts castor-oil and one of the balsam of copaiba.  When the
 inflammation has entirely subsided  and the parts become healed, the fold or
 folds of membrane should be snipped off with scissors.
     Internal haemorrhoids are far more serious in their consequences than
 those situated externally.   They are generally accompanied by more or less
 profuse  haemorrhage upon  each movement  of the bowels, a sensation of
 weight and uneasiness at the seat, and efforts  at stool followed by acute pain
 lasting from half an hour  to two or three hours.  At each visit to the closet
 the piles are extruded.  At first they  are easily returned, and remain within
 the sphincter until the next act of defecation, but in the  progress of time
 they descend whenever the subject stands or takes walking exercise.  In addi-
 tion to these symptoms there is pain in the back, frequently accompanied by
 irritability of the bladder and profuse leucorrhoea.  In a large majority of
 cases the mucous membrane covering the tumors will be found to be much
 thickened, granular, and ulcerated, the pile looking not unlike a ripe straw-
 berry.   Under other circumstances the membrane is "smooth and of a purple
 color.
     Treatment,—The smooth unulcerated pile is best removed by the wire-
 ecraseur.   If the wire  be tightened  slowly,  there will be no haemorrhage
 attending the operation and little after-pain.   The ligature, which  is  com-
 monly used, is slower in  its operation, attended with a great deal of pain
 and discomfort, and by no means  free  from danger.  After two  or three
 days of suffering the ligatures separate and leave the parts  in the same con-
 dition as left by the Ecraseur after an  almost  painless operation, lasting but
 a few minutes.
     Granular, soft, bleeding piles  I  remove  by the use of fuming  nitric
acid, which is perfectly safe and effective, and, if carefully applied, painless,
or nearly so.
        31 
242
     The  method  of application  is as follows:  The  patient, having been
placed on her left side, with the knees flexed upon the abdomen, is made to
strain until  the  piles  protrude through the anus, and their surface is then
wiped dry with a piece  of patent lint and the surrounding healthy tissue
smeared with castor-oil.   The acid is then to be  applied thoroughly by a
glass-rod or a piece of candle-wick, after which the parts should be washed
with a solution of the carbonate of soda, covered with oil, and returned with-
in the sphincter.  Three to four applications, about one week  apart, will
generally effect  a  complete cure,  even in severe cases.
     There is one great advantage in this method of  treatment, inasmuch as
it does not necessitate the confinement of the  patient to bed or to the house.
     In some cases the haemorrhoids are situated too high up to be extruded
during an ordinary act of  defecation.  In such  cases the examination  must
be made with the  speculum, the patient having first  been  aetherized.  The
anaesthetic is necessary to completely relax  the sphincter and afford an oppor-
tunity for examining the upper as well as loM'er part of the rectum.  I prefer
the speculum used by Professor Van Buren, of New York,  to any other. It
is a modification of Sims's, and is represented in  Plate  17, as  are all the
instruments required in these operations.

                   External and Internal Haemorrhoids.

                                Case 1.

     Mrs. B.; aged 32 ; admitted July 12, 1869; mother of four children; com-
plains of pain in the back  and hips, extending down the thighs ; leucorrhoea,
and frequent disposition to urinate.   Marital intercourse caused considerable
pain.   She experiences little or no inconvenience during defecation, but  for
two or three hours afterward suffers severely.
     Examination.— Uterus healthy, vagina relaxed.   The posterior wall was
too irritable to permit the pressure of the speculum.   Around the anus was
a fringe of loose skin, (external haemorrhoids,) that had previously been sub-
ject to repeated attacks of acute inflammation.  A slight straining effort caused
the extrusion of five internal piles, three of  them quite large and covered by
florid granulations, which bled with the slightest touch.
     Treatment.—Nitric acid was freely applied to every portion of the inter-
nal piles, completely destroying their granular surfaces.  The excess of acid
having been neutralized by a  solution- of soda, they were smeared with bella- 
Plate  XVII.
Instruments required for operations in and about the rectum. 
 
243
donna-ointment  and retmned within the sphincter.   This application was
repeated three times at intervals of one week, effecting their complete removal.
The external haemorrhoids were snipped off with a pair of curved scissors.
     Commentary.—The result was all that could have been desired, the symp-
toms of uterine disease from which she suffered at the time of admission dis-
appeared,  and she was relieved of all pain or inconvenience after going to
stool.  Her general health improved, and on September 17 she left the insti-
tution, cured.
                         Internal Haemorrhoids.
                                Case 2.
     Mrs. V. ; aged 37 ; married; motlier of two children.  Complains of vari-
cose veins in left leg, extending into the groin and left  labia, and haemor-
rhoids, which are extruded Mith each passage and returned with much diffi-
culty.  She always loses blood when at stool, sometimes in large quantities,
and has constant pain in her back.
     Examination,—The margin of the anus was swollen,  and an attempt  to
introduce  the speculum • caused spasmodic contraction of the sphincter and
had to be abandoned.  After a prolonged effort she succeeded in forcing the
piles out.   They were large, with broad bases; three of them were soft and
granular, as in Case No.  1, and one, which occupied the center of the group,
was hard and covered with smooth mucous membrane.
     Treatment.—The amount of surface covered by the haemorrhoids was so
great and the attachment of each so broad that it was thought advisable to
treat one at a time.  The hard pile was first removed  by the ecraseur, and
the soft ones subjected to the treatment before specified.  The cure was per-
fect.
     These two cases give a fair description of the treatment pursued with
all the patients that have been admitted to the hospital suffering from this
disease.   To report each in detail would  occupy more  time than can be
devoted to the subject. 
244
                            Procidentia recti.

                                Case 1.
     Mrs. H. E----; aged forty-four;  admitted November 8, 1868;  mother
of eight children, the youngest three years of age.   Since the  birth of the
last  child, she has suffered from prolapsus of  the rectum.  At  first it only
appeared when she went to stool, but for the last two  years the bowel  pro-
truded Mmenever she assumed the erect position, and was with difficulty re-
turned.   Medication  has been faithfully tried, and, failing to relieve her, she
seeks admission to the hospital with the view of submitting to an  operation
for a radical cure.
     Examination,—About five inches of the rectum was prolapsed; the  pos-
terior portion presented more the appearance of skin than mucous membrane,
being dry and scaly  from contact Mith the clothing; the sphincters were re-
laxed; the perineum  was entirely gone.
     Treatment.—It was  decided to  amputate the prolapsed portion of the
bowel with the  e*craseur and secure the edges by silver sutures.   The pa-
tient having  been placed under aether, a strong, straight needle was  armed
with a medium-size silver Mire, and the tumor transfixed at its base by eight
wires.  Fig. 1, Plate 18, is from a drawing taken at the time.  The  prolapsed
portion M^as then removed, the chain having been made to cut  slowly, and
but  a few drops of blood were lost;   Fig. 2, Plate 18, shows the stump  with
the wires in position; one wire has been draM-n up in the  center ready to be
divided,  one has been already severed and both ends twisted.
     Her recovery was perfect, and in six weeks from the date of the opera-
tion the perineum was restored.  No return of the disease in this case had
occurred prior to June, 1872, the date at which I last saw the patient.
     Commentary.—Before  this woman came under  my care  she  had been
submitted to a long course of treatment by tonics, astringents, and mechani-
cal supports, without relief.   The upper part of the bowel appeared healthy,
the extruded portion could be dispensed with without any interference  with
the function of the parts.   The removal of a V-shaped piece anteriorly and
posteriorly would, in my judgment, have been of little use.  To effect a cure
the operation must be radical, and, as no  contra-indication presented itself,
I resolved to assume the responsibility. 
Plate  XVIII.
Fig. i.
Prolapsus of the rectum;  wires in position previous to amputation of the prolapsed portion.
Fig. 2,
Sketch of parts after amputation. 
 
245
                            Prolapsus recti.
                                Case 2.
    Mrs. A----;  aged forty-five; admitted August 11, 1871; mother of
five children, the  youngest eight years of age; complains of inability to
control the  action of her bowels;  fluid matter flows from her involuntarily.
Upon walking or standing  any length of time the bowel protrudes, and in
order  to retain it within the sphincter, she is compelled to wear a napkin and
compress.   The general appearance of the patient is unhealthy, lips are pale,
skin sallow, and muscles flabby.
    Examination revealed a prolapse of the rectum as large as a foetal head
at full term; mucous membrane pale, but otherwise healthy. The sphincter
was relaxed sufficiently to admit three or four fingers readily, and, as soon
as the bowel was returned, it again protruded, the sphincter offering no re-
sistance.
    The patient was  placed upon chalybeate tonics, astringent injections,
and the local application of electricity.  Some benefit was derived from these
combined remedies, but it was not sufficiently pronounced to be satisfactory
to myself or to the patient,  and I decided to remove two V-shaped sections,
including the margin of the skin with the mucous membrane.
     The incisions were made through the sphincter, sections of which were
sacrificed with the rest of the tissue.   The parts were brought together by
silver sutures, which were inserted deeply and allowed to remain one month.
Upon their removal, union was found to be perfect. . This patient experienced
no further  trouble during her stay at the hospital, but the prolapse will pro-
bably return, for I have seen no case permanently cured by this form of
operation.  If she again presents herself for treatment, on account of a re-
turn  of the disease, I shall perform the same operation as in Case No. 1.
                         Fissure of the Rectum.
     This exceedingly painful and not uncommon affection is frequently found
in women who are supposed to be suffering from uterine disease.  It is almost
always accompanied by leucorrhoea and other symptoms so generally attend-
ant upon affections of  the uterus that without great care a mistake in diag-
onis may easily be made.  A lady came to me from Arkansas with the fol-
loMing history:  "Three years ago I  gave birth to my  first child,  and from
that time to the  present have not enjoyed one day's health.   I have constant 
246
pain in the back and loins, leucorrhoea, and a sensation of bearing-down, as if
my womb would come out.   I went to New York and was operated upon for
restoration of the perineum, it having been ruptured; I staid there seven
months, when I left; felt no better, but was told I was cured, and that my
pains and aches would disappear in a short time; but it is eighteen months
since then, and instead of being better I am worse."  I examined her  care-
fully and found the uterus healthy and in a normal position, vagina some-
what relaxed, and containing an  excess of mucus, unmixed with pus; the
perineum had been perfectly restored.  There was nothing about the genito-
urinary organs to account for the  woman's distress.   An attempt to pass the
finger into the rectum caused spasmodic contraction of the sphincter, which
at once excited suspicion of a fissure.  She was placed under the influence
of aether, and upon examination  I found a fissure on  the  left  side of the
anus with a small but deep ulceration.  This at  once explained the whole
case and  why the previous treatment had failed to relieve her.
     This is by no means an isolated case.  Large numbers of women con-
tract uterine derangement as a secondary affection, disease of  the rectum
being the primary disorder; and others again are supposed to suffer from dis-
ease of the womb, when the seat  of the trouble is entirely within the rectum.
The contiguity of the uterus and rectum, and the intimate connection between
their vascular and nervous  supply, while affording a sufficient explanation of
their close mutual sympathy, also suggests what clinical observation still more
powerfully indicates: the necessity of examining the state both of the rectum
and uterus, particularly when, in  disorders of the latter,  no adequate cause
can be discovered in the viscus itself to explain their presence.
     There have been fifteen  cases of fissure of the anus treated in the hos-
pital, some complicated with disease of the  uterus, eleven of long standing,
and in each of these cases there has been more or less ulceration.
     The indication has been the same in all, viz, to paralyze the sphincter
by dilatation, and touch the ulcerated surface with the  acid nitrate of mer-
cury.
     To paralyze the sphincter,  I adopt the  plan  recommended by Professor
Van Buren, of New York. The patient having been fully aetherized and placed
in the position for lithotomy, the thumbs should be inserted into the rectum
beyond the internal fibres of the sphincter and pressed forcibly outward until
they touch the tuber ischi on either side.  The operation will tire the thumbs, 
247
but it will paralyze the muscle and keep it perfectly quiet for ten to fourteen
days, which will afford abundant time for the fissure to heal.
     I very much prefer this plan to dividing the muscle by the knife, which
is generally adopted, for the following  reasons: First,  permanent  paralysis
does not uncommonly result from  division  by the knife;  it  never does by
dilatation.   Secondly, if any of the fibres are ruptured in dilatation they are
protected by  the  mucous  membrane  from contact with the air  or faecal
matter,  and no additional sore is  made.   All the  cases that have been
treated by this method in the hospital and in my private practice have been
cured.
                             Fistula, in Ano.
     Eleven cases  of fistula in ano  have  been operated upon, eight  by the
knife, and three, which were  situated high  up in the rectum, by passing
wire through  the  track and twisting it daily until it cut its  way out.   All
were cured.
     The  last   is  a tedious  and  painful  operation, and should never be
resorted  to  unless the  openings are  too  high up in the bowel  for  the-
knife to  be used with safety.    Some  practitioners recommend  inject-
ing the fistulous. track with a strong tincture of iodine or a solution of the
persulphate of iron.  I think both objectionable, for the reason that they are
tedious, very painful, and attended with much more risk than the knife, the
injection frequently escaping  into  the cellular tissue and exciting inflam-
mation, abscesses,  &c.
     During the six years which this report covers there have been over seven
hundred operations  performed in this hospital, including those which have
been operated upon  at the  clinics.
     There have been but four deaths as the direct result of surgical inter-
ference.  Two of these were from acute peritonitis, following the removal of
ovarian tumors.  Two from surgical fever, one after amputation at the knee-
joint and the other following removal of the breast.
     The tMro cases of ovariotomy Mould have been reported in detail, but the
book containing their record has been mislaid. 
 
            CONTAINING






REPORTS FROM THE DISPENSARY




           CONNECTED WITH





      THE HOSPITAL. 
 
      DEPARTMENT




           OF






THE DISEASES OF WOMEN.




           BY





     F. A. ASHFORD, M. D. 
 
REPORT OF  SECTION " DISEASES  OF  FEMALES " AT COLUMBIA
                     HOSPITAL DISPENSARY.
         By F. A. Ashford, M. D.,
(In charge of section, Assistant Surgeon of Hospital.)
  Dr. J. H. Thompson, Surgeon-in-Chief of Columbia Hospital.
     Dear Sir : In submitting my statement of the diseases treated  by
me in the dispensary attached to Columbia Hospital, I have to regret that
in so many instances both the antecedent and subsequent histories of the
cases are imperfect.   This defect arises from  the ignorance of many of the
patients, and sometimes  from their reluctance  to  give a true account of
themselves, as well as from  the  frequent impossibility of following out a
treatment to its completion.
     Of some of the  more interesting  groups a tolerably accurate  account
has been kept, as much pains have been taken to pursue the patients even to
their own homes, so as to determine results.
     It has been noted in this dispensary, and I think it must be so in most
others, that patients,  as  soon as  they begin  to  improve, discontinue their
visits to the dispensary, and  the result is that the benefits of treatment  are
frequently unknown; moreover,  sOme may  grow ill, so that they cannot
report, and then fall  into other hands; or the same  thing may occur when
they are dissatisfied with the treatment.
     The following table will exhibit a condensed synopsis of the cases pre-
sented to  me since  1869, embracing an aggregate of 1,600.   Of these,
about 600 were miscellaneous, and were  received for treatment before the
service  was  divided  in  any special  manner.    The balance have been
assigned to me, and all belong to the  class usually denominated " Diseases
peculiar to Women," and I may Mrell therefore begin their presentation
under the aphorism Uterum mulier est.
        32 
250
Table  of diseases and number  of cases  treated  at  the  Columbia  Hospital  Dispensary.
                                 SECTION, DISEASES OF  FEMALES.
Diseases.
No. of
cases.
Remarks.
„ ,  . .   r Acute....................   2
Metritis  2,
         I Chronic...................  25
^  ,      .  .   c Acute..............  22
Endometritis  2 „
              {Chronic............. 178
Parametritis.............................
Perimetritis.............................
Ulceration of vaginal cervix.............


Erosion of vaginal cervix................
Cancer of uterus.........................
Polypus of uterus......................


Fibrous tumor of uterus.............____
Prolapsus of uterus......................

Anteversion of uterus...................

Anteflexion of uterus....................

Retroversion of uterus...................


Retroflexion of uterus....................
Inversion of the uterus
Hsematocele, (pelvic)
Amenorrhoea
Suppressio mensium.....................
                 Neuralgic..........  6
                 Congestive........  4
Dysmenorrhea  <J Membranous......  2
                 Stricture of cervical
                   canal............ 13
Monorrhagia.
Metrorrhagia...........



Vicarious menstruations
Leucorrhoea.............
200
 12
  4
 22
52
^  25
 See page 252.

 See page 238.
 Will be treated of in a future report.                %
 Will be treated of in a future report.
 The granular ulcer not included, as it belongs to endometritis, above
   mentioned.   Follicular  variety,  10;  true inflammatory ulcer, 8:
   with everted mucous membrane,  3; syphilitic ulcer, 1.
 Cases of simple erosion of the vaginal cervix.
 Sent to hospital.
 All removed by twisting or by the  ecraseur.  One from cervical canal
   atfifthmonth of gestation, to prevent threatened abortion ; symptoms
,  wereimmediatelyrelieved,andpatientwassafely delivered at full term.
 Will be treated of in a future report.
 Cases resulting from the  above-mentioned conditions not included.
   Sent into hospital for radical cure, 3 ; relieved by pessary, 5.
 Cases of version resulting from neoplasms or inflammatory enlarge-
   ments are not included.
 One of these complicated with atresia of the cervical canal  at  the
   place of  flexure.
 One complicated with three-months pregnancy ; uterus was re-posed
   without  interfering with gestation ;  6 relieved by wearing  the
   closed-lever pessary ; 2 were unrelieved, as adhesions existed.
 Amputation of the elongated and strictured cervix relieved two cases.
   Much relief of dysincnorrhcea was experienced by use of closed-
   lever pessary.  Never resorted  to any form of stem-pessary, but
   have used sponge-tents  with benefit.   Sterility existed in all, but
   2 have borne  children  since treatment—1 after amputation of cer-
   vix, and  one after use of sponge-tents, and while wearing a pessary.
 Caused by traction on  the cord.   Metrorrhagia  continued for three
   weeks before she eerie under observation,  when  the  organ  was
   reverted by taxis.
 One was peritoneal, two were sub-peritoneal.  Resorption took place,
   in the first and in one of the latter cases.
 In 22, phthisis was'present, and they were referred to section on heart
   and lungs.  In 4, atrophy of uterus was present;  in  7 chlorosis ex-
   isted ; in 3, disease of  the ovaries ; in 1, Blight's disease ;  in 5, ma-
   larial toxaemia ; in G, sedation, (Hodge ;) and in 4 it was attributed
   to exposure to cold.
Not including  any connected with inflammatory conditions already
   mentioned. 43 due to cold, merely temporary; 35 proved to be pregnant.

(In the neuralgic sometimes relief  followed alterative treatment, but
£  it is not known whether it was permanent.

Nearly all cases in which menorrhagia was present have been included
  with some of the above-mentioned diseases of the uterus.   Those
  enumerated here depended upon  some disorder of the blood or its
  circulation, viz: purpura, malaria, engorgement of the liver, heart-
  disease, &c.
What is said of menorrhagia  applies also to metrorrhagia, but in 6
  of the 15 hemorrhage was due  to retained placenta.  (2 after labor
  at full term, 4 and (j weeks respectively, and 4 after abortions, 1, 2, 3,
  and 7 months.)
Will be treated  of in a future report.
Most of these were cases of simple congestive vaginal louoorrhcea, due
  to cold, disordered  menstruation, gestation, excessive coitus, &c.
  Uterine leucorrhoea, being always symptomatic, is not separated from
  the primary affection. 
251
Table of diseases, &c., treated	at the Columbia Hospital Dispensary, etc.—Coutinued.	
Diseases.	No. of cases.	Remarks.
Vaginitis.................................	43	13 were'simple, chiefly produced by irritating injections ; 4 were gran-ular, existing with pregnancy ; 28 were gonorrhoeal.
		
Vaginismus...............................	2	One caused by fissure of the vulva; the other case seemed only de-pendent upon a general nervous irritability. The first was cured
		
		by healing the fissure, the second failed to report after a time.
Atresia vagina?..........................	2	Sent into hospital for operation. Sent into hospital for operation.
_, . r Vesico-vaginal___2 Prolapsus vagina) I t Recto-vaginal.....4	] •	
1 Recto-vaginal........,......1 Fistula <J Vesico-vaginal..............2	)	
	4	Sent into hospital for operation.
[ Vesico-uterine.............. 1	)	
Ruptured perineum......................	12	Eight sent into hospital for operation. Four cases restored by opera-tion at the homes of the patients.
		
Pudendal hsematocele....................	4	In 3 it was produced by a kick, in one by a fall. Resorption took ' place in 2 and suppuration in the other cases. All resulted favorably.
		
Pruritus vulvas............:.............,	28	These were due to eczema, prurigo, parasites, a few to undetermined nervous affections, and two were connected with diabetes mellitus.
		
		(When dependent upon diseases already mentioned, as endometritis,
		&c, they were excluded from this table.)
_ , . f Purulent................... It Vulvitis < ,,. . < Folhcular ................. 24	\ 38	29 were relieved ; 9, result unknown.
Inflammation of vulvo-vaginal gland......	7	All suppurated ; 5 were lanced ; 2 opened spontaneously.
Caruncle urethras........................	12	6 were admitted to the hospital for operation ; the others were cured
		by removal with scissors and cauterizing the surfaces with nitric acid.
Calculus of bladder.......................	1	The stone, weighing two and one-half drachms, was removed per urethra after dilating with sponge-tents.
		
Ovarian dropsy..........................•.	2	Sent into hospital for operation.
. ( Acute......................3 Ovaritis < _, .	S 5	t The symptoms pointed to such a condition, but had no opportunity c to confirm diagnosis ; 4 followed criminal abortion.
Ovarian hernia, inguinal..................	2	Truss prevented descent of one; the other seemed adherent, could not
		reduce by taxis, and at each menstrual period the tumor enlarged, and sometimes it was threatened with inflammatory destruction.
Salpingitis, (right)........................	1	Abscess formed in the tube and had opened through the uterine cav-
		ity. The tube was left patulous.. (Recovery.) (Case was published
		in the National Medical Journal, District of Columbia.)
	5	Reduced by taxis.
Ventral hernia............................	8	Relieved by truss.
	22	Most all had suppurated before entering.
Gallactocele..............................	12	9 resulted from sudden cessation of nursing, and were easily resolved. 3 were freely incised ; strapping with belladonna-plaster was found
		
		very efficient.
	1	The flow had continued three years. Gave tonics and belladonna; patient failed to return.
		
	20 '33	A fine point of nitrate of silver was found very effective for their cure. 17 sent to hospital for removal, 8 of which were cancerous. The rest failed to return for radical treatment.
Neoplasms of the breast...................		
		
	5	These were patients who could not enter the hospital lor treatment.
		All improved under dispensary-attendance. Convulsions occurred
		in but one, prompt delivery was resorted to, and both mother and
		child survived.
Sterility..................................	22	Leaving out conditions already mentioned, (such as metritis, endo-metritis, displacements, flexions, neoplasmata, atresia of cervical
		
		canal or of vagina, vaginismus, &c.,) and of the 22 cases here re-
		ported, the conoid cervix ^Sims) was present in 19 cases. Most of
		these were lost sight of, and the treatment is therefore with-
		out known results. But one became pregnant, so far as ascertained,
		and that was after a long use" of sponge-tents and the bi-lateral ope-ration. Is not the conical cervix less a cause of sterility than the
Total......................-...........	1013 599	
		result of a want of development in the generative organs especially
Aggregate.............................	1612	• affecting the ovaries ?
 
252
     Of the cases in the preceding schedule I shall eliminate a few groups Mdiich
seem to be the chief subjects  of  special study to the gynaecologist, and will
not bring to  your particular notice the large class  ranged under a nomen-
clature too often founded upon a symptom, which, while it may to a certain
extent characterize a disease, does not give a true idea of its real pathologi-
cal nature.   For  instance, amenorrhoea cannot be considered  a disease,
but is  a symptom  of some  morbid lesion, or unnatural condition,  or of some
functional disturbance.  The same  may be said of leucorrhcea  and  other
symptoms which always depend upon a diseased condition of some organic
tissue, or to a general dyscrasia or diathesis.

                           ARTICLE I.

                                METEITIS.

     Inflammation of the womb, (and I refer, solely to  the non-puerperal,}
considered as involving the entire tissues of the uterus proper, is, happily,
far from being a  common  affection, although there are some who reckon
it as of frequent occurrence ;  but I am convinced, both from my service in
the hospital and dispensary, as well as from the experience  of my private
practice,  that what many  in general  terms  call  metritis  is  really  endo-
metritis, and  very  frequently merely endocervicitis.   However, I  am free to
admit  that an inflamed  condition of  the  mucous  lining of the  uterus  often
does involve  more or less  of the parenchyma of the  organ in  its morbid
action; just  as, in urethritis,  we sometimes  find  the  submucous areolar
tissue partaking considerably of inflammatory  changes.
     For  convenience of illustration, as well as because it is the received
nomenclature of most  authors who have of late written of gynaecology, I
have embraced my cases of inflammation of the womb, whether acute or
chronic, partial or  diffused, under the following divisions :
     Acute metritis, as  expressing acute inflammation of the parenchyma
of the uterus;
     Chronic  metritis,  as a  chronic inflammation of  the  parenchyma, in
whole  or in part;
    Acute endometritis, as an acute inflammation of the mucous  lining of
the uterus, subdivided as corporeal, MThen involving only that portion above
the internal os uteri, or as cervical, when limited to the lining of the cervical
cavity; and 
253
     Chronic endometritis, when  there  exists a  chronic inflammation  of
this same mucous  lining of the womb subject to similar limitations  as  the
acute.  Nevertheless I  am  aware that such a  definite  division is much
more strictly anatomical than justly pathological.
     Especially in acute  cases do I  find the lesions  affecting one set of
tissues extending to and ravaging others.   For instance, I cannot conceive
how a cervical metritis can fail, if acute in its character, to affect the ade-
jacent tissues of the uterus—indeed on several occasions I have noted a very
rapid extension of inflammation from the posterior lip of the neck, along  the
posterior wall and body of the uterus—involving the entire  parenchyma of
that portion of the organ, and depositing its usual morbid products, even
to its fundus.
     Then, again, I have frequently detected morbific changes in the uterine
tissue which at  first were confined to the mucous lining.  This, however,
is no more than should be expected, since the same general laws of inflam-
matory action prevail over the womb as over other tissues, influenced, of
course, by its own peculiar structure, and often fostered  by its functional
activities as well as by its abuses.
     The  relation which bronchitis bears to pneumonitis is a fit illustration
of that of -endometritis to metritis ; and as we sometimes find pneumonia
complicating bronchitis, so inflammation of the uterus may  result  from
inflammation of its lining membrane.  It may be pertinently remarked, that
there exists also a striking resemblance in the rarity of such an extension
of inflammatory action ;  as in the lung its mucous membrane seldom con-
veys inflammatory disease to its substance, so in the  uterus  do we find the
same  immunity  of its  parenchyma  in inflammation  of its lining  mem-
brane.
    But two cases of acute metritis have been treated from the dispensary,
and both Mrere the results of attempts to produce abortion  by the use  of
instruments.
    The first M'as a white girl, seventeen years of age, who, believing her-
self pregnant, at first  resorted to all the " forcing medicines," she could hear
of, and finally submitted herself to an operation at the hands of some abor-
tionist,  The fact is, she Mras not pregnant;  and when she came to the  dis-
pensary,  on account of  her  extreme suffering, the cervix M'as terribly lace-
rated ;  uterus someMhat enlarged;  exquisitely  tender;  vagina hot, and 
254
 covered with an offensive  sanguineo-purulent  discharge;  bowels  consti-
 pated ;  fcecal evacuations very' painful, as' was also the passage of urine,
 with a frequent desire to  micturate; much nausea;  breasts painful; and
 fainting at times.  There had been no hemorrhage, nor was there any after-
 ward,  so  that no foetus could have escaped, especially as she thought her-
 self five months advanced, and I feel assured she told the truth, for it was
 a long  time .afterward before  she would  be  convinced that she was not
 still pregnant.
     The  amount of febrile action was very slight, compared with the severe
 local symptoms, and  entirely  different  from that  which  usually attends
 puerperal metritis.   She refused to enter  the hospital, and I ordered her
 home, enjoining upon her mother the necessity of absolute rest, and advised
 her to procure immediate  medical aid.   The next day I Mras summoned to
 her bedside and found her sufferings extreme, with occasional rigors, which
 suggested that purulent formation had supervened in some  portion of the
 inflamed  organ.  Passing my  index-finger gently to the cervix, I noticed
 that the posterior lip was much more swollen than  on the previous day—
 the enlargement extending upward, giving the impression that there was an
 abscess  of the  posterior cervical wall, probably extending into the uterine
 body—but I could not appreciate any fluctuation sufficiently  definite to
 warrant a puncture.  Ordered opium and  belladonna suppositories for the
 rectum, and frequent and large injections of hot water into the vagina.  I had
 directed that a dozen  leeches be applied about the  perineum on the, day
 previous,  but this had not been complied with.
     On the  following  morning patient was more comfortable; pulse one
hundred and tMrenty.   She had  been restless all night, and the rectal and
vaginal tenesmus was very annoying.
     Drew off two pints of urine through the catheter, and  then managed to
introduce a Sims' speculum,  and, on account of the distended and engorged
posterior lip, I determined to pass a sharp-pointed bistoury into the enlarged
mass.  If was entered just posterior to the os, and, after passing about three-
fourths  of an inch, pus gushed out.   It discharged about  two ounces of
grumous matter, mixed with quite a free hemorrhage from the incised puncture
for, when  I discovered  that  it contained  pus, the puncture was  converted
into an incision as the blade  was withdrawn.   The  hemorrhage  in all
amounted to about four ounces, Mrhen  it almost  ceased, and  I plugged the 
255
vagina lightly and left her.  In the evening she suffered much from the plug,
and it was withdrawn, saturated with sanious fluid, and a feM' small blood clots
followed mixed with pus ;  but the bleeding did not recur.   The opium and
belladonna suppositories were continued so long as was necessary to relieve
pain and tenesmus.  After the opening of the abscess,  her sufferings were
greatly relieved, but the uterus was still very tender, and the  rectal pain
and  bearing-down were the most  distressing symptoms.  For several days
the vaginal injections of warm water and carbolic acid were used, and after
that  a tampon of cotton-wool soaked in carbolized glycerine (3ito3iv) v-as
introduced  daily into the posterior cid-de-sac.   She was  kept  in  bed for
six weeks, and at the end of two months resumed her household duties.
     The second case was, in its causative history, about the same as in the
preceding, except that  this woman attempted  abortion sua manu, and  she
thought gestation was about three months advanced.   She was white ; aged
twenty years ; in robust health previously; and having failed to secure the
return of her menses by many of  the teas, powders,  pills,  &c, so generally
thought to be emmenagogue  in their action, she  resolved to  " puncture the
neck of  the womb," as she expressed it, " so as to  get rid of the obstruction."
For  this purpose she sharpened a piece of whalebone, and true to her inten-
tion  did puncture through the anterior lip of the cervix, the instrument enter-
ing  just below  the cervico-vaginal attachment,  and passing upward and
backward through the anterior wall of the cervix  into the uterine cavity.
     She had visited the dispensary about two months previously, complain-
ing that she had taken cold and  that her menses v^ere suppressed on that
account; but suspecting pregnancy as the cause of her trouble and anxiety,
a placebo M'as ordered, and no more was heard from her until I was requested
to  see her at her house, as she was too ill to visit the dispensary.   I found
the poor woman suffering extremely; pulse one hundred and twenty-six;
skin  hot and dry; great rectal  and vesical tenesmus;  constant  bearing
down ; distressing nausea, but no  vomiting.
     The uterus seemed  slightly  enlarged;  the  cervix was  very much so,
especially the anterior lip, and exquisitely tender ; indeed, so little pressure
could she bear, that the examination M'as not  satisfactory, and a speculum
could not be used.  She  confessed that she had been exposed, and when
her menses stopped she believed herself pregnant, and had visited the dis-
pensary hoping to obtain some medicine that would bring her "all right;" 
256
but as the placebo had no  effect, she determined at any risk to produce an
abortion, and  finally she  resorted to the use of the whalebone.   As it had
been two months since prescribing for her, and still no decided enlargement
of the uterus  could be felt, it was not possible that  she  could be pregnant,
and this proved to be true.  A dozen leeches were  ordered, but only eight
Mere  applied  to  the perineum  and around the anus.  The bleeding was
encouraged by cloths  saturated with hot water, and quite a free depletion
resulted.  Suppositories of  opium  and belladonna were introduced every
four hours into the vagina, which was hot and painful;  but they seemed to
have a better  effect when placed in the rectum.  Large injections of  tepid
water into the vagina gave decided  relief, and were frequently called for, as
was also the effervescing draught to relieve nausea.
    After the fourth day the symptoms were so much ameliorated that the
speculum could be used.  The cervix was cedematous, turgid, and still very
tender, the anterior lip being larger, but both  equally sensitive to pressure.
The lips  of the  os  were pouting  and  slightly eroded.  Just  below the
vagino-cervical attachment a round, pouting opening could be seen covered
with sanious-pus, and a fine probe entered through this into the cervical canal
about three-fourths of an inch from the external os.  The anterior wall of
the cervix had been entirely penetrated, and probably a portion of the pos-
terior also.
    The  uterus was found slightly enlarged and very tender,  especially
over the pubes.  It was pressed backward and fixed, the tissues around the
fornix vaginas  feeling hard and unyielding, and giving anteriorly the sen-
sation of a fibroid on the  anterior uterine wall.  Pulse Mras still rapid, with
some  tympanitis and nausea.  A blister was spread over the hypogastrium,
and the  vesicated surface poulticed  with  flaxseed-meal.   Bowels moved
every other day, with enema of warm soap-suds, and the anodyne-supposi-
tories continued, as also vaginal irrigations.  After the use of the speculum
could be borne, a pledget of cotton-wool saturated with glycerine was daily
applied against the cervix uteri.  (The use of the glycerine always promotes
serous transudation  and thereby depletes the minute capillaries, relieving
oedema and often congestion,  and causing a large watery  flow from the
vagina.)
    After two  months the uterus measured two and three-fourths inches,
(from  external os to fundus ;) was normal in position, witliout tenderness, 
257
except on pressure against the anterior Mall, which remained a little enlarged,
as was also the anterior lip of the cervix;  but the wound had entirely healed,
leaving scarcely a mark.  Menstruation took place sixweeks after the injury,
Mras someM-hat painful and lasted with remissions for six days, her usual period
being three days.
     After this she improved rapidly, and four months from commencement
of the attack I could find no trace of disease, save perhaps a slight enlarge-
ment of the organ.   She had been kept in bed a little over three months,
and after that was allowed to go about gradually.   This woman is now the
mother of two children and in good health.
     These two cases of acute metritis, the only ones I have ever seen, are
unique as to their history, although they do not stand alone, either in path-
ological phenomena or in favorable results.
     I can  easily conceive how some  practitioners have considered acute
metritis not such a very rare  disease, Mrhen in fact they had never met  with
a real example, for I know it was a question with myself whether  many of
the  cases  of endometritis were not, in truth, cases of metritis, until I was
called upon to treat the two above reported.  I then comprehended, better
than I can describe, a catenation of symptoms, out of all proportion, more
marked and severe than any I had previously met with among those patients
M'hom I had almost regarded as affected with acute metritis.
     Out of all the  cases of uterine disease which I have seen, and of which
1 have notes more  or less complete, numbering nearly 2,500, this first  case
is the only one in which  I ever recognized an abscess in the uterine wall.
     Sometimes in puerperal metritis I have been led to suspect such a  con-
dition,  both from an enlargement and tenderness in some particular part of
the uterus, and from a sudden subsidence of these upon the discharge of a
considerable amount of pus per vagina.   In those cases where a post-mor-
tem Mras obtained, we usually found purulent infiltration, with, occasionally,
abscesses more or less circumscribed, and in one autopsy we found that an
intramural  fibroid, M'hich had been noted during labor, had undergone puru-
lent degeneration, forming a considerable abscess.
     Scanzoni mentions one case, the  only one  he remembers,  in which the
abscess supervened  upon a violent metritis folloM'ing a sudden  suppression
of the  menses,  and which ruptured on the 22d day into the peritoneal
cavity,  causing peritonitis, from  which the patient died nine days after. 
258
The abscess, about the size of a goose's  egg,  occupied the right superior
portion of the body of the uterus, and opened through the external layer of
the uterine substance  and its peritoneal  covering.
     Churchill mentions  having seen a preparation of an  unimpregnated
uterus which was the  seat of an abscess  containing an ounce of pus.   Eein-
mann mentions an  abscess of the uterus M'hich  opened externally through
the abdominal Malls,  and  Bird (Lancet, February, 1844) describes an  ab-
scess in posterior wall of uterus which opened into the rectum.  Mauriceau,
Van Sweeter, La Motte, and others  have recorded similar examples.
     My friend  and beloved preceptor, Dr.  Thomas Miller, furnished  me
with the details of an  abscess in the fundus uteri which caused an inversion
of the womb.  He  visited a negro woman in the jail  of the District and
found her suffering  extremely, and from the vulva a large tumor protruded,
winch at first resembled a distended vaginal cystocele ; but after a thorough
examination he found that the uterus was  inverted  and that the fluctuatiiiir
mass Mas an abscess in its  fundus.  He opened the  abscess, Mdiich dis-
charged about a half-pint of bloody pus, after M'hich he reverted the organ,
and the woman made a good recovery.
     A complication which is at once recognized in the details of the second
case Mas perimetritis ;  but as I shall devote another chapter to the consider-
ation of this  subject, I will have occasion  to refer to its relations to metritis
under that head.
     The length of  time these cases required for treatment, about four months
each, shows  not only the aptitude which the uterine tissue possesses for  the
continuance of an inflammatory action once begun, but also how frequently
this morbid process involves other surrounding structures.   A uterus which
has once been the seat  of any inflammatory action isexceedingly susceptible to
a recurrence  of this morbid  process upon the slightest provocation.   Again
and again have I seen women who,  after having been treated for metritis or
endometritis,  when the organ was apparently free from disease, become  preg-
nant, and almost invariabl}' they not only  suffer much during gestation, but
they are much  more  liable  to puerperal metritis or endometritis, or to sub-
involution of the  uterus, than females M'ho have never had such complaints.
I do not wish to  be understood that such is necessarily the case, but I do
aver that this has been my  experience,  and  the result of my observations
also confirms this opinion ; and when the nature of the uterine tissues and the 
259
 functional processes of gestation are considered, it would be strange if this
 were not the fact, There is no organ or tissue of the body that will suffer more
 insidiously the ravages of disease than the uterus, and even when judicious
 treatment has given entire relief, and the  parts  seem normal, yet the in-
 creased  activity which #  supervenes upon pregnancy, often  awakens a
 smothered spark which M-ill burn without entire abatement until rest once
 more helps its extinction.
   These considerations impressed me when conducting the treatment of the
 above  cases, and impelled me to insist, nay, to command, perfect rest in bed,
 even when scarcely a symptom of disease remained,  and when  the patients
 themselves could not appreciate its necessity or reason.  This was justified by
 the results subsequently witnessed in the second case.   She married about six
 months after her recovery and soon became pregnant.  Although her gestation
 Avas without any serious untoMard circumstances,  yet she complained more
 than is usual; a slight disposition to frequent febrile exacerbation ; a burning,
 gnawing pain ; much tenderness M'hen pressure M^as brought to bear upon the
 womb  ; once or twice a threatening of miscarriage, as if the uterus Mas some-
 what intolerant of its burden, and finally an extremely painful labor foil owed
 by quite a severe metro-peritonitis, the details  of M'hich  are not proper to be
 considered here.  The supervention of puerperal trouble in the two labors
 succeeding the primary attack,becomes of consequence,  however, as relating
 to metritis in the non-puerperal state, especially as enforcing upon the practi-
 tioner  the utmost diligence in its treatment,  as well as determining his advice
 in questions of subsequent marriage.
     In the first case, the woman has not up to this time married, and I believe
 she is in  good health.
     If treatment should end with the subsidence of the acute symptoms, little
 can be expected but that the womb will remain in a condition of chronic en-
gorgement or.inflammation, which in time must lead to serious pathological
 changes,  if it does not entirely prevent its proper functional activitv, both
as to fecundity and menstruation.   The activity of the  treatment should of
course  be in proportion to the degree of  inflammation as shown  by the
attendant svmptoms, but perfect rest in the recumbent posture should in all
cases be imperative.
     Local depletion, by means of leeches to the perineum, around the anus,
(especially'if the posterior of the uterus be the initial seat of the inflamma- 
260
tory action) and about the vulva, becomes a powerful adjuvant to assist  ia
reducing and limiting the morbid action.   (If leeches could be applied to the
cervix I am sure it Mould be better still,  but this often is impossible without
administering an anaesthetic.)  It had been directed for the first case, but com-
pliance failed ;  still,  in the second its use was attended with marked benefit
at the time, and no doubt it exercised great influence to prevent other serious
inflammatory lesions.
     As to general treatment very little was attempted in either case, as it hap-
pened that both had taken a mercurial purge, which I think would usually
be beneficial.  It is of great importance to unload  the portal circulation
early in the disease,  and to  keep the alimentary mucous membrane actively
working, but it could never be desirable to use any drastic, irritating medi-
cines.  Small doses of Rochelle salts every two or tluee hours will not only
keep the bowels soluable, but will deplete the capillaries of the mucous ali-
mentary tract, and go far toward relieving the rectal tenesmus, which is such
a constant and distressing symptom.
     After  the acute  symptoms disappear and it passes into  the chronic form,
M'hich it did to  a certain extent in both of my  cases, and I  ween it does
so generally, then  its treatment demands far different therapeutics, both
local and general, and the practice in this dispensary will  be fully set forth
under the  head of chronic metritis,  which we shall now enter upon, because
it follows both  in practice and classification.

                             ARTICLE  II.

                            CHRONIC METRITIS.
     The condition variously described as metritis, parenchymatous metritis, in-
flammatory engorgement, chronic parenchymatous inflammation of the iderus, is the
most usual sequence of acute metritis, whether puerperal or non-puerperal.
It not unfrequently results from the  invasion of  acute endometritis, or a long-
existing or neglected chronic endometritis, from a  prolonged congestion due
to a sudden suppression of the menses, from repeated or violent  miscarriages,
from abortions, from displacements,  or from any cause  that will  produce a
blood stasis in the uterine tissues.
     The following table will show some of the  causes and  their relative fre-
quency, as presented in the  dispensary: 
261
                   Causes of chronic metritis.
                                                           Cases.
Abortion...............9
Miscarriage..............2
Suppressed menses from cold .      ........2
Suppressed menses from fright.........1
Puerperal metritis............2
Acute  non-puerperal  metritis.........2
Retroversion from fall...........1
Fibrous tumors.............6

       Total..............25
     It is thus shown that abortions claim 36 per cent, of all the cases, while
 fibroids also claim 24 per cent.   This is true of the dispensary, but I am sure
 it is not of general  private practice  in the large cities, for abortion is by a
 much greater proportion the most frequent cause.   It must be  remembered
 that but few prostitutes ever visit the dispensary, nor do many of those who
 can possibly  obtain medical attendance at home when they suffer from such
 criminal acts.   So the above cannot be considered as a true proportion of its
 frequency as relates  to other diseases or to the same disease from other causes.
 When including all. my cases both in dispensary and private  practice, I find
 that abortions and miscarriages are named as causes for chronic metritis in
 60 per cent, of the whole number, and when we remember the prevalence of
 this appalling crime and then the violence which is inflicted  upon the  gen-
 erative organs by the use of ecbolic medicines, the practice of the cold vagi-
 nal douche, the murderous  assaults  of instruments, the interruption of the
 most active physiological development known to the system—gestation—its
 unnatural sufferings, its profuse hemorrhages, its nervous  shock—and  then
 the poor self-criminated subject, often without rest or proper medical advice,
 and frequently, too,  in the midst of want and wretchedness, it  cannot be sur-
 prising that it should be followed so commonly by this most intractable and
 distressing affection.
   The influence which fibrous bodies exert upon the walls of the uterus often
 disposes the organ to  take on a chronic inflammation, owing to the blood stasis
 M'hich they cause as well as to  the  constant irritation which  their presence
excites.
    From the predisposition which the negro race exhibits for these neoplasms 
262
of the uterus, we find that a large number of the cases of chronic metritis due
to fibroids are among colored women, while, let me remark, very few of this
race ever suffer from criminal abortions, such practices being comparatively
uncommon anions' them.
                o
   Metritis from fibroids:
     White  ...............2
     Colored...............  4

           Total..............6

   Metritis from abortions and miscarriages:
     White  ---------.....-  ' -  8
     Colored...............,",

           Total..........-   ... 11

     When we come to speak of fibrous tumors, we  shall have occasion to
refer to this subject again.
     The influence of cold is not very likely to excite chronic metritis (except
as a secondary affection from the much more common result of endometritis)
unless it has been very injudiciously applied,  as it appeared in two of the
cases I report.  In both instances the parties had resorted to ice-cold-water
injections into the vagina during some inopportune menstrual period, that
they might enjoy connubial pleasures.   In each subject, judging from their
histories, acute metritis resulted, although neither came to the dispensary
until some time after the attack, having presented themselves on account of
long-endured yet continued sufferings, and because of the resultant sterility.
I have met Avith several  cases where chronic engorgement could be  traced to
no other cause but suppression  of menses  from  exposure to cold and wet, es-
pecially wet  feet  after skating, Avhen the vital  forces had been reduced by
over exercise, excitement, menstruation, and the depressing effect of long ex-
posure to a cold atmosphere.
  The case in Avhich fright was supposed to be  the exciting cause of sudden
suppressio mcnsium, resulting in chronic metritis, aa^is not reliable in its history,
and I always suspected some other cause, although I had no definite reasons for
doubting the statement of this patient.
     The two cases following acute  puerperal metritis, exhibited much hy- 
                                  263

pertrophic enlargement, and in each the uterus was bound down by adhesive
inflammation to the rectum, creating  much intestinal  and rectal trouble.
Those of an acute, non-puerperal origin have  already  been detailed, and
as treatment was  continued both during  and immediately following  the
acute attacks, a better result Avas  obtained than can usually be expected.
     The sub-involution of the uterus has been reckoned a cause, but  I have
never met with the fact.   The arrest of involution is, in all the cases  I have
observed,  due  to  some inflammatory  action in  the  uterus  itself.   When
chronic  metritis followed, to  suppose that the sub-involution was the exciting
cause is to mistake cause for effect,  The retrograde  metamorphosis which
supervenes upon labor, cannot but be subject to many conditions which may
retard its action; but, so far as relates to chronic metritis, I have ahvays found
that the involution was interrupted by some primary metritis  or  endome-
tritis.  Where  metritis (or endometritis) existed at  the  time of conception,
not only do we sometimes>witness an interruption of  development, causing
abortion or miscarriage, but, if happily this does  not  occur,  Ave will  almost
certainly have  an enlarged (or non-reduced)  chronically inflamed uterus to
treat afterward.
     The distinction drawn by some writers between chronic metritis when
confined to the superior segment  of the uterus—chronic corporeal metritis—
and to the same when limited to the lower portion—^chronic cervical metritis—
is not  only just pathologically, but is of great utility practically; for  the
symptomatic complaints and complications  are as  different as are the means
resorted to for their intelligent treatment,
     When chronic metritis is thus limited  to one portion  of the uterus,  the
prognosis is greatly influenced, for, when corporeal, it is far less amenable to
means of relief or cure than when it pervades only the cervical tissues.
     While  chronic metritis as  a rule is usually connected with a previous
pregnane}',  yet that which  affects the female who has  never been impreg-
nated, especially Avhen from cold, I have  found in  all but one case Avas
confined to the bod}' of the uterus, and that the cervix seemed singularly
exempt;  while, on the  contrary, after abortions, miscarriages,  or parturi-
tion at full term, the cervix was constantly  involved, sometimes solely, often
in connection with the bod}'.
     This, more than any other condition Avhich  has presented itself at the
dispensary,  was a cause of sterility, and one patient after a treatment of four-
teen months became pregnant in the tenth -year of her married life.  The 
264
metritis was not cured but was greatly relieved, and after labor at full term
the uterus remained more  engorged than it ever had been, and the cervix,
which  before Avas unaffected, became hypertrophied and indurated.   Here,
then, was inflammation of the whole organ where before it was partial.
    The folloAving table will show this influence of pregnancy to determine
the cervical inflammation:
Parts affected.	Never been pregnant.	Been preg-nant.	Total.
Chronic corporeal metritis.......... Chronic cerA7ical metritis............	3 0 2	3 9 8	G 9 10
Chronic general metritis.........Z. Total.........................			
	5	20	25
			
    Where, therefore, the engorgement is not general, Ave find, among those
females who have  never been pregnant, that chronic inflammation in the
corporeal segment of the uterus is as three to two in the cervical, but that
this proportion is more  than  reversed where  pregnancy had once existed.
These cases are too few in number to predicate any general rule; and, that
they may not mislead as to the special cause, I insert a synopsis which Avill
suggest at once why such a localization might be expected:
Condition.	Cause.	No.	Total.
Chronic metritis, general........... Chronic metritis, corporeal.......... Chronic metritis, cervical.......... Total........................	Acute puerperal...... Acute non-puerperal . Miscarriage......•__ Fibroids .............	2 2 1 5 3 1 1 1 8 1	10 0 9
	Suppressed menses ... Fibroids .............		
	Abortion........... Abortion...... ..... Miscarriage..........		
			
			25
			
    The reason why Ave find chronic metritis of the cervix so frequently after
abortions is because injury is very often inflicted upon this  portion of the
4 
265
 organ, and  because acute cervical endometritis finds in the cervical portion
 of the mucous  membrane a  good hiding-place, subject to every exciting
 cause of inflammation for its extension.
     Symptoms.—The symptoms of chronic metritis vary so much in different
 individuals that it is almost impossible to determine its existence by the state-
 ments of the patients concerning their sufferings, and frequently it is found
 to exist when it was scarcely suspected.  I have found  that the  most char-
 acteristic symptoms are : pain in mammas about the  menstrual period, Avith
 darkening of the areolae; nausea and vomiting; painful or uneasy locomotion
 and dull dragging  pains in loins and pelvis, with uterine tenesmus;  pain in
 defecation, in coitus, in micturition,  with vesical and Aaginal  tenesmus and
 pain down the  thighs.   The digestive function is almost ahvays deranged,
 and complaints of heart-burn, meteorism, eructation of gases, a picking pain
 in the prsecordia, Avith much general nervous disturbance, often hysteria.
     Headache was a  distressing symptom in fourteen of the twenty-five
 cases, and was confined to the region of the vertex in eight.   In two  cases
 the clou hysteriauc was so violent that it caused temporary aberration of the
 mind and threatened violent mania.   One of these at each menstrual moli-
 men Avas seized Avith aphasia, generally being able to communicate her
 thoughts by writing, but not by speech, and sometimes suffering complete
 amnesia.
     Menstruation was usually disordered, Avith cutting or gnawing  pain in
 one  or both inguinal regions from congestion of the ovaries, which sometimes
 lasted during the interim of the catamenial periods.   The menstrual Aoav
 Avas generally deficient, sometimes absent for months and years, sometimes
 very foetid, often.acrid and accompanied with pruritus and excoriation of the
 A'agina and Audva.
     The presence  or absence of a vaginal discharge depended upon the
 condition of the mucous lining of the cervix and body.  Endometritis, par-
 tial or entire, usually prevailed, and a muco-purulent or muco-puro-sangui-
 neous discharge Avas present in a large number of the cases.
     As to determining the presence or localization of chronic metritis by any of
 the above symptoms it Avas found impossible, for Avhile many of them Avere
 present in a large number of cases, yet in some but one or tAvo could be elicited,
 and it was found, as Avi 11 after Avard appear, that endometritis and other patho-
logical conditions of the uterus often exhibited many of the signs just noted.
      34 
266
True, in some, whore the previous history Avas knoAvn and the symptoms care-
fully noted, a tolerably accurate diagnosis could be predicated, but such  an
affirmation needed physical exploration by the touch,  the speculum, and the
sound, to rightly locate and determine it, as much as  the differentiation of
affections of the lungs requires auscultation  and percussion by means of the
ear, the stethoscope, and pleximeter.
    These physical, then, Avere the only pathognomonic signs Ave could rely
upon, and a careful examination of them, aided by instruments, usually dis-
closed the true  condition.
    In chronic metritis, the enlarged, hypertrophied  uterus  was often felt
above the pubes from half an inch to three  inches; tender to deep pressure
and falling forward.   Sometimes  the indurated  hypertrophied organ Avas
retroA'erted, and by pressing up the posterior vaginal  cul-de-sac it could  be
raised from its bed in  Douglas' pouch and  be brought under the conjoined
manipulation as so  graphically described by Thomas.  This method of bring-
ing the womb between the grasp  of one hand, pressing doAvn the abdominal
Avails behind and above it, and the index or first tAvo fingers of the other hand
pressing against the anterior vaginal pouch,  if the organ is normal in position
or anteverted, or against the posterior, if retroverted,  has been found of the
Utmost importance, and no examination can be considered thorough without
it.  Not only does it discover the size, shape, density, position, and sensibility
of the uterus, but it at once distinguishes chronic metritis from fibrous tumors
and perimetritis, and, generally from pregnancy, three conditions Avhich might
be confounded and result in serious disaster.  In neither perimetritis nor preg-
nancy could the sound be used without great  risk, nor should it be intro-
duced unnecessarily Avhere fibroids are present, so that this  "manipulation,"
or uterine palpation, should ahvays precede  the introduction of the sound.  I
haA'e  often heard practitioners express great surprise, not to say doubt, con-
cerning the possibility of being able to grasp or investigate the Avomb in this
vagino-abdominal manner ;  but, Avith care and the dexterity which practice
gh'es, it would seem that there is  but a small proportion of cases where it can-
not be practical.  In very fat Avomen, or sometimes on account of great tender-
ness or a rigid contraction of the  abdominal muscles, it may be impossible to
elicit anything from such a manipulation; but rigidity or tenderness, aside from
the lessons the}' teach, ma}' be overcome when very desirable by anaesthetics.
  The  cervix was generally Ioav in the pelvis, engorged,  enlarged, hard to
the touch, sometimes very tender when the uterus was raised by the fino-er, 
267
and usually acute pain Avas evinced Avhen the cervix M'as pressed upon at its
posterior vaginal attachment.  The cervix often felt like a hard stem, shaping
out as it approached the body of the uterus.  The os Avas small and round in
the nulliparous,  and gaping and oval Avhere pregnancy had existed.   In  one
case the ceiwix was immensely enlarged, pressing upon the bladder and rec-
tum, and filled the vagina.   In the three cases Avhich had never been pregnant,
and where the inflammation Avas chiefly corporeal,  the  cervix Avas not much
altered, and Avith little or no tenderness, except AA'hen pressure Avas made so as
to affect the body of the uterus.   Where malposition had resulted, the point
of flection betAveen the body and neck was in each case exquisitely sensitive.
By the  rectum a larger surface of the posterior of the uterus could be exam-
ined,  and  especially useful Avas this method found to be when retroflexion
existed, as the wdiole body and fundus could be thus reached by the explor-
ing- index  finger.
     The speculum and sound in the further iiwestigation generally satisfied
as to the nature  and extent of the disease.  The congestion, erosion, ulcera-
tion, or eversion of the lips of the cervix was determined by the former, and
the position, size, mobility, and extent of  disease by the latter.   The sensa-
tion of  pain Avhich remained after exploration by the sound went far to sub-
stantiate the existence of corporeal metritis, and this tenderness of the walls
of the body and fundus, Avith increase in the size of the Avomb, as measured
by the probe, and with  augmented Aveight and Arolume,  will distinguish
chronic parenchymatous inflammation from chronic endometritis, although
the latter is generally present Avith the former and gives character to the dis-
charge.
    Often AA'hen granular  erosion existed, the slightest  touch with the specu-
lum or sound caused more  or less hemorrhage, and, after the use of the sound
Avithin the uterus, a few drops of blood often followed  its withdraAval.
    The progress of chronic metritis, Avhen uninterrupted by treatment, is
generally  from bad to Avorse.   Each menstrual molimen aggravates the pre-
vious condition; indeed, in some of the cases presented, the uterus seemed to
become acutely inflamed at these times, and scarcely could the patient recover
from one exacerbation before she Avas  subjected to another more seA'ere.
    The increase of congestion and engorgement augmented the Aveight of
the organ, aggraA'ating those distressing bearing-doAA'ii pains and bladder and
vesical tenesmus to such a degree that life became a burden and a dread, and 
268
the poor sufferer has, in the sincerity of her heart, exclaimed that she would
rather pass through all the travail of the child-bed every month than suffer
her menstrual agony.   Where the  Aoav Avas free, as Avas  usually  the  case
Avhen fibrous tumors existed, either as a cause,  coincidence, or effect,  I have
Avitnessed an aggravation of the usual symptoms it is true, but the  suffering
has not appeared so intense as when the Aoav was very slight or entirely ab-
sent—the free depletion, to some extent, mitigating the distress.
     Where chronic engorgement results from neoplasms of the uterus, from
diseases  of the heart, liver,  spleen, ovaries, fcecal tumor, or any diseases affect-
ing the general circulation of  the body or local circulation in the pelvis, then
its progress is pari passu with these primary affections, and Scanzoni says, that
when this is the case, that Ave rarely observe in the course of the disease the
exacerbation above mentioned.
     This disease does not limit itself.  If the whole uterus is affected or the
corporeal substance only, malpositions  ensue  and superadd sufferings and
changes in surrounding tissues and organs.  The period of the  cessation  of
the menses then becomes a Avelcome one, for it usually brings some mitiga-
tion, if not relief.
     Pathology.—Concerning the pathology of this affection I can offer but lit-
tle.   The cases speak for themselves, and they nearly all point to inflammation
or congestion as a cause.   Whether the proliferation of the connective tissue
is due to formative irritation (Klob) or to chronic inflammation seems of little
moment, as in this connection they would appear as convertible terms, each
expressing an irritation causing an increased flow of blood to the organ and
an increase of nutrition, resulting in hypertrophy.   While therefore, in one
sense, inflammation is regarded as a derangement of nutrition, yet even Klob
does  not deny  "the  influence of inflammatory  stimulus upon formative
action,"  and, consequently, its characteristic effects upon formation and nu-
trition.
     In some of the above cases the circumscribed inflammation or  irritation
resulted  in  proliferation  or hypertrophy of that  particular portion of the
uterus, and both in and outside of dispensary-service I have repeatedly seen
enlargements of the posterior wall of the womb Avhich were inflammatory
or formative irritation.   The cause probably of many neoplasms is  found in
this irritation, which stimulates to adventitious growths.   Klob has shoAvn
this quality  of formation  as affecting both the  external and internal condi- 
269
 tion of  organs.   Thus we  find  the shape, form, or position of an  organ
 changed, and, Avhen  like the uterus it is hollow, the shape  and size of its
 cavity also affected,  its internal  or interstitial parts being inclined to the
 development of growths, Avhich change  coincides  with  either an excess or
 deficiency of development and Avhich he terms "quantitative alteration in
 formation."
     When this alteration is "qualitative,"  Ave find it affecting the prolifera-
 tion of elements, so that the new formations partake of the character of the
 tissues from which they spring, and where this action is perverted or deranged,
 then the results vary  proportionately, giving,  sometimes, histoid  develop-
 ments.
     For these reasons Klob ranges the hypertrophy of the connective tissue
 of the uterus, whether accompanied Avith any increase of muscular substance
 or not, under the head  of qualitath'e alterations of formative  irritation, inas-
 much as the natural proportion of the normal tissues constituting the uterus
 are thereby considerably altered.  No better description of  the morbid ap-
 pearances can be found than that of this eminent German professor, and to
 insert it  here cannot but be of interest to your  readers :
     "The condition of the parenchyma of the uterus varies according to the
 duration of the disease.  In the first stages  it is more congested and turgid,
 OAving to the immatured  condition of the newly-formed connective tissue.
 The longer the duration of the disease,  the  more is the  mucous  connecthe
 tissue transformed into the fibrillary variety, accompanied with contraction
 of tissue; the parenchyma on section appears white or of a whitish-red color,
 deficient in blood-vessels from compression  of the capillaries  by the contrac-
 tion of the neAvly-formed connecth'e tissue, or from partial destruction or
 obliteration of vessels  during  the groAvth  of  tissues; the firmness of the
 uterine substance  is also increased, simulating the  hardness of cartilage and
 creaking under the knife.
     "The neAvly-formed tissue is chiefly composed of thin fibrils, deficient in
 nuclei, Avhich cross the  uterus in lines of various breadths in all  directions,
 forming a  complicated  felt-like net-work and constituting the greater sub-
 stance of the uterus.
     "In the first stages of the disease the muscular fibres are  broader and
hypertrophied, but at a later period may be completely lost  in the prolifera-
tion of connective tissue. 
270
     "The causes of this  diffuse  groAvth of the connective  tissue must be
sought for in habitual hyperemia, and I cannot concur in that  explanation
which interprets the process described as chronic  inflammation.  It is true
that inflammatory derangement of nutrition is often followed by proliferation
of connective tissue, but it is impossible to conclude that from the presence
of this formative  irritation derangements of nutrition are  produced, which
are essentially  of a destructive character.
     "Diffuse growth of connective tissue constitutes the so-called induration hither-
to considered  as a result of parenchymatous inflammation of the uterus.
     "Frequently this  proliferation of connective  tissue is developed after
repeated deliveries in rapid succession, Avithout any previous or existing in-
flammation.  It also occurs in many displacements of the uterus, especially
those in which A^enous  reflux is hindered  in consequence of  traction of the
uterine appendages.  When tumors exist,  especially fibrous, proliferation of
connective tissue almost ahvays coexists in the rest  of the uterus.
     "When the uterine cavity is distended by accumulated mucus or  men-
strual blood, this  proliferation generally exists in the form of eccentric hy-
pertrophy.   Finally it  is often combined Avith A^arious tractions to Avhich the
uterus is  subject, and  sometimes is deA^eloped  in consequence of the puer-
peral condition.
     "From  the description of this affection it is evident that the term  'infrac-
tus,' used by some gynsecolygists, is absolutely improper.  For reasons men-
tioned, I Avould also  advise the disuse of the term 'chronic inflammation.'
In most cases the  mucous membrane of the vagina participates in the  chronic
irritation,  Ave frequently finding it  in a state of epithelial desquamation, and
ev^eii of catarrh and blennorrhcea.   The peritoneal  covering of the uterus is
generally thickened and covered Avith various-shaped false membranes.  The
pampiniform and utero-vaginal plexuses are often in a varicose condition, and
this is not only caused by the contraction of the blood-vessels, but is also
frequently the  consequence  of the same  cause Avhich  produced the  diffuse
groAvth of the aboA^e tissue."
     While, doubtless, some good reasons may be interposed against the term
chronic inflamnudion, yet no other has been suggested Avhich expresses both the
pathological  condition and the morbid  action taking place  or  inciting to
change, so Avell as this term, in the sense  in Avhich it is  generally used by
English practitioners. 
271
     True,  hypertrophy does  often  result from  habitual hyperaunia, but
 so does chronic inflammation.   In one case which presented itself  at the
 dispensary since I began this report, and which is not included in the synopsis,
 there existed the greatest hypertrophy of the womb, I have ever Avitnessed,
 yet there Avas no history of either acute or chronic metritis.  (Aged twenty-
 seven; been married ten years; menstruation, since  marriage, painful and
 scanty, but for past tAvo  years entirely absent; uterine cavity measured
 four and a half inches; Avails very thick and hard,  the uterus feeling through
 the abdominal Avails about the size of a pregnant Avomb six months adA-anced,
 but much harder.)
     Here, then, aac haA'e a formative irritation resulting in the hypertrophy.
 AVhat Avill be discovered Avhen the uterus can be  examined after death it is
 impossible to tell, but it assumes the characteristics of a true  hypertrophy.
 This woman had never been pregnant, and she came  to  consult about the
 tumor, which had been increasing in size and hardness for several years.
     Whether this proliferation is muscular x>r confined to the cellular tissue
 is indeterminate at present;  but, from the cartilaginous hardness, I feel assured
 it is principally, if not entirely, of the latter.
     While, therefore, chronic  inflammation may not be a cause of hyper-
 trophy in some cases, yet it seems to be so in the larger number, for«generally
 it can be traced directly to  the causes  of inflammation; and the result-
 ant engorgement, induration, or hypertrophy are not foreign to its ordinary
 products.
     The relation of chronic metritis to malignant  disease of the uterus has
 been  traced by some observers so directly, that there Avould scarcely seem
 to be a doubt that the one  may sometimes excite or be transformed  into the
 other; certain it is, that most of the cases of cancer idcri Avhich have come to
 ni}' notice gaA^e history of pre-existing chronic  metritis, many  of them hav-
 ing had acute puerperal metritis or endometritis.
    Dr. E.  Noeggerath,  in a paper read before the Ncav York Academy of
 Medicine and published in  the American Journal of Obstetrics, Vol. ii, page
 505, demonstrates this relation by reciting five  cases  AA'here  epithelioma
 supervened  upon chronic  metritis.   Noticing the change which had taken
place  in the cervical portion since  an examination made six  Aveeks  before,
and Avhich induced him, Avith the assistance of Drs. Jacobi and Buck, to ex-
cise the neck, he found that  "the entire  thickness of the A'aginal neck had 
272
been transformed  in true epithelioma of the papillary or villous  A'ariety."
This patient, he tells us, died about six months after, of epileptic convulsions,
and the autopsy shoAved that the Avomb had "firmly healed over, and the
tissues above appeared to be quite normal, nor  was it possible to detect by
the microscope any traces of the former malignant disease.   There existed
however, an excess of newly-formed  connective tissue."  The second case
was similar  in its  history and nature, and, one year and eight months after
the operation,  was examined by Professor Veit, of Bonn, who found her con-
dition satisfactory.  The third case observed the same history, but was re-
lieved  by applications of the monochloracetic  acid applied  to  the seat of
disease.  The other two were  cured, apparently, by removal  of  the cervix.
All five cases are detailed in full, and  the writer closes his clear and succinct
article with these words:  "Diffused interstitial metritis has a tendency to be
transformed into cancroid or simple cauliflower excrescence."
     The case of Mrs. B., in Avhich I amputated  the entire neck of the Avomb
for a cervical metritis, complicated with an intractable ulceration of the
mucous surface of the cervix,  following laceration of the neck in labor and
puerperal metritis, presented an appearance which  I am sure might have in
time assumed the condition represented in  Dr. Noeggerath's cases.   The
microscopical  characters I quote here from my paper on amputation of the
cervix uteri, published in the National Medical Journal, vol. ii., page 399,
as it seems  to illustrate what might  be considered  an  intermediate  stage
betAveen chronic metritis and cauliflower excrescence.
     " I here insert a brief  of  the microscopic appearance of a duplicate of
the sections 4243 to 4248, to be seen in the Army Medical Museum,  made
from a portion of the amputated cervix by Dr. Schaeffer, under the direction
of Dr. WoodAvard.
     " The section is made longitudinally through the entire cervix and ante-
rior lip.  BcIoav (on the  instrument) is the external surface of  the cervix;
above, the internal mucous membrane.   The  line  made by the  knife  in
removing-the part  bounds the  section  posteriorly.  The principal alteration
of structure is a greatly increased development of the mucous glands around
the os, making the mucous  membrane send out a fungus-like growth imme-
diately within the  os.  The muscular fibres  deeper in, and the  connective
tissue surrounding them, also partake of the alteration  produced  by  con-
tinued  inflammation, but to a less extent. 
273
     " In the different parts of the field are seen numerous small blood-ves-
 sels, some cut longitudinally and others transversely.  The mucous glands,
 where cut across, show a convoluted appearance,  and the epithelium lining
 them has, in most instances, separated from the walls by contracting, and
 remains in most of the glands shoAvn, Avhile from others it has dropped out,
 leaA'ing an irregular hole in the section.
     " The specimen  has  been stained by carmine imbibition to sIioav the
 cell-nuclei in greater contrast.'1
     Diagnosis.—The affections and conditions of the uterus which should
 be carefully distinguished in making a diagnosis of chronic inflammation of
 the womb are  para  and  peri inflammation, fibrous  tumors,  polypi, carci-
 noma of its lower segment, and pregnancy.
     In both para and peri metritis, the fixation of the uterus, with hardness
 or induration of the fornix vaginae, will always solicit a very careful hiAesti-
 gation before the use of the sound is practiced.   The  presence of these con-
 ditions does not exclude the existence of chronic inflammation of the Avomb,
 but they should be discriminated before treatment is  attempted.
     Neoplasms of the uterus in their incipiency add  greatly to  the difficul-
 ties of diagnosis, and when menorrhagia or metrorrhagia exist vigilant search
 should be made for them.  The same may be said of uterine polypi.  When
 fibroids are sub-peritoneal, they can be recognized very early by the method
 of palpation already mentioned ; but Avhen intramural; their presence is not
 detected witliout  great care, and sometimes it is not  possible to be certain.
 Infra-uterine tumors, if of much size, not only dilate the cervical canal, but
 cause a shortening of the intra-A^aginal cervix, and we do not discover that
 hypertrophy and hardness of this portion of the uterus which are so constantly
 present in inflammatory engorgement.
     To  differentiate  between  cancerous induration  and that  of chronic
 inflammation is still more difficult, but the age and the cachectic  appearance
 of the  patient, together Avith the  extreme  hardness,  the  nodulated feel,
 the character of the ulceration if any has taken place, and, when possible, a
microscopical examination of some  of the ulcerated tissue, will assert the
probable nature of the disease.
     For the benefit of the readers of your report I beg leaAre to  insert here,
as I shall not adA-ert to cancerous diseases of the uterus at this time, a diag-
nostic  summary Avhich will be found in  By ford's " Medical  and Surgical
       35 
274
Diseases of Women," taken from Becquerel's " Traite* Clinique des Maladies
de I'Uterus."  It is the most concise and truthful that I can find anywhere.

 Caxcer ix the Scirrhous Condition.    Inflammation  with Ulceration.
Cervix bard, unequal, nodulated; os not
  always  open, sometimes  wrinkled  or
  furrowed.
Scirrhus of the neck often implicates the
  vagina.'

Hereditary influence is often traceable.
Touch is painless.
Discharge  sometimes absent,  in certain
  cases abundant, and consisting for the
  most part of  albuminous serum.
Menstruation  increased, being   neither
  more nor less painful, and passing often
  into the state of real hemorrhage.
Absence of special anemia when the vagi-
  na and body  of the uterus are involved.
  Cancerous cachexia.
Progress continuous and without cessa-
  tion.
The pain in cancer is Aery sharp, intense,
  and lancinating, and not influenced  by
  locomotion or moA*ements of  any kind.

           Ulcerated §tate.

Developed  at  the critical period  of life
  generally.
Preceded and  accompanied  by  hemor-
  rhages.
Severe, sharp, lancinating pain.
Development essentially in sharp irregula-
  rities and nodosities.
Adhesions  to other organs as  soon as ul-
  ceration  is formed; immobility  of the
  uterus.
The surface only  slightly soft; subjacent
  tissue scirrhous.
Ulceration  deep,  unequal, essentially  ir-
  regular, with  thick, elevated, and  hard
  edges.
Always granulations.

Discharges  extremely abundant, consist-
  ing of purulent  and often  sanguineous
  serum ; nauseous and often foetid odor.
Neck less hard, developed regularly in one
  of the lips;  os always open.

The induration of the neck never extends
  to the Aragina.   Mobility of uterus com-
  plete.
No hereditary influence.
Touch is painful.
Discharge constant and characterized by
  the presence  of   transparent  mucus,
  muco-pus, or purulent mucus.
Menstruation more painful, often retarded,
  almost always scanty.

Special anemia as above described.
Often stationary for a long-time.

Pain less severe, more dull, and perceptibly
  influenced by walking and other sorts of
  motion.

 Chronic Inflammation and Soften-
                 ing.

Occurs earlier in life almost always.

Not preceded by hemorrhages.

Pain dull and profound.
Enlargement regular and  rounded,  or
  regularly lobulated.
Complete  absence of adhesions  to other
  organs.   Entire mobility of the neck and
  body of the uterus.
Tissue of cervix not hard, and easily  de-
  stroyed.
When  ulceration exists,  less deep, with
  tumified edges.

Granulation often accompanies the other
  lesions.
Discharges  less abundant, consisting of
  muco-pus alone, or accompanied with a
  Little blood without odor. 
275
Great hemorrhage from time to time, not
  necessarily at menstrual period.

      Cancerous Ulceeatiox.

Developed  upon an  hypertrophed  and
  scirrhous surface.

Ulceration  deep, vast, unequal; grayish
  surface with thick  edges, and  easily
  bleeding.

Ulcerated surface hard, presenting numer-
  ous lobes and tubercles, with nodosities,
  and great hardness.
Often great loss of substance.

Cervix and corpus uteri immovable on
  account of adhesions.
Discharges  sanious, foetid,  sanguinolent,
  and of an insupportable and  character-
  istic odor.
Cancerous cachexia always present.
Always hemorrhage, but often a mere pro-
  longation of the menstrual discharge.

        Simple  Ulceration.

Ulceration often  on a healthy tissue or
  presenting the soft or hard varieties of
  inflammatory injection.
Ulceration more superficial, the edges less
  deA-eloped, and  more regular at the bot-
  tom ; not always easily made to bleed.

Nothing of the sort in chronic inflamma-
  tion and ulceration.

Ulceration is not always accompanied with
  loss of substance.
Neck and body always movable.

Discharge of muco-pus or purulent mucus,
  always less abundant.

Special anemia.
     The early period of pregnancy ma a~ generally be ascertained by the usual
 symptoms of this condition, but, if not Avell discovered, the condition of the
 cervix will ahvays discriminate,  as it Avill be  shortened and softened, instead
 of  enlarged  and indurated, and, Avhere  doubt  exists, time Avill confirm  an
 opinion.
     Treatment.—Each patient becomes a subject of special study, for not only
 are the circumstances and habits of each different,  but so also are their tem-
 peraments, constitutions, and predispositions, and to submit all, Avithout con-
 sidering these differences, to a pre-determined rule or system of invariable
 practice, is simply quackery.   NeAertheless there are indications which are
 receh'ed as pertaining to all more or less, but the Avays in which these should
 be  met must differ A'ery considerably.  It is this A'arietA' of means to  secure
 the same result that dhddes the profession upon a line of treatment to be fol-
 loAved.   There is a large class of  practitioners AA'ho rely entirely upon general
 medication, aa liile another class confide in a local therepeusis :  some are satis-
 fied AA'ith hygienic and dietetic advice, Avhile there are not wanting others who
 resort alone to mechanical appliances.  Happily, none of the great students
 of gynaecology of the present day adopt  or sanction any such  exclusive
mode of treatment.  As the pathology, as well as the physiology, relating to
the generative organs of the female has  become better understood, so also 
276
have the management and treatment of its diseases and conditions been made
to conform to rational and comprehensive systems.
     Such has been the endeavor of practice in this dispensary.   Carefully
studying each case, investigating each by every means Avhich modern science
and art have furnished, bound to no dogma of any special school, but receiv-
ing and accepting Avhatever accorded Avith our conceptions of truth, making
experience a test  and reason a judge, we have endeavored to select that treat-
ment which has been most successful in the hands of others or which seemed
to offer the best means of relief and cure.  In  no department of medicine
has the physician who is true to his trust more often  to encounter ignorant
and  mischievous  charlatanry, than in the practice of gynaecology.   The
whole army of pathics has reaped rich harvests of gold from this  class of
diseases, and, too  frequently, their subjects come to us for relief when we have
little to promise or to give.   Let us consider for a moment the indications to
be met in the treatment of  chronic metritis.
     Sometimes a sub-acute or temporarily acute inflammation exists at  the
time the patient comes under our direction, which has been excited by cold,
menstruation, or  some other cause.   Then there is the effusion of plastic ma-
terial Avhich has been organized in the tissues of the uterus, and often  also
there may be ulceration more or less extended of its intra-vaginal cervix.  But
in almost all cases of this disease there exist certain symptoms which demand
immediate relief,  and nothing will more encourage after-treatment  than to
give an earnest of what can be done by addressing remedies for their" ameli-
oration.   Nervous prostration, hyperesthesia, nervous excitability, dyspepsia,
constipation,  cephalalgia, &c, although  symptomatic  and the results of  the
uterine disease, yet often they are so prominent that in one sense they are
factors of the disease, and any mitigation of such symptoms will inspire con-
fidence in the place of despondency, and hope instead of despair.
     The treatment which was pursued in  the above-reported cases Avas  not
all that  could be  desired, as in some instances it Avas impossible to command
that rest  AAdiich Avas deemed necessary.   In most cases rest in bed is abso-
lutely a sine qua non if any success is to be expected in  the treatment of
chronic metritis.   The erect position always disposes to engorgement, and so
also does the sitting posture.  Any posture or position that may be assumed
is aggravated by  dress, as not only the Avhole weight of the various skirts is
borne upon the hips or around the Avaist, Avhen standing or walking, by a pres- 
                                   277

 sure sufficient at least to retain  them in situ, (and this pressure around the
 abdomen is just so much pressure directly down upon the pelvic viscera,) but
 this pressure is increased Avhen sitting, OAving  to the folds of the abdomen
 upon the waist-bands, or, if corsets are worn, the liver,  spleen, and stomach
 are all compressed, thereby opposing a direct barrier which retards or inter-
 rupts both the portal and A^ena cava circulations; and, in addition, the lower
 segment of the corset, being an elastic funnel-shaped article, exercises at once
 a compressive, cramming force upon the bowels, and of course upon the roof
 of the pelvis directly and of its floor indirectly.   It is unfortunate that  the
 female should be surrounded by such stays to  their full, free deA^elopment,
 and that such barriers should be drawn around them, crushing out health and
 happiness.  The whole  system of fashionable  dressing  in this  country is
 founded upon principles as false as are the tastes Avhich dictate and encourage
 it, and the more completely we can keep our patient beyond the influence of
 such a dangerous system, (which is far more pernicious in its ultimate results
 than the practice of compressing the feet by the Chinese,) the greater will be
 our success of treatment.
     In bed,  then, our patients escape such suicidal danger, and when exer-
 cise must come,  (for even rest in bed may be continued too long) suspenders
 should always be worn,  which will  carry the weight to the shoulders,  and
 then the abdominal and pelvic organs escape pressure.
     While all that is said above relating to dress applies to every ca.se, yet
 it Avould be detrimental to confine  every patient suffering with chronic  me-
 tritis to the bed.  There are times, however, in the progress of treatment
 when rest in bed is imperative.   During  monthly periods, Avhen  haemor-
 rhage exists,  while the dilation of the cervical canal by sponge-tents is beino-
 practiced, and when many other accidental conditions are present, it is clear
 that exertion would  aggravate the  disease or at least retard its  treatment.
 When exercise  is discovered to increase suffering and to  intensify distress
 (and I have found this usually to be the case,) it is best always to insist on
perfect rest, and  confinement to the bed is the only sure way of obtaining
it.   If the patient is allowed to  recline on a sofa, the injunction is too fre-
quently disobeyed, for any sudden desire to get up is gratified, and she flits
from room to room, often up and doAvn stairs, into parlor or kitchen,  and
returning to her couch imagines  she has taken no  exercise.   This is not so
apt to be the  case Avhen she is undressed and in  bed. 
27.S
    When the patient is married, sexual indulgence  must be  prohibited,
and for this reason our hospital-patients improve faster and more effectually
than those  in prh'ate life.
    The patient is easily convinced of this necessity of continence by the
acuteness of her sufferings Avhen it is disregarded, and will seek it by visit-
ing friends or watering-places, and almost inAariably finds some relief so long
as she remains away, but, often imagining herself cured, returns to her con-
jugal relations only to experience the same suffering and distress.   Widows,
Avho Avere invalids from chronic inflammation of the  Avomb during their wed-
ded life, often exhibit a  marked improvement of their general  health, with
almost entire  relief of their previously painful symptoms, for  the same
reason.  They are not cured hoAvever, for a subsequent marriage often dis-
pels such a delusion.
     The diet  should be regulated according to many circumstances  which
Avill surround  the patient, but, in the main, it should be simple, plain, and nu-
tritious.  Sometimes stimulants Avill be necessary, but generally Ave  cannot
be too particular to banish them entirely.  In  moments of nervous  prostra-
tion or melancholia, they will be pleaded for, both by the patient and her
friends ;  but,  aside from the risk of incurring  intemperance, (and there is a
great  tendency in this  direction by such sufferers,) their benefits are only
temporary, and the patient is usually worse  after than before their use.
     Fresh, cool air is an hiA'aluable auxiliary to treatment in this connection.
Because the patient is in bed does not preclude an abundance of  fresh air.
The tonic  effect of this vivifying agent  on  the respiratory function, and,
indirectly,  upon  the Avhole nervous system,  is wonderful, and should  be
furnished,  or alloAved rather, without stint.  The shutting out of fresh  air
and sun-light is one reason Avhy confinement to bed  is so pernicious to many
invalids.   The body can ahvays be protected,  and there should be no excuse
tolerated for their exclusion, and I am convinced if all of us Avould person-
ally examine  into the hygienic and sanitary surroundings of our hospital-
Avards and private sick-rooms,  Ave Avould not  find their sick occupants and
attendants so  enervated and blighted.
     The medicines Avhich have usually been  advocated in the treatment of
this disease, I have often considered of doubtful  benefit, so far as promoting
resorption  of effused material is concerned;  yet  if there are any Avhich have
seemed to  do  good, they are  the  iodide of potassium and the bichloride of 
279
 mercury.  In a few cases, Avhere no anemia existed, I think  they haAe
 assisted this process.   I have  given sometimes one, sometimes the other, or
 both combined, administering, according to circumstances, from five to ten
 grains of the former and from one-twelfth to one-tAventieth of a grain of the
 latter,  three times a day, in some of the tinctures, as there might seem to be
 indications.
     Anemia,  dyspepsia,  constipation, and other  conditions were  treated
 Avith appropriate remedies.  When anemia with constipation  existed, I have
 generally obtained the most satisfactory results from combining iron, qui-
 nia, and nux-vomica  with  small  quantities  df colocynth and rhubarb or
 blue-pill.   For instance, I have  sometimes directed the folloAving :
                        R  Quinise sulphatis, 3i.
                           Ferri sulphatis, grs. ii
                           Ext.  coloc. co., grs. x.
                           Ext. nucis vom., ) —
                           Mass. hydrarg., / a a grs' v'
                           M. ft. pil. No. x.
       Sig. One morning and night until the bowels move every day,
       then one  each morning, or one  eA^ery other day  p. r. n.
 These  ingredients being changed  and the latter omitted usually altogether
 as appeared best.
     The bromide  of  potassium often proved a valuable agent to  check
 reflex phenomena, or quiet nervous excitability.  When suffering is extreme,
 the hypodermic injection of a solution of morphia and atropia combined was
 used, or, when accompanied by  much rectal or vaginal tenesmus,  supposito-
 ries of the  extracts of opium and belladonna were resorted to.
     One of  the most useful  remedies Avhich I have tried when dyspepsia
 existed with painful distension of the stomach and  intestines Avith gas, was
 the  hyposulphite of soda, ten grains, dissolved in a little plain water, after
 each meal, and repeated if  necessary.  But this is  only palliative, and Ave
 can obtain  its cure only by  removing the  disease of the Avomb (whose con-
 nection and sympatby with the stomach is so intimate) by regulating the
 diet, and by procuring fresh air  and exercise.
     It is surprising, sometimes,  to  find how much  this disease is benefited
 by  a change of air, scene,  climate,  and Avater.  Without exception, Avhat-
 ever improves the nutrition exercises  a  favorable  influence  upon  chronic
 engorgement, and  this fact  should induce us to build up our  patients to as
near a  condition of good health as possible.   No general depletion is ever 
280
called for, and, in the use of alteratives, this danger attends, unless great dis-
cretion is exercised.
     The medicinal qualities of the A'-arious mineral springs of our country,
so rich in tonics and alteratives, and their beneficial influence in this disease,
cannot for a moment be questioned.   One  of the above-reported cases  of
chronic metritis Avhich  had been under treatment in the  hospital  for  six
months with most  decided  benefit, visited the Iodine Springs of Virginia,
and came back four months afterward, more nearly cured  than any case I
have ever  attended.  I have frequently seen patients, after a return from
the sea-side, much invigorated and strengthened, and in reality much better,
so far as this disease was  concerned.   There are iodine-springs in all parts
of our country, and I am sure, if after a course of judicious treatment these
Avere sought and the waters used perseveringly, we would not so often wit-
ness a relapse.  When the chalybeates can  also be obtained, either with
the  iodine-water or subsequently,  the best results may be expected.
    .No  system of general treatment was alone of any great benefit to the
local disease in question among the  dispensary-patients.  . By attention, how-
eA-er, to  the  general health, the use  of every means that would promote
digestion, assimilation, and  nutrition, and by keeping the various secretory
functions of the body actively employed, the patient  was placed  under
favorable conditions Avhich indirectly assisted local treatment.
     When any signs of acute or subacute inflammation existed, the  appli-
cation of leeches at two or three different times, allowing a few days to inter-
vene between  each bleeding, using  the hot-water injections morning and
evening, and keeping the patient in bed all the time, soon relieved the active
symptoms.  Long-continued irrigation of the vagina and cervix with water
as hot as could be borne produced a  very sedative effect—and, in hospital-
practice, this could easily be accomplished by a skillful nurse without much
disturbance to the patient—and the effect was very  decided.  This cannot
ahvays be practiced satisfactorily in private families, unless good, intelligent
nursing can be procured, for, if badly employed, it often annoys the patient,
and then harm, rather than good, sometimes results.
     This syringing or irrigation should be continued at least fifteen or twenty
minutes each time, for, if hot water is used but a few moments, the first stimu-
lating action  of heat is produced, to be succeeded by congestion;  but, when
continued, it relieves the parts, and sedation follows. 
281
    This effect of the  hot vaginal irrigation has been well advocated and
attested by Dr. Emmett, of New York City, in  an article published some
time since.
    Just as soon as the active symptoms disappeared, the cervical canal was
dilated by means of sponge or laminaria tents.  The result of this dilatation
Avas tAvofold:  it not only opened the Avay to intra-uterine medication, but it
excited an action in the uterine walls which often exercised a favorable im-
press upon the effused morbid material.  I know of nothing that reduces the
hardness of the tissues of the uterus so quickly as the sponge-tents, and, AA'hen
they are repeated of graduated sizes, commencing Avith the smallest that could
be retained in the uterine  cavity, and the dilatation continued until the finger
could be introduced with ease, I have invariably found that many character-
istics of chronic engorgement had disappeared, (especially the cartilaginous
hardness,)  and left the  organ in the best possible condition to receive topical
medication.
    My preference has always been in favor of the sponge over the laminaria.
Not only do the small tubules of the sponge ramify into the sinuosities of the
mucous membrane, but imbibe from and deplete, as it were, the small mucous
capillaries, besides being so much softer than the laminaria.  After removal
of the  laminaria tent, it is found to be a hard, irregular  mass, Avhich would
seem to be a most dangerous article  to place within the uterus, but 1 have
never observed any bad effects from its use.  Almost always its shape is pris-
moid, and its edges are sharp and sometimes serrated or notched.   As a di-
later I think it much inferior to the sponge, but  often it  may be  used with
greater facility, and does not become so offensive, which greatly  enhances its
value.  This last fault of the sponge was to a large extent corrected by car-
bolizing the sponge, as directed by Dr. Robert Ellis, American Journal Medical
Sciences, vol. xlv, page 276.   Shreds  of  cotton-Avick steeped in carbolic acid
are drawn through the  longitudinal center of the sponge, which is then rolled
or pressed into shape and covered with cocoa-butter, to which a certain quan-
tity of glacial carbolic acid had been added.   "The disinfectant properties of
this agent completely protect the tents, and they are withdrawn in an inodor-
ous state, even after a  stay of tAvelve or eighteen hours in the cervical canal."
A good extemporaneous way of making sponge-tents is recommended by Dr.
Hough.  The sponge is wrung as dry as it can be with the hand, and then
molded by pressing it into a quill or any tube.  It is then immersed in strong
     3G 
282
alcohol, which immediately "sets" the sponge, and it preserves this form
(which may be trimmed to any shape,) until moisture is applied, Avhen it dis-
tends to its former shape and size.
     In treating the cases of chronic metritis, the tents were sometimes made
of sponge cut into pieces of various  sizes and lengths, which, after being
soaked in mucilage containing more than the officinal quantity of acacia, to
which had been added carbolic acid, (f3ss  to f?i,) were then tightly wrapped
over an awl or catheter-canula Avith strong tAvine.  These Avere not unwrapped
until wanted for use.   Before passing the  tent into the uterine canal, it was
dipped into a mixture of glycerine and carbolic acid of variable strength, to
suit the indication.  I never use any instrument for introducing the tent but
the ordinary small uterine forceps, the cervix being exposed by means of
Sims' speculum.  By the forceps the tent can  be made to change its direc-
tion so as to  pass a point of flexion or to follow  the course of the uterine canal
in versions.   I regard the carbolic acid and glycerine as not only ridding the
sponge-tent of its most objectionable feature, but  they exercise a most salu-
tary effect upon the disease as therapeutic agents.  The tents usually remained
twenty-four hours, one being introduced upon  the removal of the other, and,
after the introduction of each, a pledget of cotton-Avool, saturated with glyce-
rine, Avas placed against the cervix.  This not only kept the tent in situ, but
the glycerine purifies the discharges and depletes the capillaries of the cervix
and of the vagina. The use of this glycerine (or glycerine and carbolic acid)
tampon Avas almost invariable after topical applications, and a string having
been attached to the cotton before its introduction, the patient could easily
AvithdraAV it.   Its benefits have been well  taught by Dr. Sims.
     Treating ulcers, tumors, &c,  by compression of sponge externally, has
been fully set forth by Drs. Batchelder and Roberts, of New York, as well as
its utility in healing old sinuses, fistulas, and abscesses, when  its action was
applied within the cavity of  the sinus.  This  same efficacy of use has been
verified upon the diseased conditions of the uterus.   The granular erosions
of the mucous membrane are cured almost immediately, and the parenchy-
matous hardening and plastic effusion are greatly modified.  Where ulceration
exists, either in the cervix or body, the sponge-tent is inA'aluable.
     Only once have I ever knoAvn the use of  the tent to be followed by any
deleterious result,  It happened in the  case of a dispensary-patient suffering
profuse metrorrhagia, and she Avas admitted to the hospital for the purpose of 
283
 dilating the cervix, so  that the cause of haemorrhage could be ascertained.
 The report of this case was read before the Clinico-Pathological Society of
 this city, and was published in the National Medical Journal, vol. ii,  page
 307.   That it maybe properly estimated, I quote from that report:
     "On September 5, (seven days after the use of the tents,) she was seized
 with violent pains in the lumbar region of the spine, which soon extended to
 the cervical portion.  She Avas not seen by any physician until the 9th, Avhen
 Dr. Ritchie Avas called, who immediately sent her again into the hospital.
     "When she entered, she complained of much pain in the umbilical region
 and of oppression around the lower part of  the chest.   The muscles of the
 neck Avere  rigid,  jaws stiff,  and  fades tetanica Avell marked.  Her symp-
 toms increased, both in extent and  severity; muscles of the abdomen became
 rigid as Avell as those of the back and anus.  After a few days the loAver ex-
 tremities became involved, causing great pain around the pubes at the origin
 of the adductor-muscles of the thigh.
     "The advance of the disease Avas gradual, positive, and sure.   It seemed
 as if this power for the production of tonic, unyielding rigidity was gener-
 ated in muscle after muscle—tightening e\Tery sinew, straining every tendon,
 and compacting ever}' fibre until her death on the 15th—ten days  after the
 first symptoms, and seA'enteen  days after the use of the tent."*
     This case  of tetanus, like many others, arose from  doubtful causes—
 whether from the deep ulcerations of the uterine parenchyma, as discovered
 after death, or from the irritation of the sponge-tents.  In none of the cases
 in Avhich it has been used, either by myself or under my observation, haAe I
 Avitnessed septicannia or  cellulitis, as has happened in  the  experience of
 others.   After the uterine canal had  been Avell dilated, sometimes the cases
 were treated by uterine injections, sometimes by applications  made  directly
 to the whole uterine cavity by means of the sponge or cotton probang.
     Three  cases of chronic metritis Avere treated by means  of uterine in-
jections or irrigations.  The first important consideration was to keep the
 cervix Avell dilated, so  that the  injected fluid could have an easy escape.
 The mildness of the fluid  Avill avail but little  to avert those  distressing
 attacks  of uterine colic which  I have sometimes observed.  It has seemed
 strange that an injection of warm  water could produce so much prostration
  * See a similar result after use of sponge-tent, by Dr. J. H. Thompson, at page 102 of
 this report: also, a case of fatal metro-peritonitis, from the same cause, ar page  0G. 
284
and, for a time, dangerous  collapse, as  occurred in the history of one of
these cases.  I  had directed the patient to use the vaginal syringe  each
morning, but the first time  she  attempted it she  evidently introduced the
nozzle into the os uteri, Avhich was open, and the result Avas almost disas-
trous.  The nervous shock  was  alarming, and perimetritis  resulted.  No
dilMation had been previously attempted in her case.
     It has  been the practice to commence the  introduction  of the  tents
three days after  the catamenia ceased,  and to persevere in  their use until
the index-finger could be passed  into the cavity, Avhich generally occupied
from four to six days.  Each day, after the dilatation had been  completed, the
uterine cavity Avas syringed Avith Avarm water by means  of a Davidson's
syringe, attached to an ordinary gum  male catheter, or the  long curved
canulaof the " Universal syringe."  This washed aAvay all the secretion and
left the surface clean for the action of the  tincture of iodine, either strong
or diluted, the strong (Churchill's) usually being injected through the canula
of Dr. Nott, (American Journal of Obstetrics, vol. ii, page 491.)   It Avould be
best, probably, to use Dr. Nott's or some similarly constructed  canula* for all
uterine injections, for sometimes,  even Avhen the cervical canal is dilated, any
irritant that Avould contract the uterus might prevent the exit  of the injected
fluid, and serious consequences would result.   It is not necessary that the
force of the injection should be small to aA^ert the danger to be apprehended—
that a part  of the  injection may pass into the peritoneal cavity or into the
uterine veins—for if the cavity contains fluid and its Avails contract, unless
some means of ready escape be provided, the whole force of the uterine con-
traction is upon the pent-up fluid, which seeks an opening anywhere; and
if the os, either external or  internal, has grasped the catheter, the contained
fluid will almost certainly pass into the ovdducts—perhaps into the uterine
Aeins.
     Vidal de Cassis, in 1840, published an essay setting forth  some experi-
ments upon the dead body with a view to test the aptitude of uterine injec-
tions to enter the peritoneal cavity.   He found that, when  the  nozzle of the
syringe  was  fastened within the  neck of  the uterus, forcible injection
caused the fluid to  enter the uterine veins and pass into the Fallopian tubes.
    *I have often preserved a ready escape for the iujected fluid by passing two gum-
catheters into the uterine cavity; the fluid entered through one attached to the nozzle
of the syriuge and flowed out through the fenestra of the other. 
285
When large injections Avere  used Avith moderate force,  the  fluid passed
tluough the oviducts in two instances, in six it entered the uterine blood-ves-
sels.  He practiced uterine injections to a considerable extent, and preferred
the solution of nitrate of  silver to iodine, recommending, however, that the
uterine cavity be deterged by warm water before  the  caustic solution  is
used.  Velpeau recommends uterine injections  as practiced by Vidal, being
assured that the injected fluid will not pass into the peritoneal cavity.  In Ger-
many, (American Journal of Obstetrics, vol. i, page 389,) says Dr. Kammerer,
experimental injections on the dead body were resumed in 1862 by C. Hen-
nig.  These experiments gave the folioAving results:  that under a gradually
increased pressure from injections made with a common uterine syringe, the
canula being hermetically ligated to the cervix uteri, not a drop of the in-
jected fluid penetrated  either of the oviducts, the orifices of the latter only
being filled to  about three millimeters.
     Klenn (same writer) found that the injected fluid, whenever the os Avas
not ligated, always returned  through it  and never penetrated the oviducts,
whether they were  injected  from  a column of water five feet high  or by
means of a small syringe.   Whenever the fluid penetrated the oviducts
after ligation of the os, the fluid  advanced  slowly, an observation which is
contrary to the assertion that the pains immediately follow the injections.
In three cases  out of eighteen,blue ink, injected through  a narrow os with
moderate force, penetrated the venous system of the uterus and broad liga-
ments Avithout  apparent laceration.  To the latter circumstance is attributed
the sudden appearance of metriti^and  peritonitis after  injections.  In the
American Journal of Obstetrics,  vol. i,  page 377, is a "Historical Review
of Uterine Injections," by Dr. Joseph  Kammerer, of New York, which  is
replete with, interest to any who wish to examine the views and treatment
of many celebrated practitioners.  I  cannot,  however, help  questioning
whether, in attributing to Hippocrates and other  ancients, acquaintance
with infra-uterine injections, he does not follow his classical translation too
literally, for it  is well  understood that Hippocrates, and many writers  of
more recent date, speak of vaginal injections  as uterine,  which, to the an-
cients, Avas a comprehensive term, and not limited as at present.
     The iodine Avas selected because it Avas thought to possess some  quali-
ties which do not belong  to  any of the other medicines  commonly used as
injections into the uterine cavity.   The  nitrate  of silver was tried, but it ex- 
286
 erted no influence beyond the mucous membrane, while iodine undoubtedly
 penetrates Avith its alterative influence into the parenchyma of the organ.
     Dr. Nott has shown hoAv little the  albuminous secretions are affected
 by the tincture of iodine, and that in its use we need not fear the formation
 of coagula, which close up the fenestra of the canula, or that it will combine
 Avith these secretions and be neutralized thereby, as is  the case with many
 other agents.   The strong  (Churcliiirs) tincture was injected at intervals of
 fh'e days, the uterus being syringed daily with warm water, to which Lugol's
 solution (one part to eight) had been added.   About one  pint of this mix-
 ture was passed through the uterus, and after each  syringing a pledget of
 cotton, soaked in glycerine, Avas placed, so as to correct any Aversion or flexion
 that existed.  If retroversion or retroflexion  was present, by pressing the
 tampon up in the posterior cul-de-sac, great comfort resulted.  The same good
 effect was  not so marked when the malposition was  anterior, as the cotton
 could not be so AATell retained; still it Avas far better than a pessary.
     Two or three times a week the upper portion of the vagina and infra-
 vaginal cervix Avas painted with Churchill's tincture.
     Tavo of the  three cases  so treated Avere greatly improved ; one so much
 so that pregnancy resulted tAvo  months after her discharge, although she
 had been sterile for  eight years.  When this last Avas admitted to treatment
 the uterus measured, by the sound,  three and three-fourths inches;  was re-
 tro verted; enlarged; tender to pressure; cervix eroded and indurated; muco-
 purulent, sometimes  sanious uterine discharge;  Avith pain in back, thio-hs,
 and hypogastrium;  A-esical, uterine, and%ectal tenesmus,  and vertex  head-
 ache.  She remained under treatment six months.  All  local treatment was
 omitted three days before the menstrual period and  resumed three or four
 days after.   When dismissed she did not suffer from any of her former symp-
 toms.  The uterus measured three inches, was  much  reduced in size, still
 somewhat retroverted, but considerably less so than it had been; no uterine
 discharge, and menstruation was Avithout pain.  The other Avas about similar
in character and results, except as to pregnancy, as she is still a widow.
     The third case  so treated was benefited  so  long as the treatment con-
tinued, but relapsed  upon  its cessation.   Twice have I undertaken it, but
without any  satisfactory results.  The patient is a virgin  and the corpus
uteri is chiefly affected.   The unsatisfactory treatment of this third case led
me to omit the uterine injections and instead  to use topical applications, by 
287
means of a small sponge-probang, Avhen the cervical canal was well dilated,
or Avhen this Avas partly closed, by the sound wrapped with cotton-avooI, and
I feel assured that this method of infra-uterine medication is much the safer.
     From quite a frequent use of both methods of  Application, I think  that
in hospital-practice the uterine injections haA'e a better effect, but the most
diligent  care  should  be exercised to avoid risk.   In treating affections so'
chronic and indestructible of themselves, the physician has no right to ex-
pose his  patient to danger, and the evidence of  occasional harm or peril is
quite sufficient to enforce discretion.   All the rest of the cases Avere treated
locally by the medicines upon the uterine sound, armed as aboAe stated, or
upon the probang.  When the latter was used (which was  immediately after
dilatation) the sponge Avas pressed so as to squeeze out any excess of fluid,  that
it might  not run over  the vagina, for the uterus will invariably contract upon
the sponge and then the fluid is forced out.  A little practice soon determined
the amount of saturation necessary.  I haAe  seen several  cases of acute
Araginitis Avhen chromic or carbolic acid had been used, either upon the pro-
bang, the covered sound, or the applicator, by inattention to  this caution
     In the management of those cases where fibroids existed, the use of the
sponge-tent  was usually omitted.   I have been able to accomplish little more
than to modify the condition of the mucous membrane of the uterus and di-
minish the tendency to haemorrhage; all intra-uterine applications generally
did more harm than good.   The  engorged veins on the cervix were some-
times punctured, or a few leeches applied when menorrhagia threatened,  and
a  comparatively slight depletion  of  the turgid vessels in this way often
averted a much more profuse and intractable flooding.  The leech-bite or
the puncture can easily be reached if the bleeding becomes profuse.
     Leaving  out  the six cases of chronic  metritis with  fibroids; the  two
folloAving acute metritis, already detailed,  and the two others,  Avhich sub-
mitted to treatment for too short a  time  to derive much benefit:  all the
others, seventeen, Avere very much relieved.   Three of these seventeen have
since borne  children,  while before treatment they had been  sterile, one for
three, one for fh'e, and the other for ten  years.
    When the cervix Avas  very much involved, the potassa  cum  calce  was
used,  as  recommended by Dr. Hughes Bennett, and its application  has in
each case verified his  experience.   Where the cervix only is the part affected
and these means fail,  amputation, as practiced  in the case already referred 
288
to, offers a dernier resort.   I cannot represent that any of them were abso-
lutely cured, that is, that the uterus resumed its natural conditions, but  in
several, and especially where the morbid action was confined to the  cervix,
the functions of the organ were to all appearances quite restored.  Menstrua-
tion has  been regular, the leucorrhoea absent, and fecundity exhibited.   In
most instances the patients have been discharged, suffering little, if any, Avith
the distressing symptoms present in the beginning, but in some, success was
only partial.  Still the results, in the main, seem to encourage perseverance.
The candor of such men as Scanzoni and Thomas is as commendable as it is
consoling to other practitioners.  "In treating this disease with all the neces-
sary perseverance and foresight, we shall at least obtain a sensible ameliora-
tion in the state of our patients, if Ave do not succeed in obtaining for them a
complete and durable cure.   When Ave  have only obtained an amelioration
and entertain but little hope of cure, we should still  endeavor to moderate
such painful symptoms as may prove obstinate, by means of a well-directed
symptomatic treatment."
                            ARTICLE  III.
                              ENDOMETRITIS.

     One hundred and seventy-eight cases of endometritis have been treated
at my dispensary service, and in one hundred and twenty the disease has been
limited to the cervical portion.   Considering the frequency of this  disease,
its prevalence among all classes  and conditions of females, and  its great
number  of causative influences, both  direct and indirect, it is of prime im-
portance that the anatomical  as well as the pathological characteristics of
the tissues involved should be well understood.  At the risk, therefore, of
being tedious, I Avould invite attention to a few practical  considerations re-
lating to the construction of the mucous membrane of the uterus, embracing
not only its lining membrane,  but  also that which covers the vaginal cervix.
     BetAveen the mucous membrane covering the external or vaginal cervix,
that lining the cervical canal and  that lining the uterine or corporeal cavity,
a dh'ision is made which is  not altogether  arbitrary, but one that is almost
necessitated  by  differences  of minute anatomical structure, by variety of
secretion, and by diversity of pathological changes.  The mucous membrane
covering the Aaginal portion of the cervix—that is, all  that portion embraced
betAveen the insertion of the vagina and the os tincse—is smooth and firm and 
281)
 coA'ered, like the vagina, A'eiw abundantly with paA'ement or tesselated epi-
 thelium.  The abundance of this epithelium-covering fills the interstices  be-
 tween the  projecting villi beneath, and when  it is remoA^ed these are dis-
 covered to be very numerous and prominent, and  after disease has despoiled
 this portion of the uterus of its epithelial  membrane, these villi  or papillae
 gh'e to the cervix that granular appearance so generally knoAvn as "granular
 erosion."   In Fig. 2, plate 12, of this report, taken from Dr. Tyler Smith's
 work on leucorrhoea,  this prominence of the villi is well sIioavii, but the same
 is often observed by  the naked eye, and the papillae  look like little grains,
 sometimes larger than at others.
     These  villi are very Avascular, their  extremities  containing a loop  of
 vessels, Avhich, AA'hen  denuded of epithelium, bleed upon the slightest touch,
 and Avhen hypertrophied and denuded, they appear so fungous as sometimes
 to be considered malignant.   Dr. Tyler  Smith contends  that there are no
 mucous follicles in the external ceiwical mucous membrane, but others luive
 seen  them,  and (if  I can  determine a mucous  follicle)  I  think I have
 obseiwed  them.  Tyler Smith himself does not  appear to be sure, for he
 says :  " That the appearances Avhich might be  mistaken for  mucous follicles
 seem in fact to be nothing else than the Ailli more or  less obscured by their
 epithelial covering."  The secretion from this portion of  mucous  membrane
 is acid and quite tenacious,  and,  AA'hen the mucous follicles or crypts (from
 some cause)  become closed, Ave  haA'e them distended Avith mucus, and in
 this state the}' haA'e  been called Nabothean ovules.   This constitutes the
 follicular inflammation of some authors.
     Within the cervical  canal Ave find the mucous membrane more vascular;
 its villi considerably larger ;  its mucous follicles infinitely more numerous;
 its rugae prominent and extensive ;  its epithelium of the cylindrical varietA^,
 and its secretion alkaline.  Within the  os uteri  is generally seen a short
 circumference of mucous membrane, which, while it  does  not differ in its
ultimate constitution  from the rugose and fossated membrane above and
lining the cervical canal, yet is not so rich in  mucous follicles as the rugae
of the arbor vitae.
     The arrangement of the rugous folds and fossa'  is not regular or uni-
form.  Sometimes they can be seen at the os uteri externus and the smoother
space above mentioned is absent.   Even in the  virgin  cervix 1 have failed to
observe any very uniform disposition of the rugae.
         .-> — 
290
     Often only one  well-marked longitudinal  fold is discerned,  and the
transverse  eleA-ations  and depressions stretch upward and outward at quite
an  acute  angle, Avliile  in others the direction  of these is  at almost right
angles.  Again, in one specimen before me, the  Avhole inner cervix presents
a reticulated  appearance, the  depressions  being deep, especially on the
posterior Avail.
     Says Dr. Tyler Smith:  "When the cavity of the cervix belonging to a
virgin uterus is laid open  by a longitudinal incision, so as to expose the
Avhole of the cervical  canal, the internal surface is generally found to con-
tain four columns of  rugae or folds  of  mucous membrane, the rugae being
arranged  in  an oblique,  curved, or transverse  direction.   BetAveen these
columns of rugae, four longitudinal  grooves or ridges are usually seen.   In
some specimens grooves, in others ridges, are present.  Of these, the tAvo
grooves or ridges in the median line, anteriorly and  posteriorly, are most
distinct.   The other longitudinal markings  are  situated, one  on each side,
between the anterior  and posterior  lips of the os uteri.  The  canal of the
uterus is flattened in shape,  and tAvo of the rugous columns are arranged on
the anterior lip, and the other tAvo upon the posterior lip ; the posterior half
of the cervix being the larger of  the two  and containing the greater num-
ber of rugae.  The  sulcus or division between the posterior rugous columns
is also generally more strongly marked than the sulcus dividing the anterior
rugous columns.  The rugae of each column, as  seen by the eye alone, vary
from about ten to fifteen in number.  In the intervals betAveen the columns,
numerous  small longitudinal folds may be seen; but these are less  distinct
than the transverse rugae.  In the healthy state, the transverse rugae, with the
fossae betAveen them, are covered with a viscid and transparent mucus;  and
when this is brushed away a reticulated appearance, caused by numbers of
secondary rugae, is  visible in the mucous membrane  beneath.   The second-
ary rugae run in various directions Avithout much regularity.  In some parts
of the fossae the mucous  crypts are deeper than usual, and here  and there
minute openings are  seen at the bottom of the pits, into Avhich fine bristles
may be passed to the distance of the  twelfth of an inch or more.   Besides
the four rugous columns and the furrows betAveen them, Avhich are found in
the Avell-deA^eloped  cervix, other rugae of irregular shape are seen, particu-
larly at the upper and loAver portions of the cervix, Avhere the regular, trans-
verse, or oblique rugae  become indistinct.   The cervical rugae have been 
291
compared to a tree, a feather, or a fern-leaf; but AA'hen the whole cervix
belonging to the  uterus which has never been impregnated is displayed, it
is not unlike an open book in miniature, printed in double columns."   (See
Fig. 10, page 34, Tyler Smith.)
     In the infant or child,  where Ave find the development of the cervix so
much  in adA^ance of the corpus uteri, the arbor vitae is  exceedingly well
marked.   Often it will be found that these  rugae or folds do not assume the
arborescent appearance.
     After  pregnancy,  these rugae  are  to  a certain  extent obliterated or
blurred from the distension  to Avhich, like those of the vagina, they haA^e
been subjected; yet some are ahvays present, and the glandular structure
still remains, saAe such follicles as may haA'e suffered irreparable injur}'.
This rugous arrangement not only furnishes a larger glandular surface, but
meets a demand of parturition Avhich preserves the integrity of  the  mucous
membrane.   When a section of  the virgin cervix is submitted to the micro-
scope,  we then become aware of the complicated arrangement and immense
glandular apparatus of its mucous membrane, so  long hidden from VieAv.
By a glance at Fig. 2,  plate 14,  some idea  can be gained of its intricacy.
     This  represents only  one  longitudinal  column, and he  states  that,
" Besides the primary rugae,  each fossa is seen to be subdivided by smaller
rugae, from which curved septa, still more minute, take their origin, dividing
the principal fossae into a great number of crypts, arranged like a piece of
fine net-work.  In each of the fossae betAveen the primary rugae, as many as
from forty to fifty crypts or  laminae may be  seen.   A cervix  of moderate
size would sIioav  between the transverse rugae of  the  four columns alone,
with this low magnifying power, from tAvo to  three thousand follicular pits."
     If the lens-poAver be increased, a vastly increased number of  mucous
follicles become visible, so that Dr. Smith has made an enumeration  "which
gh'es, as a moderate estimate, ten thousand mucous follicles to the membrane
lining the cervical canal.   If one of the longitudinal  columns be divided in
its long diameter, the cut section shows the depressions of the fossae  extend-
ing  obliquely to a considerable depth,  and occasionally mucous openings
pass into the center of the  Avails of the cervix, and may be seen filled Avith
the  tenacious  mucous proper   to  the  ceiwical  canal."   (See  Fig. 1,
plate 15.
     The mucous membrane  lining  the  cervical canal is studded Avith A-illi, 
292
in common Avith the os and external cervix and vagina, and the  sensibility
of these has been much discussed.  Dr.  F. Kilian  considered them as sen-
sitive in function, or rather as organs of sensibility, and consequently con-
cluded that nervous filaments Avere also present, but he could not demon-
strate them with the microscope.  The apparent ordinary insensibility of the
os and cervix he accounts for by considering them as sensitive to pleasurable
but not to painful impressions   M. Jobert  accounted for this obtuseness to
pain in the ceiwix, except at its upper  part, on the principle that  the nerves
which supplied the upper part passed  from this to the vagina Avithout dis-
tributing filaments to the. rest of the cervix uteri.
     While,  however, the lower or vaginal  portion of the cervix uteri is not
ordinarily sensitive to  pain, yet, in some  diseased conditions,  it  becomes
exceedingly sensith-e, and, judging from the sympathetic nervous phenom-
ena Avhich so frequently attend its diseased condition, it would seem to enter
into that general  system  of  neiwous relation which connects  the uterus
through the renal and hypogastric plexuses, Avith the cerebro-spinal and gang-
lionic centers.  Generally speaking, says Chrobak, (Strieker,) " The neck is
said to contain more nerves than the body ;  nervous filaments may be traced
quite up to  the mucous tissue, (Kilian;) on the other hand, the mucous
membrane  of the  fundus is said to be more  sensitive than any other part,
(LazareAvitsch et at.)
     There are some Avho claim to demonstrate neiwe-filaments in the papil-
lae of the cervix, (Kilian, Hjalmar ;) yet the real character of  these so-called
nerve-fibres  remains in doubt.
     BetAveen the mucous membrane lining the cervix and that  lining the
corpus uteri there  is a marked difference, and the line  of  demarcation is
well defined.  That of the  neck is "tough, firmer, more transparent," and is
more than tAvice as thick.   An inA^estment of connective tissue extends over
the orificium internum quite into the  corpus.   It lies between the mucous
and  muscular layers, and  is especially well marked on the posterior Avail,
(Rokitansky.)
     The folloAving is the most concise histological description of the mucous
membrane of the uterus that I have been able to find, by Chrobak:*  " In
the virgin state it is from 1 to 1.8 millimeters in thickness, gray or pink, and
becomes gradually thinner as it approaches the cervix and orifices of the ovi-
* Strieker, A Manual of Histology, page 608. 
293
 ducts; * no well-defined line of demarkation separates it from the underlying
 or muscular coat, and in fact it can only be isolated in small fragments.  The
 surface is smooth, excepting only about the orifices of the tubes, where it pre-
 sents very slight foldings,  but no  papillae." f
     "Again, it is covered in health Avith a thin layer of a more or less gray,
 translucent, and somewhat glutinous fluid, of slightly alkaline reaction ;  this
 contains in various and slight proportions cylindrical cells, little, roundish,
 granular cells, secretions from the uterine glands, occasional cilia, and very
 seldom intact ciliated cells, (in old people, Ave find, too,  cholesterine, monads,
 algae,  free  fat, &c.  (Donne, Taylor, Smith, Scanzoni, Kolliker, Hennig,
 Schlossberger, Hausmann, et at.)
     "The mucous membrane of the uterus has no frame-Avork of connective
 tissue.  Henle claims that he has occasionally succeeded in demonstrating a
 fine net-Avork of pale  fibres by penciling Avith a brush.   This Avas accom-
 plished by first treating the tissue Avith caustic potash.
     "This frame-Avork really consists, hoAvever, of the uterine tubular glands,
 immediately to be described,  between Avhich there seems to be a mass of free
 nuclei from 0.006 to 0.008  millimeter in diameter, together Avith many  elong-
 ated cells or various sorts of  polyhedral or little plate-like  cells, fibre-cells
 in the most various stages  of development, a proportionately large amount of
 insterstitial substance, and bundles of muscular tissue reaching from the in-
 nermost layer of the muscular coat to the base of the glands."
     The utricular glands "present in the human species a uniform type,
 though two forms are apparent in many animals."  They represent, usually,
 single tubes of varying length; "often, however, they have one or more diver-
 ticula at or below the middle; the general shape is cylindrical, or somewhat
 club-shaped at the extremity,  which terminates blindly; they discharge  into
 the cavity  of the uterus at the surface of the mucous membrane.  Here they
 are apt to be compressed laterally or upon three sides, and the diameter of the
 orifice is greater than of the caliber in other parts. J  They adopt most circuit-
 ous courses,  and  even wind spirally, like a corkscrew ;  thus the length of the
 follicles sometimes considerably exceeds the thickness of the mucous  tissue.
 On the Avhole, the inclination of the tubes is vertical to the plane of the mem-
  * Robin, Mcmoire pour sercir a Vhistoire anatomic de la membre muqueuse de Vut. Arch.
general, juillet  1847.
  f Hennig, Der Kutarrh, &c.
  \ Hennig, Catarrh dcr iceibl.  Geschlechtsorgane, 1846. 
294
brane, and this is especially marked at the loAver part of the uterine  cavity
and in the neighborhood of the tube-orifices;  on the other hand, the ducts in
the upper part of the body and at the base have  frequently an  oblique  or
nearly horizontal direction.
     "The base of these  glands is very difficult to isolate in the normal uterus;
in the menstruating or pregnant condition it is less so ;  it is also very seldom
possible to obtain a complete vieAv of it on cross-section, because of its many
turnings.  It consists of an uncommonly thin, structureless  membrane, in
which we generally find ovate nuclei, especially in the menstruating organ.
These bodies must be distinguished from the muscular  nuclei, which remain
adherent to the follicular wall during the process of isolation."
     Lott says, it is true the majority of authors ascribe cylindrical epithelium
to the human female and most mammals, yet  all do not coincide in this.
     Weber, Leydig, Henle, Kolliker, Frey, and Hennig speak of cylindrical
epithelium; others, as, for example, Grerlach, Scanzoni, Schroders, describe a
pavement-epithelium.  Leydig asserts that the glands of most mammals have
a ciliated cylindrical epithelium.
     Gustave Lott says  of Friedlander's assertion, that he saw vibrating epi-
thelium in the cervix of immatured girls, that it does not accord with the ob-
servation of  numerous others.
     The mucous membrane, upon the  approach  of the catamenial period,
thickens A7ery decidedly, and the glands swell so that the spaces intervening
betAveen them are lessened, while their length is about three times  as  great.
This is true, also, of the  cervical glands, both  at the molimen hemorrhagic um
and  during pregnancy.
     I have endeavored to bring to mind the minute and important anatomi-
cal elements  entering into the structure of the lining membrane of the womb,
for I am sure its real nature is not remembered as it  should be.  While we
mark the differences delineated betAveen the mucous membrane of the exter-
nal  cervix, the internal cervix, and  the corpus uteri, it will not do to draw
around disease such a constant line of demarkation, nor indeed must it be
supposed, Avhen we speak of endometritis, that we entirely separate the mor-
bid action from the sub-mucous parenchymatous tissue so closely united to it.
Especially during the acute stage of inflammation of the mucous membrane
does the muscular substance bordering  upon it become inflamed, infiltrated,
and congested. 
295
     Although having a class of  diseases to treat similar to that of Dr. J. H.
Bennet,* I haA'e not met Avith such a large proportion of inflammatory affec-
tions of the cervix uteri.  While Dr.  Ashwell, at Guy's Hospital, reported
one  case of inflammation of the cervix in fifty, (tAventy cases in a thousand,)
he, Dr. Bennet, at the Western General Dispensary, found, out of tluee hun-
dred cases, that tAvo hundred and forty-three were suffering  decided inflam-
matory disease of the cervix or its cavitA',  and that ulcerations existed  in two
hundred and twenty-two, either in the incipient form of excoriation or in the
more advanced state of ulceration.
     Out of one  thousand patients who haA'e sought my section or been re-
ferred  to it by my colleagues  or the house-physician, on account of some
uterine complication or disease, one hundred and seventy-eight had endome-
tritis.  In nearly all (except six) the cervix Avas affected, but,  as stated aboAe,
in one hundred and twenty  the inflammation Avas limited to  the neck  of the
uterus, the others Inning general endometritis.   When, hoavever, it is remem-
bered that  many  cases  of the one thousand Avere trivial complaints, not Avar-
ranting any physical examination, the disproportion is  not so great as it at
first appears, and the conviction Avhich impresses me is scarcely different from
the conclusions of Dr.  Bennet,  " that the very great majority of the females
who apply  for relief, Avhen laboring under confirmed uterine symptoms,  phys-
ical  or functional, Avill  be found, on careful examination, to be suffering from
inflammation of the neck of the uterus," or, I Avould like to  add, its ravages.
     The physiological molimen hcemorrhagicum of the uterus, Avhich cor-
responds to the maturation and escape of a Graaffian vesicle from the ovary,
verges upon the congestion Avhich is usually accounted the first stage  of in-
flammation, and any cause operating to intensify this periodic congestion, or
to perpetuate the same, cannot fail to  produce a train of tissue-changes Avith
attendant symptoms usually recognized as inflammatory.   This  menstrual
congestion  generally lasts ten or tAvelve days, for it precedes and folloAvs the
sanguinous Aoav by tAvo or three days, so that during only about  tAvo-thirds
of each month is the menstruating female free from the danger  incident to
such a predisposition to inflammatory action.
     Anything which induces, directly or indirectly, hyperaemia of the  uterus
or its lining membrane, such as cold, may excite an acute inflammation  which
will probably soon abate—it ma}' be, will disappear entirel}'—but frequently
*Beuuet ou the Uterus, page 44. 
296
is excited again  by a repetition of the same  or  some  similar provocative,
aided by a constantly recurring periodic congestion of the uterus, until it
finally becomes  permanently established.  This class of  patients usually
bears Avith the attending discomforts until the sympathetic troubles arrest the
attention of the physician and then these complaints are traced to their source:
this is especially the case with virgins.
     Chronic endometritis often recognizes the same causes as acute or chronic
metritis and is very frequently a  folio Aver of acute puerperal endometritis.
Miscarriages and abortions often excite this disease. Blenorrhagic contagion,
A'iolent or  excessive sexual intercourse,  any direct injuries to  the uterus,
vaginitis,  attempts to produce criminal abortion,  improper or careless use of
the sound,  pessaries, (particularly intra or stem,) and general conditions or
diseases, such as tuberculosis, exanthematous fevers, &c, may be enumerated
as causes of endometritis.   The folioAving table will give  only a  partial idea
of the causes operating to produce endometritis in the  cases as seen  at this
dispensary-service.
     Many of the enumerated  causes were really only conditions  Avhich
favored the operation  of other agencies, as for instance parturition, in which
cold, instrumental interference, want  of proper rest, injudicious hygienic  or
sanitary measures, &c, were really the direct causes of the attendant inflam-
mation.
                                Endometritis.
      General:
          Blenorrhagic....................................:....... 18
          Following parturition.................................... 26
          Other causes, cold, &c....................................   8
                                                              —  52
      Corporeal:
          Blenorrhagic............................................   2
          Cold at menstrual period.................................   3
          Unknown...............................................   1
                                                              —   6
      Cervical:
          Blenorrhagic..........................................   4
          Abortions...............................................  21
          Miscarriages............................................   5
          FolloAving parturition....................................  32
          Cold at menstrual period.................................  11
          Other causes............................................  47
                                                               —  120
Total
178 
                                  297

     Twenty-two of the one hundred and seventy-eight cases of endometritis
 were seen in the acute stage and the rest (one hundred and fifty-six) pre-
 sented the chronic or sub-acute form of inflammation.
     Symptoms.—Often the existence of endometritis is so little manifested by
 direct symptoms, that its insidious invasion has not been combated, or even
 discovered, until it has become Avell established.
     It is a great mistake to suppose, with many physicians even, that a vir-
 gin never suffers from inflammation of the uterus.   It is  not a Aery uncom-
 mon occurrence, and my own observation attests the experience of Dr. Ben-
 net as to its existence.  Frequently I have been almost satisfied of its pres-
 ence, Avhen I could not, from Avhat  I feel is a judicious delicacy, propose or
 insist upon an examination, and sometimes the  physician has to combat the
 importunities of an  anxious mother, who, on  account of  a slight A'agiual
 catarrh in her daughter, Avishes an examination to be made.  When, hoAvever,
 the gravity of the  symptoms demands it, a false delicacy that would sacrifice
 the general health and AA-ell-being < >f the patient is reprehensible.   Of the one
 hundred and seventy-eight cases, only  four were  maidens whose claims to
 virginity  Avere beyond question.
     The most constant symptom Avas leucorrhoea, Avhich in one of its forms
 Avas complained of in nearly cwery case at some stage of its progress.  To
 distinguish  betAA'een the discharges from the A'agina, the cervix uteri,  and
 the corpus uteri is of prime importance.  The discharge, if A'aginal, must
 proceed from the mucous glands about the ostium vaginae, inasmuch as there
 is no apparatus  for any considerable mucous secretion  between this and the
 os uteri.  Under the stimulus of Aenereal passion these glands sometimes secrete
 a  profuse  amount of mucus, but in their normal condition the amount se-
 creted in the absence of such excitement is so inconsiderable as to be unob-
 served.   Along  the vaginal canal a sufficient quantity of mucous secretion
 exists to  lubricate its surface; and, when irritated, the epithelium is shed very
 rapidly, the cells often being immature.  The Avhole of this vaginal secretion
 is, in  the normal condition, as before  remarked, distinctly acid and  rich in
 epithelium, and, saA'e in some cases, under sexual orgasm, is never so  abund-
 ant as to appear as a discharge.  The acidity of the vaginal secretion exer-
 cises a marked influence upon that of the uterus.   Dr. Whitehead has insisted
upon its action in Avhitening the mucous  secretion by coagulation of its albu-
men, its  less Aiscidity, and its  poAver of preventing the  coagulation of the
     38 
                                  298

menstrual Aoav.   Dr. T. Smith has shown how a little Aveak acetic acid Avill
change the thick Aiscid mucus of the cervix so as to resemble the curdy mucus
of the A-agina.   "It loses its viscidity and transparency altogether."  This
change takes place in the vagina owing to its acid secretion, and hence the
discharges Avhich  most frequently  come from the uterus may  be attributed
to the vagina.
     The secretion of the mucous glands of the cervix uteri in health is clear,
tenacious, alkaline, and filled with mucous corpuscles.   This secretion is in-
creased at the menstrual period, during gestation, and also during parturition.
When it occupies  the os uteri any length of time, the acidity of the vaginal
secretion acts upon it as in pregnancy, causing the plug to appear  opaque
and white or curdy.  Each of the above conditions stimulates the glandular
apparatus of the cervix and an increased secretion results.
     The same happens in inflammation of the cervical mucous membrane,
and it is this hypersecretion, acted upon by the vaginal acid, that in  nearly
all cases constitutes leucorrhoea.
     If the cervix be exposed Avith the speculum, a tenacious,  ropy mass of
partially changed opaque mucus hangs from its os, and sometimes the vagina
is covered with  detritus from this source, on account of the Avearing away, as
it Avere, of this ropy mass, owing to its changed character, produced by the
acid secretion of  the vagina.  Often the vaginal surface is bathed with a
creamy fluid, Avhich results from this same reaction. Dr. Tyler Smith illus-
trates this reaction and change Avhen he says: "It appears to me that, of the
tAvo principal forms of the discharge, the secretion from the canal of the cervix
uteri may be compared to soft or fluid soap.   It seems as if  the alkali of the
discharge combined with the fatty and albuminous element to form a sapona-
ceous  compound."
     When pus is formed it mingles its cells with the mucus, and then  muco-
purulent characteristics prevail, Avhile, if the denuded or ulcerated membrane
bleeds, we find blood-corpuscles entering into the discharge.   When blood
is present to a limited extent, the  discharge, as it appears at the  ostium
vaginae, is of a dirty-brown or greenish  hue.   Tyler Smith calls attention
to the fact that if the Aoav of blood is considerable, it may mask the leucorrhoeal
discharge, and be  mistaken for menorrhagia.
     The amount of leucorrhoeal discharge varied from a mere  sIioav, AAdiich
only stiffened or  stained the underclothing, to a profuse, debilitating quantity 
299
which kept the person and clothing constantly bathed and saturated.  Where
vaginitis, ulceration or erosion of the external Anginal cervix or of the cer-
vical canal did not exist, the  amount  of discharge was, as a rule, not very
abundant.
     The character of the leucorrhoeal discharge will often be of great diag-
nostic value.   I have already adverted to the difference existing betAveen the
mucous membrane of the body and the cervix, and this Avill indicate at once
Avhy Ave  should expect a difference in the character of the discharge.  The
secretion of the utricular glands of the body and the Nabothean follicles of
the neck give to the hypersecretion of each of these uterine regions a char-
acteristic appearance.    The  exudation of blood-corpuscles mingled Avith
mucus may, as Dr. Bennet says, be considered as characteristic  of internal
metritis,  as the rust-colored  expectoration is of pneumonitis; and Dr. T. G.
Thomas  verifies this observation to a certain extent:  " It is certainly a very
reliable  and  valuable sign."*  This  sanguineo-mucous discharge continues
sometimes during the whole interim of the catamenial  period.   Often, in-
deed, it is so  bloody that the patient cannot tell when her catamenial period
ceases or begins.   Another characteristic discharge which I have noticed in
some cases was a profuse sero-sanguineous flow.   It  Avas of this character in
two of the cases of corporeal endometritis.   Sometimes pus was mingled with
the discharge from the  corpus,  and this was frequently the case also with
that of the cervix; but, when present  to any considerable extent, the cases
were the most intractable to treatment.  I have noticed, moreover,  that the
discharges from the body of the uterus were more apt to be offensive than from
its neck or from the vagina.
     When the inflammation affected only the cervical mucous membrane,
the discharge was more  glairy, and as it passed from the vulva was opaque
and often like boiled starch or gum-water Avhich contains some undissolved
portions of gum arabic.  Sometimes blood Avas mixed with the discharge,
giving to it the broAvn or green  appearance before spoken of, and  pus-cor-
puscles in greater or less numbers Avere also frequently seen.  I might say, in
fine, that in the great majority of the cases of cervical  endometritis, the" dis-
charge was muco-purulent, alkaline and often contained blood-corpuscles;
that the discharge as it issued from the vulva, when alkaline, ahvays came from
the lining membrane of the uterus; that the  absence  of the alkaline  reaction
* Thomas, Diseases of Women, page 260. 
300
did not prove that the discharge was vaginal, inasmuch as its primary reac-
tion may have been changed by the acidity of the vaginal secretion,'and that
the admixture of pus or blood indicated some  destruction of the mucous
tissue.
    Another almost universal accompaniment of endometritis was pain in the
sacral, lumbar, inguinal, or pubic regions.  It was very seldom that pain  in
some one of these localities Avas absent.   Sacral pain, or probably, more fre-
quently,  sacro-lumbar pain, Avas present in a large number of cases, but was
often associated Avith pain in the left ovarian or hypochondriac region.  These
pains were much more severe and constant Avhen granular erosion and ulcera-
tion existed in the cervix, or when the corporeal section was involved.
     The sacral pain was sometimes complained of in the lower region of the
sacrum near the coccygeal articulation, sometimes at its upper part, occasion-
ally along the whole sacrum and coccyx.  This pain was usually described
as of a dull, aching, sometimes burning  character, worse after exercise and
during and immediately after menstruation.
     This backache Avas almost ahvays  accompanied by extreme muscular
weakness, and Avhen the erect posture was assumed, this weakening pain  in
the back seemed to enervate the entire system ; yet in many cases the pain
itself Avas not complained of as being acute.  Sometimes the patients stated
that they suffered most Avhen walking, but oftener they complained chiefly of
the standing posture.   Pain in the iliac regions Avas usually confined to the
left.  Many practitioners have sought for an explanation of this,  but  I have
heard of none that Avas satisfactory; yet it is a very frequent accompaniment
of  endometritis.  It corresponds sometimes to the situation of the left ovary,
but usually it is higher up; often it is seated in the left inguinal or hypogastric
regions.  When  this pain existed at  the same  time  with  backache and
extreme muscular Aveakness and debility, I have  never failed to find uterine
disease of some kind, most generally endometritis, partial or entire.  Dr.
Bennet says, speaking of this pain in the left ovarian region, and failing to
explain its relation to the uterus: "The fact, however, is undeniable, and ren-
ders the  existence of a dull, aching, constant, circumscribed pain in the left
ovarian region all but pathognomonic of inflammatory disease of the cervix
uteri."
     One case  Avas  so illustrative  of these symptomatic truths,  that I will
brief!}' narrate it.  A young lady,  aged eighteen years, had ahvays enjoyed 
301
excellent  health until within about sixteen months.   She Avas of fine phy-
sique, and ahvays Avas very strong, but since the time mentioned, her strength
has been failing and she has suffered much from a gradually increasing pain
'tin the loAver part" of her back; pain in the left ovarian region; a feeling of
fullness and weight in the pelvis; frequent headache; distressing distension
of the boAA^els, which compelled her to undress and seek her bed;  frequent
vomiting, and, occasionally, a  slight leucorrhoeal discharge; menstruation
continued regular until recently, when dysmenorrhoea was added to the  list
of her complaints, aggravating  all the others.  From having been a strong,
sprightly, and accomplished young lady, fond of  exercise, household duties,
and the dance,  she is now utterly prostrated, melancholic, spiritless, and  de-
spondent, unable to walk  a square without extreme suffering, and can only
amuse or employ herself as an  invalid.  Her  chief complaints Avere pain  in
her back, greatly increased by  standing or walking;  " Avant of strength," as
she expressed it;  and meteorism, her abdomen becoming enormously dis-
tended, interrupting respiration, interfering with the heart's action, and unfit-
ting her for the enjoyment of society and the ordinary pleasures of life.   A
physical examination discovered corporeal endometritis.   She was a Airgin
and the hymen Avas intact.
    In some the pain Avas referred to the uterus itself, but only in a feAV cases,
and these were complicated with parenchymatous inflammation.   Pain during
coitus Avas a very frequent accompaniment.   Severe dysmenorrhoeal pains
were  frequently complained of, and sometimes  uterine tormina or spasm,
during which the suffering Avas extreme ; pain and tenderness were sometimes
present also along the crest of the ilium.
    In nearly all  these cases  of endometritis, pain Avas  increased at  the
menstrual period.   It  is  not to be inferred that painful menstruation Avas
ahvays a symptom of inflammation of the uterus, but when dysmenorrhoea
did not previously exist, its subsequent  appearance Avas a symptom of no
small  significance.   Neither  did its absence  prove that uterine inflamma-
tion Avas not present.
    Accompanying some of the aboA'e-mentioned pains, a feeling of bearing-
down, or Aveight in the pelvis, was generally complained of.   Sometimes this
sensation Avas in the back; often in the pelvis, or at the perineum.   In a few
cases, uterine tenesmus Avas so  distressing that the  patient could not stand
up or Avalk Avithout the  greatest distress; a feeling as  if the pelvic organs 
302
would drop or be strained  out of the body.  By a careful research among
the many  pains, aches, and distressing sensations complained of in  these
cases of endometritis, I find that most of them can be referred to that cate-
gory of nervous  disorders usually denominated sympcdhetic  or  reflex, and
often the distress or suffering complained of was so remote, and  apparently
so disconnected from the uterine region, that Avithout constantly keeping in
mind the Avidespread sympathetic relations of the womb to the entire  nerv-
ous system, mistakes Avould constantly occur.
     Too often are these complaints unheeded by the friends of the patient,
or they fail to command that sympathy Avhich their reality deserves. Those
who surround the patient do not comprehend such remote sympathetic suf-
ferings, Avhen, as so often is the case, the general physical appearance of the
patient does not  indicate disease.   They  are  apt to suppose, because at
times, under the influence of excitement, these sufferers seem to forget them-
selves and pass, as it Avere, from the  bed of torture  to the  rooms of social
pleasure  or the halls of gaiety and mirth, that the  patient's  sufferings  are
more imaginary than real.  This mistake is a very serious one, for the  want
of consideration and sympathy, to say nothing of the reproaches and  rude-
ness with Avhich their complaints are sometimes received, depress and  para-
lyze the already impaired mental and moral faculties, which, reacting  upon
the disease itself, aggravates all the symptoms,  besides sometimes inducing
a state of depression  and melancholia more painful to witness than  the
agony of disease.
     Fortunately the days luive gone by when these sufferers fail to find any
appreciation  of their complaints by physicians, who understand why  these
transitions  may be sudden and  complete, yet not merely Avhimsical.   I am
almost afraid that many medical men do not remember as they should Iioav
frequently aberrations of the mind, mental hebetude,  morbid hallucinations,
irritability of temper, moroseness of disposition, and sometimes even insanity
are induced  or  excited by uterine disease.  They  fully  understand how
menstruation and pregnancy react  upon the nervous  centers,  but often for-
get that disease may in a greater degree affect the same.
     If time and  space allowed, I Avould like to classify and group  these
reflex complaints and diseases, but they forbid, and I can only refer to a
feAv of the most prominent.
     Headache, so frequently considered neuralgic, was  a very constant 
303
attendant upon cases of endometritis.  Sometimes the Avhole head Avas affected,
but most  frequently the pain or ache complained of Avas in the croAvn or
back of the head.  This form of headache is mentionod by most authors as
symptomatic of uterine disease.  Says Byford:  " It is almost invariably the
case that a woman has  cinonic  uterine disease, if she complains of persis-
tent pain in  either of these regions.  The occipital pain I  have observed in
this connection much oftener than  the pain on the top of the head."  This
last observation does not hold  good of cases seen in this dispensary, for
pain at the vertex, or  on top of the head from the vertex along the sagittal
suture to the frontal  bone, was present in a much larger  number of  cases
than where it Avas confined to the occipital region.  Frequently, hemicrania,
pain in the eyes, through the temples,  or OA'er the brow, existed.   The
character of  the pain is important.   That on the top of the head was usually
spoken of as a "burning pain," as a " hot spot on the head," and Avas oftenest
noticed in sterile women, and, as might be inferred, in those suffering cor-
poreal endometritis, for sterility is most usual where this exists.   My obser-
vations  correspond Avith Dr. Byford's in that, when headache was much com-
plained of, the  patient seemed to  suffer  fewer  other  symptoms of uterine
disease, although an examination  disclosed its presence, and a cure of the
uterine disease relieved the cephalalgia.
     Headache  Avas frequently  accompanied by nausea or sometimes by
vomiting, (sick-headache.)   The sympathy existing between the uterus and
the stomach I haA'e already referred to in the  article on chronic metritis.
This sympathetic disturbance of the stomach in  endometritis Avas of an ordi-
nary dyspeptic  character, sometimes induced by special articles of diet.  In
one case, the patient rejected apparently eA'erything soon after eating.  In
many others, great distress was  manifested  after meals.   Cramps attacked
some after each ingestion of food—anorexia, A7oracity, depraved tastes, some-
times Avere features of this stomachic derangement.  The boAvels were con-
stipated in a large number,  sometimes  diarrhoea alternating Avith constipa-
tion.
    The intestines often, as mentioned on page 301, became distended with
"•as; borborA'anms Avas common, and sometimes in the married this meteor-
isnius Avas mistaken for pregnancy by  the  too Avilling  patients or  their
friends. 
304
    Hyperesthesia of the skin in some portion of the body \a;is also pre-
sent at times, especially over the abdomen and scalp.
    It Avill be noticed that many of these sympathetic complaints are usu-
ally recognized as hysterical, and such they may be called.  Most of the cases
of hysteria, I have generally found were connected Avith, if indeed they were
not caused by, uterine  disease.   Convulsions, when  this is  the case, are
much more apt to occur during or about the menstrual period.  The cases
of so-called " spinal irritation" in females, especially virgins, are, much more
frequently than is usually supposed, the subjects of endometritis.
     When these sympathetic phenomena had existed for a long time  and
the leucorrhoeal discharge had continued  profuse, the  patients Avere gener-
ally anaemic.   In some,  marasmus Avas extreme,  and  the Avorn,  emaciated,
feeble invalid had succeeded to the buoyant, well-developed, strong woman.
Nervous suffering, Avith its despondency,  loss of rest, and morbid excitabil-
ity, seemed, in a few instances, to have AA'orn out health as Avell as  life,
Avithout being complicated by any great drain upon the  economy, such as
excess'iA^e leucorrhoea or hemorrhage.
     I do not know of any patients Avho  have died directly from endome-
tritis, but in some instances the health was so much deteriorated by the dis-
ease and its sympathetic affections that the subject was predisposed to many
intercurrent diseases and their ravages.
     Although, from the presence of some  of the  above-mentioned local,
sympathetic, and  general symptoms, Ave may be almost sure of the pres-
ence of uterine disease,  yet we cannot be so certain of its  location, extent,
character, or complications.  What, however, remains  to be determined will
be quite satisfactorily ascertained by a careful physical examination of the
pelvic  organs
     By  the bi-manual method of palpation, when  the endometritis was gen-
eral, the whole organ was found to be enlarged,  (not  so much so as in me-
tritis, however;) tender to deep pressure, and exquisitely painful if the cervix
was bent upon the body, which caused the inflamed surfaces to rub against
each other.   The neck was puffy, or more or less indurated, and if carefully
pressed at the os uteri, this gaping, dilated opening seemed  to be the open end
of a hard cylinder, the cavity of which was represented  by the dilated uterine
canal and  its Avails by the mucous  membrane  and  adjacent parenchy-
matous tissue, which had partaken of the  morbid change.   This denoted 
305
 endometritis, Avhich had existed for a  considerable time.   The organ rolled
 about in the pelvic caA'ity in some,  and assumed a mal-position determined
 by gravity.  The cervix Avas low in  the vagina, and often, from its increased
 size, pressure upon the rectum or neck of the bladder explained  any local
 symptoms relating to these important viscera.   Erosion or ulceration of
 the external vaginal cervix could generally be detected by digital explora-
 tions.   By using the speculum, the amount of congestion, inflammation,
 and ulceration  of the  upper portion  of the vagina and external  vaginal
 mucous membrane  Avas  noted.    In tAvo  out of  three  of  the  cases
 Avhere  the cervical  canal Avas affected, abrasion or  erosion of the  mu-
 cous  membrane of  the  vaginal  cervix uteri Avas observed, and  in  each of
 these  cases the  leucorrhoeal discharge Avas purulent.   The A'aginal cervix
 Avas generally discovered bathed in muco-pus, Avhich required to be Aviped
 away before the real character and extent of this erosion Avere manifest.   Dr.
 Bennet has cautioned against supposing the bright, rosy hue of the  vaginal
 and cervical mucous membrane  in  Avomen of A'ery fair complexions to be
 indicative  of inflammation or congestion; and, moreover, the Avhite,  creamy
 secretion often present soon after menstrual periods, or when a little con-
 gestion from cold prevails, must be discriminated from  muco-pus.   Ordina-
 rily the erosion  or ulceration Avas so Avell marked that no difficulty  Avas ex-
 perienced.
     Sometimes  the lips of the uterus required to be gently separated before
 the excoriation could be seen, and  in  some cases, although A'ery feAv,  a so-
 lution of nitrate of silver, as suggested by Dr. Bennet, Avas penciled over
 the surface of the os  and A'aginal cervix, Avhen its presence and limits could
 be easily defined.
     Ulceration, as usually referred to, when speaking of uterine disease, is
 so often misapprehended that I doubt if I shall  be understood Avhen I say
 that, in the sense as comprehended by some, I have never seen in any of these
 cases  of endometritis the excavated ulceration they seem to suppose exists;
 that is, destruction and loss of tissue, as characterized by elevated edges  and
 depressed centers.  In some stages  of follicular ulceration, Avhen the follicle
 lias just burst, a  depression may exist; but this is very soon  filled up by
 hypertrophic enlargement of the Ailli, Avhich soon protrude beyond the sur-
 rounding surface.  When the anatomical characters mentioned in  the be-
ginning of this  article  are  considered, it aa ill be easy to understand avIiv
       39 
306
the depressed  excavated ulcer does not appear on  the cervix and os uteri
much oftener.  The abrasions, excoriations, and granular erosions are but
stages of the ulcerative process.  We may discover  erosion or separation of
the epithelium, hypertrophy  of the villi,  which  crowd  upon each  other,
choking out the most weakly, or fissures between these exuberant villi, giv-
ing to the surface of the cervix a resemblance to raw beef.   The granula-
tions bleed very easily, and often they may be seen studding the cervical
canal.
     A condition resembling, at first glance, an abrasion about the os uteri,
or its vaginal surface, I met Avith in two cases at  the  dispensary^ and they
were similar to those mentioned by Chomel in his  "Clinical Lectures," re-
ferred to by Dr. Tilt*  as being  similar to the port-wine stains or erectile
spots on the skin, and, in reality, are the result of  exaggerated  blood-ves-
sels of the villi.  In both of these cases profuse hemorrhage had been suf-
fered, and they were cured by destroying the diseased surface with the po-
tassa cum calce.
     In nearly all the cases of endometritis, especially Avhere the neck was
involved or where abrasion or ulceration existed, the external os uteri Avas
open to a greater or less degree—greater in those who had borne children,
less in those Avho  had  not.   Sometimes, from the swelling  of the mucous
membrane of the cervical canal, its cavity appeared reduced in caliber, but
this oedema soon disappeared Avith the acute symptoms.  This  opening or
dilation of the external os and cervical canal, and of the internal os when
the disease extends beyond it, has never, that I know of, been satisfactorily
accounted for; yet the fact exists and constitutes an important diagnostic
symptom.
     In those cases Avhere the sound entered the uterine cavity Avithout recog-
nizing any narrowing of the internal os, the fundus  and body of the  uterus
were found enlarged and very tender, and gave other signs of corporeal inflam-
mation ;  while, on the contrary, Avhen this strait Avas appreciable  by a slight
resistance to the progress of the sound, these indications of corporeal disease
Avere usually absent.
     Treatment.—The  treatment of  endometritis at  this  dispensary has
been far more satisfactory  than  of  metritis.  Much that  Avas  attempted
for the cure of chronic metritis had a  decidedly better effect upon endome-
* Braithwaite, part xxix, p. 286. 
307
tritis.  Strict attention was directed to the general health of the patients, and
as the .disease almost ahvays presented itself in the chronic stage, its effects
had been already felt on the constitution, therefore tonics, especially the
chalybeates, were liberally prescribed, with moderate out-door exercise, and
a good, nourishing, plain diet; ameliorating by appropriate medicines, as far
as possible,  the distressing symptomatic affections, so as to procure comfort
and rest; and  counseling moderation in (but not ahvays entire abstinence
from) coitus.
     Very much can be accomplished in the management and cure of endo-
metritis  by general treatment.   Medicines  administered constitute but a
small part of the general treatment referred to.  We must include, attention
to hygienic  and sanitary laws,  the regulation of  diet, the  avoidance of
fatigue and exposure, the procurement of moderate and judicious exercise.
We must allow an abundance of fresh air, surround the sufferer when possible
by cheerful associations and companions, enlist the sympathies of her friends,
infuse hope,  and relieA'e, Avith such therapeutic agents as  are applicable,
Avhatever distressing symptoms  may  be most complained of, never losing
sight, hoAvever, of the fact that any general depletives always do harm.
     Nervous  symptoms were often relieved by the bromides of potash, of
ammonia or of soda, the Aralerianates of quinine, of iron, or of zinc, and coun-
ter-irritations of iodine or turpentine.  The digestive function Avas particularly
interrogated, and  promoted  Avhen deranged by pepsine, mix vomica, etc.;
but stimulants Avere particularly avoided for reasons already mentioned.!  1
have often prescribed a formula, hoAveA'er, AAdiich I learned from Dr. Thomas,
of New York,* and I lurve seldom failed to observe the " best results" Avhich
he so often obtained from its use in these cases of sympathetic derangement
of the stomach, where the gastric juice seems to be inefficient in digestive
properties.   It is the following:
   IjL One rennet, washed and chopped.
     Sherry wine, Oi.
     Macerate for twelve days;  then decant, filter, and add:
     Dilute nitro-muriatic acid, 3ii.
     Tinct. nux vomica, 3ii.
     Subuitrate bismuth, 3ii.
     One tablespoonful in a quarter of a tumbler of Avater before each meal.
               * Thomas, Diseases of Women, page 245, 2d ed.
               t Article ii, p. 278. 
308
     The above was often modified thus :
   IjL Bismuth subnit., grs. v.
     Pcpsine puh\, (sacch.) grs. x.
     Kucis A'omicse pulv., grs. ii.
     M. (I^ut in capsule.)
     Sig. Take immediately before each meal.
     When acidity Avas present and the stomach and bowels distended with
the gases of fermentation, it  has  been customary to direct 5, sodae hypo-
sulph., gr. x to xx,  about an hour after each ingesta,   When  constipation
existed the compound liux-A^omica pill (omitting the mass, hydrarg.,) as di-
rected in Article ii, page 279, Avas found efficacious, provided  the  patients
ayj'11 assist its action  by habitual and regular attention to alvine evacuation.
     It is surprising how the rectum can, as it Avere, be educated to discharge
its contents  at regular times.
     Rest in some cases  was found to be  necessary, especially if any acute
action Avas present or Avas excited by menstruation or sexual over-indulgence.
Of course, during some  of the stages of local treatment, the patient Avas kept
in bed or compelled to remain in the reclining posture.  After local treatment
had been prosecuted for a reasonable time, the patients Avere advised to seek
a change of air and scene, but in this class of individuals Avho frequented the
dispensary,  compliance Avas rarely within their power.
     The benefits to be expected from general  treatment alone, Avhile  very
considerable, are not satisfactory; but, Avhen united with  local measures,
reasonable expectations are  usually realized.  Often the relief afforded is as
gratifying as it is unexpected by the patient and friends.
     Where excoriations or ulcerations exist Ave cannot  expect a cure with-
out topical treatment.  Much relief may be attained by other  means, but I
have  }^et to find an  erosion  or ulceration  of the os or ceiwix uteri Avhich
healed spontaneously.   Patients have repeatedly consulted me about this
condition, and after having  been  examined they have gone aAvay,  often to
the country, and when they returned,  although  greatly improved and much
relieved, yet the local lesions remained about the same.  Dr. Thomas* has
expressed this  opinion also Avhen speaking of granular ulceration.   "There is
no proof existing that this disease is ever recovered from Avithout surgical inter-
ference.  Although, as to this being impossible,  I am by no means positive."
     If acute symptoms  prevailed at the  time  of commencing treatment  a
                * Thomas, Diseases of Women, page 305,2d cd. 
309
 few leeches were  applied  to  the  cervix  or  the  cervix Avas scarified, the
 patient being kept in bed  and the vagina syringed with  hot water every
 few hours.  This mode of local depletion, by leeching or stabbing the cervix,
 Avas repeated every other day, until the symptoms Avere relieved.  Very often,
 after   each syringing,  the  glycerine-tampon Avas applied,  as  hi  metritis.
 Often a Aveek of such treatment sufficed to abate every acute symptom; and,
 where the patients remained under treatment until discharged, they have had
 no return of the trouble, except in cases where the acute attack  supervened
 upon a previously existing chronic endometritis. In all but tAvo of the hventy-
 tAvo cases seen in the acute stage, the disease Avas confined to the cervical canal.
     Of these latter, tweh^e Avere discharged cured, and the rest (ten) failed
 to report  after the acuteness of the  disease disappeared.   The two where
 the Avhole uterine canal Avas invohed Avere blenorrhagic and A'ery obstinate,
 running into the chronic form  and requiring about six months of treatment
 for their restoration.   After the acute  stage,  if any appearance of  disease
 remained, the same treatment was pursued as  with the  chronic cases hoav to
 be mentioned.
     In chronic endometritis, sometimes called chronic catarrh of the uterus,
 the use of the sponge-tent is almost invaluable.  When  it is remembered
 how many thousands  of mucous glands  are hidden betAveen the folds of the
 cervical rugae, and how impossible it is to bring any medicament into con-
 tact with  them, it  aa ill at once commend  itself that  a very great  advan-
 tage is gained if  these folding  and rugae are  distended so as to expose the
 whole  mucous surface to the action of whatever agent we use to modify their
 diseased condition.   In addition,  we  obtain the good effects of  the  sponge
 itself—pressure upon  the hypertrophied and engorged papillae.  In  Article
 ii, page 281, the sponge-tent has been discussed, and no doubt much of the
 good resulting in its use in chronic metritis is due to its beneficial effects upon
 the concomitant  mucous disease in that affection.  Then, again, the  tents
 may be so medicated  as to possess alterative and  astringent properties and
 may be carried to the fundus uteri.
    In the dispensary, the tent has been much used as  an accessary to other
 means  of local treatment, but often its direct effect Avas decidedly beneficial.
 In those cases Avhere granulations, (fungous and sometimes polypoid in form,)
 extended into the cervical cavity, and doubtless into the corporeal also, its
advantages were most apparent.  During its use, the  recumbent posture Avas 
310
enjoined, or, at least, confinement to the house.  Sometimes patients would
go about their usual occupations Avithout an}' inconvenience while wearing
the tent, but this is to be condemned as imprudent in any case.  After dilata-
tion had been completed, sometimes the uterine injections Avere practiced, or
the sponge or cotton probang, armed with some caustic or alterative medicine,
was  used.   Uterine injections and intra-uterine applications were mentioned
in connection with  chronic metritis, *and I refer the reader to that article,
to avoid repetition.
     As a  rule  in  these cases,  Emmett's "applicator," a  flat silver probe,
around the end of which raw cotton had been tAvisted, was used to make intra-
uterine applications.  The end  covered Avith the cotton Avas  dipped into a
saturated solution of carbolic acid, and, after carefully Aviping aAvay all excess
of the acid, it Avas passed into the cervical  and into the  corporeal uterine
cavity, if affected, turned about in Aarious directions, and then gently with-
drawn.  The applications  were made twice a Aveek, and, when it was possi-
ble,  the patient  remained in bed during the rest of the day.   Every day a
pledget of cotton soaked in glycerine was pressed against the cervix or into
the  posterior cid-de-sac, and allowed to remain  until evening, Avhen it was
removed and the vagina syringed freely Avith Avarm Avater containing alum
and  sulphate of zinc.  The alum and tannic acid solution is better, but the
latter ingredient stains the clothing, so as often to be disagreeable.
     While it is  true that vaginal  injections  generally fail to reach the "real
seat  of the disease, yet their use is of great benefit, not only in deterging the
parts, but  they  impart  tone to the vaginal mucous membrane, so often re-
laxed,  causing contraction in the walls of the vagina,  and thus  raise the
partially prolapsed uterus.  In addition, they reach the external mucous  sur-
face  of the uterine neck, Avhich is often implicated, come in contact with the
mucous follicles  of the os, and often penetrate into the cervical canal.  In treat-
ing virgins th's latter is often the only mode of treatment that can be adopted,
saA'e Avhat is general.
     The nitrate of silver Avas frequently used Avith great success, but I am
afraid it sometimes caused cicatricial hardness Avhen applied indiscriminately.
It has been a custom Avith  some to pass the stick of nitrate of silver into the
cervical canal, irrespective of any visible ulceration, and this Avas persisted
in, month  after  month, to cure chronic uterine catarrh.  Some cases treated
in this Avay have presented themselves, and I have invariabl}- found the  sur-
                          * Article ii, p. 281 to ISO. 
311
faces around the os uteri hard and inelastic, seeming to be cicatricial.  I am
not certain that this condition proceeded from the use of the caustic, but it
has  appeared so sometimes.   Nevertheless  it is a valuable agent  and par-
ticularly adapted to the cure of follicular erosions.  Its use Avas almost in-
variably folioAved by more or less hemorrhage.
     Chromic acid Avas  occasionally used, especially in  cases complicated
by granular erosion, or  Avhen the os and  cervical canal seemed studded Avith
mucous polypi.  In some instances it Avas introduced into the uterine cavity,
in the same maimer as the carbolic acid.
     Tincture of iodine and persulphate of iron were  also  used, especially
the former, in intra-uterine injections, or applied by means  of a  camel-hair
pencil. Next to carbolic acid it has been used at the dispensary in the treat-
ment of chronic endometritis more frequently and Avith better results than any
other local remedy.
     The curette, as recommended  by Rdcamier, and more recently by Tilt,
I have never used, nor do I consider it to have ever been called for in  any
of the cases I have met Avith, either in hospital, dispensary, or private practice.
     The foregoing will give some idea of the general and local treatment of
this disease, and while I cannot, in the ultimate history of each case treated,
record a perfect cure, yet there is sufficient evidence to  attest that its results
have been flattering to the institution, as they have been advantageous to its
beneficiaries.
     I had hoped that I  might be able to  report in full the cases of para and
perimetritis, but the very short time that has elapsed since the report  was
determined upon, and an unusual demand upon my time and energies, com-
pel me to abandon my first purpose, and to submit the foregoing hastily pre-
pared papers, with the general synopsis,  for your consideration.
     The increased facilities which the hospital and dispensary Avill possess
in the  coming year, the more thorough acquaintance with its special depart-
ments, the more accurate record of its cases, and the augmented interest groAv-
ing out of these advantages will enable and stimulate those having charge of
its various sections in the future, to present such a statement of its workings
as Avill be commensurate with its progress and success.
     I  desire to express my thanks to my colleagues and to the dispensary-
assistants for their unifonn courtesy and  kindness, and to yourself for  that
counsel and aid Avhich haA'e so often been sought, but neA'er in A'ain. 
 
       DEPAETMENT




             OF






THE  DISEASES  OF CHILDREN.




             BY





     SAMUEL C. BUSEY, M. D. 
 
DEPARTMENT  OF  DISEASES OF  CHILDREN
     My  Dear Doctor :  In compliance Avith your request I hereAvith trans-
mit my report of the  operations of this  department of the  Columbia Dis-
pensary,  arranged in tabular  form and  accompanied Avith remarks upon
several interesting subjects  connected  therewith.  I have simply sought to
present my own opinions and to explain the practice Avhich has yielded  the
most favorable results, and haA'e not  pretended to discuss  fully and com-
pletely the causes, nature, pathology, and treatment of the several diseases
alluded to, nor to enter into any minute  and detailed description of the  va-
rious forms in which they  present themseh'es, nor to discuss the relative
merits  of the different methods of treatment or of the Aarious  substances
employed in the treatment,  but have confined myself closely to the precise
points Avhich I desired to set forth.
     I regret that I  am unable to call your attention to many interesting
and anomalous cases Avhich have been presented at the dispensary, Avhich,
perhaps, might haA'e added  more interest to  your  report than'any opinions
of my  OAvn.
     Hoping, hoAvever, that the accompanying report may prove acceptable,
I remain  yours,  &c,
                                               S. C. BUSEY, M. D.
  J. 11. Thompson, M.  D.,
                 Surgeon-'in-Chief
       40 
 
DEPARTMENT OF DISEASES OF CHILDREN.
By  Samuel  C.  Busey, M. D.,
    {Physician-in- Charge.)
                              Article  I.

                          Febris Intermittens.

     To facilitate the summing up and analysis of the operations of this de-
partment, I have  constructed the  following tabulated statement,  which
shoAvs  at a  glance the sex, color, and diseases  of the patients which have
been treated in this  department since its  organization, in September, 1869.
No one over fifteen years of  age is  admitted, and all  applicants suffering
from ophthalmic and aural affections haA^e been referred to the department
of diseases of the eye and ear.   Those suffering from any menstrual trouble
have been referred to the department of diseases of  women and a number
Avho could not be properly treated in the dispensary have been sent  to the
Children's Hospital.  Neither of these classes are enumerated in this table.
The fifty-two "not classified" comprise all trivial complaints which needed
no special attention, cases of obscure and uncertain diagnoses, and cases of
novel and anomalous character, to some of the more interesting of which I
may briefly refer hereafter.
     In classifying the diseases much embarrassment has been occasioned
by the Avant of a  uniform and accepted nomenclature of the diseases of
children.  In the selection of the nosological terms herein employed,  I have
followed approved authors.   Doubtless some incongruities Avill be apparent
to the intelligent reader, but I have sought to avoid  the not  unfrequent
error of employing nosological terms indiscriminately drawn from different
lanjmao-es, according to the fancies of the author. 
		o o, 5" a < P.	3	Tj	^			3 o	2	1		>	
rf-		to to i- co				Eebris remittens.	to o		a co -a to CS o o o				Febris intermittens.
*.		*.	*".			Catarrhus vaginae.	o		CI >£. CI rf* CO 00 -J *.				Entero-colitis.
Ife.		— CO 10 M				Prolapsus ani.	tC OX Cl CO		40 20 55 33 46 15 49 38				Bronchitis.
CO		CO ' CO '•				Polypus nasi.							Scrofulosis.
CO		'< U 19 p				Insomnia.	CI o		CO >-» CO •— h- tO H to				Helminthiasis.
CO		10 K H 15				Morbus coxae.	►c		to to tO *-» ' h- O CI cs				Catarrhus laryngis.
CO		CO ' 1 CO				Hydrocele infantali's.	CO CI		I—1 I— •—'JO to ca co to				Alvus adstricta.
to		'• tO I-" l-»				Epilepsia.	to		tO M h o o m				Pertussis.
M		,- ,- H. -				Icterus.	to CI		CI O l-1 *.				Tonsillitis.
to		i to to !				Ozasna.	to to		O O l-> I-"				Syphilis ingenita.
to		>-> l-> '. to				Hernia ingenita.	to		*. -J O 1-^				Cholera infantum.
		f I-1 tO i				Parotides.	to o		O K H O				Eczema.
. >o		c (-> 1 10				Furunculosis.	-J to o		O -I O ~J				Stomatitis.
		to				Hydrocephalus ingenita.			CO -1 CO -J				Dyspepsia.
		to		to		Morbus Brightii albuminuria.	C/i		o to -J 00.				Herpes.
-		-		M		Phymosis ingenita.	—		CI to o .*.				Hypertrophia tonsillarum.
1 1-1 i *"*				-		Panula.	l£.		O J- O J.				Phthisis pulmonalis.
Ml		~		M		Cryptorchidia.	>u		O CI to Cl				Dysenteria.
				~		Paraplegia.	-		© i-> — o				Rachitis.
m|		-	M			Atrophia musculorum ingravescens.	CO		1—' —I —1 I—•				Neuralgia.
m|		-	~			Torticollis.	cc		to O Cl CO				Otorrhoea.
~\		: - ~				Rheumatismus acutus.	to		ca co co			CO	AiiDsmia.
^		~	-			Hernia pudendalis.	-J		* W *				Pharyngitis.
		M	-			Epistaxis.	-J		Q P U *				Hernia umbilicaris.
-		-		H*		Hydrocephalus acutus.	-1		f es ■ -J				Adhaesio linguae.
.-		M		.-		Labrum leporinum.	CI		to CO co to				Myalgia.
it.		: m		-		Cellulitis.			to *■ CO CO				Dentitio difflcilis.
		to *o to to i: « p *k				Injuria?,.	CI		ifc ►-> J. h-				Incontinentia urinae.
		*. : co m				Asthma.	00		~ CO - CO				Laryngitis.
to		to ^ to to *. 00 to CO				Not classified.			a w o to				Vomitus.
	1	QO -l -J -1 c to 00 CT				Aggregate.	Cl		*. i«k ttt *. ffl ^ *. u O Oi t-1 rf-				Aggregate.
DIG 
317
     Every physician who has had  any experience in a dispensary-practice
is fully aware of the attendant difficulties and of the unsatisfactory manner
in AAiiich the histories of interesting cases are frequently recorded.   These
difficulties and embarrassments  are  multiplied in this department.  Adults,
not dependent on others for physical assistance, are prompted by their indi-
vidual sufferings to  return regularly at the stated hours, but the parents
and  friends  of sick  children, among the poorer classes,  Aviio seek medical
aid at-public dispensaries, are proA'erbially indifferent to the ailments and
sufferings of their offspring and wards ; hence the great carelessness  in fol-
loAving the prescribed directions, in the proper administration of medicines,
and the dereliction of duty in failing to present. the suffering  child  at the
dispensary at the regular and stated periods.   Consequently the practical
results,  so far as  they relate to the advancement of medical science, refer
almost  entirely to  statistical observations of the \Tariety  and frequency of
diseases in particular localities.   Few opportunities are afforded for the study
of pathology and morbid anatomy, and mortality statistics are utterly val-
ueless.  The diagnosis and treatment of diseases  are  the practical lessons
of a dispensary-service.   The final result of the treatment is frequently left
in doubt by the failure of the patient to continue attendance until finally
discharged.  Yet the observation of a number  of  cases  of  any particular
disease, presenting in their A^aried aspects all  the phases of the disease  and
exhibiting  the partial, if not  conclusive,  effects  of the  different plans of
treatment,  furnishes a rich store of useful information.   As a school for the
clinical teaching of the differentiation  of diseases, it  is  only excelled by
hospital-opportunities, inasmuch as ample facilities are afforded to verify di-
agnoses, so far as such can be  accomplished by the physical  inspection and
examination of the patients, and  the  not unfrequent opportunities to com-
pare the phenomena of particular affections exhibited  by a  number  of pa-
tients present at one and  the same  stated period.  Hence the value of all
statistics of the variety,  number, and  relatiA^e  frequency of the  diseases
treated in dispensaries, together with the ages, sexes, and colors of the patients.
For though this class of patients is draArn from  the poor and needy, who
inhabit  the alleys  and filthy streets of populous cities, occupying illy-con-
structed and badly-ventilated tenements, frequently croAvded together Avith-
out proper protection and Avith a scanty subsistence, the  prevalence of dis- 
318
ease among  them must be accepted as the  criterion by which the health-
fulness of cities is to be determined.
     According to my experience, dispensary-practice is singularly exempt
from the exanthematous  diseases and  from diphtheria.   This observation
acquires  additional interest  from the fact that during the period in which
these statistics haA'e been gathered, Avide-spread epidemics of measles and
scarlet fever  have prevailed throughout the adjacent cities of Washington and
Georgetown, and within the geographical limits from Avhich  the larger propor-
tion of the patients visiting this dispensary are draAvn.   Admitting the ordi-
nary caution and care against " catching cold," Avhich usually the poor and
needy take to prevent the "driving in" of cutaneous  eruptions, as the bar-
rier to the presentation of such patients at the dispensary-building, neverthe-
less, if these epidemics had prevailed to any considerable extent among these
classes of inhabitants, there would surely haAre been  many cases seeking
relief from their obstinate sequelae.   Yet but a meager number of cases of
bronchitis and diarrhoea have been traced  to these causes,  and these are the
only tAvo sequela? Avhich have been presented.
     In the foregoing table I have enumerated the diseases in  the order of
their frequency, and though the observations cover, in the aggregate, but
1,028 cases of disease, the numerical results are attested by the ordinary ex-
perience of private practice.  In the order thus established by relative fre-
quency,  intermittent fever is considerably  in excess of any other.  The rela-
tive proportions of the sexes and colors are singularly interesting.   Its greater
prevalence among the males and whites is not simply the lesson deduced from
the aggregation of all the cases admitted within the dates  mentioned, but  it
is likeAvise sIioavii by the folloAAing analysis of each year, thus  materially
enhancing the value of these statistical results:
                   Analysis of the sexes and colors of each year.
1	1870.	1871.	1872.	Total.
r Males......	23 13 11	41 26 23 13	10 3 4 o	78 40 29
AVhito \ „				
				
Colored \				
				
Total..........................	71	103	19	190
				
     This excess of males and whites over the females and the colored is not
due to any excess of males and whites admitted to the dispensary, for, in the 
319
general aggregation of the sexes and colors, it is sIioavii that more females
Avere admitted than males, and more colored than Avhites, thus: males, 509;
females, 519; Avhite, 487; colored, 541.
    The conclusion, then, is inevitable that, Avithin the area of the operations
of this institution, intermittent fever more frequently attacks the male sex and
the white race than the female sex and colored race, and it becomes a matter
of importance to ascertain, if possible, the causes of this difference in the sex
and color of  its subjects.  If this difference was only confined to the sexes,
it might be very easily accounted for on the  very probable hypothesis that
the male sex  Avas more generally exposed to the causes of this disease; but
this theory is untenable in AieAV of the facts that in a number of  patients, in
Avhich the colored and females are in excess of the Avhite and males, a larger
proportion  of the white males and Avhite females than of the colored males
and colored females are seized Avith the disease.
    With the view of testing the Aalue of these results, I have, through the
kindness of my  colleague,  Dr. William Lee, to Avhose department in this
institution all the cases of intermittent-fever among adults are referred, made
the following analysis of such cases.   During the same period coA^ered by the
cases among  children, Dr. Lee has admitted to his department 1,114 cases of
all  diseases,  of which there were:  whites, 550; colored, 564; males, 380;
females, 734.
    Among these 1,114 patients,  there Avere 334 cases of intermittent fever,
which, being  classified according to race and sex, show the following results :
	AVbite.		Colored.		Total.
	Male.	Female.	Male.	Female.	
AVholo number................ Intermittent fever............	207 111	343 108	173 51	391 64	1,114 334
     Thus it appears that the results shoAvn by my statistics are fully cor-
roborated by those of Dr. Lee.  The simple  fact that there Avere a greater
number of colored female than of colored male cases, thus differing in  this
particular from my figures, is clearly due to the very considerable excess of
females in the gross aggregate ;  but the ratio of the disease among the females
of both races is very considerably less than among the males, and less anions:
the colored than among the white.
     Among medical men there  are tAvo theoretical explanations of the cause 
320
of intermittent fever.   One is based upon the idea that, under certain influ-
ences and conditions, a substance denominated malaria, occult in its proper-
ties  and in its  form,  is generated and taken  into the system;  the other
seeks its explanation  in the  diurnal changes of temperature.   Neither of
these theories furnishes a satisfactory explanation for this disparity in the
sexes and colors of its subjects, for if the disease owes its origin to the absorp-
tion of a poison so minute and diffusible that it cannot be recognized, except
by its peculiar and characteristic phenomena, surely there  is no reason Avhy,
in a locality in Avhich  the  colored outnumber the white, and Avhich is per-
vaded by an atmosphere  impregnated with  this subtle poison, there should
not be more colored than whites, and an  equal ratio of females among the
aa hite and colored, made to feel its deleterious influences.  As yet, physi-
ology recognizes no difference in the structure and function  of the alimentary
mucous membrane of the AAiiite and colored races, neither has any difference
been discovered in the pulmonary organs  of the  different races and sexes
Avhich favors or facilitates the introduction of poisonous malaria into the sys-
tem.  Hoav far  the marked and opposite distinctive colors of the skin may
operate in promoting the absolution of  atmospheric poisons into the general
system, I shall not, in the absence of other data, seek to determine; but the
comparative  exemption of the African race and very general, susceptibility
of the Irish people to  malarial  influences  impress me Avith the belief that
constitutional and national peculiarities  play an important part in the causa-
tion and development  of intermittent fever.
     The diurnal changes of temperature, either as 'the exclusive or associate
cause, are equally unsatisfactory in furnishing an explanation of the  facts
exhibited by these statistics, for there is no reason why these changes
Avould not affect alike  both races and both sexes; yet it appears that in the
Avhole number  of patients of all diseases, in which the colored race and
female sex. are  in  excess, intermittent  fever is more prevalent among the
Avhites and males; and, of the intermittent-fever patients, the larger number
of both races  are males, and  the  female Avhites exceed the colored males.
In vieAv of these considerations it is evident  that  some additional cause or
agency, other than the absorption of  noxious  malaria  or exposure»to the
diurnal changes of  temperature, must be sought to account for these appar-
ent idiosA'iicracies. 
321
     To pursue the inquiry thus suggested I have classified  below the ages
of the sexes and races of the intermittent-fever cases among children:

                       Classijication of ages and colors.
	1 and under.	1 to 5, in-clusive.	5 to 10, inclusive.	10 to 15, inclusive.	Total.
	3 2 3 5	16 21 11 12	29 17* 12 4	30 12 14 5	78 52 40 26
AVhite \ „					
					
Colored \ ,„					
Total..............................					
	13	60	62	61	196
					
     Thus it appears  that among infants one  year old  and less there were
six males and seven females, five white and eight colored; so that, viewing
these figures in their relation to the aggregates of each race and sex, it seems
clear that the causes operated alike during this period of life upon both sexes
and both races, and as the proportion of the cases of disease among those of
one year of age and under is so small, whether compared to the gross aggre-
gate of all  the cases or to the  aggregate of the respective classes of  the
cases of the disease, it seems equally evident that infants are either less sus-
ceptible or less exposed to the operation of the causes.   Tracing the relation
which the three  subsequent quinquenniads bear  to the frequency of  the
disease among children between one year and fifteen  (inclusive) years of
age, it appears that among the male whites there is an  increasing  ratio and
among the  female whites a diminishing ratio, AAdiile  among the colored
males there exists but a slightly altered and among the colored females a
markedly diminished ratio of  disease between the first and  third  quin-
quenniads.  This  result, considered in connection Avith the universal laAv,
that disease among all classes of children is  far more frequent under five
years  of  age  than during  the  subsequent  periods  of  childhood,  and  the
conclusion seems irresistible that exposure in the open air and to the sun's
rays constitutes an important factor in the causation.   This  conclusion is
corroborated by a consideration of the habits of the four classes of children
studied in this connection.   The helpless infant,  unable to walk  or go
beyond its mother's grasp, is usually, even among the indigent  and squalid
classes, protected and sheltered, as best their scanty means and comfortless
lodgings will afford, from the vicissitudes of the weather and the rays of an
       41 
322
autumnal or vernal sun.   During this period of life intermittent  fever finds
but few subjects, and they irrespective of sex or race.   During the immedi-
ately subsequent period, Avhen the child is  permitted to  enjoy its liberty,
pleasures, and sports in the street, away from the sheltered seclusion of the
lodging-room, exposed to an atmophere purer and more salubrious, basking
in the sun-light, and yet, perhaps, breathing in the noxious and subtle mala-
rial exhalations, the figures exhibit a marked increase in the  proportion
seized Avith fever, and this  proportionate increase  is  common to  the  four
classes of patients, though  more marked among the Avhites.  During the
third  and fourth periods of childhood the proportion  of disease increases
among the males, being  less marked among  the  colored, and  diminishes
among the females of both  races.   This  is the period of boyhood useful-
ness and boyish sports in  the open  air, earning a scanty subsistence or
playing  at tops and battledoor, while the girl is lending a helping hand to
the mother under the shelter of the family domicile or at service at a more
comfortable abode.   Surely this is not  an overdrawn picture, but simply
the tracing of the cause of disease through the habits of nature, seeking  cor-
roboration of the  deductions from statistics through the incidents of  every-
day life, and conforming the peculiarities  of a disease,  in the selection of its
subjects, to the well-knowm habits of its victims.
     The statistical results in regard to the relauwe frequency of the disease
among the races and sexes of  children are corroborated by the statistics of
the adult cases.
     The following tabulated statement exhibits the gross  aggregates  of the
races and sexes of both classes of patients, adult and children, and  the  per-
centages of intermittent-fever patients of the sexes and races of each of these
two classes of patients:
	'a 3	o "a 3		u o "o	O H
Whole number of each race and sex of the adults___	380 42.63 509 23.56	734 23.42 519 14.66	550 39.63 487 26. C7	564 20.56 541 12. 21	1,114 1,028
AVhole number of each race and sex of children.....					
					
     Thus, as among children, the adult males and Avhites are more liable to
the disease than the females and colored.  Thus far the analogy is complete. 
                                    323

•  But when the adults are classified according to the sexes of the two races, as
  below,
	White.		Colored.		Total.
	Male.	Female.	Male.	Female.	
	207 111 53	343 108 31	173 51 29	391 64 • 16	1,114 334
Whole number of intermittent fever . Per cent, of intermittent fever........					
					
it appears that the percentage of the disease among the adult white females
is greater than it is among the colored males.  Hence the force of the sugges-
tion in regard to the causal influence of open-air exposure is weakened, for
it cannot be that the colored males are less exposed than  the Avhite females.
In the absence of any other explanation of this discrepancy, made apparent
by these statistics, I am compelled to conclude that it is only susceptible of
explanation  through certain physiological peculiarities.*   How far color
operates in determining the susceptibilities of the two  races cannot, in the
absence of any statistics of the disease among the mixed race, be estimated.
Whatever may be its influence, it does not present itself  to my mind as the
conclusive and determining distinction.  The excess of whites is shoAvn, by
actual enumeration, to be due to the great predominance of immigrants, espe-
cially the Irish and their descendants; hence acclimation becomes a constituent
in the  general summing up of the causes.  As physical and Aital qualities are
transmissible by inheritance, Avhy may not acclimation, which has been ac-
quired by the African through generations, be transmitted to their  offspring ?
Thus may be explained the differing susceptibilities of the native colored and
the native children of the white immigrants.  Perhaps no two races are more
opposite  in their temperaments than the Irish and the African; the  former
are nervous, excitable, and impressible, the latter phlegmatic, stolid, and in-
different ; yet, perhaps, none more alike in their manner of liAing, herding
together  in squalid and comfortless houses, not caring for the ordinary com-
forts of life,  disregarding the simplest laAvs  of health,  and subsisting upon
meager diet.  Acclimation, acquired and inherited, Avhich is so frequently
illustrated in the comparative immunity of individual members and of fami-
  * Gait, in his memoir, entitled medical notes on the Upper Amazon, (American Jour-
nal of Medical Sciences, vol. Ixiv, p. 403,) states that in the regions bordering on the
Lower Amazon the unative red man " is less able to resist the malarial feveis than the
u  white or negro." 
324
lies of the white races, Avho are alike, so far as is apparent to our observation,  •
exposed to the causes which are supposed to induce intermittent-fever, fur-
nishes a rational, though not a conclusive, explanation of these varying sus-
ceptibilities.   Doubtless there are many other influences, physiological and
atmospheric, Avhich enter into the constitution of the composite and complex
causation of this fever.
     The  marked and rapid destruction of the colored blood-corpuscles in
malarial fevers, suggests, as intimated by Dr. Joseph Jones, of New Orleans,
"the action of a special poison."   Chill is the characteristic phenomenon of
malaria, and so likeAAise is it a marked feature, though perhaps not so regu-
larly periodical, in all other diseases in Avhich there is a  rapid destruction of
the colored blood-corpuscles.  Dr. Jones (American  Practitioner, vol. vii, p.
1G)  asserts that, "in malarial fever the constituent of the blood which suffers
to the greatest and most essential degree is the colored blood-corpuscles,"
and that the destruction takes place principally in the liver and spleen.   The
analogous phenomena of intermittent fever and pyaemia, and the character-
istic alterations of the normal color of the liver and  spleen, resulting  from
the accumulation of the disintegrated colored blood-corpuscles, together with
the  nutritive changes in the same organs, present important considerations in
connection Avith the study of the cause.
     In thus pursuing the inquiry suggested by the statistics before me, I am
led  to the folioAving conclusions:  first,  that some  additional  or associate
element, other than the absorption into the system of the poisonous miasmatic
exhalations or the  impression upon the system  of the diurnal changes of
temperature, must play an important part in the production of this disease;*
secondly, that exposure to the sun's rays in the open air enters largely into
the general constitution of that complex, though as yet mythical, substance,
  *Galt, in his " Medical Notes on the Upper Amazon,"  (American Journal, vol. Ixiv,
pp. 405-408,) calls special attention to the fact observed by him during his wanderings
along this  great river and its tributaries, that the cause of malarial fever was far more
intense and the number of cases ATastly greater in the localities and among the people
most exposed to the tropical sun. He expresses the opinion, which is corroborated by
many observations, that " excessive dryness and excessive moisture both seem to pre-
Aeut the accession of malaria."  He says, further, " When the wanderer leaves the main
river and betakes himself to the higher grounds of any of the tributaries of this huge
Avatery cormorant, where he begins to encounter rocky beds to the streams, rocky sides
to the riATers, a comparative chillness of air in the mornings and evenings, with a greater
frequency of fogs, while the  mid-day is a  glowing heat, there begin  the tirciana, as
the malarial intermittents are called." 
325
malaria; and  though, perhaps, not  an essential element, yet like  heat and
moisture,  holds  no inconsiderable place in this etiological relation.   And
thirdly, That the susceptibility to these causes, whatever they may be, is very
much more highly developed among the white than African race, due either
to the distinctive characteristics or habits of the races; for surely no one who
has lived among a mixed population of the Avhite and black can have failed
to have observed that malarial diseases either possess an elective affinity for
the Avhites or that  the African is less impressible by their  causes, and that
the latter  suffers less frequently and  less severely from the secondary effects
of malarial poisoning, is more amenable to treatment, and  less liable to re-
lapses.
     The  symptomatic phenomena  of intermittent  fever during childhood
differ somewhat  in the earlier years of life from  those  marked  and regular
symptoms which  ordinarily characterize its invasion and progress among
adults, in the frequent absence of the cold stage, with defined rigors  and shiv-
erings.  The fever, with sudden and high elevation of  temperature, not un-
frequently attended with great cerebral disturbance, and, occasionally, Avith
alarming  nervous phenomena, is usually  the first warning of  its  inception
When the febrile stage is ushered in  by prodromata,  they are often illy de-
fined and demand the closest scrutiny to detect its insidious invasion.  In many
cases, especially in the milder forms, the periodic seizures, not unfrequently
irregularly intermittent, are attended with symptoms so variable and protean
in their character, that only those who may have had opportunities to observe
the multiform phases  in AAiiich malaria exhibits  its  phenomena will readily
detect the insidious inception and progress of the disease.  Periodicity is the
only uniform characteristic, and this may be manifested in a single symptom,
sometimes slight and tirvial, at another time in a convulsion varying in dura-
tion and intensity, perhaps succeeded by a high fever and alarming  delirium;
or it may present itself in a state of  collapse apparently threatening imme-
diate death, or, again, in an array of seemingly harmless  symptoms,  which
one feels disposed to attribute more to the anxiety and imagination  of the
mother than to disease.  But hoAvever mild and trivial the  symptoms  in the
beginning, if not  promptly arrested, they  progress into  well-defined and
characteristic forms, and surely eventuate  in the unmistakable impression
upon the general system.   These insidious forms of  invasion and  indefinite
phases are proportionately more frequent among infants and very young chil- 
326
dren.  With the advance  of  age the fever assumes its  more  regular and
marked characters, and presents, very generally, the  symptoms of its three
distinctive stages.
     When neglected and persistent, intermittent fever produces in children,
as in the adult,  its ordinary sequences, and the younger the child  the more
speedily are these effects to be anticipated.  Anaemia, marked with a blood-
less skin, and, in the white, Avith a peculiar sallow color, a small, pale tongue,
almost bloodless lips and buccal  mucous membrane, in the colored, with
pearly-white  sclerotica,  though  occasionally  tinged yelloAv, which yellow
tinge is usual in the white; an hydraemic state of the  blood,  occasionally
eventuating in dropsical effusion; and enlargement  of the spleen are its most
frequent sequences.
     *The relation,  as cause, which malarial  fevrer bears to renal disease is
exceedingly interesting, and demands more careful consideration and study
than haA^e been  bestowed  upon it.   It can no  longer be denied that chronic
malarial poisoning AAill,  in occasional cases, eventuate in the establishment
of disease of the kidneys, f Professor Jones, of New Orleans, who seems to
have carefully studied this relation, concludes, from his observations and in-
Arestigations, that, in cases  of malarial fever in which albumen appears in the
urine, it is due to one of the following conditions:
     1.  "To preceding disease of the kidneys, of the liver, or heart."
     2.  "To the prolonged action of the malarial poison, and the structural
alterations induced by it in the spleen, liver, and kidneys."
     3.  "To the congestion of the kidneys from cold, or from the impaction in
the capillaries of pigment-matter, or from the  irritant action of  the malarial
poison upon the excretory structures in cases  which have suffered with re-
peated attacks of intermittents."
     In the American Journal of Medical Science  (vol. lxv,  p. 123) will be
found a report of a number of cases of renal disease in children, which came
under my observation in the Children's Hospital of this city.  In tAvo of the
    * Eoberts has  not met with any case of renal disease occurring as the sequela to ague.
Both Becquerel and Frerichs likewise state that, in dropsies following intermittent fever,
they had never found evidence of kidney-disease; but Eosenstein found in theHantzic
hospital 23 per cent, of the cases of Bright's disease  referable to antecedent ague.
Heidenhaiu found secondary renal disease in a very large proportion of malarial fe\'er
in some epidemics.  Parkes,  Niemeyer, Stewart, and. Hr. J. J. Woodward, have wit-
nessed eases of Bright's disease referable to malarial poisoning.
    f American Practitioner, vol. vii, p. 19. 
327
cases the numerical  relation of the Avliite and colored blood-corpuscles was
very markedly disturbed.   At the time of preparing the report I entertained
the opinion that the  colorless corpuscles were actually increased; but, defer-
ring to the  opinion of Dr. Jones, since published, I must conclude that the
increase  was relative, due to the great destruction of  the colored corpuscles.
This view is sustained by the favorable prognosis of such cases, for the indi-
cation to restore the normal relation of the white and red blood-corpuscles
by increasing the latter, rather than by diminishing any actual numerical
excess of the former, is, in the present state of therapeusis, more suggestive
of medication.
     The enlargement of the spleen is, I think, proportionately, more frequent
among children under ten years of age than among adults.   From the con-
clusion set forth by Dr. Jones the inference Avould folioav as a logical sequence
that there Avas some constant coincident relationship between splenic enlarge-
ment and kidney-disease,  but so far as my observations have extended none
has been recognized.   In the  reported cases of kidney-disease consequent
upon chronic malarial  poisoning, there Avas no  appreciable  enlargement of
the spleen.  Dr. Jones states that, while he has failed  to detect any evidence
of kidney-disease  in those cases where, from "prolonged action of the ma-
laria," profound structural alterations of the liver had taken place, accom-
panied with "ascites and extreme dropsical infiltration of the loAver extremi-
ties," yet, in all cases of chronic malarial poisoning in which he has detected
albumen in the urine, he has found "structural alterations of the kidneys."
     The treatment is so simple and uniform that little need  be said.  The
notes of my cases present a feAv points of interest, which may serve to cor-
rect  some errors in the ordinary mode of practice.  Quinia is emphatically
the remedy, and the  principle regulating its  administration is to control, as
speedily  as possible,  the paroxysms.  Experience has taught me  that unless
there exists  constipation it is altogether unnecessary to precede  it with any
purgatiA^e.   In  former years it Avas  considered  indispensably necessary, to
facilitate  its effect and to avoid excessive cerebral disturbance, to precede the
administration of quinia Avith a full purgative  dose of calomel, and this prep-
aration of the system was  deemed  an essential prerequisite in those  cases
where the secondary effects, indicated by a sallow skin and yellowish-tinged
cornea1, had supervened.   Such practice I am compelled  to reject  in toto.
Mercury, either as an alterative or a cholagogue is contra-indicated, and should 
328
never be given, unless as a purgative when constipation exists.   AVhatever
hepatic complication or derangement may exist, it is simply one of a series
of resultant phenomena, and is best treated by curing the primary disease.
The salloAv skin  is a characteristic sign of malarial ansemia,  and speedily
yields to appropriate treatment: quinia alone  or in c ombination with iron
Except in children of one year of  age and under, there  is no absolute cer-
tainty of arresting the paroxysms, unless  from fifteen to twenty grains  be
given during the intermission, and the dose of the medicine and intervals of
administration should be regulated by the time to elapse betAveen the con-
sultation and advent of  the expected  paroxysm.  It is  ahvays important,
especially in very young, feeble, nervous, excitable children, to arrest  the
paroxysms  promptly, and without unnecessary waste of time,  for,  though
many children bear  one or more paroxysms, without  any  serious conse-
quences, occasionally alarming and dangerous symptoms suddenly complicate
the case.   Nor should the risk of  a recurring paroxysm  be incurred rather
than give a sufficient quantity of medicine during a A'ery brief intermission,
because of any fear of the  detrimental operation of  quinia during  the  ex-
istence of  fever.   I know of no more  efficient diaphoretic, and  fully
coincide Avith  Jacobi, that quinine reduces the temperature more mark-
edly and quicker than any other remedy, and does  not act  so rapidly on
the pulse."
      During the first year of my service in  this institution I employed
the sulphate exclusively, usually in the form of solution, dissolved with sul-
phuric acid. I experimented very extensively,  with a vieAv to  discover some
method of concealing the bitterness of the drug, but after many fruitless
attempts finally abandoned it as a hopeless undertaking.   With  adults, since
the introduction of the capsules and  the compressed  pills, the taste can be
very easily entirely concealed.   Children take the  bitter  solution  more
readily than either of these.  The admixture of quinia with the fluid extract
of liquorice is wholly inadmissible, because the  quinia, being insoluble in  the
extract, soon settles at the bottom of the bottle, forming, with a  sediment from
the extract, a tenacious glutinous substance, which can only with great diffi-
culty be again shaken into a homogeneous mixture, and if any acid be added
to dissolve the  quinia the saccharine matter is precipitated, and hence  the
solution is as bitter as if the menstrum had been simply  Avater.
     In 1871, my attention was arrested by the perusal of the article entitled 
                                   329

"The useof Quinine in the Diseases of Childhood," by Professor Binz, of Bonn,
Germany, and published in the American Journal of Obstetrics, (vol. iii, p. 1,)
in Avhich he enunciated the three folio wing conditions to be kept in vieAv in
the use of quinia in infantile disease:  "First, the dose should not be too small;
secondly, a readily digested preparation should be  selected; and, thirdly, the
drug should be administered before the disease has obtained its acme."   It
Avas  Bricquet Avho first recognized the fact,  since accepted by Binz, and
Jacobi  of  Ncav York, that  the  infantile  age  especially tolerates  quinia in
large doses.   My OAvn experience, both in dispensary and priYate practice,
attests the truth of this conclusion. •  The tentative and time-wasting plan of
administering quinia in minute fractional doses, with the view only to miti-
gate the severity and shorten the duration of successiA^e paroxysms, is  ex-
ceedingly reprehensible, inasmuch as it prolongs the course of the disease and
demands additional sacrifices of the constitutional  vigor.  The second con-
dition can be  fulfilled by dissolving the sulphate with hydrochloric acid or,
Avhat is preferable,  by using the hydrochlorate of quinia.  To any child one
year and under five  years of age a scruple of this salt can be given in six
doses during an intermission of twelve hours with entire safety, and if neces-
sary the dose can be increased.   The  advantages of this salt consist in its
quick absorption, diffusibility, less  liability to produce gastric irritation or
vomiting, and in the mildness of the  ordinary nervous  and cerebral dis-
turbances.*   It invigorates the  appetite  and stimulates  digestion, in these
qualities differing,  in a marked  manner, from the sulphate  when given in
full doses.
     During the autumn of 1871  I administered in fourteen cases of inter-
mittent fever  carbolic acid, the same haAing  been previously employed by
Freulich.   The history  of these  cases, Avith  the  failures and successes, I
subsequently  published in  the  National Medical  Journal, (vol.  ii, p.  297.)
The conclusion drawn from these experiments was that carbolic acid would
cure the disease, but that it was uncertain, unreliable, and slow in producing
such  results.   Subsequently to this publication  Dr.  Yandell, of  Louisville,
published in the American Practitioner the result of a series of experiments
made 1)a~ him with the same agent in the same disease, with the opinion that
    *Binz says that gastro-intestiual irritation is only caused -by quinia when the gas-
tric secretion is not sufficiently acid.   This can always be avoided by giving quinia in
a slightly acid solution.  (Archives of Scientific and Practical Medicine, January, 1873.)
      42 
330
 it was  utterly worthless.   To  test the accuracy of my oavii conclusion I
 selected five well-marked cases, in two of Avhich it proved successful, though
 not until it had been given during ten days in  gradually increasing doses.
 In one of the failures it Avas suspended after ten days' unsuccessful employ-
 ment, because of the appearance of a papular eruption over the whole sur-
 face of the body, attended Avith constant and excessive itching, which grad-
 ually disappeared without treatment.  More recently Dr.  Didat,  of Paris,
 has used carbolic acid in the  treatment  of intermittent fever by injecting
 subcutaneously a  solution of the strength of one part of the  acid  to one
 hundred parts of water.   Four injections are made  the first day, three the
 second, and tAvo the third.  Dr. Didat says the fever is ahvays abated by
' the first operation and frequently  cured.   The other two are merely a mat-
 ter of precaution.*
      In the  treatment of the   ordinary  sequences  of  intermittent fever,
 angemia, and chronic enlargement and induration of the spleen, quinia and
 iron, with a  proper and nutritious diet, furnish the only hope of  successful
 results.   Anaemia is  very amenable  to  treatment;  not so,  however,  with
  chronic splenic enlargement.   Acute enlargement will usually subside Avith
  the entire elimination  of  the malarial poison from the system and the resto-
  ration of the blood to its normal  condition.   These conditions  are fulfilled
  with  quinia and iron.   In chronic cases the  spleen  occasionally  attains
 .enormous size, half filling the abdominal cavity, compressing  the thoracic
  cavity, displacing the viscera of both cavities, and attended with the vari-
  ous functional disturbances incident to such visceral  displacements.  In two
  instances, (the notes of which are in my case-book,) the heart  Avas entirely
  displaced to the  right*of the mid-sternal line.  In  such chronic  cases the
  issue is one  of time.  Every effort,  by means of tonics, quinia, iron, and a
  nutritious diet, Avith proper and prudent  regulations in 1 egard to exercise
  and exposure, must be made to restore the general health and  the constitu-
  tion to its normal condition and to maintain it at that standard.  Such result
  being obtained and maintained, time may eventually effect the reduction of
  the "ague-cake."  If relapses of the fever are  permitted, or renewed at-
  tacks incurred in consequence of a suspension of the treatment or fresh ex-
  posure to the causes,-the sequences become more obstinate and  protracted
  and less amenable to treatment.  A  large  portion of those seized with the
* The Lancet, January 11, 1873. 
331
 fever in the autumn will suffer a recurrence in the spring, and these vernal
 recurrences are usually much more obstinate than the original autumnal
 attack.   In this latitude the tendency to relapse is very common, and can
 only be  prevented by the daily use  of a  moderate quantity of quinia, to
 be combined Avith iron if ansemia  co-exists.  In those occasional instances
 where quinia fails to arrest the paroxysm, the explanation of the failure is
 to be found in  the existence of some of the secondary effects or in some
 imprudent exposure or habit.   In such cases the special cause must be de-
 tected and removed, and such general therapeusis adopted as will best meet
 the  indications presented.
      Chronic malarial poisoning, in AvhateATer form it  may localize itself, is
 best treated with quinia, iron, and  a nutritious diet.  It occasionally hap-
 pens that  the  characteristic phenomena  of chronic malarial poisoning are
 completely masked by an array of symptoms which  may present  a Avell-
 defined picture of some malady in  nowise resembling the real disease ; for
 instance,  during the past autumn there were many cases of diarrhoea, Avith
 profuse serous stools, which readily submitted to quinia, and  Avhich ob-
 stinately resisted the remedies ordinarily found efficient in diarrhoea.   These
 masked malarial affections cannot be accurately diagnosticated.   The prev-
 alence of malarial disease is suggestive of the complication, but the  mani-
 fest  benefit derived from the  administration  of quinia furnishes the only
 point of positive diagnosis.
                               Article II.

       Eutero-colitis, Cholera infantum, Dysenteria, and Dentitio difficilis.
     As the purpose of this report  is simply to present to the  reader the
 points of  special interest indicated by the notes of the cases of the different
 diseases treated, and not  intended to be an extended dissertation on the na-
 ture  And pathology of the diseases respectively, I have, to avoid confusion
 and repetition,  associated these four allied  disorders.   The three diseases,
 and, usually, the last, (if it be entitled to a distinctive  designation as a dis-
 ease,) besides other points of similarity, have one symptom—increased fre-
 quency of the alvine dejections—common to  them all.  Authors of very
high repute have sought to establish distinctions based upon peculiar char-
acteristics of the  stools and locality of morbid lesions;  yet all admit that,
clinically, it is impossible to determine, with accmacy, the pathognomonic 
332
differences.   The local morbid lesions are to be found, more or less defined,
in  the  gestro-intestinal mucous membrane,  most usually in  the  larger
intestine.   Entero-colitis  and dysenteria  are nosological  terms, intended
to represent  the precise anatomical  locality  of some grade of an  inflam-
matory process, having its beginning, if not also its termination, in the
mucous membrane of the digestive  tube ; yet tit  is not ahvays easily de-
termined Avhere entero-colitis terminates and dysentery begins, or  Avhere
cholera infantum  ends and  entero-colitis  commences.    The  choleriform
stools of cholera infantum may eventuate in the establishment of either en-
tero-colitis or dysenteria, and if frequent muco-sanguinolent stools, accom-
panied with tenesmus, abdominal tenderness, and fever, be accepted as pathog-
nomonic of  dysentery, many  cases running the course of entero-colitis
terminate with  well-defined  dysenteric symptoms.   Even so eminent a
Paediatrica as  West, of London, recognizes  no other difference than the
grade of the  morbid process.
     If  the frequent and  exhaustive serous  and. choleraic stools, attended
Avith rapid Avaste and collapse, define and limit cholera infantum according
to the systematic classification of diseases, where can be classed that com-
mon form of simple diarrhoea not usually attended with fever or abdominal
tenderness 1  Is not the distinction one of degree rather than of kind 1
     The  term entero-colitis implies an inflammation of some portion of the
intestinal mucous membrane.  West says the  anatomical changes are found
" chiefly, though not exclusively, in the large  intestine," and that the affec-
tion of the  small intestine is "secondary and subsidiary" to colitis.   J.
Lewis Smith found in his 81 autopsies,  Avith a single exception,  "lesions in-
dicating inflammation  of the mucous membrane of the colon," and "in a
large proportion of the cases, also, ilietis."  Bouchut discovered  constant
change  in the large intestine, and maintains that  the " mucous membrane
of the small intestine is the only  one of the constituent parts of this organ
Avhich  participates  in the  changes of entero-colitis,"  and,  furthermore, that
the lesions AAiiich it presents are to be  found  " in nearly all the subjects."
Meigs and Pepper "invariably found," in their numerous autopsies of cases
of entero-colitis, inflammatory lesions of the large intestine, in some cases
limited to  it, in others extending to the small,  and maintain that it is clearly
established that inflammation is much more frequently found in the large than
in  the small intestine.  Notwithstanding these very decided opinions, based 
333
upon post-mortem investigations, experience  and observation, affirmed by
post-mortem examinations, demonstrate  the uncertainty of the clinical dis-
tinction betAveen inflammatory and non-inflammatory diarrhoea.  For, with all
the symptoms of the former present during life, the autopsy may fail to dis-
close any inflammatory lesion  appreciable to  the naked eye.   In 127 au-
topsies of children who had died of intestinal diseases, Billiet  and Barthez
discoA^ered the characteristic appearances of entero-colitis in 84 cases, which
had presented the symptoms of that disease ;  " in 24, though no symptoms
had existed  during  life,  similar  changes  Avere discoA^ered;  in 19 the
signs of disease were  present  during life, but its  morbid appearances Avere
absent."   West has enjoyed a similar experience, and Bouchut and Smith
have occasionally failed to discoA'er any morbid  lesion.   M.  Bertin in
57  autopsies  failed in 4 to  recognize  any appreciable lesion.   And  M.
Ballard expresses the opinion that children  at the breast may  have di-
arrhoea without  a trace of inflammation of the intestines.  If  these be
facts, they establish nothing more than that a certain array of symptoms
represents, in one class of cases,  certain Avell-marked morbid lesions, and in
another class nothing.   To seek explanation of the  absence of any morbid
lesion by ascribing the symptoms to functional disorder, is simply the admis-
sion that functional disturbance may eventuate in tissue-change, a fact well
established. If hypersecretion, increased peristaltic action, and flux represent
in one case functional disturbance and in another some grade of the inflamma-
tory process, analogous reasoning would deduce the conclusion that the latter
had its beginning in functional distm-bance.  If like causes, under like condi-
tions, produce like symptoms,  which in one class of cases terminated  fatally
Avithout and in another class  of cases with appreciable lesions, the logical
inference Avould be that the difference Avas one of degree, and not of kind.
Functional activity augments  secretion;  so does simple hyperaemia; and the
two conditions may be correlative  phenomena.   In catarrhal  intestinal in-
flammation it is perhaps impossible to determine, by the objective symptoms,
Avhich is the precedent condition.  But the true explanation of these  discre-
pant  results lies. in the fact expressed in the failure of the investigator to
find any morbid  lesion.  I  am convinced that further and more accurate
research will establish their identity in morbid process.
     The simple diarrhoea, so frequently supervening upon irregular, tedious,
and difficult dentition, ordinarily  harmless in itself, and, perhaps, salutary 
334
in the beginning, not unfrequently, in  subjects favorably predisposed by a
bad  physical condition  and improper hygienic surroundings, eventuates in
the  establishment of one of the more serious forms of intestinal diseases,
and possesses, in this connection, no other significance than its causal rela-
tion  to inflammatory and non-inflammatory diarrhoea.  Having its origin, as
is almost universally held, in the development of the muciparous follicles of
the  intestinal  mucous  membrane, stimulated  to  excessive activity and in-1
creased secretion by the physiological process of dental evolution, during
Avhich period,  with rare exceptions, cholera infantum seizes its victims,  select-
ing,  most generally,  those of feeble, delicate, and nervous constitution, the
close relationship which the  natural process bears to the disease as cause
seems to be more than a mere coincident circumstance.
     For convenience and comprehensiveness I have classified all the cases of
non-inflammatory diarrhoea under the head of entero-colitis.  In doing this,
I feel fully justified by the  additional considerations  that the latter is  almost
invariably preceded by the former, Avhich, from  neglect,  injudicious,  or im-
proper treatment, gradually, and oftentimes  imperceptibly, develops the
lesions characteristic of one of the more serious forms of disease.  Rarely,
if ever, does ilietis or  colitis mark their inception.  Hence, as West says,
the  distinction betAveen them "is one of degree rather than of kind."
     I am seeking to establish the identity rather  than the unity of these
diseases,  and  the foregoing considerations show the practical inutility of
these  classical subdivisions and make apparent the  danger  of  too much
reliance upon the names  rather than upon the symptoms.  Undoubtedly,
cases  of these diseases  occur, typical  in  their  inception,  symptoms, and
progress;  yet the far more frequent  commingling  of their  phenomena
renders classification difficult and, to a certain extent, valueless.   The causes,
symptoms,  and  course, together  with the  age,  physical condition, and
hygienic surroundings of the patient, demand the attention and suggest the
appropriate treatment.
     Cholera infantum, so well marked by a group  of symptoms, more dis-
tinctive in their general array than in their separate and pathognomonic sig-
nificance and  more formidable  in their concurrent impressions upon the
general system than in the  special and solitary effect of any one of them
presents in typical cases, the clinical features of a Avell-defined disease.  The
sudden onset  of the  assemblage  of  symptoms;  their marvelous  haste 
335
toward decisive  and calamitous results;  their tenable  ravages,  speedily
expressed in the rapid prostration and exhaustion of the physical and vital
poAvers,  would seem to entitle  this group to a  distinctive  appellation,
Trousseau, in his graphic delineation of the disease, as  it came under his
observation,  evidently had  in view its  similarity to Asiatic cholera;  yet,
holding on  to  the doctrine, so constantly promulgated by him, and which
Bouchut also maintains, that  diseases owe their  characteristic and  distin-
guishing features to specificity, he maintained that the points of dissimilarity
are the " evident stamps of specificity."  Its infrequency,  as compared, Avith
non-inflammatory diarrhoea and entero-colitis; the  occasional absence  of
appreciable morbid lesions, and,  when present, their insignificance as com-
pared to the gravity of the symptoms, and its frequent and direct association
with dentition, manifestly point  to some constitutional  peculiarity  as  an
additional  determining  cause.  This  suggestion  acquires  force  from the
circumstance, believed to have been first suggested by Dr. J. F. Meigs, that
in some families there exists a hereditary predisposition to the disease.  More
than once I have observed that the children  of some families suffered from
the grayer disorder, while others in the immediate Aicinity, and apparently
liAing under less favorable hygienic conditions, escaped disease.  The chil-
dren of some families are never sick Avithout  becoming ill.
     Dysentery, as nosologically defined, is so rare a disease during child-
hood, and especially during the earlier years, that some authors have denied
its occurrence except as a secondary effect.   Bouchut doubts its occurrence,
and Yogel asserts that  sporadic dysentery frequently occurs in infants.
West, Smith, Meigs and Pepper, Trousseau, Tanner, and Ellis recognize the
essential fact—the localized  inflammation—but fail to  indicate any other
anatomical peculiarity of the morbid condition.   In 1,028  cases of all dis-
eases, I have memoranda of but 14 cases.   These were  sporadic.  Basing
my diagnosis upon the presence  of fever, abdominal pain  and tenderness,
tenesmus, and  muco-sanguinolent stools, I have felt compelled to separate
them from the  cases  of  entero-colitis, though the similarity of causes, con-
ditions of life under AAdiich the}' appeared, and the not unfrequent occurrence
of cases of entero-colitis, in Avhich the same symptoms ultimately appeared,
strongh' impress  me with the futility of a  nosological distinction.   Epi-
demic dysentery is marked by peculiar phenomena; but as the disease ordi-
narily  appears  during infancy and during  the  summer  months, the few 
336
cases being  scattered here and there among a number of cases of entero-
colitis and cholera infantum—all seemingly living  under like conditions—
the practical advantages of a distinct classification do not present themselves
Avith much emphasis.
    In the large and populous cities of this country the annual epidemics of
intestinal diseases  are  the scourges which decimate the  infant population.
In this city all  combined  fall far  short of the number of cases of intermit-
tent fever, as shown  below :
		6 "a I	CO	T3 © S-i O "o O	"a o H
	23.56 11.76	14.66 14.59	26.67 12.28	12.21 14.01	19.06 13.23 1,028
					
					
	509	519	487	541	
					
    Recurring to the statistics before me, I find nothing specially interest-
ing or instructive exhibited by a classification of sexes  and races, beyond
their more frequent occurrence among the females and colored :
	.2			
	^	c		
	o o	"9	'E	
	6 S		n S	
				
	a	a «-*		o
	W	o	R	H
	44	11	5	60
	57	10	9	76
White............	48	7	5	60
Colored.......... Total..........	53	14	9	76
	101	21	14	136
    When compared, as below, by their percentages to the whole number
of each class of patients, the relations shown above vary; yet in the aggre-
gate the percentages exhibit the same relation of frequency:
	Male.	Female.	White.	Colored.
Total..................................	509	519	487	541
				
	8.62 2.16 .98	10.91 1.93 1.75	9.85 1.43 1	9.79 2.56 1.66
				
				
				
	11.76	14.59	12.28	14.01
				
    The diseases separately do not follow any constant or general laAv as
to frequency among sexes and  races, but in the aggregates they exhibit
greater frequency among the females and the colored.   This is more clearly 
007
exhibited by the folloAving arrangement, which  sIioavs the number of each
disease for each year, classified according to sex and color, and the whole
number of patients for each year, similarily classified.  Thus it appears that
the proportion of each disease to the whole number  of each class  varies in
each year:
	Entero-colitis.		Cholera infantum.			Dysenteria.			AVhole number of patients.		
	1870.1 1871.	1872.	1870. 1871. 1672. 1 1			187.).	1871.	1872.	1870.	1871.	1872.
Male..............	22 ; 16 20 ! 30 26 , 14 16 | 32	6 7 8	7 3 4 6	3 8	1 1	4 6 2 8	1 2	1	182 179 188 173	236 263 236 263	91 77 63 105
White............ Colored.......... Total..........							2 1 1 1				
	42 i 46 13 1 10 10 1 1					10 3		1	361	4W	168
	1										
     These negative results are corroborative of the suggested  identity of
the three diseases.  Meigs and Pepper think cholera infantum more frequent
among the males.  My statistics sustain this opinion, but the aggregate  per-
centages sIioav that the female sex is more liable to the diseases.
Per cent, of cholera infantum............
Aggregate per cent, of the three diseases .
Male.  Female.
 2.16
11.76
 1.93
14: 59
     Dysentery exhibits an  excess among the females Avhich may be ac-
 counted for by the greater number of female patients, or, perhaps, by inac-
 curacy in the differential diagnosis, Avhich latter circumstance  might depre-
 ciate my standing as  a diagnostician,  but would, presumably, affirm the
 similarity of the diseases, at least in their  symptomatic  and objective phe-
 nomena.
     The greater frequency of the diseases among the colored may, perhaps,
 find its explanation in tho greater number of illegitimate births, and the con-
 sequent neglect and improper diet and feeding.   Mothers, Avithout husbands
 and means of support, are frequently compelled, to obtain "service" among
 respectable and  well-to-do families, to board their infants with those Avho pur-
 sue such business for  a livelihood, only giving them the  breast during a hur-
ried visit morning and evening.   During the intervals the child is frequently
insufficientlA' and improp' rly fed.  Numerous such instances fuwe come under
in}' observation, and Bouchut makes mention of the fact that, in Paris, non-
inflammatory diarrlnea is A'ery prevalent among the infants of mothers Avho, 
338
 " obliged to Avork in order to sustain their existence, quit their infants in the
 morning, return  at  several moments of the  day to give them the breast."
 Apart from any consideration of the physiological or constituent alterations
 Avhich may be induced in the mammary secretion, by the mental disquietude
 growing out of the conviction of moral turpitude or the privations of poverty,
 the  "disagreement"  of the milk Avith the  child, so frequently the alleged
 cause of the  early Aveaning so generally practiced by these "at-service
 mothers," may find its explanation in the Avatery condition of the milk, Avhich
 lias been sIioavii, by M. Peligot, to be proportionate to the length of time it
 has been retained in  the breast.   Upon the  consequences of this  partial
 weaning, and the subsequent improprieties of the feeding, I need not now
 dilate.
     The influence of lactation, both natural and artificial, in the causation
 of infantile intestinal diseases, is far too frequently overlooked by the careless
 practitioner.  Milk is the natural aliment of young animals, but the nursling
 is very frequently fed exclusively upon milk wholly deficient in  the neces-
 sary nutrient  and healthy constituents, and, indeed,  often upon it when it is
 diseased.  In this resume of the causes I cannot venture to discuss this sub-
 iect in extcuso, and might Avell content myself with a simple reference to the
 A~ery full and  instructiA*e Avorks of Routh on "Infant-Feeding," and  Donne1
 on  "Mothers  and  Infants,"  but I desire to impress the  young practitioner
 Avith the importance and, in many instances, with the imperative necessity of
 searching for the  cause in the habits, mode of life, and diet of the mother, and
 in the manner and frequency of nursing the sick infant.  It is not only neces-
 sary to ascertain that the secretion is healthy  in quality and that it comes up
 to the proper  standard in its normal  constituents.  The deleterious influence
 upon the lacteal secretion of sudden bursts of passion, of a nervous tempera-
 ment, of menstruation and pregnancy,  of excessive sexual indulgence, of
 irregular habits of life, and of certain articles of diet is too Avell established
 by clinical observation, if not by chemical analyses, to be  considered as mere
 coincidences unAvorthy of the attention and investigation of the scientific
physician.   Dr. Decaisne has recently (London Lancet, September, 1872)
shown that insufficient food may occasion very serious and varied disturb-
ances of the quality of the milk.   In his  report to the Academie des Sciences
of the results  of his observations of  forty-three women avIio nursed their in-
fants  during the siege of Paris, he deduced the conclusions that some Avomen 
33!)
may, upon insufficient diet, produce abundant and rich milk, and their chil-
dren Avill thrive, Avliile they themselves Avill emaciate;  another class will pro-
duce  but little  milk,  and that very poor, and their children will suffer for
want of  nutriment and sicken Avith choleraic diarrhoea, and a third class Avill
produce  scarcely any, and their children will die.  In syphilitic mothers  the
proportion of sugar is diminished and Avater increased in the milk; fever less-
ens and may suppress  the secretion; emotion,  mental anxiety, and soitoav
may diminish and also render it poisonous; puerperal fever seriously  dis-
turbs its healthy qualities;  insufficient  air, sedentary habits, and Avant  of
cleanliness not unfrequently impart to it conditions injurious  to the health of
the nursling.  Certain drugs administered to the mother may affect the infant.
Iodine can be detected in the milk;  mercury given to syphilitic mothers will
be conveyed to the child; opiates and some purgatives  Avill demonstrate their
physiological influence upon the sucking infant.  All these circumstances, and
many others, present considerations which'demand the careful  attention of the
practitioner,  and should not be overlooked in the study of  the causes and in
the application of remedies.
     Without attempting to enumerate, in detail, the  long list of causes  so
universally recognized as contributing to the production of these diseases, I
Avill venture to suggest a few considerations.   AVhatever may be the influence
of bad atmosphere and bad hygiene, something more than an elevated tem-
perature, filthy streets, squalid lodgings, and personal uncleanliness is neces-
sary.   Neither of the three diseases is peculiar to the children of the poor,
or of the habitants of the narrow and foul alleys, or of the dAvellers in  the
illy-A'entilated and stinking tenements of populous cities.   They invade  the
palaces of the rich, the fashionable thoroughfares, where dAvell the families
of  leisure  and  affluence.   Nor with  all  the  care  and  vigilance of   the
health-officer, nor with the lavish expenditure of the accumulated Avealth of
the millionaire, can they be shut out from  the nurseries of populous cities,
hoAvever cleanly, comfortable, and luxurious the apartments may be.  Nor
are they exclusively  confined to the ill}'  and improperly  fed, to the early
Aveaned, the harshly treated, or the imprudently exposed, for all these causes
are, presumably, of as frequent and constant occurrence during the winter as
during the summer months; yet it is  during June, July, August, and Septem-
ber that the Avide-spread epidemics annually occur.   From the extensive table
of Meigs and Pepper, showing the monthly mortality in Philadelphia during 
340
the years 1862, 1863, 1864, 1865, 1866, 1867, 1868, from cholera infantum,
dysentery, and diarrhoea, during the first five years of life, compared VAith the
total monthly mortality from all causes, and the mean monthly temperature, 1
have collated the following tabulated statement:
Months.
January ..
February .
March___
April.....
May......
Juno......
July......
August...
September
October ...
November
December
Mean monthly mortality for seven
 years, from 1862 to 1868, both in-
 clusive.

 11-7
 15-7
 2 2-7
 4
 7 4-7
 67
358 3-7
304 2-7
 77 2-7
 21 5-7
 31
 2
 21-7
 11-7
 3
 2 2-7
 6
24 2-7
27 2-7
13
 4 6-7
 2 2-7
 14-7
 3 3-7
 1
 3 2-7
 3 5-7
 4 3-7
 9 6-7
34 1-7
29 1-7
114-7
 6 4-7
 2 5-7
 2 4-7

1,296 5-7
1, 206 5-7
1, 344 2-7
1,281 1-7
1, 234 2-7
1,173 1-7
1,837
1, 825 3-7
1,215 3-7
1,218 1-7
1, 052 1-7
1,191

30.87
33.89
40.85
52.27
62.77
71.97
77.71
76. 62
68. 31
56.3
46.68
34.7
      Thus it is shown that elevated temperature is not an essential element
 of the cause.   Rare in sparsely-populated localities, rarer still  in  elevated
 regions, they are rarest when to these conditions is added aridity.  Occa-
 sionally occurring  in  the farming  regions, more frequently in  the country
 villages, as a wide-spread epidemic in populous and compactly-built cities,
 they become the scourge of infant-asylums  and  homes for foundlings and
 the houseless.   Then to the numerous causes of bad  air, foul with the  ex-
 halations from decaying animal  and vegetable matter; to the many impro-
 prieties of diet;  to the injudicious feeding; to the causes and effects of mal-
 nutrition ; to the elevated temperature and personal neglect, must be added
 the conditions of moist atmosphere, of lowness of situation, and of the con-
 gregation  of a number of individuals within a limited area, to complete  the
 series of causes and fill full the measure of the endemic requirements.  But, after
 all, these  are  but  coincident  and  accessary influences.    Numbers,  even
 among those most exposed to these various  elements, escape, and  the dis-
 eases, to a limited extent it is true, do appear Avhere all  these conditions of
 atmosphere, locality, congregation of individuals, privation, and uncleanli-
ness are absent.   Their nature and causes, like the diseases themselves,  are
so intimately blended that the physiological and anatomical peculiarities of 
341
infancy and childhood must be studied in order to reach  a solution of this
complex and intricate problem.  The first quinquenniad comprises the years
during which disease is most frequent and mortality runs highest.   Accord-
ing to the report of the registrar-general, (England,) nervous diseases share
the highest mortality under one year  of age,  the respiratory second, and
digestive third.  Under five this order is  changed as  regards  the first and
second,  the mortality from the diseases of the digestive organs being far less
than from either of the other during each period.  West furnishes the fol-
lowing statement (deduced from the reports, fifth and eighth—for 1842 and
1845—of  the registrar-general) of the proportion per cent, of deaths  from
the diseases named, in  childhood, as compared Avith the total mortality from
all causes, in London:
	Under 1 year.	Between 1 and 3.	Between 3 and 5.	Under 5.
Percentage from diseases of the nervous system . .. Percentage from diseases of the respiratory system Percentage from diseases of the digestive system...	30.5 26.9 17.5	18.5 39.5 12.8	17.6 33.0 5.5	24.3 32.8 14.1
     This order of precedence in the mortality establishes, in the consecu-
tive diminution of the mortality from the nervous  and digestive  diseases
during the same  periods of life, a direct connection between their causes
and the causal effects,  or  rather a  connection in physiological tendencies
and sympathies.  This is further illustrated by a  similar comparison during
the advanced periods of childhood,  (also from AVest:)
	5 to 10.	10 to 15.	All ages above 15.
Percentage from diseases of the nervous system . .. Percentage from diseases of the respiratory system. Percentage from diseases of the digestive system ..	15.1 29.5 6.5	10.6 30.7 8.8	10.4 38.0 7.7
     If these statistics prove anything, they establish, at least by inference,
the intimate physiological and pathological relation of the diseases of these
two  systems.   They act and react upon  each other as cause and effect.
Not  so  Avith the  respiratory affections.  Though less  frequent than  the
nervous diseases under one year of age, in  all subsequent  periods of life
the}' are more frequent.  The first quinquenniad is also  the period of most
rapid groAvth of the tissues, of the physical and functional development of
organic  life, and of cumulative  nutrition.   During these years of  rapid 
342
 growth  and marked  pathological tendencies,  the  machinery of life runs
 with delicate precision and amazing celerity, assimilating  nutriment for the
 store-house  of groAvth.   The child, like  the sAvift-groAving and  succulent
 plant, exhibits in the softness  and delicacy of its tissues, in  the  looseness
 and tenderness of its structure, in its sensitiveness to impressions,  and in its
 pathological tendencies, the  hasty appropriation of the elements of nutri-
 tion and feeble powers of  resistance to the  accidents and improprieties of
 life  and to  the  ever-varying changes of the natural elements.   It is, fur-
 thermore, during this period that the first dentition runs its successive series
 of somewhat singular events, strangely commingling physiological  and path-
 ological phenomena.  Various local irritations and general disturbances may
 mark the evolution  of the teeth.  Meigs and Pepper assert that they "have
 rarely observed  cholera infantum before  the beginning  of the  process of
 dentition and very rarely after its completion."  J. LeAvis Smith says "it usu-
 ally occurs under the age  of tAvo years."   In 282  cases  in Avhich the  ob-
 servations Avere made, 47 had no  teeth and  28 had all the teeth.   The sta-
 tistics of Dr. Emerson shoAv that it is more fatal in the first year than in the
 second,  thus contrasting the causal  influence of  the  very rapid  groAvth of
 the first year with the more active and continuous  dental evolution of the
 second.  In 138 children at the Necker hospital, laboring  under the first
 dentition, Bouchut says 26 were free from all indisposition, 38 had transient
 diarrhoea, 46 had abundant diarrhoea; in 19 it appeared at the time of swell-
 ing of the gums  and ceased with  it  to re-appear  with the eruption of the
 teeth.  Vogel, Avho  confounds entero-colitis  with cholera  infantum  under
 the term catarrhus intestinalis, says  " in children  over one  year of a«*e  the
 process  of dentition is the most  frequent  cause," and "that the  ordinary
 simple looseness  of the boAvels, which usually accompanies dental evolu-
 tion,  may become cholera-like and prove fatal in tAventy-four hours.   AVest
 Avho classifies the three diseases under two divisions of diarrhoea—simple or
 catarrhal, and inflammatory or dysentery—deduces the general conclusion
 "that the greatest prevalence of  diarrhoea or dysentery coincides exactly
 Avith that time during which the process of dentition is going on  most ac-
 utely,"  and asserts that half of  his cases  (2,129)  occurred betAveen the
ages of six months and two years.  J. LeAvis Smith concludes from his 576
observations that infants "under the age of six months are less liable to en-
tero-colitis than between the ages of six months and  tAvo  years.   Bouchut 
343
asserts that "the influence of the dental evolution upon the  diseases of the
alimentary canal is completely established."   So constant and aetiA e an in-
fluence does Trousseau  consider dentition,  that he  insists  that  weaning
should not be  completed prior to the  evolution of the fourth group, and
that it should never be terminated suddenly, but gradually.   Eustace Smith
says the bowels are, during dentition,  "ripe  for  diarrhoea," because  of the
augmented irritability, groAving out of the increased development of the fol-
licular apparatus; but, "Avithout the presence of the ordinary exciting causes,
diarrhoea is by no means  a necessary result of such a condition of the ali-
mentary canal."
     My oavii observations, covering 120  cases, in Avhich the records Avere
accurately kept, give the  following results :
     The three diseases : one year of age and under,  39 ; one to  three in-
clusive, 56 ; three  to five inclusive, 13 ; over fiVc, 12.
     Of the 39  one year old  and under, 9 had no teeth, of which 6 Avere
from five to eleven months old, and 3 Avere under  the age Avhen it is  sup-
posed  the  process of dental evolution has actively  begun.  Among the
second  class 1  one year and 1 fourteen months  old had no teeth,  Of the
56, 11  had completed  the first dentition.  Of the third  class all  had
completed  the  first dentition.   In 87  cases, dentition had either  begun
or  Avas  in  active progress;  in 3  it  had  not commenced,  and  in 36
it  had been completed.   It seems, then, fair  to  conclude that nearly Iavo-
thirds of all the cases occur during the period of dentition; hence its influ-
ence as a predisposing cause can  be readily appreciated.   Bouchut  thinks
the SAVollen condition of the gums determines increased peristaltic contrac-
tion of the intestines, through  the nervous irritation  set up, and that the
inflammatory  state of  the buccal mucous membrane  is  extended  to the
intestinal mucous  membrane, both  conditions thus  uniting  in  the  cause.
"Besides this influence of nervous  irritation in  quickening for a time the
peristaltic action of the bowels, and thus inducing diarrhoea," AVest holds
that " all parts of the digestive canal, and of its dependencies, are undergo-
ing active evolution to fit them for the  proper assimilation of the varied  food
on Avhich the young being will  soon have to subsist."   These explanations,
undoubtedly true in themselves, are not entirely satisfactory.  That devia-
tions from the normal course of dentition should  produce other morbid  con-
ditions seems reasonable ;  but that a purely physiological process should be 
344
so uniformly complicated with serious pathological conditions seems a con-
tradiction.   The fact that these concomitant and consequent morbid condi-
tions are peculiarly incident to a certain season of the year, and to a life in
the cities, certainly detracts from the intensity of its  influence as a cause.
     It is a Aery common, perhaps too prevalent, habit among medical men
to ascribe all intestinal disorders to  indiscretions in diet, and to insist upon
such errors, notwithstanding the pertinacious denial  of the patients or their
friends.  The indiscretion,  if such it can be called,  not unfrequently con-
sists in some temporary or accidental disturbance of the digestiAe and assim-
ilating processes, and these  latter conditions may find  their cause in func-
tional and structural  alterations of parts remote from the alimentary canal.
     The frequency of these allied affections during infancy and childhood,
bearing, apparently,  a direct relation with the frequency of the diseases of
the nervous system, and their rapid diminution in frequency with the advance
of life, corresponding Avith the  lessened frequency of  the nervous disorders,
point,  Avith unmistakable significance, to  two important factors : age and
the physiological and anatomical peculiarities of infancy.  Witliout intend-
ing to depreciate the  sad effects of the accessary and co-operative influences,
bad air,  unwholesome diet, improper exposure,  and  the numerous  other
alleged causes, I must insist that an exaltation of nervous irritability and an
augmented  delicacy of nervous susceptibility, or, rather, that functional and
organic derangement of the nervous system, or some  part thereof,  constitute
an important element of causation.  Trace the history of the disorders through
all their A^aried phenomena, and each objective adds corroboration to this
conclusion.   The period of life during which the nervous system manifests,
with peculiar energy and force, its pathological tendencies,  furnishes, by
far, the largest quota  of patients.  Dentition, with its various nervous excite-
ments, febrile exacerbations, and local irritations, adds its contingent. Feeble
development,  Avith marked nervous  irritability, temptingly invites local
intestinal disturbances.  Residence in the city, none the less so because of
the filthy streets, foul exhalations, and densely-populated area, Avith its con-
stantly recurring scenes of excitement, and its adv need society-regulations,
no less detrimental to adult  than to infant.health, is a  fruitful source of nerv-
ous as it is of intestinal disorders.  Nervous enervation and  prostration, so
frequently  the result of  continuous exposure  to a  high temperature, find
their sequences  in digestiA e and nervous  disturbances.   How marked the 
345
 contrast!  In the sparsely-populated  and elevated regions these  disorders
 are rare visitors to the family nurseries of the country residents, yet growth
 and development go on.  Dentition runs its regular course  comparatiAely
 free from the reflex and sympathetic phenomena.   The sedation of the pure
 and invigorating country air, of the quiet and physical life of the farming-
 regions, rather than the exciting, irregular, and stimulating life of the city,
 is the great preventiAe  of nervous as it is the great curative of the  intestinal
 diseases of  childhood.  The physique and pathological aptitudes of the
 young  permanently residing in the cities are so markedly in contrast with
 those of the rural districts that the manner and circumstances of life
 peculiar  to  cities,  in  prematurely  stimulating  functional  development,
 especially of the  nervous system, constitute a far more  important  factor in
 the causation than the normal physiological and anatomical peculiarities of
 infancy and  childhood.
     Intestinal diseases among children in the farming-regions are,  in a Aeiw
 large majority of  the sporadic cases, attributable to the ingestion of articles
 of diet  altogether improper.  Berries,  green peas, new potatoes, and fruit of
 all kinds are rarely absolutely forbidden, eAen during  the period  of denti-
 tion, to children in the  remote  country districts ;  and those who have had
 the opportunity of treating such diseases  among the former  slaAes,  even
 among  those who Avere  huddled  together in illy-constructed quarters, cannot
 have failed  to observe how  rare  these  disorders were  among them,
 and, in the  occasional instances, to trace  them  to improprieties  of  diet.
 The familiar dinner-scene,  at  the  plantation-quarters,  of a  child, perhaps
 several, being stuffed with the masticated  food from the parents' mouths, not
 only Avithout detriment, but  as  the  sure  promoter of health, strength, and
 groAvth, has impressed me with the conviction that there is an immunity from
 disease  Avhich belongs  exclusively to  children permanently residing in the
 agricultural  regions.   This  practice,  so  customary among  the slaves, of
 feeding the child Avith morsels of food already masticated, though repulsive
 to cultiAated sensibilities, suggests a method of preparing food Avorthy of
 intelligent trial.  Among the poorer  classes  of country residents it is the
 common habit to feed young children from the family table, and only among
the cultiA'ated families are dietary regulations stringently enforced, and among
this latter  class disease is  most  common.  Through these  gradations  of
societAr the diseases peculiar to  infancy and childhood regularly ascend the 
346
scale of frequency.   Why this is  so I know not, unless cultivation, refine-
ment, and luxury multiply and accelerate the pathological  aptitude.   That
this is true with regard to disorders of the nerAeus system is, I believe, gen-
erally conceded ; and in this circumstance the relative frequency of diges-
tive  disturbances may find its explanation.  To Pilliet and Barthez is per-
haps due the credit-of having first suggested, especially in regard to cholera
infantum, the relation of the nervous to digestive disturbances, as cause and
effect.   I forbear to folloAv these distinguished authors in their definite trac-
ing of the precise nervous influences and changes Avhich may determine the
enteric disease.
     The disturbance of the normal relation subsisting between the skin and
intestinal mucous  membrane is' another important  element of causation.
This fact has been universally conceded by Avriters  upon the diarrhceal
complaints of adults, but  among Psediatricas it is only casually enumerated
in their multitudinous array of influences.  The physiological antagonism
betAveen the cutaneous and intestinal secretions is so  manifest that it is not
difficult to understand why the suppression of the former should determine
an alvine flux.  It may not only impose additional functional activity upon
the intestinal mucous membrane, to relieve the system of accumulated  fluid,
but also to effect the vicarious elimination of effete matters; and thus local
irritation, hypersecretion, increased peristaltic  action, and alvine flux may
find their immediate and direct cause.   The manifest effect of the sudden
arrest of the cutaneous transudation, as the most frequent cause of the cases
occurring during the autumn, Avinter, and spring months, is apparent, even to
the most casual observer; and I apprehend that  it is  far more frequently
the immediate influence  during hot weather, especially in moist localities
and  during  rainy seasons, than is generally belieAed.  I  have uniformly
obseiwed an accession of  disease and frequent relapses following the sudden
and  violent lessening of temperature  which so frequently terminates our
brief "heated terms," and more especially so if accompanied Avith moist and
rainy Aveather.  Trousseau has called attention  to a  form  of diarrhoea de-
nominated  " sudoral," Avhich he intimates most frequently occurs  among
children, and differs  from that arising from suppressed perspiration, inas-
much as both secretions  are simultaneously abnormally increased from ex-
cessive heat.  Hoav far such sympathetic augmentation of these secretory
functions may enter into the causation of infantile intestinal diseases  I am 
347
not  prepared to determine, but  their occasional  simultaneous occurrence
cannot be denied.
     Conceding the analogy of causes, the distinctive natures of the diseases
aa ill be recognized and maintained so long as the pathological lesions are
regarded as peculiar and characteristic.  AVhatever ma}' be the local morbid
phenomena, they are admitted to have their localized beginning in the intes-
tinal mucous membrane.   If, then, the tissue diseased is  common  to  all of
them,  the clinical distinctions must be due  to  some  peculiarity of locality,
or of the morbid process, or to the localization of the disease in some one
of the histological elements of the structure iiiAohed.   No  one Avill for a
moment maintain that entero-colitis is anything more than an advanced stage
of catarrhal  diarrhoea, or that  the ordinary non-inflammatory  diarrhoea is
anything less than an  irritation of some part of the intestinal mucous  mem-
brane, preliminary to more manifest morbid conditions.  The morbid pro-
cess, the structure invoked, and the pathological lesions Avhich complete the
picture of dysentery, present no other distinctiAe feature than locality,  and
this  is very often only descriptive.   Cholera infantum, singularly distinctive
in the suddenness and intensity of its phenomena, differs from a more fre-
quent, milder, and more tractable forni of serous diarrhoea in the degree of
exhaustion and copiousness of choleraic stools.   The concomitant condi-
tions and circumstances Avhich  enter into  and complete its history—pertain
more directly to the individual peculiarities and to the stage and condition
of development than  to  any essential difference  of nature.   Exhaustion,
Avhich after all is the alarming symptom, is more frequently the result of de-
ficient constitutional vigor and defective nutrition than of  the extent and in-
tensity of the  morbid  process.  The graver forms  terminate  speedily in
death, the milder in the establishment of some  grade of the inflammatory
process.   In  one, life submits to exhaustion; in the other, life resists.  Is not
the  difference  then simply one of degree  and duration, and not of kind ?
Entero-colitis and catarrhal diarrhoea differ only in degree ; dysentery and
entro-colitis, according to their nosological designation, only in locality, and,
clinically, only in the presence  of symptoms indicative  of some grade of
the inflammatory process  located in the  mucous  membrane of the loAver
boAvel.  I am aAvare that there is a form of dysentery Avhich has so frequently
decimated European armies, Avhich, in  its clinical history and pathological
anatoniA',  differs essentially from that morbid process Avhich 1 am iioav dis- 
348
cussing.   Occasionally sporadic cases occur among children, but they bear
no relation to  the summer-diseases of infancy and childhood.
     I believe that the morbid process common to these allied disorders is
inflammation,  varying in intensity and  running through all the gradations,
from simple irritation  and inflammatory hyperaemia to ulceration and gan-
grene.*  I do not propose to minutely detail the morbid lesions so elabor-
ately described by authors avIio haAe made the subject a study, but, in vieAv
of the consideration sought  to be established in this discussion—the iden-
tity of the morbid process—I Avill briefly refer to the feAv points upon  AA'hich
their separate and distinct natures are based.
     The first and important point in this connection  is the occasional ab-
sence of local lesions, and the assumption that in  such cases the disease is
one  of functional disturbance.   The fallacy of this mode of reasoning and
of the conclusion is obvious.   The exceptional cases are far too meager, in
A'ieAv of  the immense number of the cases, to establish any distinction when
the  symptoms and causes are identical.  In all  cases where local  lesions
have been discovered, they have been recognized as the manifest phenomena
of some stage of the inflammatory process, and  it is far more  rational to
conclude that the absence of any such phenomena is  to be  ascribed  rather
to the failure of the obserAer than to a difference of kind.   Until such cases
are  subjected to thorough microscopic  examination by competent micro-
scopists  and the negative clearly established, all  conclusions are obviously
fallacious.  The attempt to explain and  establish a distinct kind of disease
upon the hypothesis of  functional activity or disturbance,  is simply  an ad-
mission  that there is a stage of the morbid process in Avhich the lesions are
not  cognizable  to  casual observation.   The history of the fatal cases in
Avhich no lesion has been  recognized  clearly establishes one fact: no one
can positively and invariably determine, during life, the presence or absence
of local lesions. In many cases the gravity of the symptoms bears no rela-
tion to the extent of the inflammatory condition, and, in a vast majority of
cases, the duration of the disease is the only circumstance determinate of
its   grade  and  extent.  Niemeyer says  "the anatomical changes left in the
cadaver by acute catarrh are sometimes pale, at  others dark redness, swell-
     * It is perhaps proper that I should qualify this declaration, inasmuch as it has oc-
curred to me that further research will establish an important distinction, based upon
exemption or implication of Peyer's glands in the morbid process. 
349
ing, relaxation, and friability of the mucous membrane, Avhich is sometimes
diffuse, at others limited to the vicinity of the solitary glands, and a serous in-
filtration of the sub-mucous tissue.  Occasionally, after death, the injection
has entirely disappeared,  and  the mucous membrane appears  pale  and
bloodless.   Swelling of the solitary glands, and glands of Peyer, is an al-
most constant appearance;  they distinctly project above the surface of the
mucous membrane.  The mesenteric glands also are usually found hyper-
aemic and somewhat  enlarged.   The contents  of the  intestines consist, at
first,  of plentiful serous fluid, mixed with  detached epithelial  and young
cells,  subsequently of cloudy mucus, which is adherent to  the Avail of the
intestine and contains epithelial structures."  Dr.  J. J. AVoodAvard, in his
work on camp-diseases, though adhering to the established nomenclature of
these allied affections as the}' appeared  among adults  in the Army, clearly
foreshadoAvs the opinion that  the nosological  distinctions is merely an ar-
rangement convenient for study, and not conclusive of distinct morbid pro-
cesses.  He says simple diarrhoea is usually "the (page 216) result of irri-
tation  of the intestinal mucous membrane,"  "expressing itself in increased
secretion throughout the intestinal tract."  "The irritation may even amount
to inflammation."  And at page 251, after minutely  describing the histolog-
ical lesions to be found in chronic diarrhoea, he concludes  with this expres-
sion:  "There  can be  little doubt that this affection is  to be regarded as
consisting essentially, of a chronic inflammatory process, iiiA'olving primarily
the mucous membrane of the  ilium and   colon," Avitli a tendency to ul-
ceration.   The advocates of the  distinctive  nature  of  cholera infantum
mainly rely upon the absence of morbid lesions or, Avhen present, their pro-
portionate insignificance  to  the gravity of the symptoms.   The manifest
error of this process of reasoning consists in the attempt to measure the in-
tensity of the symptoms by the  extent of the  local  intestinal lesions,  Avith-
out any consideration of the concomitant  conditions and  constitutional pe-
culiarities under which this form of disease usually appears.  It  is a Avell-
established  fact that in all  these  forms of intestinal disease,  peculiar to
infancy and childhood, the graAity of the symptoms bears no constant rela-
tion to the extent or degree of the  pathological lesions.  Omitting am' con-
sideration of the clinical fact that this form  is frequently the  preliminary
stage of the inflammatory, the lesions observed in cases proving fatal  in the
acute  stage establish its  inflammatory nature.   These are, according to 
350
Meigs and Pepper,  "enlargement of the mucous follicles and, to a less de-
gree, of the glands of Peyer, and softening, and in some  cases erythema-
tous inflammation of mucous membrane."   "These appearances," add the
same authors,  "depend upon the presence of an early stage of inflamma-
tion of the tissues of the intestinal walls and of the mucous follicles;" and
that the inflammatory process is similar to that  found in entero-colitis is
clearly established by its frequent eventuation in the lesions usually found
in primary entero-colitis.   In the opinion of Pilliet and Barthez, cholera in-
fantum is a catarrh localized upon the digestiAe tube and great sympathetic
nerve.   "Its catarrhal nature  is demonstrated by the causes, which are
those of all catarrhs, (improper alimentation, epidemic  influence, &c.;) by
the analogy of the symptoms;  by the gradual passage of  the mild into the
grave forms, through intermediate causes; and lastly by the fact  that sim-
ple intestinal catarrh is  often but the prodrome of choleriform  enteritis."
Rindfleisch says "the relations are  different in very many catarrhs of the
gastric  and intestinal mucous membrane.   The  ordinary diarrhoea-stools
depend upon  a serous transudation  in  the  region of the small  intestine.
The blood-serum, Avith  albumen and salts, has passed  from the vessels  of
the villi directly to the surface, and is carried doAvn the  intestine by strong
peristaltic movements so rapidly that resorption in the large intestine cannot
keep pace with it.  The cholera-catarrh distinguishes itself from ordinary
diarrhoea, on the one hand, by the exclusion of albumen from the  transuda-
tion ; the choleraic transudation consists entirely of common salt and water,
(Schmidt;) upon the  other by the participation of the whole tract, from the
cardia  to the  anus;  finally, by the  enormous quantity and rapidity with
which the transudation  ensues.   The rapidity, especially,  is so great  that
the epithelium of the small intestine, together with the epithelial lining of
the glands of Lieberkulm, is  lifted off and Avashed away in larger  and
smaller shreds.   Meal-soup or rice-water stools."
     In this cursory examination of  the causes, nature, and morbid anatomy
of these allied disorders, I have endeavored to  trace, accurately and fairly
and comprehensively, their  similarity, and to establish the conclusion that
their distinctions are in degree, and not in kind.   There is nothing new or
original in this view,  but it possesses  the  merit  of directing the attention
immediately to the urgent symptoms and fastens upon the practitioner the
importance of seeking explanation of the varying  phenomena in conditions
peculiar to the patient, rather than in differing and distinct  morbid processes. 
351
     In discussing the nature and causes, I have so fully indicated my views
in regard to  the  methods of prophylaxis  that  I  need  not  dilate upon
this  interesting  topic.    The  influence  of locality,  of " croAvd-poisoning,"
and of the bad hygiene of cities can be either entirely avoided or materially
modified by temporal'}' removal of residence.  Diet, personal cleanliness, ex-
posure, and clothing appropriately belong to the judicious management of the
nursery, and, except among the  poor and ignorant, AAdien either, from  im-
proper management, become the cause of disease, it is, generally, the result
of Avanton neglect upon  the part of  parents.  The influence of age  is one
rather to be  endured under  careful dietary and hygienic regulations, and
every wise provision should be made to promote growth  and  development
and to maintain at the normal standard the  physical condition.
     In regard to diet, I have nothing special to say, beyond giving expression
to my firm conviction that milk  is the only suitable article.  To the nursling
natural or artificial lactation, to  the weaned a diet of pure and fresh countr}/
grass-fed cow's milk.*   Farinaceous articles and compounds are, at best,
miserable substitutes, and frequently  injurious expedients.   In occasional
cases, where milk disagrees, usually because it is poor in quality, badly pre-
served, or improperly fed, some one of the farinaceous preparations—those in
which milk is a constituent only  should be allowed—may temporarily supply
immediate necessity, but the milk-diet should be restored at the earliest prac-
ticable opportunity.   The recent experiments and researches by Dr. Pros-
pero Sonsino,  (London Practitioner,  September,  1872, p. 155,) if true,  clearly
establish the fact that starchy aliments are  indigestible, in consequence of
the absence of digestive  poAver in the salivary, pancreatic, and enteric juices
of young animals.   This  conclusion is corroborated by the facts that milk
contains no  starchy element,  and that the  young herbiAerous animals
are exclusively nourished upon milk for a limited  period.   Sonsino's  experi-
ments Avere made by taking from a recently-killed young animal the pancreas,
Avhich Avas hashed and reduced to the consistence  of pap.   A small quantity
of pancreatic infusion, made Avith distilled water, was dropped upon "the glue

   * It is important that the milk should be fresh, for every minute that elapses after
the milk is secreted, or drawn, deteriorates the emulsification, and, Avhether retained in
the lactiferous  ducts or in artificial A'essels and allowed to cool, such chauges take
place as may destroy the natural emulsification. 
352
of starch," Avhich failed to transform the starch into glucose, thus establish-
ing the condition of  "physiological dyspepsia in infants for starchy aliments."
Fresh pancreatic emulsion, prepared from adult animals, produces the trans-
formation almost immediately.   The same author asserts that not  only are
starchy aliments indigestible, but  they are deficient in "materials  for the
reintegration pf the  principal tissues, which is so  necessary to the growing
infant."
     More recently Dr. Sonsino has published (London Practitioner, January,
1873, p. 11,) the details of a series of investigations, instituted  "in order to
bring forward not merely more eAidence of the existence of that dyspepsia,
but to  establish also, if possible, the limit of age in which it  ceases."  The
researches were made at the East London Hospital for Sick Children and
Avere " directed to the examination of the stools of infants that were fed
with starchy aliments, Avith the object of recognizing  if they contained un-
altered starch."   The stools were examined with iodine as a test for  starch
and Avith the microscope to detect starch-granules.  The number of investi-
gations were too few to be accepted as conclusiAe, but they go to show that
some children can digest a limited quantity of starch, while others fail alto-
gether.  The doctor gives the following table of  the results of the experi-
ments in regard to the second question:
Age.	No. of cases.	Results.
	4 1 3 1 1	Starch in motions. Starch in motions not quite clear. No starch in motions. Starch in large quantity. Starch in small quantity.
		
		
3 years....................		
		
     Dr. Dobell  (London Practitioner,  October,  1872, p. 234) insists that
pancreatic emulsion possesses, also, in a very high degree, the property of
promoting the digestion of fats, and thus combining  the tAvo properties of
transforming starch into glucose and promoting the assimilation of fats, the
latter quality being the more valuable, for the reason that starchy aliments,
even AA'hen rendered easily digestible, are not proper articles of diet of young
animals.  AVith children who have teeth, I prefer  some form of concentrated
animal food—beef-essence or raw beef—to any of the farinaceous articles or
compounds.  The great and important consideration is to maintain healthy
normal  nutrition and to prevent and supply Avaste.  In  chronic cases suffi- 
353
 cient and assimilable nutriment is the conservator  of life.  The indications
 Avhich pertain to diet, hygiene, and the ordinary  conditions of the general
 management of children being fulfilled, in a large proportion of acute cases
 little else is needed.  Medicine may be a source prolific of mischief as Avell
 as a means of  cure.  Experience has satisfied me,  not only of the  inutility,
 but of the impropriety of  calomel.   Commencing practice with full confi-
 dence in the efficacy of this chemical, I haAe been driven, by the sad expe-
 rience of many failures, to abandon, except in occasional cases, its employ-
 ment.  If the morbid lesions are understood and medication is to be based
 upon the teachings of pathology, surely mercury is contra-indicated.   The
 proneness to exhaustion and Avaste cannot be combated Avith calomel, for cer-
 tainly its constitutional  operation is to exhaust, to lessen strength,  to con-
 sume, to  depress, to  favor all  adynamic tendencies.   If  useful,  it  is
 through its  alterative,   purgative,  or  cholagogue action.    The very na-
 ture  of  the  diseases   clearly contra-indicates any  demand for altera-
 tives, and morbid anatomy has failed to reveal  conditions  calling for its
 cholagogue action.   As a purgative its  place can be  supplied, and surely
 no  one  Avill maintain that mercury Avill correct  acidity, arrest serous
 exhalation from the alimentary mucous membrane, diminish peristaltic action,
 promote appetite,  invigorate digestion, arrest waste, or  stimulate the failing
 powers of life.   If neither lesions nor symptoms demand its use, its employ-
 ment must be empirical.   That it will occasionally allay gastric irritability
 and stop vomiting, when all things else seem to fail, I admit; but is the effect
 not due rather to its mechanical than therapeutic operation?  The failure of
 remedies to allay gastric irritability is frequently not so much due  to  their
 inappropriateness  and inefficiency as to their bulk  and  careless administra-
 tion.'  One or two doses may be retained and the third will occasion imme-
 diate  emesis, not because the medicine is any less effective, but because  of
 the addition to the contents of  the stomach.  Hoav often it happens that the
 stomach will tolerate  small pieces of ice, or eAen spoonfuls of pounded ice,
 and, so soon as the liquid contents reach a certain bulk,  will reject the Avhole.
 Mercury,  through its  diminished bulk, secures Avhat the stomach most needs,
 rest.  That it may possess and  exercise some  sedative influence upon the
 gastric mucous membrane  I am not prepared to deny.   If so, it must operate
locally, and not through the system.   Such being the case, I cannot compre-
hend hoAv the very minute quantities given can cover the entire irritated sur-
      4.~> 
354
face of the mucous membrane and thus arrest hypersecretion, or Iioav, Avhen
once in the stomach, it can be determined tOAvard its local sedative effect upon
remote parts of the intestinal mucous membrane  and fail to enter the system,
and thus exercise its very injurious constitutional effect.   I cannot tell Iioav,
but experience and observation teach me that mercury does promote increased
flow of the biliary secretion, and that the surest Avay to obtain  its constitu-
tional effect is to administer it in frequent small doses.  Hoav its local seda-
tiAe action can be obtained independently of its constitutional and chola-
gogue operation I cannot understand, and do not believe.   Take, for illustra-
tion, a case of congenital syphilis; giAe to the patient minute doses of mer-
cury and the constitutional and alterative effects are soon manifest, sometimes
before there is any evidence of increased biliary secretion.  If the specific
action of mercury in the treatment of syphilis be accepted as the criterion
by Avhich its modus operandi is to be determined, then the conclusion is obvi-
ous that its curative  A'alue in infantile intestinal diseases is through its action
upon the system.  The mercurialist must accept this explanation and  seek
to demonstrate that this alterative  action fulfills the indications presented in
infantile  intestinal diseases.
     The indications to be met in the medical treatment are gastric irritability,
increased peristaltic  action, hypersecretion of the mucous membrane, serous
exhalation from the intestinal mucous membrane, acidity, pain AA'hen present,
exhaustion, loss of appetite,  indigestion, and  the consequent local lesions.
It is important to determine the succession of these phenomena, because effects
become concomitant causes.   Nausea and  vomiting may occur  under very
different  conditions.  As the  effect of the ingestion of improper articles of
diet  or of impaired  digestion, they usually take precedence of the other
symptomatic phenomena.  As reflex or sympathetic phenomena they su-
pervene  upon  intestinal irritation and become continuous AA'ith the more
marked morbid conditions.   Increased peristaltic action, with  fcecal  dis-
charges, if not co-incident with,  is usually consecutive to gastric irritability.
Hypersecretion, serous exhalation, and acidity occur subsequently to these
conditions, but as a  universal laAv there is no  definite  order of sequence.
Several may occur simultaneously and each become an influence promoting
and impelling onward the morbid process;  hence the  preliminary condition
may be concealed by the graver secondary effects ;  and, as these  become
concurrent and co-operative morbid conditions, the therapeutical applications 
355
must be adapted to combat symptoms as representatiAes of both causes and
effects.  Grave inflammatory lesions succeed the  lesser and milder effects,
though the immediate cause, perhaps the ingestion of some crude and im-
proper article of diet, had ceased to offend because of its expulsion through
the anus.   Simple looseness of the boAvels,  expressed either in increased fre-
quency, greater quantity, or loss of consistency of the stools, is a secondary
effect, representing some morbid process, and its  cure cannot  be assured
simply through remoA'al of the offending foreign substance from the digest-
ive tube or by exclusively attacking the process and act of evacuation.  Yet
so long as the offending material is permitted to remain in the canal, or the
peristaltic action continues Avith increased  frequency and energy, the  local
lesion, in itself an effect, though operating as a cause, cannot be successfully
treated.  The local morbid condition,  in a vast majority of cases, perhaps
in all, is some stage of the inflammatory process, varying in intensity and
extent from simple irritative hyperemia to extensive destruction of tissue,
manifesting itself in an array of symptomatic phenomena, each one of Avhich
becomes an exciting cause.  Admitting, for the sake of argument, that hy-
persecretion may result from functional actiAity, continuous functional ac-
tivity Avill surely produce organic alterations.   If  to arrest the flux is to cure
the disease, Avhy is death so often, especially in the choleraic form,  preceded
for hours by  a partial or complete cessation of the diarrhoea, and why, even
in the milder forms, is the diminution in the frequency and  quantity of the
stools so frequently the premonition of a fierce relapse ?   Yet  it Avould  be
Avorse than folly to attack the inflammatory process with antiphlogistics, while
its  effects, the manifest phenomena, are  permitted to run on with unabated
intensity.   While the source is being dammed up, the stream of life may run
dry.  The great principle that underlies the science of cure—the tendency
of inflammation toward  resolution and health—should not be forgotten or
overlooked.   FeAV children die of these diseases before they are consumed.
Life feeds so  long as there is food to  supply its demands.  Inanition and
exhaustion are the  ominous harbingers of death.   Waste must be supplied,
assimilable nutriment must be furnished, nutrition must be restored.   In-
stead of bringing milk, jostled, churned, watered, and otherwise injured, to
the child, carry the patient to the cow, to  the country, not to  the scantily-
supplied and "crowd-poisoned" village or road-side boarding-house, but to
the farm-house, Avhere milk, pure and fresh, and air rich  in oxygen, and 
                                  356

free from the putrid exhalations, can be obtained.  These opportunities, per-
haps, inure only to the better classes; yet the free and public parks are closed
to none.   Even the street air is far preferable to  the  poisoned atmosphere
of the foul and  stinking lodging-room.  I have often thought that carrying
the child through the  streets, washed and dressed for exhibition, to the dis-
pensary-building, worked  no  inconsiderable  curative  influence, and have
fancied that the cleanly and better dressed were more  amenable to medica-
tion.   To express in a few words both the method of prevention and surest
plan of cure, remove the child from the city, away from the immediate and
accessary influences;  maintain and restore nutrition; supply proper food.
     Quite sure am I  that at that stage of the inflammatory process where
the general exhaustion and the asthenic type of the morbid process  can be
arrested  or staid, there Avill begin the process of restoration.   The  type  is
adynamic; and the course and duration depend more upon the intensity  of
the type, and its consequent exhaustion and waste, than upon the extent or
locality of the intestinal lesions.   Some die during the early stage, when the
lesions are only microscopical; others during the stage of  hypersecretion
and increased peristaltic action; others when the inflammation is sharply de-
fined ; and others perish subsequent to extensive ulceration and sloughing;
but only a few cases  terminate fatally, except from intercurrent complica-
tions, during the sthenic  vigor of the morbid process, and these few are vic-
tims to that Avearing-out exhaustion induced by positive suffering.   Vitality
is Avorn out by the persistent intensity of  the symptoms.
     Grastro-intestinal irritability,  as manifested by nausea  and vomiting,
lientery, and augmented peristaltic action, constitute the essential phenome-
na of the morbid condition.  In this connection I  cannot too strongly urge
the importance of securing and  maintaining  the  rest  and quiet of  the ali-
mentary tract.   The symptomatic manifestations of this abnormal irritability
are mainly the  obstacles to digestion  and nutrition.  To pour food  into, to
fill to repletion a  stomach which refuses to  retain it, or which forces  it
through the pyloric orifice before it has undergone the  preliminary  process
of digestion, is simply to provoke the  extension of the  abnormal irritability
along the entire line of the mucous tract,  and to invite other and more seri-
ous disturbances.   Usually the gastric irritability is the precedent condition,
having its origin in the  abnormal  irritation of  nutriment.   The increased
and augmented peristaltic action is due, at least in the  beginning, to the ex- 
357
 tension from the stomach of the excessive irritability to the muscular coat
 of the intestinal Avails and to the irritation of the mucous  surface set up by
 the wholly or partially undigested food, hastened through the gastro-duodenal
 orifice.   This excessive  muscular contraction  is the primary pathological
 condition of the intestines.
     The normal structure of the mucous membrane of the alimentary canal
 favors the occurrence and continuance of hyperemia, and its delicate and
 penetrable epithelial  stratum favors  the access of irritants to the irritable
 elements of the membrane.   Its structure opposes no barrier to  the disten-
 sion of its congested capillaries, and the natural softness of its parenchyma
 permits  an almost unlimited dilatation.   " The relation,"  says Rindfleisch,
 " in which the contractions of the  intestinal muscular coat stand to the dis-
 tribution of blood in the covering mucous  membrane, appears to be of pecu-
 liar interest.  As is known, the trunks of  the arteries and  veins,  which sup-
 ply the blood to the vascular nets of the gastric and intestinal  membrane,
 pass through the muscular coat in an oblique direction.   They are there sur-
 rounded by a sheath of loose connective tissue, Avhich is tolerably strong in
 the arteries, so  that there remains a wide space between the vessel and mus-
 cular bundles;  in  the veins, on the  contrary, very insignificant,  so that the
 lumina of the veins are easily compressed by a contraction of the muscular
 coat.  In consequence  of this arrangement, with every contraction of the
 intestinal muscular coat, an obstacle occurs to the return of the  blood from
 the intestinal mucous  membrane ; there takes place an increased congestion
 of blood, which continues as long as the contraction  lasts, and may assume
 a more  permanent character by the more frequent repetition of the contrac-
 tions."   Hence the great significance of augmented peristalsis.  Apart from
 the locomotion  of the contents, it materially affects secretion, by means of
 the hyperaemia maintained.   This mechanism,  so essential to the due per-
 formance of  the normal functions  of secretion and  resorption,  upon  the
 slightest disturbance  becomes converted into  a serious calamity.   The
 physiological   becomes   transformed  into  a   pathological hyperaemia.
 The normal and  transient  retention  of blood becomes  a passive and
 permanent congestion,  to be  augmented and  extended  by every recur-
 ring contraction.   "At  no mucous  membrane," continues the  author,
 " does the catarrhal  disturbance  of the  circulation  attain  so  high a
grade as just at the gastro-intestinal mucous membrane, because the path- 
358
ological irritant which affects the mucous membrane awakens the peristaltic
action just as promptly, and in yet stronger measure than the physiological
irritation by ingesta.  Dysentery and cholera present us Avith examples on
the largest scale of the injurious effects of this mechanism; the enormous
oedema of the mucous membrane  of the large intestine, the hemorrhages,
secondarily, diphtheritic disturbance in the former, also  develop under the
influence of very severe tonic  contractions of the muscular coat; and if we
accept that in cholera  also  an enormously increased peristalsis contributes
its share to the immense transudation on the  part of the gastro-intestinal
mucous membrane, we have established only a causal connection between
tAvo knoAvn phenomena of this  disease.  Meanwhile we need  not  turn to
dysentery and cholera; what occurs there upon a large scale  is repeated
upon a lesser in the  slightest  catarrhs."  Accepting these views as the cor-
rect interpretation of the phenomena, the suggestion heretofore  presented,
that the symptoms represent effects and causes, becomes of paramount im-
portance in the adaptation of medicines to the cure of  the disease.   The
gastric irritability, set up by the  abnormal irritation of nutriment, is trans-
mitted to the  muscular  tunic of the intestines; at the same time the undi-
gested material, forced through the  pylorus, acting as a local irritant to the
delicate epithelial  surface, increases the intestinal irritability—hence accele-
ration of the  locomotion of the contents—augmented and  more frequent
tonic contractions of  the muscular coat, and, by virtue of the  anatomical
arrangement, hyperaemia is established.  Hypersecretion and altered secre-
tion follow as the  necessary result  of the continuance of this pathological
hyperaemia, and, subsequently, tissue-changes ensue.
     The first  indication to be met with medicines is to allay the gastro-
intestinal  irritability and to quiet the peristaltic  contractions.  As  a seda-
tive, in this  condition, I have  found no agent comparable to the subnitrate
of bismuth.   To a child one year old it should not be given in less than five
grain doses, repeated  every two or three hours, as occasion may demand.
Usually I associate it with the tinctura opii camphorata or with the tinctura
hyoscyami, the former being preferable.  I believe that the  subnitrate is a
direct  sedative to  the irritated mucous  surface,  and, in the language of
another,  that  it   "stimulates,  strengthens,  and  regulates  the  appetite,
confining  the  boAvels, rendering  the  stools ' black and depriving them
of  their foetor;   and, further,   that  it produces no  general  symptoms 
359
 whatever."  It may also subserve the purpose of forming a protecting cov-
 ering to the irritated surface.   Harmless in the absence of any effect upon
 the  general system, it  should be  giAen in sufficient quantity, at short inter-
 vals, to  secure its local sedatiAe  influence.   But  to  relieve the spasm,  to
 quiet the peristaltic contraction,  no  remedy is so certain as opium.   AVith
 children I prefer the camphorated tincture, because of the minute divisibility
 of the opium.  But to dally with  one, two, or three drop doses ever}*  tAvo  or
 three hours to a child a year old is simply a AA'aste of time.  AVatching
 carefully,  to avoid its narcotic influence, it should be given in doses, regu-
 lated according to the  age of  the child, sufficient to produce marked effect
 upon the frequency of  the stools. The greater the flux  and the more fre-
 quent the  contractions  the more urgent is the demand  for its use.*   The
 danger of producing cerebral  disturbance, or rather brain-complication, is
 not more imminent from its proper and judicious employment  than  conse-
 quent  upon the  exhaustion from an excessive and protracted flux.   AVhen
 nausea and Aemiting exist, as is usual in the outset, the aromatic spirits  of
 ammonia has proven a most valuable addition to the bismuth-mixture.   It is
 a stomachic stimulant,  slightly excitant to the nervous system and  antacid,
 hence  admirably adapted  to the debilitated  state of the stomach.   AVith
 these conditions, frequently from the very beginning, is associated acidity.
 This is not always due to the character of the ingesta, but occasionally, and
 perhaps, frequently, to  an ascescent  diathesis.  Acid seems to be excreted
 in great  excess by the  stomach,  and  the  intestinal secretions  undergo the
 acetous  fermentation.   Acidity  intensifies  the abnormal irritability, pre-
 cipitates the peristaltic  contractions, and hastens tissue-change.
     As a simple.antacid the ordinary prepared chalk is preferable to any other
 medicinal agent,   If the acidity is provoked by the nutriment,  it should be
 suspended or rendered  alkaline  by the addition of lime-water or by a solu-
 tion  of carbonate of soda.   The former is preferable when any considerable
 quantity is  required, and can be  Aery conveniently administered in  milk,
 thus subserving a twofold purpose, correcting the acidity and favoring the
retention of nutriment.  Milk, as obtained in the cities, even though it may be
fresh from a stall-fed cow, should  neAer be given Avithout the addition of an
     * Besides the anodyne, opium and its alkaloids possess anexosmotic properties—
that is, the power of " preventing the  flow of liquid through the  intestinal walls iuto
the canal."   Morphia possesses this anexosmotic property in the highest degree and
narcein next.  (American Journal of Medical Science, vol. lxv, page 24l'.) 
360
alkali, for it is never free from an excess of acid.   For this purpose I prefer
the carbonate of soda.   AVhatever nutriment may be given should be given
in small quantities and  repeated at shorter or longer  intervals according to
the circumstances  of  the case.   Fullness to repletion  provokes nausea,
vomiting, lientery, and flux.   Rest to the stomach will frequently accomplish
all that is desired, and abstinence from food, even for a day, may, in a large
majority of cases, in the beginning, be practiced, not only AA'ithout detriment,
but with the  most salutary result.   In fact, so long as the stomach rejects all
nutriment, digestion is suspended, and the impropriety of persistently tempt-
ing the child Avith nutriment to be immediately thrown up is so glaring and
so manifestly injurious  that it seems unnecessary to dilate further upon it.
Occasionally the thirst is so intense that it is impossible to resist the demand
for fluid.   This generally is more apparent than real.   The child is not able
to appreciate the difference  between  dryness of  the mouth and fauces, and
the demand of  the system for fluid.   Unless there have been copious and ex-
hausting serous stools, the thirst is usually simply the dryness of the mouth
and fauces, and  may generally be mitigated by the judicious use of very
small quantities of finely-cracked ice frequently placed in the mouth. Pure wa-
ter should neAer be giAen.  If it does not  aggravate the gastric irritability,
it Avill surely provoke a stool.  If fluid  cannot be dispensed with  and is not
alloAved  in sufficient quantity in  the nutriment taken, thin barley or rice-
water or gum-water may be allowed.   But the  eau  albumineuse,  so  highly
extolled  by Trousseau, made by diluting the Avhite of four eggs Avith a litre
of water, SAveetened to taste by the addition of sugar and aromatized with
orange-flower Avater, is by far the most valuable form of  giving liquid to
slake thirst.  It supplies, in a moderate degree, nutriment, and in some cases
proves an  efficient adjuvant in allaying gastric irritability.
     Medicines should be given to children in the liquid form,  and the physi-
cian should order his mixture or solution precisely as he wishes it given.  No
preparation should be left to the nurses,  for they will exercise their judgment
and indulge  their whims and caprices.   If poAvders  are directed they will
employ a  vehicle  suitable to their taste, or  conformatory to  the imagined
wants of the patient, and disregard the  most positive injunction.  The mix-
ture or solution should ahvays be made  agreeable to the little patient, inviting
to the' taste.  It is a great thing to win the affection of the child Avith pleasant
medicine, and avoids the fretting and struggling, so frequently positively in- 
361
jurious.  As a menstruum, I have found none so agreeable to children, and so
valuable as a stomachic, as cinnamon-water.  AVith the addition of sugar and
gum arabic in sufficient quantities insoluble substances may be cqnAeniently
suspended, or rendered temporarily so by slight shaking of the bottle, so
that the child AAill usually take it without trouble.
     In cases Avhere the treatment Avith bismuth,  as  above indicated, has
failed, Avhich is more especially adapted to recent cases, I haAe derived Aery
decided benefit from the employment of the aromatic sulphuric acid, in com-
bination Avith  the officinal solution of the sulphate of morphia.   Two to six
drops of the acid, Avith an equal proportion of the solution of morphia, may
be given at intervals of tluee or four  hours to a child one year old.   The
effect of this treatment is sometimes immediately decisive, cases AAiiich had
obstinately resisted yielding speedily and terminating in one or  two days in
complete recovery.  The action of the morphia is easily understood; not so
readily, hoAveAer, the action of the acid.   It may be through the poAver of
constringing  the mucous  surface, but I am  not entirely satisfied of this.
Certainly I have never derived such immediate  and decisiAe beneficial re-
sults from the use of any other astringent;  indeed, in my hands all vegeta-
ble astringents have proved either entirely worthless or absolutely detrimen-
tal in infantile intestinal diseases.  Kino, catechu, rhatany, and tannin have
more often hastened death than saAed life.   In  no single instance have I
Avitnessed any good effects from the acetate of lead.   Usually, Avhen given to
children, it has proAeked excessive nausea and vomiting.   I have sometimes
arrested the frequency and copiousness of the stools with astringents, but the
promise of relief was so brief, and the relapse so fierce, that the temporary
suspension in no manner compensated for the subsequent aggravation.  In
diarrhoeas dependent upon relaxation and attended with a copious serous trans-
udation astringents may subserve a useful purpose, but Avhen the flux is the
manifest phenomenon of some grade of  the catarrhal  process,  they appear
to me to be not only inefficient  but contra-indicated.  The catarrhal  trans-
udations and excretory products contain albumen, Avith Avhich all astringents
containing tannin and many others are incompatible, so that when given in
intestinal catarrhs they simply coagulate the albumen constituent of the con-
tents of the bowels and exercise no influence directly upon the mucous sur-
face.   On the contrary, the coagulum may become a source of reneAved irri-
tation.
     46 
362
     In the later stages of the disease, when there exist manifest eAidences of
 tissue-changes, and loss of continuity, ulceration, and sloughing, recourse must
 be had to other remedies than those heretofore suggested.  Nitrate of silver,
 sulphate of copper,  and the Lig. ferri pernitrat. each haAe their advocates.
 In occasional cases I seen very marked  good  effects  folloAv the use of the
 nitrate of silver ; the other two I have very rarely employed, and my experi-
 ence with them does not justify a repetition.  AVhen satisfied of the existence
 of ulceration, copaiba and turpentine  hold out the surest hope of benefit.
 But in all such cases the sheet-anchor  of hope  is in supplying suitable and
 assimilable nutriment, in restoring waste and in supporting the waning powers
 of life.  Paw beef and rigid hygienic regulations Avill restore many children
 to health whose lives seem past all hope.
     The employment of tonics  and stimulants  demands very great care; yet
 I  am convinced that danger is far more frequently incurred by the failure to
 use them than by their injudicious employment.   Whenever  exhaustion is
 marked and threatening, their employment seems imperatively demanded, and
 especially is this the case in the  choleriform variety.  The' aromatic spirits of
 ammonia and pure brandy are* the most available  and efficient of the stimu-
 lants,  the former being  preferable where the exhaustion is temporary and
 slight  and accompanied Avith nausea and  acidity,  the  latter where there is
 tendency to collapse.  As a tonic and  stimulant Huxham's  tincture of bark
 is very useful; it invigorates the appetite, promotes digestion, gives tone to the
 enfeebled stomach, and in those cases, which not unfrequently occur in tliis
 region where the poison  of malaria complicates the catarrhal affection, it is
 specially serviceable.  In such cases occasionally  quinia is demanded.
     In those cases of cholera infantum where the  exhaustion  is  very great
 and fatal collapse is threatened, as indicated by coldness of the extremities dif-
 ficult and laborious breathing, great thirst, lividity of the lips, a feeble and rapid
 pulse, diminished secretion from the kidneys, great pallor, sunken and pinched
 features,  and cold breath, it is important to produce re-action as soon as pos-
 sible.  The hot mustard-bath  is, incomparably, the most efficient means to
 accomplish this purpose.   It may be repeated several times during the day,
to maintain a proper and equable temperature and to restore surface-circula-
tion.
     The treatment of the dysenteric form does not differ essentially from
that of entero-colitis, except from the more constant presence and greater in- 
363
tensity of tormina and tenesmus,  opiates are more necessary and better borne.
There is always danger of prolapsus ani where the straining is great and con-
tinuous, and though not in itself dangerous, it is an exceedingly troublesome
complication.   Opium-suppositories  are preferable  to enemata, being more
easily retained by a properly-adjusted pad and bandage.  Astringent injec-
tion are objectionable.   To retain in an inflamed rectum a fluid injection, the
mere  presence of which excites contraction of the intestine, requires, to afford
time for the action of whatever anodyne it may contain, considerable exer-
cise of the Avill.  This is impossible with children.  Rest of the bowel and
the recumbent posture are essential in the treatment of dysentery. .
    AVhenever fever is present, a diaphoretic should be employed, the liquid
acetate of ammoniais the least objectionable.  In the dysenteric form, ipecac-
uana  is often very efficacious.
    In thus hastily sketching the treatment, I have intentionally avoided any
general review of  the subject, preferring to confine myself closely  to  the
observations which the dispensary-practice has  permitted.
                            Article  III.
           The value of certain drugs in the treatment of bronchitis.
    In this discussion of the treatment of bronchitis, I  have reference only
to the catarrhal form.  Catarrh, as defined by Niemeyer, "consists in engorge-
ment  of the blood-vessels of  any mucous membrane, accompanied by abnor-
mal secretion, swelling, succulence of its tissues,  and  a copious  generation
of young cells," and  is marked by certain definite stages.   As it  occurs
in  children,  attacking the  mucous membrane  of the  air passages,  it is
usually the result of " taking cold," and, so far  as the adaptation of remedies
to  the treatment  is discussed here,  reference is only had to  such cases
occurring in children.   Cold impresses itself  either  directly, producing local
irritation and disturbance of  nutrition and circulation, or by some systemic
derangement of which the  local manifestation is only a  part.
    The seAeral stages of the morbid manifestations are, first, dryness of the
mucous membrane, secondly, a scanty tenacious secretion containing a few
young cells, and a few detached mature ciliated epithelial cells, and, finally,
an active deAelopment of young cells mixed Avith an abnormal and copious
secretion.  These young cells are pus-corpuscles, and identical Avith the white
blood-corpuscles.  The stage of dryness corresponds more directly Avith the 
364
primary pathological condition of engorgement, manifested in an intense red-
ness of the mucous membrane, either uniform or in patches.  The succeeding
stage, marked by the re-establishment of the secretory function—the mucus
being thin, scanty, tenacious, and mixed with a feAv young and detached epi-
thelial cells—denotes the preliminary structural changes, which in the third
stage are more precisely expressed in thickening, softening of the diseased
tissue, and the very copious cell-development.   In a practical point of vieAv,
these stages and conditions are not so sharply defined.  The order of succes-
sion is well established, though not uniformly divisible into  determinate
stages.
     My purpose is simply to portray the  course  of the  catarrhal process
and to fasten  attention to the relation subsisting  between the  successive
stages of the  morbid process and the secretory product, Avith the view to
elucidate the  inutility of the method of treatment  by the employment of
medicines designed to act through their selective affinity for the secretory
glands of the mucous membrane of the air-passages, either to re-establish
the secretion or to  arrest or modify a secretion morbid and excessive.
     The stage of dryness  represents the condition of engorgement;  the
 successive stages  of augmented and altered secretion  and active  cell-
 formation represent the progress of the morbid process  through its condi-
 tions of SAvelling, succulence, and friability.  The irritation of the mucous
 membrane supervening upon the cause is immediately folloAved by fluxion-
 ary hyperemia—ubi irritatio, ibi affluxus—and the subsequent lesions are the
 consequent conditions.   If a patient is presented during the stage of dry-
 ness—engorgement, is  it the part of science  to seek relief through the ac-
 tion  of  medicines designed to promote  progress through the  successive
 stages ?   Ordinarily the terminal point in the course of catarrhal inflamma-
 tion of the lining membrane of the air-passages is augmented secretion and
 cell generation.  In this condition the case is usually presented for adAice.
 Is the cure to be sought  through agents  designed  to  produce this precise
 condition?   If so, it is nature's method, and will usually, under proper hy-
 gienic regulations,  run  its  course to  a successful termination.
      To pursue this discussion intelligently, it is necessary to definitely de-
 termine Avhat is meant  by expectoration and the modus operandi of  expecto-
 rants.   Expectoration is a tAvofold  act, expressed in the secretory function
 of the muciparous glands of the mucous membrane  of the air-passages and 
365
 the expulsion of the product of this functional action.   The medicinal agents
 may, for convenience and comprehensiveness, be classed as true  and indi-
 rect expectorants.  AVith the latter I have naught to  do at  present.   True
 expectorants,  as I propose to  consider them, are medicines which, entering
 the general circulation by absorption, possess a special direction toward the
 mucous  membrane of  the bronchial tubes, a  selective  affinity for the
 muciparous glands of the pulmonary surface.  The  doctrines of selective
 secretion and of action by direct contact through the circulation  seem Avell
 established.   They are  constituent factors of. the eliminative action.  A
 substance absorbed into the general circulation may be eliminated through
 an emunctory Avithout possessing any selectiAe direction toward it, but true
 eliminatives possess inherently the  quality of selective secretion.   The se-
 cretory apparatus of the bronchial mucous membrane and of the pulmonary
 air-cells are, to  a certain  extent, and  especially so Avith regard to certain
 odorous and volatile substances, emunctories.   But their emunctory function
 is so incomparably less than other glandular parts, and essentially so in refer-
 ence to inodorous and fixed substances, that  no one would seek  to deriAe
 the specific and direct  action of any  medicinal agent through  the  mere
 probability of its  elimination  through the pulmonary surface.  Hence the
 explanation of the special expectorant-property must be sought in the  qual-
 ity of selective secretion.  The action is by direct contact, and the effect is
 the same, Avhether it reaches the secretory apparatus through its special af-
 finity or through the  emunctory function  of the part.  A medicine, being
 itself excreted through  any particular gland, exercises the same  influence
 as if it possessed a special tendency to that gland.  It is its selective tend-
 ency Avhich giAes to it its  determinate therapeutic value and regulates its
 application.   Eliminatives enter the blood, pass out through certain glands,
 and in passing through the glands the normal secretion of the gland is aug-
 mented.   The increased secretion results from the increased Avascular sup-
 ply, and this vascular fullness may be carried to  such an extent, through
 the effect of the eliminative,  that  congestion  may ensue  and the normal
 secretion be temporarily suppressed.  The condition of engorgement found
 in the primary stage  of bronchial  catarrh, resulting from  the influence of
 cold, may be  produced  by medicines eliminated through the pulmonary
 surface  or by medicines possessing the  special tendency tOAvard  the secre-
tory apparatus of the bronchial mucous  membrane.   This fact  is so well 
366
established that all writers on therapeutics caution against the employment
of medicines possessing this selective affinity during the stage of simple
engorgement.   Congestion of the bronchial mucous membrane at  first  ar-
rests, subsequently augments, the secretion; the product is composed of mu-
cus, the normal secretion of the glands proper, and pus, the product of the
inflammatory process.   If the congestion had  its origin in excessive  stim-
ulation of the normal function  and persisted  through continuation of the
exciting  cause, the  same  inflammatory changes would  ensue.   If  con-
tra-indicated in the primary stage, because  of a special  tendency tOAvard
the inflamed membrane, and useful  in the subsequent stages of the  same
morbid process, Avhen the consequent lesions are superadded to congestion,
it must be by virtue of some other influence than the selective secretory action.
"Hypersecretion," says  Rindfleisch,  (p.  333,  Text-book of  Pathological
Histology,) "never exists without a simultaneous hyperaemia of the mucous
membrane," and  "this hyperaemia is  the proximate  cause of the hyper-
secretion,"  and is at the same time the  remote  cause  of the other "disturb-
ances, of tumefaction, haemorrhage, pigmentation, hypertrophy, &c, which,
taken together, first make out the anatomico-pathological  picture of  catarrh
of the mucous membrane."  "The hyperaemia may be either passive or act-
ive.  In the first case, it precedes the catarrhal inflammation for a longer
time  and has the significance of a remote cause; in the  second case,  it is
the immediate consequence of the pathological irritation."  Thus it appears
eAident that expectorants, as eliminatives, are  inadmissible in  catarrhal in-
flammation.  Hyperaemia being the anatomical foundation of  catarrh, cer-
tainly eliminatives would augment rather than  diminish the physical cause.
Surely a cure cannot be sought through the  action  of  agents which will
produce the morbid condition—the immediate cause of hypersecretion, and,
remotely, tumefaction and  softening.   The migration of white corpuscles
cannot be thus arrested.  If the purpose be to eliminate effete products
from the blood, why not resort to  cathartics, cholagogues, diaphoretics, or
diuretics, far more efficient  and  energetic eliminative expedients ?  If the
hypersecretion be symptomatic  of augmented function,  surely agents de-
signed to promote  functional  activity are contra-indicated.    The morbid
process being inflammatory, it may be claimed that the emunctory function
is antiphlogistic.  The air-cells and mucous glands of the pulmonary sur-
face are far less efficient as emunctories than the mucous  glands  of the ali- 
367
mentary canal, or the kidneys, or the liver, or  the skin; and hence sound
judgment and philosophic reasoning  dictate the promotion  of elimination
through one or more of these sources.  Besides the direct antiphlogistic ef-
fect thus more efficiently induced, the  necessary and  consequent reAudsive
influence would materially favor the relief sought.   Pulmonary elimination,
as an antiphlogistic in  inflammation of the  mucous membrane of the  air-
passages, would not only prove an inefficient remedial resource, but Avould
be contra-indicated, because of the tendency to increase and  intensify the
fluxionary hyperaemia.  It  is universally conceded that expectorants  are
harmful during the stage of pathological irritation, the immediately antece-
dent condition of actiAe  hyperaemia, because of the certainty  of augment-
ing the vascular fullness.  In this condition the indication is to remove the
physical cause, hyperaemia, and to prevent the ulterior tissue-changes, swell-
ing, softening, &c.  The suppressed or diminished secretion is an effect—the
sign, not the disease.   Resolution being established the secretion is restored.
To stimulate the secretory function is to increase the  vascular supply,  and
consequently the active or passive congestion.   Medicines having an especial
direction toward the respiratory mucous  membrane, and given to restore
or promote the natural exhalation, to  re-establish the secretory function, do
not remove the capillary congestion, do not promote the contraction of the
capillaries, and are consequently inadequate to the removal of  the physical
cause.   The hyperaemia  continuing, augmented and altered secretion  and
other evidences of the progress  of the morbid process soon  take place.
This is the regular  course of the  diseased phenomena, Avhen  the unaided
powers of nature and the withdraAval of the aggravating and exciting influ-
ences fail to  terminate  the  process by resolution.   Derivation, revulsion,
counter-irritation, elimination  through the more active emunctories, fulfill
the pathological indications.   True  expectorants possessing, as most of them
do, other medicinal properties, some  combining diaphoretic, some diuretic,
others general eliminating and relaxing qualities, and perhaps all being nau-
seants, and thus depressing to the heart's  action, may, and certainly  do,
through these revulsive qualities, at least partially prove remedial.  But  this
is not the result  of any expectorant action, and in no manner justifies their
employment with the AieAV to obtain the alleged specific direction to  and
effect upon the mucous membrane of the pulmonary surface.  Their select-
ive and revulsive actions are  antagonistic. 
368
     A ATast majority of the cases of  simple bronchial catarrh terminate favor-
ably Avithout internal medication.  The disease in itself is not self-limiting,
but, if the aggravating cause is withdrawn, the unaided powers of nature will
frequently speedily terminate  the morbid process.   It is important to under-
stand how this result is accomplished.*  So long as the irritant, the inhalation
of cold air  perhaps, is re-applied day after day, there will be continued ac-
cessions to the pathological irritation and  consequent augmentation of active
hypenemia and increased distention of the congested capillaries.  The mucous
membrane of the respiratory tract is richly supplied with elastic fibres.  This
elasticity is the only barrier to  the capillary dilatation induced by the in-
creased volume of blood, and  the resisting power is more vigorous in propor-
tion to  the  distention-force, until destroyed or greatly lessened by too con-
tinuous tension. The elasticity and the blood-pressure are counter-forces.  So
long as the first maintains the  mastery nature will prove sufficient to accom-
plish the cure, and.so soon as  it  regains the mastery, after haA'ing been lost,
the process of cure will begin.  Following the indications of nature, the treat-
ment must begin with the withdrawal of the  cause of  the  irritation, and,
secondly, to lessen the blood-pressure.  The first may be fulfilled by remain-
ing in-doors, and the second frequently by hot pediluvia and Avarm draughts
at bed-time.  Hence, it is manifest that it is to the removal of the cause and
to the maintenance and restoration  of the elasticity of the  mucous  mem-
brane, and not to the secretory function, that the remedial resources must be
directed, at least in the primary stages.
     Failing to arrest the disease, the definite changes of the inflammatory
process succeed.   Increased and altered  secretion, mixed AA'ith young cells
and detached epithelial cells, occur.    Thickening and softening of tissue fol-
Ioav.  A copious migration of  AAmite blood-corpuscles through the stroma of
the capillary Avails takes place.  The suppurative process becomes established.
The muscular tunic becomes relaxed.   The bronchial tubes are more or less
    * Inflammation of mucous membranes  causes an abundant formation and shedding
of epithelium and mucus-cells, which after a time present all the character of pus-
globules ; and the free discharge of these may terminate the inflammation. This is the
common course of catarrhal inflammations.  And further,  where the inflammation is
deeper, involving the sub-mucous tissues, and  even the connective tissue and paren-
chyma, so long as the sarcophytes, proceeding from the blood-vessels and proliferating
in the tissues, retain their vital properties of motion and  migration, they may likewise
escape to the surface and be thrown off;  and thus the products of bronchitis and pneu-
monia may be cleared away by free mucous and purulent expectoration.  (C. J. B. Wil-
liams, on " Pulmonary Consumption," p. 69.) 
369
dilated and filled AA'ith the niuco-purulent  secretion.  InflainmatoiA' oedema
adds its counter-pressure to the other phenomena.   So long as the causal iiri-
tant is permitted to increase the pathological irritation, so long will accessions
of active hyperaemia take place.   The  irritant cause being withdraAvn, the
second indication is to remove the pathological condition—the passiAe conges-
tion.  The counter-pressure is derived from two sources : the volume of blood
stagnated in the capillaries and the oedema-fluid.   If there be any medicines
specifically adapted to the  cure of this condition their action cannot be elimi-
native, nor can the cure be sought  through  the emunctoiw function  of the
pulmonary surface.  Either process occasions a physiological hyperaemia, and
consequent augmented functional activity.   The  inflammatory product, so
abundantly poured into the lumina of the  bronchial tubes, unlike the normal
secretion, is tenacious, purulent, and irritating.  Hence, it becomes important
to facilitate its evacuation.  It is held that certain medicines possess the medi-
cinal property of liquefying the  secretion.   That the inflammatory product
maA' be liquefied by  agents brought into direct contact  with it through inha-
lation seems hardly to  admit of a doubt, but that there are agents,  acting
through the general circulation, possessing special tendency toward the bron-
chial secretory apparatus and capable of inducing an undue secretion of the
fluid portion of  secretion, is not so clearly established.  It is Aery true that
there are medicines AA'hich produce diuresis, diaphoresis, and catharsis, but the
organs through which these serous exhalations take place are active emuncto-
ries, upon  Avhich the  medicinal  agent  acts through its special eliminatiAe
tendency to a particular emunctory.  " Medicines which increase secretion
are themselves excreted."   It is  also an established law, with perhaps few ex-
ceptions, that substances contained in the  blood, and intended to be excreted,
pass out  through particular organs.  The  kidneys are the  natural  emuncto-
ries of Avater,  and betAveen them  and the skin there exists a compensatory
relationship;  the bowels eliminate certain  effete products and the liver certain
other matters.   The therapeutic action of medicines in producing diuresis is
simply an augmentation of the physiological function, and not a modification
of the  secretory process.   The liquefaction  of the  morbidly excessive and
tenacious secretion  of bronchial catarrh, by medicines introduced through
the general  circulation, cannot be a process analogous to diuresis or dia-
phoresis, for these denote increased functional actiAity and increased vascular
supply.  The altered product denotes altered structure, and the indication is
     47 
370
to modify the morbid action and conditions.   The liquefactive is more prob-
ably a pathological than a therapeutical process, and may, perhaps, find its
explanation in an altered condition of the blood and in the expulsion of the
oedema-fluid, which may be expelled from the infiltrated tissue by the restora-
tion, to a greater or less extent, of the normal elasticity.   In the latter case
it is to the elastic tissue, and not to ther glandular structure, and in the former
to the condition  of the blood, that the remedies should be addressed.
     The pathological irritation is  the immediate cause of  the hyperaemia.
Swelling is the second anatomical element of catarrhal inflammation, and is
evidently derived from the increased vascular fullness, from succulence  due
t< > the saturation of the soft parenchyma and sub-mucous tissue Avith serum,
and partly from  the migrated colorless blood-corpuscles.   Congestion is the
foundation, the point aVappui of these  tissue-disturbances.  To produce reso-
lution it is necessary to arrest the amoeboid movement.  The abnormal secre-
tion  is composed partly of the normal secretion, a feAv detached mature  epi-
thelial cells, and to a greater or less extent, according to the progress of the
morbid process,  of young cells.   Rindfleisch says,  "It is manifest, that if by
our medical skill Ave could succeed  in removing the cells which haAe wand-
ered in an inflamed organ, this organ would return to the same  condition in
Avhich it Avas before the inflammation ;" provided the modification of connec-
tiAe  tissue Avhich may have ensued  be deducted, AArhich might likewise soon
disappear.  He suggests, in this condition, that one of two methods of reso-
lution  ma}' be adopted—either to Avander out the migrated colorless blood-
corpuscles or to promote their resorption by favoring their fatty degeneration.
The  latter process is materially promoted by the co-existing succulence of the
inflamed structure.   So far as I know, and as suggested by the same  dis-
tinguished pathologist, heat is the only agent that Avill cause "already exuded
colorless blood-corpuscles to wander farther;" but this agent must be  em-
ployed within  proper limits or  else the process of emigration will be renewed
and intensified.  Apart from these considerations the indication is to remove
the hyperaemia.  As I understand and have endeavored to explain the modus
operandi of the medicines alleged to possess the peculiar expectorant qualities,
they are inadequate to the fulfillment of these indications.   The subsequent
lissue-disturbances and morbid lesions are only  the evidences of the further
progress of the same morbid process, having their origin in the persistent con-
tinuance of the hyperemia, which,  perhaps,  is augmented and extended by 
                                   371

 repeated accessions, and aggravated by the consequent general debilitv and
 exhaustion  and by the softening and relaxation of the parenchyma of the
 membrane.   It therefore appears unnecessary to trace the histological  rela-
 tion of the haemorrhage,  pigmentation, hypertrophy, and other changes to the
 primary and essential condition—hyperaemia.   In  the treatment, it is the
 objective  against which  any method of cure must be directed, if the patho-
 logical indication is to be fulfilled.
     True expectorants,  if  there be any which will transform the unhealthy
 into a healthy action,  must act by direct application  or by contact through
 the circulation.   None others are true expectorants.   As  yet  carbolic  acid
 is the only agent which  is  believed to  possess the property of arresting, by
 contact, the  suppurative process.   Stille limits  the  adaptation of true ex-
 pectorants to the cure of that condition of the bronchial mucous membrane
 " in which the secretion is  excessive and morbid," and maintains that by
 their employment the secretion  and  diseased  condition  may be modified.
 Like most authors of repute he classifies them A'ariously,  adapting them to
 different conditions  of the  morbid  process.  Some  are stimulating, others
 depressing;   some augment functional activity,  others  diminish  secretion.
 This subdivision, and classification according to their special and additional
 qualities, are essential to adapt them, as expectorants,  to the cure of the dif-
 fering conditions of catarrhal inflammation  of the respiratory tract.   The
 pathological  lesions succeed one another in  regular order.   To explain the
 curative influence of a class of medicines supposed to possess a peculiar and
 specific direction toward the lining membrane of the respiratory tract, and
 to adapt them to  the varying conditions and progressive stages of the same
 morbid process, it has  become necessary to  qualify their mode of action  as
 stimulants or depressants.   In this connection it is important to bear in mind
 that, according as they are stimulating or depressing, they hold other prop-
 erties to  a greater or  less  degree.   The depressing quality is proportionate
 to the nauseating or emetic  action.   All nauseants are indirectly expectorant;
 that is, by their relaxing  influence upon the system generally and depressing
 influence upon the heart's action, thev afford relief to the local congestions.
 The stimulating quality increases proportionately to-the lessened emetic and
nauseating action.   Tartar-emetic stands at the head  of the depressants :
ipecacuanha  next in order; folloAved by squill and senega, as the mildest of
the stimulating.   The first  two are  active emetics; squill, and senega,  sue- 
372
cessively, mildly nauseating and gently stimulating expectorants.  In view
of these  considerations, is it not probable that the expectorant effect is the
result of other properties than their specific action, by contact, upon  the
muciparous glands ?  If eliminated through the pulmonary surface, thus aug-
menting  the functional activity, their presence in the product should be sus-
ceptible of easy demonstration.  Magendie and Orfila found in animals killed
by tartar-emetic and ipecacuanha, traces of inflammation and congestion in
the lungs.  Headland and Pereira maintain that these tAvo  substances  pos-
sess, in a higher degree than any others, the peculiar quality of true  expec-
torants.   I am notaAvare that any of the true  expectorants, excepting  tartar-
emetic, have been  detected in the pulmonary  secretion.  Headland thinks it
probable their presence might be demonstrated, but is ignorant of any at-
tempt to  do so.  Unlike Stille, most authors seek to illustrate the  expecto-
rant action  of medicines by their supposed  analogous effects upon  other
mucous membranes.   This, perhaps, in the  absence  of the evidence of their
presence in  the  bronchial secretion, furnishes the strongest proof of such
action, but the analogy is not complete.  Facts  should  be  eliminated from
hypotheses.   If  any one or all of them produced definite and determinate
effects upon the  alimentary mucous membrane, ahvays independent of their
other properties, such effects might be accepted as the true representation of
their therapeutic action.  For instance, tartar-emetic, however introduced into
the system, is in great part eliminated through the stomach,  and even Avhen
injected into the veins  of an animal, from Avhom the stomach had  been re-
moved and  replaced by a bladder, vomiting was still excited by  the con-
tractions of the diaphragm and abdominal  muscles.  In all cases, whether
introduced into the system  by absorption or by injection into the veins, the
post-mortem examination disclosed Avascular injection of certain portions of
the alimentary mucous membrane.   Here is an illustration of definite action
and  effects.   If the effect upon the bronchial mucous membrane is analogous,
surely it is not adapted to the cure of catarrhal inflammation by virtue of its
peculiar action upon and direction toward the  alimentary mucous membrane.
It is an active nauseant and  emetic, hence  expectorant, but to secure fully
the latter effect its nauseating influence must be kept within its proper limits
for emesis does not favor its  expectorant influence, Avhich is  secondaiw and
resultant, and measured by the degree and duration of the  nausea.  Thus
it is perceived that its alleged expectorant quality cannot be separated from 
373
the other more definite and determinate influence, and is not analogous, either
in its mode of action or local effects.   But the effects of tartar-emetic upon
the bronchial mucous membrane  are not left to inference  or  to  deduc-
tion from  its analogous  effects upon the alimentary mucous membrane.
Besides the experiments of Magendie and Orfila, Dr. Richardson has deduced,
from  his experiments on  animals, certain conclusions  in regard to its effects
and mode of action, Avhich  I  quote, in part, as follows from Stille:   "All
permeable  tissues absorb, and its jeffects are specifically the  same by Avhat-
ever channel, including the blood,  it may enter.  After absorption  it may
be detected in the blood, the serum, the urine, and all the organs.   It  ex-
cites marked local effects  in any membrane by which it is eliminated," and
hoAvever introduced into the system it causes redness of the  gastric mucous
membrane  and  the symptoms which  attend its direct application to this
organ.   The  post-mortem phenomena are congestion and  fluidity  of the
blood, Avith local inflammatory lesions  in  the  membrane,  through Avhich ii
may be eliminated.  These conclusions.haAe been substantially corroborated
by many eminent imestigators.  Recently, Nobiling  (Schmidt's Jahrbuch,
1866) deduced from a series of experiments instituted  to determine its effects
upon the living organism, AAdien giAen in small doses continued for a length
of time,  the  folioAving conclusions:  " Tartarized antimony produces tvvo
distinct effects—one upon the heart, another  upon the alimentary  canal.'
The influence of the alkali is exerted upon the heart,  and is  either relaxing
or depressing. Whether caused by direct paralysis of the muscular texture of
the heart or through action upon the cardiac ganglia,  he failed to determine
satisfactorily.  "The influence  of  the antimony  is  upon the alimentary
canal."   The action of the chemical combination is the combined action of
the alkali and antimony, no direct or independent effect being derived from
the tartaric acid.   Hence  "it  is an article altogether unadapted for  use  in
typhoid fever, in pneumonia, bronchitis, -and pleurisy.  Its apparent bene-
ficial effects are counterbalanced by its deleterious influences upon  the ali-
mentary canal."  It is evident from these investigations that the explanation
of its curative poAver over catarrhal inflammation  of  the lining membrane
of the  air-passages must  be sought through its antiphlogistic action, as ex-
pressed in its nauseating quality, and in its influence upon the heart's action
and plasticity of the blood, and through its revulsive action upon the alimen-
tary canal and skin.  It is eliminated principally through the stomach, kid- 
374
neys, and liver;  very moderately, and fortunately so, through  the lung.
Only adapted, by virtue of its  antiphlogistic and nauseating action, to the
primary stages, its marked local effects upon the eliminating surface contra-
indicate its employment when such surfaces are inflamed.
     Ipecacuanha is the next in order of the true expectorants, and is closely
allied, in its  nauseating  and depressing qualities, to tartarized antimony,
though not so active and  certain an emetic.  I am not aAvare  that  its pres-
ence has been recognized in the bronchial  secretion, and hence its  elimina-
tion through  the  pulmonary  surface has not been positively demonstrated.
Its expectorant quality must then be studied in connection Avith its physio-
logical effects and therapeutic action upon the mucous membrane of other
organs.   It is singularly true that authors are not agreed as to its precise
effect upon the muciparous glands, though  generally it is claimed to possess
a special direction to the mucous membrane and especially to that lining the
respiratory tract.   By some it is held to be applicable to cases  of morbidly
excessive secretion,by others to cases of scanty secretion.  "The emollient and
nauseating [emetic tartar and ipecacuanha] expectorants," (says Pereira,) "are
adapted for the more acute forms of bronchial irritation and inflammation."
It is a familiar fact that Avhen  applied to an abraded cutaneous surface it pro-
duces inflammation, and when  applied, directly or by inhalation, in many
persons, to any portion of the respiratory tract, it occasions all the signs and
symptoms of catarrhal inflammation.  Ringer says it " excites a catarrhal in-
flammation of the mucous membrane"  whenever applied to it, and that its
varying effect in different individuals is simply a difference in degree.  Large
doses have been known to produce in animals inflammation of the gastric, in-
testinal, and bronchial mucous membrane.   Emetina introduced into a vein
or injected hyperdermically will produce vomiting, an effect similar, perhaps,
in its mode of action to that of tartar-emetic.  When taken into the stomach,
ipecacuanha, in quantities insufficient to produce vomiting, excites the mu-
ciparous glands  of  the gastro-intestinal  tube to augmented secretion, and
through absorption into the  blood it is  claimed to  produce a similar effect
upon the bronchial tube.   It  is nauseating,  and some maintain that it is only
during this action that the bronchial secretion is augmented, and that this is
the effect of its relaxing influence, wliile others hold that its action upon the
bronchial secretory apparatus is wholly independent of any other influence, as
illustrated by the effect of minute quantities, in certain persons, upon  the pul- 
375
monary surface, in AA'hom it requires much larger quantity to produce  nau-
sea or vomiting.  This is  undoubtedly true, but it only proves that in Aery
small quantities applied  directly to the bronchial mucous  membrane it is a
poAverful irritant, and that thus applied it more quickly sets up the inflam-
matory process than when introduced into the system.  Stille, hoAvever,
maintains that the sooner the nauseating effect is obtained  the speedier and
more certain the  bronchial secretion is  excited.   Pecholier's  experiments
upon rabbits showed that the rate of the pulse, the temperature of the body,
and muscular vigor depressed under its operation, and  this, suggests Stille',
"avouM tend to explain  the efficacy of ipecacuanha in bronchial affections
by its general sedatiAe operation upon the circulation and its specific poAver
of reducing the quantity of blood in the  lungs."   Through its property of
exciting  the muciparous  glands it is laxative and a valuable addition to
cathartic medicines.  Dr.  C. D. Phillips (The Practitioner, November, 1869)
extols the power it exerts "over all diseased mucous membranes in check-
ing profuse mucous secretions, Avhether from the air-passages, the alimentary
canal,  or the genito-urinary apparatus," and considers it  most  useful  "in
spasmodic coughs attended witli profuse mucous expectoration and vomit-
ing."   He  claims that it is expectorant, anti-spasmodic, and anti-emetic.
Especially adapted to whooping-cough, "where the Aemiting is more trouble-
some than the AA'hoop ;" to nocturnal spasmodic asthma unaccompanied with
organic disease of the heart or lungs; to dysenteria and diarrhoea, "Avhere
nausea, vomiting, and retching  exist," and  to the sickness of pregnancy.
Ringer's vieAvs of the action and uses of ipecacuanha do not differ materially
from Phillips's, but Iioav far they are corroborated by the experience of the
profession generally I  do not know.  If  it is adapted to all the conditions
and applicable to all the  pathological phenomena for Avhich it has  been so
highly extolled by the various authors and  observers  avIio have given to
the profession  their experience, smely little  else is needed to complete the
art of cure.   Its marvelous poAver, Avhen  given in Aery large doses, to con-
trol and subdue the morbid phenomena of dysentery (so well attested by
several  careful observers)  must be  derived from properties altogether
different from those it possesses and exerts to augment mucous secretion and
produce  catarrhal inflammation.  Its efficacy in  checking  the nausea and
vomiting of pregnancy, of diarrhoea and dysentery, of the vomiting of Avhoop-
ing-cough, Avhen  the Avhoop is not troublesome; its  activity as a nauseant 
376
 and emetic  when  these  effects  are desired;  its  poAver  to  arrest profuse
 mucous secretion from the air-passages, alimentary canal, and genito-urinary
 apparatus, and equally efficient and certain office as a promoter of mucous
 secretion  of  the gastro-intestinal tube, when its  laxative  operation, and of
 the bronchial secretory apparatus when  its expectorant quality, is desired,
 seem to impart to it the Avill to fulfill the purposes of the giver.   I may have
 been unfortunate, but I have failed to derive these multiform  advantages
 from its employment,   If so admirably adapted to the cure of catarrhal or
 diphtheritic inflammation of the colon and rectum, why not equally efficacious
 in the treatment of similar affections  of the respiratory tract?  Can it be
 that in the gut  it acts by direct contact, and  in the other  instance it acts
 through  the  blood %  Who would  think of dusting into inflamed fauces or
 bloAving into an inflamed larynx  powdered ipecacuanha ?  If applied to the
 conjunctiA'a it excites inflammation, to the nasal fossae it excites increased
 secretion, to  the bronchial  tubes it  produces  the phenomena  of catarrhal
 inflammation, to the gastro-intestinal mucous membrane increased functional
 activity;  as  a nauseant it depresses the heart's action and relaxes muscular
 tension ;  as a sudorific it determines to the skin.   If Phillips's theory of its
 action is correct, and his and Ringer's suggestions be the practical teach-
 ings of their experience,  its expectorant quality  is subordinate to its anti-
 spasmodic influence.  I cannot explain its utility in these  essentially differ-
 ent morbid conditions, and shall not attempt to reduce its therapeutic action
 to any one definite modus operandi;  but, accepting the  facts separated from
 hypotheses and  individual opinions, will  study them solely in  reference to
 its utility in  the treatment  of  catarrhal inflammation of the mucous mem-
 brane of  the respiratory tract.   What  are these  facts ?   As a nauseant it is
 relaxing and sudorific, and thus revulsiAely antiphlogistic ; as an anti-spas-
 modic it may exercise an important influence in governing the secretion of
 mucous membranes.  The intimate relationship between the nervous system
 and the secreting  activity of certain glands is  established by many facts,
 but hoAvever the nervous  influence may be  developed, or through Avhatever
 channel it may operate, the poAver over the secretory function is through the
 [lower to dilate or contract the coats of the arterial capillaries.   " The gen-
eral conditions," says Marshall, " which influence the functions of secretion
and excretion are  the quantity of  blood  supplied to respective  glands, the
 quality  of that  blood, the presence of external stimuli, acting directly or 
377
indirectly on the  nerves, and, perhaps, some  goAerning influence  of the
nervous system generally."  As yet the doubtful power of ipecacuanha over
the capillary circulation  exerted through the nervous system has not been
definitely determined, but if it be permissible  to  infer its mode of action
from its knoAvn effect in  augmenting the secretion, when applied directly to
mucous surfaces, it may  be  assumed that it dilates the  arterial  capillaries,
thus fulfilling one  of  the general conditions by increasing the  vascular
supply.
     As a local or external irritant it produces phenomena resembling catar-
rhal inflammation.   Hence it may be concluded that its specific action on
mucous surfaces is by virtue of its power to augment the supply of blood,
to induce active hyperaemia.   The functional action of  the secretory appa-
ratus of mucous membranes and the primary condition of catarrhal inflam-
mation, except  so far as  they may differ in the nature of the  causes, in the
absence of pathological irritation, and actiA'ity and passiveness of the hyper-
aemia, are somewhat analogous processes.   In  the former case the stimuli
are purely  physiological, in  the latter pathological; yet either  may be
induced  by  therapeutic  agents.   The normal function may be  carried
beyond the  limits  of a  true physiological process, and become a patho-
logical one.   The  one terminates in the precise condition Avhere the othei
finds its beginning—engorgement.  Whether the engorgement arises from
excessive  physiological  stimulus  or  pathological  irritation, the  primary
disturbance is one of nutrition.  An uninterrupted transmission of  arterial
blood through a part, and not  an excess of blood stagnated in a  part, is
essential to normal nutrition.  The analogy subsists only so far as invohes
the fluxion of blood, and ceases where tissue-disturbance begins.   The  con-
gestion, and  not the irritant  or irritation, is the pathological  foundation of
the subsequent  tissue-disturbance  and changes.   During the early stages oi
engorgement the physiological action is suppressed; subsequently a morbidly
excessive secretion is poured out.
    In  Avhat respects  does this inflammatory  product differ from  normal
mucus?  "Mucus," says Marshall, (Outlines of Physiology, p. 766,)  "is the
clear, or slightly turbid, colorless, Aiscid fluid found on mucous membranes.
It is partly secreted by the epithelial cells of the compound racemose glands,
but in part, also, by those of the surface  of such membranes.   It is a special
secretion from the plasma of the blood, and differs from it chemically.  *  *
     ■ts 
378
 It contains desquamated epithelial cells, mucous corpuscles Avhich closely re-
 semble white blood-corpuscles, and pus-corpuscles, and also contains nucle-
 ated cells intermediate betAveen true mucous cells and epithelial cells," and
 OAves its viscidity to mucin.  Flint says it contains a few leucocytes, which are
 produced upon the mucous surface with great facility, and are the result of
 irritation and not constant constituents of normal mucus.   The morbid pro-
 duct, besides other constituents derived from  the transformation of the his-
 tological elements of mucus, is, so far as regards its cellular constituents and
 the mucin,  analogous to the physiological secretion.  These elements it
 contains in great excess.  But it  is more than probable that the  leucocytes
 found  in normal mucus are not wandering, colorless blood-corpuscles.  Flint
 says they are formed on the surface, and Rindfleisch maintains that pus-cor-
 puscles are not exclusively migrated Avhite  blood-corpuscles.   At page 111,
 (Text-Book of Pathological Histology,) he says:  "The mass of pus is every-
 where formed by the emigration of colorless blood-corpuscles out of the ves-
 sels;  only that, first, the way Avhich the wandering cells take  is  directed in
 one case tOAvard a free surface, in  the other toward a point situated in the
 parenchyma of connective tissue; and that, secondly, in the production of pus
 upon mucous and serous membranes, the participation of the epithelium in
 the production of  pus cannot be excluded," and suggests the further proba-
 bility that a formative irritation of the stable connectiAe-tissue  corpuscles
 may cause their breaking up and  impart to them the amoeboid movement.
 According to Flint the production of leucocytes on the surface of mucous
 membranes never takes place except as the result of irritation. The epithelial
 cells are exclusively the  mucus-forming bodies, from which, as .a physiologi-
 cal product, it is cast out; as found in catarrh, it is the product of their de-
 struction.  Mucin  is  a constituent of normal  mucus,  not deriAed from the
 blood,  but formed of the elements of secretion.   It exists in great abundance
 in the inflammatory product,  and is  especially copious in the product of
 bronchial catarrh  produced by cold.  This excessiAe formation of mucin
 cannot find its source in the ordinary physiological production of mucus, but
 must be  a transformation resulting from an abnormal process.   It, like pyin,
 Avhich is the  distinguishing  characteristic constituent of purulent mucus, is
 an albuminoid body and a transformation produced by a morbid action.  Its
formation is a part of the structure-change which completes the picture of the
catarrhal process. The product of catarrhal bronchial inflammation sometimes
contains  blood, and albumen, which is either derived from the  extravasated 
379
blood or escapes uncombined through the desquamated epithelium.  "The
changes," says Rindfleisch, (p. 338,) "AA'hich the secretion of the mucous mem-
brane experiences by catarrhal inflammation, are so striking, and present
points of support so important for clinical decision, that it has been here and
there believed that Ave  could define catarrhs immediately as anomalies of
secretion.   This is not correct, for the anomaly of secretion is not the essence,
but the consequence, of the catarrhal inflammatory condition."  But it would
be completely erroneous, did we see in catarrh only an increase of the nor-
mal secretion. There is a difference betAveen secretion and excretion; and this
difference prevails here.  The physiologically most important secretions of
the mucous-membrane tract—the gastric and intestinal juices—are bynomeans
secreted in greater quantity from the catarrhal than from the healthy mucous
membrane;  on the contrary, a decrease of this secretion is constantly to be
expected as a functional disturbance accompanying catarrhal inflammation.
It is already different Avith the physiologically less important  mucus, Avhich
also  covers  the normal  mucous membrane.   We know mucous catarrhs in
which mucus is  furnished in increased amount.   They occur, par excellence,
at such places of the tract as are distinguished for their greater abundance
of mucus-preparing  glands, at the  pharynx, the respiratory passages,  the
stomach and large intestines.  Yet we know that the  preparation of mucus
does not  exclusively belong to acinous glands, but that the mucus-metamor-
phosis is  the same for the protoplasm of the epithelium of the mucous mem-
brane that the bony metamorphosis  is  for the cells of the  epidermis,  and
hence Ave do not wonder at finding mucous catarrhs and mucous admixtures
to catarrhal secretions, also, from mucous membranes without glands, for ex-
ample, at the urinary bladder."
     "A  somewhat more intense irritation than the simple mucous catarrh
presupposes the  increased secretion of  cellular elements.  We distinguish
in this connection epithelial and purulent catarrhs according as the secreted
cells are predominantly epithelial cells or pus-corpuscles.  I say predomi-
nantly because,  as a rule, Ave find both together.  A purely epithelial ca-
tarrh is, for example, observed upon the mucous  membrane of  the tongue,
where the so-called coating of the tongue is nothing else than a massy  sep-
aration of paAement-epithelium,  such  as is characteristic for that point of
the mucous-membrane tract.   We  have no grounds Avhatever to assume
that epithelial cells produced in excess are formed according -to  any other 
380
than the normal principle of development, and  in this connection we may
conceiAe the epithelial catarrh as a simple hyperplastic  process.   But Avhat
if avc find pus-corpuscles in the catarrhal secretion, if Ave have to do Avith a
purulent catarrh?  It is a question whether the catarrhal pus-corpuscles are
also to  be  regarded as emanations  from sub-epithelial connective tissue.
Against this formerly universally-received opinion, the  circumstance espe-
cially testified that we could ahvays demonstrate an epithelium, either by
scraping the surface or by vertical section, upon mucous membranes which
were completely in the  condition of purulent catarrh, and  that this epithe-
lium presents not any or but unimportant deviations from normal relations.
In fact, later investigations,  in Avhich I myself have participated after Remak
and Buhl, have taught that the pus of mucous membranes  can arise by en-
dogenous formation of the superficial epithelial cells themselves.   All the
pus-corpuscles of the catarrhal secretion, nor all the pus-corpuscles in every
catarrh, are not formed in this  manner.   Young cells  possess spontaneous
mobility and may migrate.  Thus the cellular elements of the sub-epithelial
germinal tissue may penetrate between the epithelial cells and thus come to
be throAvn  off.   Mucus and  cells  are  productions  of the mucous mem-
brane;  they represent the supplied  nutritive material in increased  amount
after it has already been subjected to a  certain alteration into  secondary
products."
     Having thus traced the physiological  and pathological processes, so
far as they relate to the formation of the mucous secretion and of the  product
of catarrhal inflammation, and having brought out the points of resemblance
betAveen the functional and morbid action, and between the secretion of one
and product of the other, the final inquiry arises: by virtue of Avhat property
or  influence is ipecacuanha adapted to the cure of the diseased  pheno-
mena?
    In view  of the  analogy established between  the physiological and
pathological processes and products, how can a remedy, Avhich, by virtue of
its specific  action  upon the tissue involved, supplies the needful stimulus
to augmented functional activity, be adapted to the cure of the  same pro-
cess, morbidly augmented and intensified by the consequent and secondary
tissue-disturbances?  All observers and  experimenters are agreed that this
drug, whether applied directly or through absorption to the gastro-intestinal
or bronchial mucous membrane, augments the normal  secretion, intensifies 
381
the physiological action.   It  cannot, then, subserve the purpose of arrest-
ing the pathological  process  which is so  analogous.  It is inadmissible
during the stage of primary engorgement—actiAe hyperaemia—because, from
its knoAvn effects upon the mucous membrane, it may determine a more active
fluxion to  the already hyperaemic membrane.  It then possesses no influence
to contract the arterial capillaries  and thus diminish  the vascular supply,
and cannot, consequently, be  adapted  to  the  stage of passive hyperaemia,
when the  capillaries are dilated and gorged Avith blood.  It is not a pulmo-
nary eliminative nor  excreted through the pulmonary surface, and hence
cannot  exert any direct influence  upon the mucus-producing  bodies,  nor
restore epithelial cells to the desquamated basement-membrane, nor  arrest
the hyperplastic process  so  long as it  augments the  nutrient  supply.   It
cannot dissolve the Aiscid and tenacious product, for that is only soluble in a
free alkali.  It cannot diffuse the mucus, for it sAvells by imbibition, and in
small quantities Avill  saturate comparatively large  quantities of water.   It
cannot promote resorption, for, as such, mucus cannot  pass from the tissues
into the blood.  Its resorption can  only be accomplished through  its fatty
metamorphosis.   It cannot arrest the surface production of leucocytes,  for,
as Flint asserts,  irritation  increases their production. It cannot wander
out migrated colorless blood-corpuscles, for this is only accomplished through
the combined  agency of heat  and moisture;  and, if it  possessed such  a
power, how Avould  it  be possible to limit its action to wandering out already
migrated  colorless blood-corpuscles, and not to intensify the migration?  So
long as the pathological condition  favoring migration continues, great cir-
cumspection and care are requisite  in the employment of  agents to accom-
plish dispersion, because of the danger  of producing a  stronger  concen-
tration of these mobile cells.  It thus  becomes  manifest that ipecacuanha,
through its alleged expectorant  quality,  its specific tendency toward  and
effect upon the bronchial mucous membrane, is not  adapted to  the cure of
the morbid conditions.   That it may prove beneficial  through its  antiphlo-
gistic and relaxing qualities,  I  do  not deny.   It  may also, as shown by
lA'cholier's  experiments, diminish the  amount  of blood in the  pulmonary
structures, and thus subserve  a useful purpose in the treatment of bronchial
catarrh.
     It is hardly necessary for me to trace separately,  in detail, the physio-
logical action of  squill and senega.  Both are classified as stimulant expec- 
                                   382

 torants, and probably, through their stimulant  qualities, may prove bene-
 ficial in the later stages of catarrhal  inflammation of the respiratory tract.
 Both are locally irritant and contain  an acrid principle Avhich is carried into
 the  general circulation  by  absorption and  into  the  emunctories through
 Avhich they escape.   Both in large  doses produce analogous effects upon
 the gastro-intestinal mucous membrane, and each has  been knoAvn to pro-
 duce inflammation of the  urinary passages, strangury, and bloody urine.
 Senega is eliminated principally through the skin and kidneys.   According
 to Sunderlin  it copiously augments  the Aoav of  urine.  Bocker found it
 slightly diuretic.  Scroti says it increases the bronchial secretion and adapts
 it to the cure of cases of excessive secretion.   Squill is essentially a diuretic.
 Its nauseating,  emetic,  and  expectorant qualities  are secondary.  It is,
 probably, chiefly eliminated through the kidneys, and, according to  Wood,
 excites the capillaries and secretory apparatus.
     Through AvhateAer channel squill is introduced into the system the effects
 are the same.   That it possesses some special and  specific direction tOAvard
 mucous membranes cannot be doubted, but the action is excretory rather
 than secretory, and hence eliminative rather than nutritive.   Its effect is to
 augment the  excretion of Avater, and consequently an active diuretic, and,
 Avhen  expending its  force upon the gastro-intestinal mucous membrane, an
 energetic cathartic.  Whatever effect it may exert upon the respiratory tract
 is through the same common quality of increasing the aqueous exhalation.
 In consideration of the fact that mucus is not soluble in Avater, nor diffusible,
 but,  on the  contrary, Avill  saturate and retain  comparatively a very large
 quantity of Avater,  thus  increasing in  volume  without - losing  viscidity, it
 does not seem desirable to augment the watery transudation through inflamed
 surfaces.   It  is true that fatty metamorphosis  is greatly favored  by an
 abundance of fluid in the inflammatory focus, thus promoting the resorption
 of the cellular elements and other exuded matters.   If this be the  explana-
 tion of its beneficial influence in bronchial catarrhs, it is by virtue  of its
 general effect  upon  mucous  membranes, and should be equally applicable
 to all catarrhal inflammations  and to all stages of the catarrhal process, and
 surely would  possess a wider range  of usefulness in the catarrhs  of the
mucous surfaces tOAvard Avhich it more uniformly and directly expends its
force.  It is conceded to  be inadmissible in acute bronchitis.   As an  expec-
torant, says Stille, it is " useful in cases of bronchial inflammation of a mild 
383
form, when the sputa are tenacious and  scanty and the lungs are free from
acute inflammation," and thus especially " serviceable in chronic bronchitis
complicating emphysema, and in all forms of chronic and subacute catarrh.1'
If contra-indicated in acute catarrh because of the  danger of augmenting
the A'ascular engorgement, either by stimulating the heart's action or by dilat-
ing the capillaries, how is it possible that it can be  useful in mild forms  of
the same process or in any stage  of the  existence of the physical  cause I
Conceding its utility as a stimulant in the chronic forms, its specific  action
and direction tOAvard the mucous surface are at once ignored.
     In this connection it is relevant to refer to a property common to all of
these expectorants, expressed in the possession of other qualities, definitely
determined, through the operation  of Avhich their specific action  upon the
lining membrane of the respirator}' tract may be diverted.   That this diAer-
sion action may prove salutary cannot be denied, but it so markedly charac-
terizes their physiological influence that it subordinates their alleged direct
expectorant qualities.  When once the cliAersion action is established  it is
impossible to obtain any specific and direct action upon the bronchial sur-
face.  The utility  of this diversion action is lost sight of in the favorable
result Avhich is .ascribed to  the predetermined  direct action, rather than  to
the resultant indirect  influence; hence the common  practice is  to employ
them in such minute quantities that, practically, no benefit is deriAed.    Tar-
tar-emetic, ipecacuanha, and squill will produce their characteristic effects,
whether introduced into the system through absorption from the stomach or
through any other  channel;  and, howeAer introduced into the general circu-
lation, their expectorant action is always  associated with the .manifest phe-
nomena of some other quality, and is,  usually, proportionate to the degree
of nausea, but not to the activity and energy of emesis.  It is not only impos-
sible to separate the associated  qualities, but equally so to predetermine any
special direction tOAvard the bronchial mucous membrane alone.
     Stille, perhaps rightly, limits the therapeutic application of true expec-
torants to conditions of the bronchial mucous membrane  "in which the se-
cretion is  excessive and morbid."  Then Avhy are  the}' not more  generally
efficacious in Avhooping-cough ?  It is a catarrh, distinguished from ordinary
bronchial  catarrh in the mode of its origin and in the spasmodic  character
of the cough.   NotAvithstanding its distinct nature, and apart from any con-
sideration of the element of contagion,  its manifest local lesions are identical 
384
with those of catarrhal inflammation.  The paroxysms of cough  terminate
Avith the forcible expulsion of the glutinous and tenacious sputa, and do not
recur until provoked by accumulated secretion.  The frequency and dura-
tion of the paroxysms of coughing depend upon the rapidity of the excre-
tion and its tenacity; then how important to  correct the morbid  excretory
process.   As yet no one has found an agent among the expectorants which
holds out the hope of any uniform beneficial action, either in modifying the
diseased conditions or in diminishing the morbid secretion.  Meigs and Pep-
per haAe occasionally, Phillips uniformly, and Ringer only in  certain epi-
demics, found ipecacuanha useful,  the first basing its utility upon its emetic
and nauseating property and Phillips upon its anti-emetic and anti-spasmodic
action.   Singular antagonism  of A'ieAvs !   In the present state of medical
science the medical  mind, singularly forgetful of the much-A^aunted power
of expectorants to modify diseased action and morbid secretion, seeks to
adapt remedies  to the neurotic and not  to the  local phenomena.  Undoubt-
ed!}' deriving its origin  from a  specific contagion, yet it curiously appears
most generally  during the  season of the  year and with, greater intensity in
the localities where  bronchial  catarrh is most  prevalent.  The  poison is
eliminated through the pulmonary  surface, and there are located the tissue-
disturbances.
    In the further advocacy of the view that the salutary influence  deriAed
from true expectorants, in the treatment of bronchial catarrhs, is  not through
any direct action upon  the membrane, I may be pardoned for quoting the
folloAving passages from Stille*, (Therapeutics and Materia Medica, Ael ii, p.
495 :)
    " True expectorants are those Avhich  appear to have an especial direction
toward  the bronchial mucous membrane  alone or toward it in common Avith
the mucous membranes of other organs.   They are  all  stimulants, and  the
greater number of them contain a resinous element more or less modified by
its association Avith other principles.   With such qualities and such a tendency
to the seat of bronchial inflammation, it is evident that, if they are adminis-
tered during the active stage of such inflammation, they must almost of neces-
s'ty aggravate it, by arresting that process of restoration of Avhich the inflam-
matory symptoms are the signs.  *   *  *  As in chronic inflammation of
other  mucous membranes, the blood-vessels remain enlarged, the membrane
itself becomes thicker than  in health, and from its surface mucus is secreted 
385
of Aarious degrees of consistence and shades of color, more or less mixed Avith
a serous liquid, and ultimately containing more or less pus.  Under these cir-
cumstances, as in similar conditions of the mucous membrane of the eye, the
nasal passages, the fauces, urethra and Aagina, a stimulant treatment is found
to be the most successful."
     It is manifest that Professor Stille is miAvilling to accept, in its entirety,
the doctrine of an especial direction toward the bronchial mucous membrane,
and, in ascribing to them the quality of stimulants, he must refer to their
local stimulation.   For in forbidding their use during the active stage of the
inflammation he  surely does not refer to their relaxing poAvers, and general
antiphlogistic influence exerted through the revulsive operations of diuresis, dia-
phoresis, catharsis, and theirsedatiAe effect upon the heart's action; and, again,
in likening their salutary influence in controlling the morbid conditions charac-
terizing the advanced  stage of catarrhal inflammation of the respirator}' tract
to the beneficial  effects of local  stimulation of conjunctiAitis, rhinitis, and
vaginitis, he surely does not refer to a method of treatment by general stimu-
lation or by medicines introduced into the general circulation, for avIio would
commit the folly  of attempting  to cure  catarrh  of the  conjunctiva,  of the
mucous membrane of  the nasal passages, or of the vagina, by general stimu-
lation induced by introducing tartar-emetic, squill,  or ipecacuanha into the
system.  The simile is deceptive.   The  agents employed in these local
catarrhs are not remedies possessing any special direction to the mucous mem-
branes.  They are useful through their local effects, through their power of
modifying  the diseased action by direct application, and, perhaps, Avith most
of them, the benefit is derived through their power of constringing the; local
capillaries.  None of the expectorants possess any such property, and no one
Avould think of applying tartar-emetic, squill, or ipecacuanha to the surface
of an inflamed conjunctiva, or vaginal or nasal mucous membrane, Avith the
expectation of diminishing the caliber of the capillaries or of diminishing the
fluxion or congestion of blood.   If, as local stimulants, the}' are. inadmissible
durino- the stage of active inflammation,  because of the tendency to augment
i]ie hyperaemia, surely, if useful during any subsequent stage of the inflam-
matory process, it must be by virtue of the same influence.   If contra-indi-
cated during the stage of active hyperaemia, because  of their general  stimu-
lating properties, and beneficial during the stage of bronchial relaxation, thick-
ening and softening of the mucous membrane, and copious cell-generation, it
       41) 
386
must be by virtue of the same therapeutical operation.  I have  maintained
that, locally, the}' Avere irritants, and thus, indirectly, they  ma}' accelerate
the heart's action; and I deny to them any property of general stimulation,
that is, any poAver of accelerating the heart's action or of increasing its force.
It is impossible to concede any such influence to substances  Avhich, even in
Aery minute quantities, hoAveAer introduced info the system, are, in their gen-
eral operation, depressing, relaxing, and sedative to the heart's action.   I am
not prepared to deny that, in  certain stages of  the catarrhal process, general
arterial stimulation Avould prove serviceable in distending the capillaries Avith
healthy nutrient blood, and, perhaps,  by the vis a tergo, facilitate the removal
of passiAe hyperaemia, and, secondarily, aid in restoring the normal elasticity
of the capillary Avails; but I have not much faith in the healthfulness of such
an  operation.   I  can just as readily understand Iioav  the local temperature
may be elevated, and the emigration of the colorless blood-corpuscles be
thereby intensified;  and Iioav, also, the active determination of blood to the
already congested capillaries  may  extend the area of  hyperaemia, and  thus
intensify the morbid process.
    To certain other substances containing a Aelatile oil  are ascribed, not,
hoAveAer, A'ery definitely,  expectorant qualities.   These Aelatile and odorous
principles are  partly eliminated through the pulmonary surface, not by virtue
of aliy special direction tOAvard the lining membrane, but in accordance Avith
the huv regulating the interchange of  gaseous substances separated by mem-
branes.   If takes place chiefly in the pulmonary air-cells, and, as a rule, is
AAithout manifest  effect upon the tissue.
    Copaiba and the turpentines are substances analogous in their modes of
action,  Thev are general stimulants,  increasing the frequency of  the pulse
and eleA'ating the temperature.  They are eliminated through the lungs and
skin, but more obAiously through the kidneys.  Their  influence on the bron-
chial mucous membrane  is comparatively  feeble.   "It  is probable,"  says
Wood,  "that  all  their effects, both local and general,  are dependent almost
exclusively on their Aelatile  oil, AA'hich  enters the circulation, and escapes
unchanged  or modified, through A'arious  outlets, exciting the several tissues
in its  passage," and hence are adapted to conditions " marked by the Avant
of general febrile excitement, and of  active congestion in the part affected."
Turpentine is a local irritant,  and is believed by Wood to dilate the  capil-
laries.   No one can doubt the decided  curatiAe  power  exerted by these sub- 
387
stances over certain conditions of the mucous membrane, especially of the
gastro-intestinal tract; but thev are conditions which  pertain to the chronic
tissue-changes, and  to ulceration, and therefore their consideration is not
directly germane to the question discussed in this paper.  In this city copaiba
is quite extensively employed in catarrhal croup, and is regarded by its advo
cates AA'ith very great favor.  Not  having Avitnessed its beneficial effects in
this disease, I am not prepared to commend its utility or to estimate its efficacy.
    In discussing the adaptation of remedies, I have  reference only to acute
catarrh, as defined by the stages and tissue-disturbances previously described.
I have regarded the stage of pathological irritation  and active hyperaunia as
the preliminary or primary condition, and  have sought to  confine acute
catarrh to certain phenomena, rather than to limit it according to time.  A
bronchitis  Avhich may  endure  from  early  autumn  to spring, Avithout
passing beyond the ordinary anatomical lesions, which, perhaps in a majority
of cases, are reached in a Aveek or fortnight, is no more a chronic bronchitis
than the latter. Chronic catarrh is usually a more extensive inflammation than
the acute, and ma}' be said to begin at that  stage of the inflammatory process
where,  as Rindfleisch says, "the mucous membrane passes over into the con-
dition of hypertrophy."   This hypertrophy is a production  of the  catarrh
and a condition advanced beyond the phenomena constituting acute catarrh,
hyperaemia, sAvelling, softening, and hypersecretion.    It is a true hyperplasia,
ha vino- its  origin in the connective tissue, and  may involve  the  epithelium
and glandular structures.  But I do not propose to enter upon any discussion
of these tissue changes.   I simply desire to define the limitations of the acute
inflammation, to avoid confusion in the further discussion of the treatment.
     I do not intend to enter into the minute details  of the  treatment.  In
the milder forms, before any important tissue disturbance has taken place,
the withdrawal  of  the aggravating cause—the inhalation of cold air, and
 quieting the cough, which is ahvays a source of irritation, will usually ac-
 complish the cure.   These may be supplemented  Avith some  revulsive  ac-
 tion ;  usually diaphoresis  is the preferable method.   The cough  is a symp-
 tom,  but in its  mode  of operation it becomes a  concurrent cause, and  I
 cannot too strenuously urge the  importance of  promptly allaying it, espe-
 cially during the early stage, prior to  the disturbances manifested in an ex-
 cessive and morbid  secretion.  With me h\ oscyamus and hydrochlorate of 
388
morphia have proven the  most valuable agents to mitigate  or control  the
cough.
     Niemeyer  distinctly asserts that it matters not in what manner or with
what agencies the diaphoresis  is produced; that it is simplythe revulsive,
depletory, antiphlogistic action of the cutaneous transudation that is service-
able.  I admit  the value  of diaphoresis, however effected, yet I maintain
there is a choice of agents.   This issue brings me directly to the considera-
tion which I Avish to present: the utility of ammoniacal preparations in the
treatment of catarrhal inflammation of the respiratory tract.   In this con-
nection I refer  exclusively to the liquid acetate, hydrochlorate, and carbon-
ate of  ammonia.   They are all, to a greater or less extent, diaphoretic ; all
enter the blood by absorption,  are eliminated through the general emuncto-
ries—skin, kidneys, and but very partially through the pulmonary surface.
Locally they are irritants, and  in passing out through any of the emuncto-
ries they stimulate the normal  functional activity of the  excretory appara-
tus.  Neither of  them possess any special direction to the pulmonary sur-
face alone, and their peculiar  and perhaps characteristic effects upon the
mucous membrane are the result of direct application.   Their utility in
these affections depends not so much upon their antiphlogistic as upon their
anticatarrhal virtue.   Niemeyer thinks they "excite the action of the skin
and modify the nutritive condition of the mucous membrane of the bronchi."
Liquor ammoniae acetatis has  been  justly  regarded,  since  the  time of
Booerhaave and Minderer, as an efficient and certain diaphoretic, combining
also the qualities  of sedative and refrigerant*   Voigtel found it a  "mild
and transient stimulant, with a special  direction to the skin and kidneys."
Richter claimed that it "augmented the secretion of the lungs and kidneys."
Stille*  commends  its efficacy in  "mild cases of catarrh, sore tlneat,  and
muscular rheumatism."f   Yaidy found it  serviceable in an  "epidemic of
pseudo-membranous broncho-pneumonia."  Besides its efficiency as a seda-
tive and refrigerant diaphoretic, it possesses other properties Avhich  enhance
its value.  Cloquet and Carriere, Avho employed it successfully in menorrha-
gia, held that it exerted some controlling power  over the fluxionary  move-
ment.   In common with the alkalies, though to a much less  extent, it is anti-
plastic, resolvent, and liquefacient, contributing also, perhaps, to the solution

                * Stille, vol. ii, Therepeutics and Materia Medica.
                t Ibid., p. 522. 
389
of albuminoid exudations, mucus,  and  eoagulable lymph, thus promoting
their resorption, and probably exerts an inconsiderable influence in dimin-
ishing the plasticity of the blood.  I must not, hoAvever, be understood as
claiming for it any A'ery decided influence in these respects.   It is as a diaph-
oretic and sedative that it is chiefly useful, and especially adapted to the treat-
ment of the stage of  actiAe hyperaemia.  The additional qualities which I
have indicated Avould extend its usefulness.
    Ammonii Chloridum,—This salt is now Aery generally classed among the
expectorants, and, as  such, is  held in high esteem by many physicians.*  It
certainly possesses no direction toward the mucous membrane of the respi-
ratory tract alone, yet all experimenters unite in the general conclusion that
it exercises certain marked influences upon the  mucous  surfaces.   Gmelin
declared that it Avould dissolve  "viscid and stagnant  humors," and prevent
putrefaction, Avhether applied externally  or  internally.  This opinion, re-
marks  Stille, corresponds  closely Avith more  recent results.   Sunderlin
ascribes its effects to its  sedative influence upon the system and antiplastic
operation upon the blood.   Bocker demonstrated that it  augmented the ex-
cretion of urea,  and claimed  that it  quickened the "moulting," or Avaste of
the mucous membrane.   Stille holds that it is only adapted to the treatment of
catarrh after the stage of actiAe inflammation has subsided, and even then should
not be continued too long, because of the danger of promoting the destruc-
tion of the  mucous membrane.  It  possesses, in an eminent  degree, the
general properties of  the alkaline salts, and oavcs its  efficacy chiefly to  its
antiplastic, resolvent,  and liquefacient properties.  It lessens the  quantity
of fibrin in the blood, dissolves albuminoid substances and mucus, and sa-
ponifies fatty substances.  How far these qualities are available in the treat-
ment of bronchial catarrh remains  to be determined; the  theoretical  con-
clusions seem very plausible.    Pereira refers Avith approbation to  the  sug-
gestions of Gulliver, that the alkalies keep asunder the corpuscular elements
of the  blood, prevent the aggregation  of the white corpuscles,  and dimin-
ish their number and adhesiveness.   Be  the explanation Avhatever it may,
the practical fact cannot be controverted, that it will in many cases resolve

  * Dr.  H. C. Wood says : " Iu obstinate acute bronchitis, after the first intense stage;
in  catarrhal pneumonia, both of children aud adults;  in bronchorrhcea, and also in
ordinary chronic bronchitis, he has obtained more apparent good from the  use of mu-
riate of ammonia than any other remedy.''—New Remedies, April, 1S72. 
390
the inflammatory process and  dissolve1 the  morbid  excretion Avith  amazing
rapidity.   The difficulty Avith me has been to determine the exact condition,
or rather stage,  of the catarrhal inflammation to which it is applicable.  In
the stage of active hyperaemia, marked by dryness of the mucous surface,
actiAe and energetic derivative action through the skin Avill, usually, prompt-
ly relieve the capillary engorgement.   In this condition the liquid acetate is
preferable  to the muriate, because of its more decided diaphoretic quality.
After the abatement of the actiAe hyperaemia, as marked  by the  re-estab-
lishment of the  secretion, though abnormally liquid and abundant, and con-
taining young cells, the latter is peculiarly valuable.  It  hastens the process
of resolution, mitigates the cough by its solvent power over the excretion,
and perhaps favors resorption of the  albuminoid exudation.  In the  later
stages I have not found it as valuable as the carbonate.  "Like  most salts,"
says Sunderhii, "sal ammoniac operates on the alimentary canal as an excito-
irritant.  After its absorption it appears to reduce moderately the  action of
the heart and large arteries, and  in this respect  belongs to debilitating* and
temperant  agents.   But it acts as an excitant and irritant to the venous and
arterial capillary systems;  to the lymphatic vessels and glands; to the  skin;
to  the  kidneys, and especially to mucous membranes; not only increasing
secretion, but also improving nutrition and assimilation,  and counteracting
organic abnormal conditions.   It promotes not  only mucous secretion, but
also cutaneous exhalation;  Its diuretic effects are less  obvious."
     The carbonate does not, perhaps, differ essentially from the hydrochlo-
rate, except in its greater diffusibility and more  . decided general stimulating
property.  With some it has held high rank as an arterial stimulant.   Stills
thinks its  classification as a general stimulant  is " very  questionable," and
maintains that its Aery transient  stimulant operation is  "speedily replaced
by  its  grave and important alterations of the  blood."   Pereira says it  is
" antacid, stimulant, and sudorific, possessing also in a marked  degree the
qualities of a resolvent and liquefacient."   The essential distinction betAveen
these tAvo salts is to be found in  the different conditions  to AAiiich they are
applicable.  I have found  the  carbonate peculiarly adapted to the  stage of
excessive and morbidly tenacious secretion, attended Avith dyspnoea and
evidences of general prostration.   Neimeyer adapts it specially to  the  con-
dition marked by dilated, relaxed, and paralyzed bronchi, accompanied Avith 
                                  391

profuse and tenacious secretion.   In these conditions the effect is, frequently,
marvelous.
     There is nothing neAV in this adaptation of ammoniacal preparations to
the cure of bronchial catarrh.  The results which I have obtained have been
obtained by man}' others.   Nor is there  anything original in  the  special
applications of the different preparations to particular stages of the catarrhal
process.   I have but folloAved the suggestions of Niemeyer, and corroborated
his conclusions.  I have set up  no explanation of the mode of action, but
favor the  opinion, so generally held by therapeutists,  that it is through the
qualities which belong to  alkalies.  Nor have I attempted  to explain why
they should be respectively applicable to special conditions ; I have simply,
and briefly, attempted to indicate the results of my own experience.
     I have not sought to discuss, in cxtenso, the  treatment of catarrh, but
endeavored to  confine myself closely to the proposition  set forth in the
beginning.  Many points  of interest have been passed unnoticed, because
they were not, necessarily, relevant to this discussion. 
 
DEPARTMENT
DISEASES OF  THE  EYE AND EAR.
D. WEBSTER PRENTISS,' M. D.,
Attending Surgeon. ' 
 
REPORT
                                 OF

SECTION  OF  DISEASES  OF  EYE  AND  EAR
                               AT THE
  COLUMBIA HOSPITAL DISPENSARY FROM SEPTEMBER 1, 18G9, TO
                            JULY 1,  1872.
D. AVebster Prentiss, A. M., M. D., Attending Surgeon.
    Sik : In accordance with  your request I have the  honor heroAvith to
submit the report of diseases of the eye and ear treated  at  this dispensary
from September 1, 1869, to July 1, 1872.
    During this time four hundred and eighty-three patients have applied
at my service for relief, of which  one hundred and ninety-six were for affec-
tions of the eye; thirty-eight effections of the ear, and the remaining two
hundred and forty-nine, diseases of a different class, aa Inch were referred to
their appropriate sections for treatment.  Space does not admit of a detailed
consideration of all the cases which have presented themselves, even Avere
that desirable,  and I have therefore selected from the  report tAvo of the
more prominent  diseases in a dispensary practice, namely,  Herpes  of the
cornea,  and Trachoma, for particular notice.
    The diseases of the ear have been only one-fifth in number of those of
the eye, and were met Avith  principally in children.  Only two cases were
internal to  the tympanic membrane; five were inflammation of this mem-
brane, and the  remainder were affections of the external meatus or external
ear. 
396
                       Case of rupture of both eyes.

    . The case in the table classified as " Rupture of both eyes," is AA'orthy
 of  notice from  the  peculiar manner in  Avhich the  distressing  injury  Avas
 inflicted.
     The victim was a respectable  German a\ oman,  aged  forty-two years,
 married, and the mother of a family.
     She  had been out nursing a sick  friend, and Avas returning home on
 the night of August 26,  1871, between the hours of 11 and 12 o'clock at
 night;  Avhen in front of ,the hospital she was suddenly approached from
 behind by some person, avIio grasped her around the head with his'hands—
 a finger of each hand coining over  the corresponding eye.   He then with a
 quick jerk, threAv her on her back, but Avas frightened off by her  screams
 for help.  Her  last recollection  of sight Avas seeing a black face for an
 instant, and then everything became dark, though she did not lose conscious-
 ness.   When seen in the hospital the following day she Avas  totally blind,
 and an examination  of the  eyes  shoAved  them to  be  ruptured at the inner
 corneal border at almost precisely the same point in both eyes.
     The rupture was as  clearly defined  in its  edges as though cut by a
 knife, and extended into  the posterior  chamber.  The eye-balls were col-
 lapsed,  and the poor Avoman Avas suffering great agony at the time.
     There Avas  no other appearance of injury Avhatever excepting that the
 upper  eyelids were slightly ecchymosed  and oedematous.   The treatment
 consisted of anodynes to relieve pain and soothing applications.  After two
 weeks  the eye-balls shrivelled up,  pain  ceased,  and the  patient Atas dis-
 charged.
    It is remarkable that the injury in this case should haAe been so sym-
metrical.  It is evident that Avhen the hands Avere passed around the fore-
head, that the brutal assailant pressed  his fingers into  the victim's eyes to
prevent identification.   The finger-nails must have  come in direct contact
with the eye-ball, for the wound Avas clean cut, and the  skin of the eyelids
not broken. 
397
Tabidar Report.
 1
 2
 3
 4
 5
 6
 7
 8
 0
10
11
12
13
14
IS
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
Herpes of the cornea.............
Keratitis punctata...............
Diffuse keratitis.................
Suppurative keratitis............
Hernia of the cornea............
Gunshot wound of cornea........
Foreign bodies in cornea.........
Pannus ..........................
Ulcer of cornea..................
Opacity of cornea.................
Sloughing of cornea from old ago
Staphyloma......................
Ulcer of sclerotic.................
Amaurosis.......................
Anosmia of retina................
Iritis.............................
Catarrhal conjunctivitis.....................
Contusion of conjunctiva....................
Blenorrboea.................................
Ophthalmia neonotorum....................
Trachoma....................................
Herpes of conjunctiva.......................
Pterygium..................................
Blepharitis ciliaris...........................
Hordeolum..................................
Symblepharon........ ......................
Trichiasis....................................
Entropion....................................
Phlegmonous inflammation of lachrymal sac
Blenorrhoea of lachrymal duct................
Tremor of eyelid..................
Contusion of eyelid...............
Cataract..........................
Myopia..........................
Strabismus........................
Neuralgia in stump of optic nerve.
Neuralgia of orbit.................
Rupture of both eyes.............
Atrophy of eye-ball...............
          DISEASES OF EAR.
Accumulation of cerumen................
Acute inflammation of external meatus ..
Chronic inflammation of external meatus.
Abscess of external meatus...............
Inflammation of niembrana tympani.....
Chronic disease of labyrinth..............
Closure of eustachian tube...............
Otalgia..................................
            Summary.
Diseases of the eye..........................
Diseases of the ear..........................
All other diseases, referred to their appropri-
 ate sections..............................
196
 38
     It Avill be seen by an  examination of the foregoing list of diseases of
the eye  that affections of the conjuctiva and cornea have  constituted by far
the larger number of cases that have come under notice at  the dispensary
service, there being of the different forms of conjunctivitis sixty-four cases,
and of inflammation  of the  cornea sixty-nine,  making one  hundred  and
thirty-three  out of the whole number of one hundred and ninety-six.   With
the  exception of  trachoma, the  diseases of the conjunctiva haAe been sub-
missive  to treatment, and easily removed, Avliile  those of the cornea have
been of  a much more serious character, both as  to duration, intractability,
and danger  of permanent damage to the function of vision.
     Of the affections  of the  cornea, a  reference to  the table sIioavs  that
Herpes of  the cornea lias largely predominated, there being, out of sixtA'-
nine cases of  Keratitis, thirty-nine  of this disease.   The frequency of the
occurrence of Herpes, and the evil results  which so often folloAv, render it  a
matter of the  utmost importance that it should be properly understood  and
properly  treated.   It is  then  manifestly appropriate  that this disease  and 
398
trachoma,  which  bears  a  similar relation  to  conjuntivitis, should  receive
special notice.
     To a proper understanding  of diseases  of the cornea  it  is  necessary
that its structure should be understood.   The cornea  bears  to  the  eye the
relation of a watch crystal to the  dial  of the watch, perfectly transparent,
not interfering with the passage of rays of light,  but affording  protection to
the tender parts behind from injury.
                 Plate I.—Showing vertical section of cornea. (From Strickir.)
Plate II.—Showing nerves of cornea.
   a a Epithelium.
 b V b' Corneal substance.
   v v' Canal of Schlemm.
   c c' Membrane of Descemet.
    d Process of iris.
    e Endothelium of mem. of Descemet.
 e' e' e' Lig. pectinatum iridis.
e" e" c" Lig. of iris.
    / Network in space of fontana.
    J Iris.
  Section of frog's cornea prepared at
Army Medical Museum, Washington, Dis-
trict of Columbia.  Stained wTith chloride
of gold.
 a a a Large nerve trunks.
 b b b Small nerve fibres.
c c c c Corneal corpuscles. 
399
     In structure it is composed of four Livers, as folloAvs, in order from the
external surface in Avar d:
     1. The epithelium.
     2. Membrane of BoAvman.
     3. Corneal substance.
     4. Membrane of Descemet.
     1. The  epithelium is of  the pavement  variety, perfectly  transpar-
ent,  increasing in thickness toward the  center.  It is  continuous AA'ith  the
epithelium of the conjunctiva, being transformed at the border of the cornea
to conform to the special purpose it is designed to fill.  This transformation
can  be traced Avith the microscope.
     2. The  membrane of Boivman is the floor of the  epithelium, and  lies
betAveen  it and the corneal substance.  It is a structureless, hyaloid mem-
brane, not ahvays  present, and AA'hen present  not  ahvays well  defined,  the
posterior surface mingling insensibly Avith  the corneal substance.  It is a
matter of doubt whether it has any claim to be considered a distinct membrane,
appearing rather to consist of a thickening of the  third layer at its anterior
portion, such as is  noticed in the connectiAe tissue at other portions  of  the
body.  It is also  called anterior limiting membrane, AAdiich expresses its re-
lation to  the other structures of the  cornea.
     3. The  corneal substance makes up the  bulk of the cornea.   It is modi-
fied connectiAe  tissue, composed of  delicate,  perfectly transparent fibrilla',
arranged in layers and bundles held together by a transparent cement having
the same refractive power.  In the interspaces betAveen these filiments  are
found the corneal corpuscles in analogy to the connective tissue corpuscles.
     There are no blood-vessels in the cornea, these forming loops  at its bor-
der.   It  is  nourished in a matter someAvhat  similar   to  cartilage,  the
nutritious fluid finding its way betAveen the layers of fibrillse from corpuscle
to corpuscle.  The  nerves of the cornea are situated in the  corneal substance,
beino- more numerous in its anterior  surface.   They are  terminal branches
of the ciliary trunks, and lose their medullary substance immediately upon
entering the  cornea, becoming transparent;  the}' then divide  and spread
themselves into a netAvork in its substance.
     The existence of nerves in the cornea lias been  denied by an eminent
microscopist, (Beale,) but  the}' are sIioavii  in  the beautiful preparations in
the Arms' Medical Museum Avithout the possibility of a doubt,  even were the
intense tenderness of the part alone not sufficient evidence.  (See Figure  II.) 
400
     4. The membrane of Descemet is the posterior limiting  membrane  of
the cornea, separating the corneal substance from the aqueous humor.   It
also is a structureless, transparent membrane, having on its posterior surface
a layer of polygonal epithelial cells.  It is quite firm, easily separated from
its attachment, and Avhen so separated is so elastic that it rolls up anteriorly.
     The structure of the cornea as  a whole presents  an  example  of the
Avonderful poAver of nature to accommodate the means to the end ; it is a per-
fectly transparent body,  yet composed of structures, epithelium,  connective
tissue, nerves, &c,  found in all portions of the body, but  here made trans-
parent to meet the especial use for Avhich it is intended.
     A consideration of the anatomy forms a basis for the  classification  of
diseases of the cornea, AA'hich is as follows:  (After Stelhvag von Carion:)
1. Vascular inflammation of the cornea:
       Characterized  " by more or less  irritation of the  ciliary portion  of
           the globe, a gray opacity of and development of Aessels in the
           cornea."
2. Herpes of  the cornea:
       Characterized  "by circumscribed rounded points of inflammation
           about the size of a poppy-seed in the  superficial layers of the
           cornea, and the presence of injection" in the ciliary region around
           the eye-ball."
3. Inflammation of posterior layers of corneai, (keratitis punctata,  Stelhvag:)
       Characterized "by the appearance  of groups of small, round, gray
           spots in the different layers, of regularly clouded gelatinous-look-
           ing corneal substance, and on the free surface of Descemet's mem-
           brane."
4. Diffuse inflammation of  cornea:
       Characterized  " by a moderate infiltration of the  cornea  with  an
           opaque, grayish or yellowish white product, occurring with  in-
           flammatory symptoms, which sIioavs little inclination to  disinte-
           grate, and usually collects in extensive, cloud}', distinctly bounded
           points."
5. Suppurative inflammation of the cornea:
       Characterized  "by purulent collections in the cornea, which disinte-
           grate and break doAvn into fatty granular detritus." 
401
       This includes all the  forms of  distinct inflammations of the  cornea,  but
there  are  other  affections  which  result as  effects of one  or  other of these
diseases,  such as opacities, ulcers, pannus,  onyx,  and the different forms  of
staphyloma,  which call for special treatment.
                                    Cases of herpes of the cornea,
I	c
3	'So o
1	17
2	26
3	41
4	43
5	55
C	61
7	64
8	50
0	85
10	93
11	102
12	108
13	112
14	113
10	126
16	129
17	24
18	44
19	49
20	51
21	51
2'2	61
23	71
21	95
2o	100
26	105
27	109
23	131
29	157
30	179
31	183
32	193
33	212
34	22S
3.")	230
36	232
37	235
38	236
 Date of
admission.
Dec.  10,1869
Jan.  18
Mar. 29,
Apr. 5
May 17
June 10,

June 17
June 21

Sept. 20
Oct. 14
Dec. 13.
Dec. 27,
Jan. 6

Jan. 13,
Mar. 3,
Mar. 7,
JaD. 24
Mar. 24,
Apr. 11
Apr. 14
May 2,
May 12
June 6,

Aug. 4
Aug. 15
Aug. 22
Aug. 25
Oct, 17
Dec. 12,
Jan. 23
Jan. 26
Feb. 27:
Apr. 16
June 7
Juno 11
Juno 11
June 21
June 21

51
1870
1870
1870
1870

1870
1870

1870
1870
1870
1870
1871

1871
1871
1871
1871
1871
1871
1871
1871
1871
1871

1871
1871
1871
1871
1871
1871
1872
1872
1872
1872
1872
1872
1872
1872
1872
v W	;£	u o o
	Years.	
F.	7	AV.
M.	6	B.
M.	16	AV.
M.	16	AV.
F.	2	AY.
F.	10	AV.
F.	7	AV.
F.	13	AV.
M.	8	AV.
M.	64	AV.
F.	13	AV.
M.	17	AV.
F.	8	B.
F.	28	AV.
M.	4	B.
F.	4	B.
F.	7	AV.
M.	17	AV.
M.	48	AV.
M.	2	AV.
M.	7	B.
M.	23	AV.
F.	9	B.
M.	10	AV.
F.	2	AV.
M.	2	B.
F.	7	B.
M.	5	B.
F.	2	AV.
F.	6	B.
F.	35	B.
F.	5	B.
M.	11	AV.
F.	4i	AV.
M.	12	AV.
F.	16	B.
M.	5	B.
F.	5	B.
Nativity.
Dist, of Columbia
.do
Virginia.........
Dist. of Columbia
.....do  .........
Virginia.........
Dist. of Columbia
New York.......
Virginia.........
Ireland..........
.....do..........
California........
Dist. of Columbia
Maryland.......
Dist. of Columbia
.....do..........
.....do..........
California........
Ireland..........
Dist. of Columbia
.....do..........
.....do..........
Maryland.......
Dist. of Columbia
.....do..........
.....do..........
.....do..........
.....do..........
.....do..........
.....do..........
Virginia.........
Dist, of Columbia
.....do..........
Maryland.......
Ireland..........
Maryland........
Dist. of Columbia
.....do..........
 Date of
discharge.
Jan.  24,1871

Feb.  10,1870

Apr.  8,187;)
May  10,1870
May  17,1870
July  19,1870

June 17,1870
Sept4 23,1870
Oct.  25,1870
Dec. 13,1870
Jan. 31,1871
Jan.  31,1871
Apr. 14,1871
Apr. 21,1871
June 16,1871
Apr. 14,1871
May 5,1871
May 30,1871
Juno 6,1871

Sept. 1,1871
Sept. 5,1871
Sept. 1,1871
Aug. 29,1871
Feb. 27,1871
Dec. 12,1871
Jan.  30,1872

Apr.  19,1872
June 11,1872
Result.
Cured.
Cured  of
  herpes.
Cured.....
...do .....
   (?)
Cured.....
   (?)
Cured  o f
  herpes.
Improved.
Cured.....
   (?)
Cured.....
Improved.

   (?)
Improved
Improved.
Cured.....
...do ......
...do .....
   (?)
Improving,
Cured___
   (?)
Cured.....
... do .....
...do____
    (?)
Cured----
    (?)
Improving
Cured____
Cured---
Improved
...do....
   (?)
Remarks.
Cornea perforated ; followed meas-
  les ;  scrofulous.
Scrofulous; eczema and bronchitis;
  transferred.
Cornea perforated ; seen but once.
Phthisis; transferred to section
  on chest.
Seen but once.
Still under treatment for trachoma.

Came but twice.
Single ulcer.
Seen but once.

Eczema;  scrofulous ; still  under
  treatment.
Seen but once.
) Twins ; scrofulous ;  still  under
i   treatment.

Relapse from No. 12.  Painter.
Secondary syphilis. Laborer.
Seen but once.
Seen but twice.
Laborer;  intensely scrofulous.
Herpes of ten days' standing. Seen
  but once.

Herpes of conjunctiva.

Seen but twice.

Relapse from No.25. Seen but once
Still under treatment.
Single papule.
Still under treatment; scrofulous.

Still under treatment.
Still under treatment.
Seen but once.
Still under treatment; scrofulous.
Still under treatment; scrofulous*. 
402
                               Article I.
                         HERPES  OF THE  CORNEA.
     Under this name  is classed the disease formerly called phlyctenular
ophthalmia or strumous ophthalmia, Avhich, however, are more general terms,
including herpes of the conjunctiva in their meaning.  It is called by Soel-
berg Wells phlyctenular corneitis.  This is perhaps of all other diseases the
one to which the eye is most  subject.  LaAvrence  and Mackenzie consider
that it constitutes ninety per cent, of all the cases that present themselves to
an ophthalmic service for treatment.  The present  report, however, does not
sustain this statement, giving but tAventy per  cent, of the whole number.
     When the disease is brought to the notice of the physician  it has usu-
ally passed through the first stage of the eruption, Avhich is that of the vesicle
in analogy to the herpes of the skin.  It happened only in two  or three in-
stances that the vesicular stage was seen, and then in cases Avhere successiAe
eruptions made their  appearance during the course of treatment.    The
Aesicle retains its Aesicular character onh' for a short period, varying from
twelve to thirty-six hours,  when it is either ruptured by the pressure  of the
eyelids, or its fluid absorbed, leaving in each case a papule, which may be
seen eleA^ated above the surface of the cornea by looking across its surface.
                  Plate III.—Showing peculiar efflorescence of herpes.
a a Herpetic efflorescence.
b b Herpetic eruption on cornea.
     Iii a small  proportion of cases  the papule Avas  single, but more fre-
quently there Avere from tAvo to six or eight spots  noticeable in one cornea,
or tAvo separate collections at different portions of the  cornea.   Around each
spot, like a small halo, is  found a  cloudiness of the  cornea, and Avhen the
papules are aggregated the cloudiness of one spot runs into another, so that
a superficial opacity of considerable  extent is created.
     During the acute stage, congestion of the  conjunctiva was present in all
the eases, the congestion taking the form of an  efflorescence, radiating in a 
403
triangular form from the herpetic eruption to the circumference of the eve,
and on that side nearest to the eruption.
    This peculiar injection of the conjunctival vessels has  sharply-defined
borders and ends abruptly at the edge of the cornea for the patent reason that
the latter has no blood-vessels. (See Plate III.)  Sometimes, however, the tri-
angle is completed by the deAelopment of vascular keratitis leading up to the
herpetic papule.   This occurred in one of the cases reported.   Great intoler-
ance of light,  Avhich is Aery generally  a characteristic symptom of this dis-
ease, Avas not  so prominent as Ave are led to suppose from a  narration of the
symptoms in the text-books.
    In only two cases Avas it extreme, so as to prevent a proper inspection
of the eyes.   In these two cases there was severe conjunctival inflamma-
tion and profuse lachrymation, Aery greatly increased by the attempt to ex-
amine the eyes.
    In a small proportion of the cases only did the photophobia occasion
suffering, Avliile in the larger number it could not be said  to  exist at all.
This Avas probably due to  the fact that most of the patients had passed the
acute stage of eruption at  the time of  presenting themselves for treatment.
Herpes of  the cornea may be conveniently  divided into  tAvo stages, for the
purpose of study and treatment.
     First.  The  acute stage, from the onset of the disease to the subsidence
of the symptoms of acute inflammation, varying in length  of time accord-
inglv as treatment is applied early.    The condition of the  eruption corre-
sponding to this stage is from the vesicular, through the papular, to the ulcer
or opacity, as the result may be.  In  case  1 of the table  the  patient Avas
under treatment over a year, going through  eight or ten different eruptions
of herpes during that time, and  giving an opportunity of observing the in-
vasion of the  attack at the earliest intimation of its approach.
     The symptoms corresponded to those  aboAe narrated; sharp pain in
the ca'c, increased flow of tears, and  marked intolerance of light ushering
in the relapse.  But by the next regular dispensary-day, (three days' inter-
val,) under appropriate treatment, the  acute symptoms would  have nearly
disappeared.  The sight of the affected eye is impaired according to the sit-
uation of the  eruption, AA'ith reference  to the pupil,  and  the amount of the
photophobia and hypersecretion of tears.   The latter tAvo symptoms occur
in cases of foreign bodv imbedded  in the  cornea, an  accident which fre- 
404
 quently happens to blacksmiths and stonecutters,  and are due in both affec-
 tions to the same  cause, namely, irritation  of those  branches  of the fifth
 nerve distributed to neighboring parts, just as in  facial neuralgia a carious
 tooth is sometimes the starting-point of the disorder.
     Second.  The second stage is that of repair, or the remoA7al of effects of
 the first.   The eruption of herpes corneae is situated upon the epithelial layer
 Avith the membrane of BoAvman, or corneal substance for a base.  As the
 acute stage subsides in the most favorable cases, the  papules  either dry up
 into small  surface opacities or  develop into excavated ulcers, the depth
 of the epithelium, but not extending into the substance of the cornea.  These
 ulcers are  converted into a simple opacities by being  filled up with a Avhite,
 fibrinous deposit, Avhich is  then gradually removed  by absorption and the
 transparency  of the cornea left unimpaired.
     In cases  less faAerable the floor of the ulcer is not limited to the mem-
 brane of Bowman, but extends  into the substance of the cornea  more or
 less deeply, enlarging its borders on all sides until its progress  is  checked
 either by treatment or the efforts of nature.   It heals slowly by a white
 opaque deposit from the bottom, and leaAes a permanent opacity, Avhich is in-
 jurious to the sight accordingly as its position is near the center of the cornea.
     In the least faAerable cases  the  ulcer continues  its course of destruc-
 tion until it reaches the  membrane of Descemet, Avhen, if this be not rup-
 tured, hernia  of the  cornea  is likely to occur  by its protrusion  from the
 pressure of the aqueous humor.  When the membrane of Descemet rup-
 tures, the ulcer  has become  perforating,  and the  aqueous humor escapes,
 draAving with  it the adjacent iris.   In  two of the cases reported this occurred,
 and the iris became adherent to the  inner surface of the opening—consti-
 tuting anterior synechia—but Avas afterward disentangled by the persistent
 use of atropia.
     A collection of pus, or puriform  fluid, in the  anterior chamber, (hypo-
 pion,) Avas noticed in cases 1 and 10,  but  onyx did not occur in  any case.
     The reason Avhy Ave do not haAe onyx in this form of keratitis would
 seem to be that the borders of the ulcer limit the infiltration from extending
 betAveen the laminae of the corneal substance.
     The  graAer results, such  as complete  pannus,  staphyloma, complete
 anterior  synechia, &c,  are occasionally obseiwed  in  the  seAerest cases of
 Herpes occurring under unfavorable circumstances, and are to be treated as
independent diseases. 
405
     Causes.—It is not an easy task to trace the cause  of disease in  dispen-
sary practice, both on account  of the  uncertain intelligence of those who
apply for its benefits, and because of a degree  of unwillingness frequently
to give correct ansAvers.  This difficulty is increased in cases of eye disease,
for the reason that the loAver classes almost invariably consider inflamma-
tion  of the eye in any form "a cold," and either resort to domestic remedies
or do nothing, thinking it Avill get well of itself in a feAv days.  It  is com-
paratiAely seldom, on this account, that Herpes  of the cornea is seen in the
vesicular stage, and when it is so seen, it  is usually in relapses under treat-
ment at the time of the relapse.
     The names scrofulous and strumous ophthalmia Avould seem to indicate
that  the  disease was essentially of a scrofulous character.  Such an induc-
tion, however, is by no  means correct, according to the cases enumerated in
this report; for out of thirty-eight cases only eleven Avere in subjects con-
sidered to be scrofulous.   The fact seems  to be that the scrofulous diathesis
bears to the disease the relation of predisposing cause, and the usual surround-
ings  of poverty, ill ventilation, filth, and overcrowding act as exciting causes.
     In tlnee cases only was the cause  actually determined.  In case 1,
where it  followed measles; in case 8 it Avas due to trachoma, and in case
10 to injury.   In case 19 the patient had secondary syphilis, but whether
the latter had any connection Avith the Herpes I am unable to say.
     The following table shows the proportion according to age, national-
ity, &c.:
1		AGE.				NATIONALITY.			COLOK.								SEASON.						
a o						R														■^		t*	
o																					r;	,o	
			©	o																		e	
u	Cl	CO				fr-															^		
				o	a	o		rt											Sfl				
S3	o	o		o	o	ta	M	o H	£	1	H	^	&	S	<	a	z	^	<	o •r.	o	o	t
21	9	o	1	2	r>6	34	4	38	23	15	38	5	1	4	4	^	9 0 4			1	2	0	
     A^e is an important element in the causation of this affection—it being
almost confined to the period of childhood.  Out of the thirty-eight eases
twenty-four are under the age of ten years,  and nine of the remaining four-
teen betAveen that age  and twenty years;  so  that  of the Avhole  number
onl\' five occurred after the age of twenty.   As the time of  life increases, so
does the liability  to herpes diminish.  Nationality seems to  exert no influ-
ence, though the  value of statistics in this  respect is greatly impaired by 
406
the fact that most of the patients are children who, whatever the nationality
of parents, are most likely to be born in this country.  The nationality of
parents was not taken.   In regard to color, nearly two-thirds of the patients
are Avhite.   As to  season, although Ave Avould  naturally  expect the cold
weather,  when ventilation  is most defective  in  the  habitations of  the
poor, and their houses are oftentimes filled AA'ith smoke, and filth is especially
liable to accumulate, Avould give rise to the greatest number of  cases, still,
June leads  the van, furnishing  nearly as  many cases as the three Avinter
months combined.   It is, hoAvever, worthy of notice that the relapses haA'e,
as a rule, occurred during the cool or  cold-Aveather  months, probably for
the reasons aboAe mentioned.
     The most discouraging element in the treatment  of herpes  of the cor-
nea is the tendency to frequent relapses, or rather to frequent new crops  of
the eruption.  This tendency is especially marked in  the  scrofulous  cases.
     In cases 1, 15, 16, 32, 37, and 38, Ave have an exemplification of this
fact, they being under treatment the longest of any in the list—the latter fiAe
still attending the service.
     The  successiAe crops of the eruption folloAved each other  at varying
intervals, the interval being  longer during the warm Aveather, and shorter
during the cold.
     The interval between the appearance  of the relapses during the winter
was three or four Aveeks.
     Chronic granulation of the lids is  an occasional cause, as in case 8.
This acts  mechanically by irritation from  constantly rubbing over the sur-
face of the cornea, in the motions  of the lids, and  is to be classed among
the traumatic causes.  The converse of this proposition is also true, Herpes
of the cornea sometimes acting as a traumatic cause of trachoma.
     Treatment,—The treatment of Herpes of the cornea deserves careful con-
sideration,  not because it is difficult or complicated, but because the use of
improper  remedies readily produces increased irritation and favors the de-
velopment of those sequelae Avhich permanently  injure vision.   It is a mat-
ter  of regret that  even the  most  frequent of  all eye  diseases, A'iz, corneal
Herpes and Trachoma, should receive so little consideration from the profes-
sion at large; for it is a fact deAeloped in the history of all eye services, either
dispensary or hospital, that a large proportion of these cases  applying for
treatment have been the subject of  mismanagement at the hands of the gen- 
407
 oral practitioner.  The sulphate of zinc collyrium, AA'hich is almost a panacea
 for all inflammations of the eye in general practice, is especially to be dep-
 recated  in the earlier phases of the disease iioav under consideration.  The
 treatment of Herpes may very conveniently be diAided, according to the divi-
 sion of the symptoms, into two stages:  First, the treatment of the acute stage ;
 and second, the treatment of the stage of repair.
     First, of the acute stage.—Herpes of the cornea is essentially a disease of
 irritation, and  may be compared  in  symptoms to those produced by the
 presence of a foreign  body imbedded in the cornea, the herpetic papules
 taking the place of the foreign  body.  From this condition of irritation  Ave
 draAv the therapeutical indications in the first stage.   The natural teaching,
 then, is  to avoid the  application of all irritating remedies, and to use only
 those Avhich are found most efficacious in  soothing and alleviating the pain
 and photophobia.
     This end  is accomplished  most speedily by the use of instillations of
 sulphate of atropia, and the protectiAe bandage.  The strength of the solu-
 tion of atropia usually employed is two grains to the ounce of AA'ater, applied
 from tAvo to six times a da}', according to the urgency of the case.
     The action of the atropia is twofold, as a narcotic locally, numbing the
 sensibility  of the parts, and by the dilatation of the pupil, thus relieving intra-
 ocular pressure.  The protectiAe bandage consists of  a strip of Avhite flannel
 Iavo inches AA'ide and seAen inches long, cut bias to make it elastic, Avith tapes
 attached at each end long enough to pass around the  head and tie OAer the
 forehead.  After the atropia solution is dropped in the eye, a smooth pad of
 well-picked lint or soft raAv cotton  is applied OAer the closed eyelids, adjusted
 in such a manner  as to make gentle, eAen  pressure Avhen the bandage is tied
 on over it.   This treatment has not failed in a single instance to give marked
 relief,  and  Avhere it is intelligently carried out abridges  very materially the
 first stage, and  lessens the probability of the formation of troublesome ulcers.
     Cases  may occur  in Avhich the inflammation is of sufficiently high a
 o-rade to call for local depletion by means of leeches, but such did not happen
in the  fore°ein<r service, and AA'hen we remember that the disease is only too
prone to occur  in scrofulous and badly nourished children, the frequent .pro-
priety  of even a small taking of blood Avill be more than doubtful.
     In  children  of  highly  nervous  temperament, leeching is  absolutely
contraindicated from increasing nervous  irritability. 
408
     Treatment of the second stage.—The treatment which is required to pro-
mote the absorption  and removal of the products of the acute  stage is just
the opposite of that required in the latter, and it is  in consequence a matter
of delicate discrimination to determine Avhen we should suspend the one and
resort to the other.   After the herpetic papule has become an ulcer or opacity,
for a variable period the cornea  retains its irritable condition, and the appli-
cation of  irritant remedies  may  induce a second crop of herpes, or produce
one of the other forms of keratitis.   It is better, therefore, that we wait  for
a short period after the photophobia and congestion of the conjunctiva have
subsided for the eye to regain something of its normal endurance, leaving it
Avithout treatment during the interval.
     The  most favorable result of herpes  has been mentioned to be a sur-
face opacity, or superficial ulcer.  Either of these, in a favorable state of the
constitution, may  be safely trusted to nature, only guarding as much as
possible against the original causes of the  disease, and cautioning the patient
to avoid strong  light and over-use of the eye.  But Avhen the ulcer extends
into the corneal substance, and is still extending, it is of the utmost impor-
tance to limit the  progress  as quickly as  possible.   If this extension of  the
ulcer is accompanied with symptoms of inflammation, conjunctival conges-
tion, and dread of  light, the irritating applications Avouldnotbe alloAvable,  but
recourse  must again be had to the atropia and pressure bandage.
      If, however,  the ulcer is more indolent  in its  character, the  nature of
the pathological condition going on in its Avails is to be altered  by the  use
 of such remedies as may, from  their irritating properties, change the nature
 of the inflammation and cause an exudation of fibrin.
      The remedies best adapted to accomplish this end are sulphate of copper,
 calomel,  or the ointment of the yelloAV oxide of mercury.   The blue-stone
 is used in the form of pencil made by scraping or  filing a crystal doAvn  to a
 small point and rubbing it smooth Avith a moist cloth.   It is then to be very
 carefully applied to the ulcer in such a manner that no violence is used.  This
 is to be repeated every second or third day.  When calomel is employed, it
 should be reduced to a fine powder in a mortar, that ordinarily found in the
 shops being too coarse and gritt}' for  application to the eye.  It is  applied
 AA'ith  a camel's hair pencil, by dusting in with a  short quick knock on the
 handle of the pencil.
      The yelloAV  oxide of mercury is to be preferred to  the red oxide in 
109
making ointment for the eye on account of its being in the form of an impal-
pable poAA'der, aa hile the red oxide consists of bright, shining crystals AA'ith
A'ery sharp edges and points, which cannot readily be gotten rid of by tritu-
ration.  The yelloAV  oxide is  prepared by precipitating a solution of  the
bichloride  of mercury AA'ith caustic potash;  for the  proportionate quantity
of each, see Parish pharmacy.   The  strength of the ointment found to be
most beneficial was one to two grains to the drachm, but sometimes an in-
creased strength is called for.
     It is to be applied night and morning OAer the inner surface of the lower
lid, Avhen the motions of the lid carry it on to the cornea.
     ()pacities  left by ulcers of the cornea require  the  same  treatment to
promote their absorption as is given to the indolent ulcer itself, the yellow
oxide ointment having the preference in selection.
     When, hoAvever, the floor of the ulcer has become very thin, and per-
foration is  imminent, quite a different plan of treatment  is indicated.  It is
better under these circumstances not to Avait for spontaneous perforation, but
to forestall it by performing a paracentesis through the thinnest part of the
floor with a fine needle and alloAv the aqueous humor to Aoav off  slowly.  The
advantages of this proceeding are that it procures a small, smooth opening
instead of  a rough, jagged one, and diminishes the danger of anterior syne-
chia by preventing a sudden evacuation of the aqueous humour.   The pu-
pil is to be dilated Avith atropia, or contracted with  calabar bean,  according
to the position of the ulcer, the former if the ulcer is central, and the latter
if it is on  the periphery of the cornea.  A pressure-bandage is  iioav to be
applied, and the case treated as acute ulcer.
     In addition to the aboAe treatment  addressed to the local disorder, it is
to be borne in  mind that the scrofulous diathesis, and a depressed state of the
system, is frequently an accompaniment, if not a cause of  the herpes,  and
requires attention at the hands of the  physician.
     Cod-liAer  oil and sirup of the iodide of iron proved most beneficial in
the dispensary service in improving the constitutional  condition, and  was
necessary to the cure in the cases attended with  frequent relapses.
     The  citrate of quinine  and iron  was given  Avith good  effect-as atonic,
readily taken by children, where the appetite and digestion were impaired.
        5ii 
410
  Article II.
   True horn u.
Cases of trachoma.
t-V 5 S	Date of admission.				Nativity.	Date of discharge.	Resuli..	Remarks.
cl. 4		B.	X	cl				
	Oct. 8,1860		r.	Years. 60	Dist. of Columbia	June 21,1870	Improved .	
29	Feb. 8,1870	W.	F.	50	Ireland...........	Apr. 22,1870	Relieved ..	
26	Jan. 18,1870	B.	M.	6	Dist. of Columbia.	Feb. 11,1870	...do.....	Scrofulous; transferred on ac-
37	Mar. 8,1870	AV.	F.	35	Ireland...........	Mar. 29,1870	Improving	count of bronchitis.
38	Mar. 15,1870	AV.	F.	20	......do...........	May 10,1870	Relieved ..	Etropion, pannus.
44	Apr. 8,1870 Apr. 15,1670	AV	F	12		Apr. 8,1870 Apr. 14,1871	(?) Improved .	Seen but once ; Irish parentage. Herpes & pannus ; Irish parent'ge.
50		AV.	F.	13	New York........			
02	Oct. 14,1870	AV.	M.	18	Dist. of Columbia.	May 16, 1871	Cured.....	Fannus of both eyes.
106	Dec. 20,1870	AV	F	30				
20 26	Jan. 6,1871 Jan. 25,1871	B. AV,	M. F.	60 55	......do...........	Feb. 24, 1871 Jan. 27,1871	...do (?)	Seen but twice.
					......do...........			
27	Feb. 14, 1871	W	F	30			Improved .	
42	Mar. 21,1871	AV	M	25	.....do...........	June 25, 1871 June 19,1871		
56	May 9,1871	W.	M.	50	......do...........			Waiter.
82	June 23,1871	W	F	16	......do...........	June 23 1871	(?) Improved .	
104	Aug. 16,1871	\V.	M.	13	......do...........			Pannus. Still under treatment.
127	Oct. 3,1871	B	F	20		Nov. 3,1871		
145	Nov. 3,1871	AV	F	33		Nov. 3 1871	Improving. (?)	
160	Dec. 15,1871	B	F	24	Virginia..........	Dec. 15,1871		Seen but once.
161	Dec 15,1871	AV.	F.	12	Dist. of Columbia	June 18,1871	Obstinate .	Irish parentage; pannus.
104	Feb. 27,1871	B.	F.	24	Maryland........	Mar. 1,1871	(?)	Seen but twice.
202	Mar. 26,1871	B.	M.	73	Dist. of Columbia	Apr. 2,1871	Improving.	Diffuse keratitis: seen but twice.
205	Mar. 29,1871	W.	F.	21		May 3,1872	Improved .	Servant.
								
     As in considering affections of the cornea we have found Herpes to be
 the most frequent and most important of the  diseases met with, so Ave find,
 AA'ith diseases of the conjunctiva, Trachoma to be the most important though
 not  the most frequent.
     Catarrhal conjunctiAitis is the most frequent, but from its more  simple
 character is usually not a grave disease, being readily amenable to treatment
 or terminating in recovery Avithout treatment.
     The reverse, hoAvever, is true of chronic granular conjunctivitis, it sel-
 dom terminating in spontaneous cure, and proving obstinate under treatment,
 Avhile its results, Avhen not relieved, are among the worst to Avhich the eye is
 liable.
     The  record  sIioavs sixty-four cases of conjunctival inflammations,  of
 which tA\entv-three are of the affection under consideration, or more than
 one-third.   We cannot suppose, hoAvever, that this represents the true propor-
tion of  cases in the AA'hole number of conjunctival affections, because a large
proportion of patients with  milder  catarrhal  conjunctiAitis do not present 
411
themselves for treatment, rather resorting to domestic remedies, and in due
time, finding themselves Avell.
    Then, further, it is naturally the chronic cases which drift to an eve-
service, after having tried other sources of treatment, or exhausted limited
means in priAate treatment.
    Trachoma is classified by Stellwag Aen Carion into four varieties:
    1.  Pure granular.
    2.  Capillary.
    3.  Mixed.
    4.  Diffuse.
    First. Pure granular Trachoma is characterized bv clear spa.Avn-like granu-
lations, resembling sago grains, situated principallA' on the reflection of the
ocular  conjunctiva to the tarsal, and most abundanfU' on the palpebral fold
of thelowerlid.   They  differ in number in different  cases,  in proportion to
the severity" of the disease, being in some instances only three or four, and
at other times completely studding the mucous membrane.  They are attended
Avith more or less inflammation of a loAv-grade at their base, Avith serous effu-
sion immediately beneath the conjunctiva, Avhich giAes them the appearance
of resting upon a transparent, Avax-like foundation.  The disposition to serous
effusion becomes more prominent in severe cases, and causes extensive oedema
of the  palpebral fold, so that upon eversion of the eyelid,  it protrudes  as a
large  tumor, completely filling up the ocular fissure, and shoAving on its sur-
face abundance of the characteristic granulations.
    From the vesicular appearance of these granules, it Avould seem  that
they might be evacuated by pricking, but such is not the case,  although by
the exercise of care they may sometimes  be reinoved entire.   They consist
of a u stroma of  connectiAe tissue containing nucleated cells like lymph cor-
puscles, Avith a little fluid.   They are surrounded by a delicate  layer of con-
densed  connective tissue, which has  no proper enveloping membrane, but
passes OAer into the neighboring less condensed tissue."—{Wells.)
    They are  situated  just beneath the  conjunctiva, projecting up into it,
and are most abundant  in the palpebral  fold  of the loAver lid, though  also
found sparingly upon the ocular and tarsal reflections.
    These follicles are  microscopic in the normal condition, onh' becoming
perceptible to the  unaided eye in disease, and are  analogous to the closed
Follicles oFthe alimentary mucous membrane.
    The closed follicles of the small  intestine may be taken as the type of 
412
this structure, and are  considered by eminent histologists to be physiologi-
cal in their function, being the commencement of the lymphatic system.   In
this  situation they are ^ of an  inch  in diameter,  and  are  distributed
tlnoughout the intestine in the proportion of one bundled to the square inch.
     They contain within their stroma Avhite blood corpuscles,  and are simi-
lar in structure to lymphatic  glands.  According to Dr. Woodward, United
States Army, these follicles are to be found in many of the mucous  mem-
branes.   Their presence  in the eye, therefore, is  physiological,  and their
favorite situation locates  the usual position of this form of Trachoma.   The
granular,  or, as it is sometimes called, the vesicular, is the simplest form of
Trachoma, and frequently bears to the other forms  the relation of cause and
effect.   This fact has an important bearing in military practice as suggesting
prophylactic measures  against the  development of chronic  granulations, it
having  been observed in armies, as elseAvhere, that vesicular granulations
precede the  seAerest forms of Trachoma in a majority of cases.
     Timely treatment, therefore,  of the former, Avith proper observance of
hygienic  conditions, may be expected to  cut short the spread of an epi-
demic.
     Second. Papillary Trachoma.—The papillae of the conjunctiva are con-
fined principally to the mucous lining of the upper lid, and are arranged in
roAvs from its ciliary border to the beginning of the palpebral fold.
     They are similar in structure  to the papillae  of the skin, and vary in
size from before backward, the largest being found on the palpebral border,
being about one-tenth of a line in diameter.
     This  corresponds with the fact that the most exuberant granulations are
usually found at this point in disease.  The granulations are small and even,
and  regularly distributed over the extent of  surface above  described as
papillary.   When  the inflammation is of a high grade,  they become smooth
and velvety and of a deep red color.  The color  A-aries Avith  the grade of
inflammation from bright red to dark purplish color, or pale flabby appear-
ance, haAing  a  purplish  hue in a  Ioav condition  of system  and sluggish
circulation, and being pale in anemic  individuals.
     Third and fourth. Mixed and Diffuse Trachoma,—When granular and
papillary Trachoma occur together it is called the mixed, and as this is almost
ahvays  found to be the  case when the patient applies for treatment, the
mixed Trachoma is the form almost ahvays observed in private  or dispensary
practice. 
413
     The pathological condition  is the same as above described, Avith the
addition of an increased amount of irritation and inflammation.
     After this disease has continued for some time, the pathological process
extends to the surrounding connective tissue, and proliferation of the con-
nective tissue corpuscles  gives  rise to neoplastic  grovv'ths along with the
enlarged follicles and papillae.  This is diffuse Trachoma,
     Mixed and diffuse trachoma are  not, therefore, different forms of the
disease, but only the higher grades in the development of the two previous
forms.
     The granulations of  the lid change from their regular character to
rough nodulated prominences, or are scored  through with deep seams sepa-
rating granulations Avith  broad bases.  As the  disease advances  cicatricial
bands are formed,  especially at the palpebral reflexion, sometimes destroy-
ing the fold, and uniting the upper border of the tarsal cartilage to the ocu-
lar conjunctiva, producing what is called symblepharon posticus.  The tarsal
cartilage also is implicated; it  becomes  softened and elongated, losing its
elasticity, so  that  the lid droops, and when  everted shows  no tendency to
return to its normal position.
     The weight of lid is so increased  that the levator palpebrarum muscle
no longer has the power to elevate it, constituting one of the forms of ptosis.
     Dryness of the eye (xerophthalmia) is produced by an obliteration of
the tear-ducts from cicatricial contractions.
     The evil results, however,  are not confined to  the lid and conjunctiva;
the most serious of the complications  are the affections of the cornea, pro-
duced mechanically by friction with the roughened surface of the lid.   The
most frequent of these are pannus, herpes  of the cornea, and  ulceration,
while staphyloma follows as a remote result.
     The clinical history of Trachoma varies with  the form  and degree of
inflammation in each case.
     The vesicles of the  first variety sometimes exist without giving rise to
any symptoms and Avithout the knowledge of the patient.
     This state of tilings, however, does not long continue; upon the super-
vention of some cause of irritation, the eyes  become  more sensitive; there
is difficulty in using them in bright light or at night, and they soon become
fatigued by close application.
     Increased flow of tears is noticed, and  the discharge, as the disease
advances, becomes yellowish and mixed Avith pus and flocculi. 
                                  414

     The ocular conjunctiva, in pure granular and papillary Trachoma, may
not be at all affected, but in the mixed and diffuse forms it is almost ahvays
greatly injected, with the development of granules on its surface.   The sight
is affected according to  the  amount  of photophobia, the increased Aoav of
tears and discharge, and in the later stages by the sequela?.  Pain is not a
prominent symptom in  trachoma, being of a  dull, aching character, rather
than sharp or acute,"the feeling being that of  having sand in the  eye, from
the roughness of the granulations.
     Causes.—We may take it as a starting-point in determining the cause of
Trachoma, that it is a  disease which may be  produced in susceptible per-
sons by any irritation of the conjunctiva that is severe or long continued.
Lawrence recognizes this fact when he  calls it "lunar-caustic" ophthalmia,
considering the abuse of that chemical to be a fruitful cause.
         ©
     In like manner Mackenzie states that chronic granulations are most fre-
quently the result of catarrhal ophthalmia, the latter acting as  a long-con-
tinued irritant to the follicles and papilla?.  This also gives  us an explana-
tion of  the relation betAveen the simple granular  and the severer forms of
Trachoma, the former being regarded by some ophthalmologists as the cause
of the latter,  which, indeed, is  the case, viewing the granular or vesicular
variety in the light of keeping up a condition of irritation in the conjunctiva.
Contagion also is an important element in the causation of this disease, as
shown by its spreading from  a focus among persons crowded together, as in
ships, jails, hospitals,  and armies,  and also by the extension from one  eye
affected to its fellow, from the discharge  being  carried over the bridge of the
nose.
     It may, however, be questioned Avhether  the matter of contagion, that
is, the discharge, contains a specific virus, because  by inoculation with other
eyes it  does not ahvays  produce Trachoma, but sometimes blenorrhcea or
even diphtheritic conjunctivitis.
     The folioAving  table gives the relation to age, nationality, &c, in the
cases reported:
			AGE.					NATIONALITY.					COLOR.							SEASON.							
«									|								j								,		
																											
																											
					o	3																					
1	o	re p	O	o		•^D	H	.3	M	<	5	H	^	1	1	,5	£\2	<	5	|	^	<1	rj.	|	fi	P	CS o H
--	--	-	----		--	--	--	--	--	-- --		~—	--														
1	0	7	3 1		4	1	23	(1	3	10 1		»	1(1	7	23	3	:•, ! 5 i	2 1		1		1	....	^	I 3		23
 
                                  415

     BetAveen twenty and thirty years gives a greater number of cases than
an}- other decennial, while from ten to forty years embrace three-fourths of
the Avhole number; only one case occurred under the age of ten years.  It
is therefore more especially a disease of adult life, being less frequent both
in childhood  and old age.   As  to nationality, the Irish and those of Irish
descent stand pre-eminent, covering more than  half the entire number.
     An inquiry into the mode of life of the lower class of Irish Avill perhaps
furnish a cleAv to the cause of its preA'alence among them. If Ave folioav these
people to their homes, Ave shall find among them an almost national predilec-
tion for lhing upon an equal footing Avith domestic animals, such as  cows,
pigs, goats, dogs, and geese, and ghing them free entree into their houses.
The result of this  is an  accumulation of filth and a contamination of the
atmosphere AA'hich no physician  AA'ho has ever been unfortunate enough to
spend the night  Avith a michvifery case, amid  such surroundings, v\ ill  easily
forget.
     The disease is  found  prevalent not  only among  the Irish, but in all
nationalities where a similar mode of life prevails, especially Avhere domestic
animals are domiciled with human beings.  Indeed, according to Stromeyer,
vesicular granulations are met with among some of the domestic animals,
particularly pigs, which are kept in a notoriously filth}' condition.
     On this  point Dr. Marston says, "So certain  do  I  feel that the preva-
lence of vesicular disease  of the lids is in direct ratio to the amount and
deoree of defective sanitary arrangements, that I conceive the palpebral con-
junctiva offers a delicate test and evidence as to the hygienic conditions of a
regiment."
  ©
     As to color, the number of Avhite persons affected were more than double
the blacks.   It might here be urged that the  sanitary condition of the latter
in their homes, both as  regards  crowding, ill-ventilation, and cleanliness, is
quite as bad  as with the lower class of Irish.   This is quite true, but it is not
characteristic of the negro to admit the lower animals to companionship, and
the peculiar aroma of the negro hut is not usually due so much to extrinsic
causes as to intrinsic emanations from the odoriferous glands.  The  fact of
Trachoma being comparatively infrequent in the negro has a significant bear-
in o- with reference to the question of Trachoma being a scrofulous disease, the
scrofulous diathesis being much more prevalent in the black  than the white
race. 
416
     As to season, the six coldest months have given eighteen  cases against
five  cases for the remaining six months.   It is true that the  patients Avere
affected Avith the chronic  form of granulations, but as long as the disease
remains quiescent, they are apt to consider themselves improving and do not
resort to treatment.   In this way we may conclude that there was an exacer-
bation brought on by the chilling winds out-doors, and the confined quarters
in-doors that drove the patient to the dispensary for relief.   A  cause  AA'hich
Avill produce an exacerbation, it is fair to suppose, would promote the action
of exciting causes ab initio.   March ghes the greatest number of cases of any
one  month,  because, perhaps,  of the  high prevailing  winds during  that
month.
     Prognosis.—The prognosis in trachoma is difficult; it is a tedious disease
to treat, difficult to cure, and still more  difficult to prevent  its recurrence.
     The  gravity of  the prognosis as to interference with vision depends prin-
cipally on the complications, and is of consequence  greatest in the mixed and
diffuse forms.
     The  prognosis is therefore least faAerable in these latter forms, Avliile it
is more so in the papillary,  and most favorable in the simple granular.  In
children recoAery may take place spontaneously, but in  adults Ave cannot
flatter ourselves with any such hope.
     The  difficulty of getting this class of patients to continue  returning for
treatment until legitimately discharged is an obstacle in the Avay of estimating
the length of time required for the cure of the disease.  This also differs Avith
the form of the  disease, being longer or shorter according to the seAerity of
the case.
     The  effect of one or two applications of the remedy is to make the sur-
face of the eyelid smooth and relieve  the  feeling  of grit in the eye Avhich
the granulations had caused, and remove the symptoms of irritation.
     It is  a peculiarity with trachoma patients  that as soon as they feel them-
selves better, they imagine that they are well,  and consider'further treatment
unnecessary.
     We had in  the dispensary serAice only mixed and diffuse cases, and of
those aaIio were faitliful in attending the  service the time varied from six
months to one year and.a half, and I have  ventured to pronounce but three
of these cured; that is to say, three in Avhich there seemed little probability
of the disease returning. 
417
     The remaining cases Avere relieved or improved.
     This would not seem to be very encouraging as to the value of treat-
ment, but it is to be remembered that there are diseases which, if not cured,
must be palliated, to prevent consequent complications, or to relieve suffering.
     This is particularly true of Trachoma, since it is the results rather than
the disease itself which are to be dreaded, and the treatment is of the utmost
benefit in relieving symptoms of irritation, and of the  utmost  importance in
preAenting the injurious  sequelae.
     Treatment.—The treatment of Trachoma is different in the different forms
and stages  of the disease.
     It may be  laid doAvn as a rule that no irritant or caustic applications
are to be employed as long as symptoms of acute inflammation are present
in the eye.
     The inflammatory symptoms are  characterized by intolerance of light
and congestion of the ocular conjunctiva, and, Avhatever the form of disease,
must be removed by appropriate treatment before the granulations can claim
attention.
     The treatment to be employed is the same as indicated for the first stage
of Herpes of cornea, namely, instillations of sulphate of atropia solution and
the protective bandage,  and occasionally the cold compress, Avhen  there is
much heat about the  eye.
     As in Herpes of the cornea, it is here also not an  easy matter ahvays to
determine  just the right period for the transition from  the antiphlogistic to
the irritant remedies, the conjunctiva frequently retaining a morbid sensitive-
ness after the acute symptoms have subsided, which is lighted up into inflam-
mation by any unusual irritation.  It is proper, therefore, to alloAv a short
interval  to elapse after the acute symptoms  have subsided before applying
remedies to the  trachoma proper.
     It is a matter of the highest importance in all the forms of the disease
that exciting causes should be removed as far as possible, and the patient
placed under the best hygienic conditions.   This  is of especial importance
in armies, hospitals, and prisons.   Each person should have  clean water,
clean toAvels, &c, and trachoma patients should be kept separate, and have
good ventilation and  a regular temperature.
     These directions are easily carried out in the case of hospitals,  &c, and
in private practice among the better class; but I have found it almost impos-
       53 
418
sible to accomplish anything in the way of hygiene among the dispensary
patients,  avIio are so situated  that cleanliness and good ventilation at home
could only be secured by pecuniary sacrifice.
     Tobacco smoke is  a cause of irritation deseiwing  special mention, as
smoking  is a universal habit among the loAver class of Irish, and Avhen doors
and AvindoAvs are closed in the cold weather their habitations are not endur-
able to one unaccustomed to the fumes of tobacco.
     A proper observance of  sanitary measures  alone "will  probably suffice
for the removal of the milder forms of  simple granular  trachoma, when re-
sorted to in the  earliest  stage of its development, but when  it has already
continued for some time, something more is necessary to its cure, such  as
mild  astringent  collyria, sulphate of zinc  or  acetate of lead, tAvo  to four
grains to the ounce of water,  or borax, six grains to the ounce, droriped into
the eyes  three times a day.  If the case should prove obstinate, the granula-
tions should be lightly touched  Avith the crystal of sulphate of copper, every
third day, the collyrium being used during the interval.   The  vesicular ap-
pearance of the granulations tempts one to prick them open, but experience
has shown this  not only to accomplish no good, but to be injurious from
increasing irritation.
     In the second form of Trachoma, the papillary, the treatment is the same
as above, Avith the exception that remedial measures are ahvays necessary to
the cure, and must be more decided in their action.   The pencil of sulphate
of copper is to be applied to the granular surface every second or third day,
and the collyrium to be  used  as above.
     As the  simple  granular  and papillary Trachoma increases in  severe
cases, and the granulations become  more  developed, they merge into the
mixed and diffuse forms, Avhich, as before mentioned,  are the forms usually
met Avith in practice.  These latter are essentially chronic in their charac-
ter, but are  liable to inflammatory exacerbations, to which the remarks on
inflammatory symptoms are applicable.
     As the  evil results of Trachoma are due to the roughness of the lids from
the prominence  of the granulations, treatment is to be  directed at once to
their removal.
     This may be accomplished either by knife, nitrate of silver, or sulphate
of copper.   The cases Avhich  require  the use of the knife are those in AAiiieh
the granulations are very exuberant, Avith distinct or pedunculated bases. 
419
     The lid is to be everted and carefully steadied by an assistant, Avliile
the prominence is sha\ed off  close to  the  mucous membrane AA'ith a knife,
or cut off with scissors  curved on the flat.  The mucous membrane must
not be injured, however, for fear of leaving cicatrices.   After each  promi-
nence is thus removed separately, the surface is touched lightly with nitrate
of silver, and the cure is to be completed by the frequent application of this
agent or the sulphate of copper.
     In the diffuse variety, there is a uniform hypertrophy of the surface of
the lid, the granulations being  exuberant  and merging into each other.  In
this condition it is not practicable to use the knife, and the caustic is substi-
tuted.   The lid is everted as before, and the surface touched freely Avith the
nitrate of siher pencil over those parts Avhere the development  of diseased
tissue is.greatest, and lighter OAer the  parts less  diseased, Avashing off with
a little Avarm  salt water any of the remedy that may remain free.   The same
care is necessary Avith the caustic as with the knife, not to carry the destruc-
tion of tissue into the proper structure of  the mucous membrane.  Another
metlied is by rubbing doAvn the surface Avith sulphate of copper until quite
smooth, or apply acetate of lead in the form of powder, filling up all the
interspaces between the  granulations  to make an  even surface.  In either
instance the surplus of the remedial agent is to be carefully washed away.
     It is, hoAveAer, exceptional cases that call for treatment so heroic, the
granulations  not  ordinarily being in such  excess  that  they cannot  be re-
moved by lighter applications of the blue-stone crystal, frequently repeated.
The majority of the cases coming to the dispensary Avere of this character,
and touching daily with this remedy afforded immediate and  marked relief.
As the granulations disappear the application can be made at longer inter-
vals, at first two days, then three or four, increasing the inteiwal gradually and
Avatchin"" whether there is any disposition evinced for a return of the disease.
Even Avhen the patient is pronounced cured it is  better  to keep  him  under
observation for some time, to guard against a  relapse.   As a valuable  adju-
vant to the direct treatment, Ave have employed in obstinate cases coimter-
irritation to the exterior of the eyelid,  by means of nitrate of silver penciled
over the surface,  or tincture of iodine  applied in the same manner.
     The result Avas sufficiently favorable to encourage its further use.
     Of the  complications  of trachoma, pannus is the  most frequent, but,
unless unusually  aggravated, does not  call for distinct treatment, the vascu- 
420
larity and opacity of the cornea disappearing as the granulations diminish
in size and roughness.
    The treatment of obstinate pannus, as also of resulting staphyloma, does
not belong to the subject of trachoma proper.
    Respectfully submitted.
                          D.  WEBSTER PRENTISS, A. 31, 31. D.
    De.  J. H.  Thompson,
         Surgeon in Chief Columbia Hospital. 
INDEX  TO   HOSPITAL   REPORT.
                               DISEASES OF WOMEN.
                                                                                      rage.
Aetius on cancer............................................................................125-152
Albucasis, treatment of cancer..................................................................  152
Alsaharavius on cancer..........................___...........................................  124
Antyllus on cancer.............................................................................  126
Archigenes on cancer........................................................................  12'.!
Aretaens on cancer.............................................................................  124
Arnott, case of mammary cancer................................................................  178
Astruc, causes of cancer........................................................................  150
Baxter, F. H., treatment of constipation........................................................  220
Billroth on cancer......................................................................,......132-133
Bladder, removal of Jiandle of crochet-needle from............................................202-204
        foreign bodies in,..................................................................205-210
        removal of stone from, by vaginal section............................................219-220
Boyer on the return of  cancer after extirpation..................................................  177
Brown, Baker,  on ruptured perinseum, causes of................................................    12
                                  operation for............................................   15
Burns, Allen, on excision of the parotid gland..................................................  225
Byford, causes of ruptured perinseum...........................................................   12
Cancer, pathology of........................................................................120-143
        frequency of........................................................................143-145
        influences, temperament...............................................................  145
        age...................................................................................  146
        fecundity  in connection with........................................................146-148
        hereditary..........................................................................148,149
        causes of............................................................................149-151
        treatment of ......  ............................................... .................151-154
        cases of titerine......................................................................154-165
        cases of mammary........................,..........................................165-176
        remarks on..........................................................................176-179
Caruncles, urethral.........................................................................220-222
Celsus on cancer................................................................................  124
Churchill on the causes of ruptured perinseum......'............................................   12
Coccyodynia, treatment of......................................................................   19
Cowling, E. O., on tetanus...................................................................104-106
Cystocele,  cases of........................................................................---66-69
Emmet, operations for  reetoeele--- ..........................................................   59
Endometritis, causes of........................................................................  194
            symptoms of...................................................................195,196
            treatment of..................................................................196,197
            cases of....'....................................................................197-201
Erichsen on excision of parotid gland..............................-............................  225
Faces, impacted, diagnosed as ovarian tumor.................................................227-232
Fair, table showing comparative mortality from  cancer..........................................  115
Femur, extracapsular fracture of...............................................................  175
Fistulas  vesico  and recto vaginal, remarks upon................................................45-53
        vesico-utoro-vagiual..................................................................53-55
        case of vesico-vaginal.................................................................   56
        in ano, case of........................................................... ........... 247 
422
                                                                                            Page.
Frey on cancer................................................................................  133
Fricke, operation for prolapsus uteri...........................................................   76
Galenus Claudius ou the treatment of cancer...................................................  152
Gross, on excision of the parotid gland..........................................................  225
Hemorrhoids...............................................................................240-243
Haly, Abbas, on cancer...................................................................124,125,152
Hammond, Professor, on tetanus................................................................  106
Hewitt Graily, causes of ruptured perinseum...................................................   12
Hippocrates on cancer......................................................................123-152
Hospital, Columbia, history of the..............................................................  3-6
                   summary of cases treated in................................................  7-9
Lisfranc on amputation of the cervix uteri.....................................................  154
MacFarlaue on the return of cancer after extirpation............................................  177
Malgaigne, operation for prolapsus uteri...........................................  ............   76
Mammse, cancer of, cases.....................................................................165-176
         remarks on___.....................................................................176-179
Masturbation................................................................................204-219
Mayo on the return of cancer after extirpation.................................................  177
Metritis, chronic  cervical, causes  of.............................................................  194
                         symptoms of.......................................................195,196
                         treatmentof........................................................196,197
                         casesof............................................................197-201
Morgagni on masturbation and foreign bodies in the bladder...............,...................206-219
Noeggerath, E., causes of cancer...............................................................  150
Nonnus on cancer.............................................................................  125
Parotid gland, case of extirpation of..........................................................223-225
Paulus ^gineta on cancer.............._...............................................121-123,150
Pelvic cellulitis, remarks on.................................................................233,234
                 cases of.....................................................................234-239
Perinseum, lacerated or ruptured,  causes of......................................................11-13
           sequelse............................................................................13,14
           operation for........................................................................15-17
           cases of............................................................................17-44
Preface........................................................................................  1-9
Eectum, prolapsus of, cases..................................................................244,245
         fissure of, cases......................................................................245-247
Ehaseo, on cancer........................................................................124,125,126
Eindfleisch on cancer....................................................................129-132,150
Eobiu, Charles, mucous membrane of the uterus...............................................187-192
Eokitansky on cancer.......................................................................126-129
Scarpa, return of cancer after extirpation......................................................  177
Scribonius Largus on cancer....................................................................  124
Serapion on cancer............................................................................  125
Simpson, Professor, case of urethral caruncle.............................  ......................  221
Sims on vesico and recto vaginal fistulse.......................................................45-52
     operation for reetoeele..................».................................................   59
     dangers of ecraseur......................................................................  153
Smith, Tyler,  anatomy of os uteri and vagina.................................................180-187
              causes of ruptured perinseum......................................................   12
Soranus on the treatment of cancer.............................................................  152
Sphincter ani, method of paralyzing the.........................................................   15
Syphilis, secondary, case of...................................................................117-119
Tables of comparative mortality from cancer  ...................................................  145
       of fecundity in connection with cancer.................................................147; 148
Tetanus, case  of..............................................................................102-104
         remarks ou..........................................................................104-106
Thomas, Gaillard, causes of ruptured  perineum.................................................    12
                  mode of dissection  in reetoeele................................................   53
Thompson, J.  11., prefatory remarks...........................................................   1_9
Thyroid gland, removal of a hypertrophied third lobe of the...................................225, 226 
423
Tumors of the uterus.........................................................................01-112
Urethra, case of entire loss of..................................................................    ^
        caruncles of........................................................................220-222
Uterus, diseases and displacements of.........................................................70-230
       prolapsus of, causes....................................................................72-74
                   symptoms.................................................................    ~4
                   treatment.................................................................74-78
                   cases.....................................................................78-91
       tumors of............................................................................91-112
       subinvolution of.....................................................................113-120
       cancer of, its pathology...............................................................120-143
                frequency.................................................................143-145
                causes................... ..................................................145-151
                cases  of...................................................................151-165
       cervix of, its anatomy................................................................180-193
             amputation of.................................................................200-201
Vagina, reetoeele of the.........................................................................    57
       treatment.............................................................................57-50
       cases................................................................'..................60-65
       anatomy of the.....-................................................................180-10:!
Van Buren, method of paralyzing the sphincter ani....................................:.........    15
Velpeau on vesico and recto vaginal fistula?....................................................    53
        on return of cancer after extirpation...................................................  179
West, causes of metritis and endometritis.......................................................  194
Woodward, J. J., on cancer....................................................................134-143
Yandell, D. W., on tetanus...................................................................104-106
INDEX  TO  DISPENSARY  REPORT.
                               DISEASES  OF FEMALES.

Abortion, laceration of cervix in attempting.....................................................  253
         puncture of cervix in attempting......................................................  255
Abscess of breast.............................,.................................................  250
        in wall of uterus......................................................................  254
        in fundus uterus.......................................................................  258
        iu right superior portion of uterus, (Scanzoni)...........................................  257
Albuminuria in pregnancy......................................................................  250
Amenorrhcea...................................................................................  250
Amputation of cervix uteri....................................................................  272
              in chronic metritis___...........................................................  28H
Anatomical characters of uterine mucous membrane..............................................  288
Anteversion of uterus..........................................................................  250
Anteflexion of uterus...........................................................................  250
Aptitude of uterine tissues for the continuance of inflammation...................."..............  258
Applicator, Enimett's...........................................................................  310
Ashford, Dr. F. A., dispensary report, section diseases of females..................................  249
Atresia of cervical canal in anteflexion...................,......................................  250
Bromide of potash in chronic metritis..........................................................  270
                   endometritis...............................................................  307
Calculus, vesical..............................................................................  251
Cancer of uterus...............................................................................  271 
424
                                                                                              Page.
Carbolized sponge-tent...................................................................:.....  281
Carbolic acid with glycerine for dressing cervix uteri............................................  282
             applied to mucous lining of uterus................................................  310
Caruucula urethre.............................................................................  251
Cervix uteri, ulceration of....................................................-................  250
             erosion of........................................................................  250
Chromic acid in endometritis...................................................................  310
Dress, bad effects of during treatment..................-........................................  276
Dysmenorrhoea.................................................................................  250
Dyspepsia in uterine disease....................................................................  307
Endometritis....................................'..............................................  288
             cervical...........................................................................  252
             corporeal.........................................................................  252
            frequency of .....................................................................  288
            anatomical and pathological characters of the tissues involved in....................  288
            limits of  morbid action of...........................................................  294
            effects of menstruation on.........................................................  295
            causes of.........................................................................  295
             acute.............................................................................  297
            chronic...........................................................................  297
            symptoms of.....................................................................  297
            effects of, on nervous system.......................................................  302
            effects of, on mental and moral faculties............................................  302
            effects of, on digestive function....................................................  303
            termination  of....................................................................  304
             ulceration in......................................................................  305
            exaggerated blood-vessels of villi in...............................................  306
             treatment of.....................................................................  306
Exercise, influence  of,  in uterine disease........................................................  277
                         endometritis..........................................................  307
Fibroid tumors of uterus.......................................................................  250
               a cause of chronic metritis.........................................,............  261
Fresh air auxiliary  to treatment of chronic  metritis.............................................  278
                   in endometritis..............................................................  307
Galactocele....................................................................................  251
Galactorrhcea..................................................................................  251
Glycerine tampon in acute metritis..............................................................  256
                    chronic metritis...........................................................  282
                    endometritis............................................................309,310
Hematocele, pelvic...............................................................,............  250
             pudendal.........................................................................  251
Hernia, ovarian................................................................................  251
        femoral.................................................................................  251
        ventral................................................................................  251
Hyposulphite of soda in chronic metritis........................................................  279
                       endometritis...........*................................................  308
Injections, hot vaginal, in acute metritis........................................................  256
                         chronic metritis......................................................  280
                         endometritis.........................................................  309
          vaginal, effects  of on the uterus......................................................  310
          uterine, (see Uterine injections.)
          of iodine  in chronic metritis..........................................................  284
          of iodine, effects of, on the albuminous secretions, (Nott)...............................  286
          of iodine in  endometritis.............................................................  310
Leeches in acute  metritis.......................-..............................................  259
           chronic  metritis....................................................................  280
           endometritis .......................................................................  309
Leucorrhosa...................................................................................  250
           in chronic  metritis......____......................................................  265 
425
                                                                                             Page.
Leucorrhoea in endometritis....................................................................   •-"•)"
Menorrhagia...................................................................................   250
Metrorrhagia................................................................................•-   250
Motritis, acute................................................................................   252
             causes of........................................................................   253
             symptoms of, in first case.........................................................   253
                             second case...........................................  ..........   ~55
             infrequency of, in non-puerperal state..............................................   257
             abscess in........................................................................   257
             liability of, to become chronic................................... .................   258
             treatment of.....................................................................   259
         chronic...............................................................................   260
                causes of.......................................................................   261
                relation of abortions and fibroids to.............................................   261
                its relation to negro race......................................................   261
                corporeal or  cervical...................-.........................................   263
                a cause of sterility.............................................................   263
                influence of  pregnancy upon....................................................   264
                symptoms of..................................................................   265
                progress of...................................................................   267
                amputation  of neck in.........................................................   272
                diagnosis of...................................................................   273
                diagnostic summary, (Byford).....................................„.............   274
                treatment of..................................................................   275
                medicines as absorbents  in.................................................... .   278
                results to be expected in........................................................   288
Mucous membrane of uterus....................................................................   288
Neoplasms of the breast........................................................................   251
Nipples, ulcerations of...............................................•..........................   251
Nitrate of silver in endometritis................................................................   310
Nux-vomica in chronic metritis.................................................................   '27<J
              endometritis.....................................................................   307
Ovaritis..............................................:........................................   251
Ovarian hernia.................................................................................   251
Pain in chronic metritis.................1......................................................   265
       endometritis. ..;.......................................................................   300
Pepsine in endometritis.........................................................................   307
Perineum, rupture of..........................................................................   251
Persulphate of iron in endometritis............................................................   311
Polypus uteri..................................................................................   250
Potassa cum calco iu chronic metritis..........................................................   287
Fruritus vulve................................................................................   251
Eest in bed iu chronic metritis.................................................................   277
              endometritis.....................................................................   308
Salpingitis.................... ...............................................................   251
Scarification of cervix uteri in chronic metritis.......'..........................................   287
                             endometritis.....................................................   309
Sexual intercourse during treatment of uterine disease...........................................   278
Sponge-tents, (see Tents.)
Sterility.......................................................................................   251
        in chronic metritis...................................................................   287
Suppressio meusium...........................................................................   250
Tents, sponge, in chronic metritis.......................................".......................   281
                 endometritis..................................................................   309
      laminaria compared with sponge..........................................................   281
      mode of introducing.....................................................................   282
      bad effects of............................................................................   282
      tetanus following use of.....,...........................................................   2s;!
      use of, when fibroids exist................................................................   2*7
Vaginismus........ ....................................-......................................   251
       f>t 
                                               426

                                                                                              Page.
Vaginitis......................................................................................  251
Vicarious menstruation.........................................................................  251
Vulvitis...................................:...................................................  251
Vulva, pruritus of..............................................................................  251

                                DISEASES OF CHILDBED.

Adhesio lingue...............................................................................  316
Albuminuria, its relations to malaria...........................................................  326
Alvus adstricta.................................................................................  316
Amnion, acet. liq. in acute catarrh.............................................................  388
        carb. in acute catarrh.................................................................  390
        chlor. in acute catarrh.................................................................  389
Anemia......................................................................................  316
Asthma........................................................................................  316
Atrophia musculorum  ingravescens...........:................................................  316
Ballard on entero-colitis......................................................................  333
Becquerel, relation of renal disease to malaria...................................................  326
Berfrin on entero-colitis........................................................................  333
Binz on the use of quinine.....................................................................  329
Bismuth, subnitrate of, iu intestinal diseases....................................................  358
Bocker on senega.............................................................................  382
           ammon. chlor.......................................................................  389
Bouchut on entero-colitis......................................................................  333
            dysentery........................................................................  335
            cholera-iufantum..................................................................  337
            dentition........................................................................342-343
Bricquet on the use of quiuine.........................................-•.......................  329
Bronchitis....................................................................................  316
          value of drugs in..................................................................363-391
          catarrhal form  of, defined..........................................................363-364
Busey, S. C., letter of,  accompanying report.....................................................  314
Calomel iu intestinal diseases................................................................353-363
           intermittent fever..................................................................  327
Carbolic acid in intermittent fever...........................................................329,330
Catarrh, treatment of  acute..................................................................387-391
Catarrhus laryngis............................................................................  316
          vagine.............................................................................  316
Cellulitis......................................................................................  316
Cholera-infantum...........................................................316,331,334,335,337,342
Cloquet and Carriere on liq. ammon. acet.......................................................  388
Ciyptorckidia.................................................................................  316
Decaisne, Dr., ou milk.........................................................................  338
Deutitio difficilis..............................................................................  331
                 a cause of intestinal diseases................................................342-344
Diaphoresis...................................................................................  388
Diarrhcea, sudoral.............................................................................  346
Didat, Dr., on carbolic acid in intermittent fever................................................  330
Diet in intestinal  diseases....................................................................351-353
Diseases, classification of.......................................................................  316
Dobell, Dr., ou the pancreatic emulsion.........................................................  352
Doune" on mothers aud infants..................................................................  338
Dysenteria..............................................................................316,331-335
Dyspepsia.....................................................................................  316
Eau albumineuse.................................................-............................  360
Eczema.......................................................................................  316
Ellis on dysentery...........................................................................  335
Emerson, Dr., on cholera-iufantum..............................................................  342
Emetina, action of............................................................................  374
Entero-colitis.......................................... ................................316,331-334 
                                                427

                                                                                              Pago.
 Epilepsia.......................................................................................  316
 Epistaxis.....................................................................................  316
 Expectorants...........................................r....................365-367,370-386,;'.89-391
 Fats, digestion of..............................................................................  353
 Febris intermittens, statistics of......  ...................................316-318,319,321, 322, 323-336
                    symptomatic phenomena of.................................................  32o
                    sequele of.................................................................  326
                    relation of, to renal disease.................................................  326
                    spleen in..................................................................  329
                    treatment of.............................................................327-331
       remittens...............................................................................  316
 Flint on mucus___..........................................................................378-381
 Frerichs on relation of malaria to renal disease.................................................  326
 Freulich on carbolic acid in intermittent fever..........................................-.......  329
 Furuuculosis..................................................................................  316
 Gait on the influence of malaria on race ..  .....................................................  323
            cause of malaria..................................................................    324
 Gmelin, on ammon. chlor......................................................................  389
 Gulliver ou ammon. chlor.....................................................................  389
 Headland and Pereira on tartar emetic and ipecacuanha........................................."  372
 Heidenhain on the relation of malaria to renal disease...........................................  326
 Helminthiasis.................................................................................  316
 Hernia ingenita...............................................................................  316
       pudendalis.............................................................................  316
       umbilicaris............................................................................  316
 Herpes.......................................................................................  316
 Hydrocele infantalis...........................................................................  316
 Hydrocephalus acutus........................................................................  316
               ingenita........................................................................  316
 Hypertrophia tonsillarum......................................................................  316
 Icterus........................................................................................  316
 Incontinentia urine...........................................................................  316
 In j arise.......................................................................................  316
 Insomnia .....................................................................................  316
 Intestinal diseases, statistics of*..................................................... 336,337,340,341
                  relations of, to each other................................................ 331-338
                  causes of................................................................ 338, 343
                  pathology of............................................................ 348, 350
                  treatment............................................................... 350-363
 Ipecacuanha....................................................................372-377,380,381-1 Wl
 Jacobi on quinine.............................................................................  329
 Jones, Dr. Jos., blood in malarial fever  .........................................................  324
               albuminuria with malarial fever.............................................. 326, 327
 Lactation, its influence on intestinal  diseases....................................................  338
 Laryngitis..................................-.................................................  316
 Labum leporinum.............................................................................  316
 Lee, William, intermittent fever.................................................................  319
 Mageudie and Orfila on tartar emetic and ipecacuanha...........................................  372
 Marshall,  on secretion  and excretion......................................................... 376,377
 Meigs and Pepper on entero-colitis.............................................................  332
                    dysentery................................................................  335
                    mortality....................................:............................  340
                    cholera infantum.......................................................337-342
                    pathological  changes in diarrhoea..........................................  350
                    ipecacuanha..............................................................  384
Meigs, J. F., on entero-colitis...................................................................  335
Morbus Brightii albuminuria...................................................................   316
Morbus coxa'..................................................................................  316
Mucus................................................................................... 377-380
Myalgia.......................................................................................  316 
428
                                                                                            Page.
Necker Hospital, dentition in the..............................................................•  312
Neuralgia.....................................................................-...............  316
Niemeyer on the relation of malaria to renal disease.............._..............................  326
            catarrh...................................................................... 348,363
            diaphoresis.......................................................................  388
            ammon. carb.....................................................................  390
Nobiling on tartar emetic and ipecacuanha.....................................................  373
Otorrhcoa..........,..........................................................................  316
Ozena........................................................................................  316
Pancreatic emulsion...................................■-.......................................  352
Paraplegia...................................................................................  316
Parkes on the relation of malaria to renal disease .,.............................................  326
Parotides.....................................................................................  316
Pecholier on ipecacuanha................'......................................................  375
Peligot on the milk............................................................................  338
Pereira on tartar emetic and ipecacuanha.......................................................  374
           ammon. chlor.......................................................................  389
           ammon. carb................................................  ......................  390
Pertussis......................................................................................  316
Pharyngitis...................................................................................  316
Phillips, Dr. C. D., on squill.........................,........................................  382
                  on ipecacuanha.............................................................  375
Phthisis pulmonalis............................................................................  316
Phymosis ingenita.............................................................................  316
Polypus nasi..................................................................................  316
Prolapsus ani.................................................................................  316
Quinia in intermittent fever.................................................................327-331
Rachitis................................................................:.......................  316
Rauula.......................................................................................  316
Richardson ou tartar emetic and ipecacuanha...................................................  373
Richter on liq. ammon. acet...................................................................  388
Rilliet and Barthez on entero-colitis............................................................  333
                      relation of nerves to digestion...........................................  346
                      cholera infantum........................................................  350
Rindfleisch, on diarrhoea....................................................  ..................  350
               hypersecretion..................................................................  366
               mucus.......................................................................378,379
               mucus membranes..............................................................  387
Ringer on ipecacuanha..................................................................374,375,384 ,
Roberts on the relations of malaria  to renal disease.............................................  326
Rosenstein on the  relations of malaria to renal disease...........................................  326
Routh on infant feeding......................................................................  338
Scroff ou senega............................................-...................................  382
Scrofulosis..........................-.........................................................  316
Senega......................................................................................381,382
Smith, Eustace, on dentition....................................................................  343
Smith, J. Lewis, on cholera-iufantum..........................................................  342
Smith on entero-colitis.......................................................................333,335
         dysentery...........................................................................  335
Sonsino, Dr. Prospero, on diet.................................................................351,352
Spken enlargemeut in intermittent fever......................................................  327
Squill.......................................................................................381-383
Stewart, relations of malaria to renal disease...................................................  326
Still6 on amnion, chlor.........................................................................  389
         tartar emetic and ipecacuanha......................................................372,375
         squill.................................. .............................................  382
         expectorants....................................... ...............................383, 384
         liq. amnion, acet.......................................-•..............................  388
Stomatitis....................................................................................  316
Sunderliu ou senega..........................................................................-  382 
                                               429

                                                                                             Page.
 Sunderlin on ammon. chlor...................................................................3^0, 390
 Syphilis ingenita...................................................................  ..........  316
 Tables classifying diseases treated.....................................................  ........  316
       of analysis of percentage of cases of intermittent fever in adults, according to sex and color,  323
                    sexes and  colors for each year treated for intermittent fever................  318
                 for adults..................................................................  319
                 of ages, sexes, and colors treated for intermittent fever........................  321
       of gross aggregate  of race, and sex of adults and children, with percentage of intermittent
         fever................................................................................  322
       showing percentage of intestinal diseases and intermittent fever..........................  336
       showing proportionate frequency of intestinal diseases among races and sexes.............  336
               percentage of intestinal diseases to the whole number............................  336
               proportion of each  intestinal disease  to the whole  number of each class for three
                 years........................................................................  337
               percentage of cholera-infantum as to sex.........................................  337
               mortality from  intestinal diseases...............................................  340
               percentage of deaths under 5 years.............................................  341
                                   above 5 years.............................................  341
 Tanner on dysentery...........................................................................  335
 Tartar emetic...........................................................................___372-374
 Thompson, J. H., letter of Dr. S. C.  Busey to....................................................  314
 Tonsillitis.................................................................................-__  316
 Torticollis.....................................................................................  316
 Trousseau on dysentery........................................................................  335
             dentition.........................................................................  343
             sudoral diarrhoea.................................................................  346
             eau albumineuse.................................................'................  360
 Turpentines as expectorants....................................................................  386
 Vaidy on liq. ammon. acet......................................................................  388
 Vogel on dysentery...........................................................................  335
         cholera-infantum.....................................................................  342
 Voigtel on liq. ammon. acet.....................................................................  388
 Vomitus.......................................................................................  316
 West on enterocolitis.........................................................................  332
         dysentery............................................................................  335
         dentition...........................................................................  343
 Wilson, C.J. B., on catarrhal inflammations....................................................  368
 Wood, II. C, on ammon. chlor..................................................................  389
 Wood on squill................................................................................  382
         the turpentines..................................................................'.___  386
 Woodward, J. J., on the relations of malaria to renal diseases.............................:......  326
                    diarrhoea..................................................................  349
 Yandell, Dr., on the use of carbolic acid in intermittent fever....................................  329

                         DISEASES OF  THE  EYE AND EAE.

 Analysis of table of  cases of herpes of the cornea...............................................  405
 Analysis of table of  cases  of  trachoma..................-....................................---  414
 Cornea, classification of diseases of..............................................................  400
        epithelium of..........................................................................  309
        membrane of Bowmau.................................................................  399
        membrane of Descemet.......................................................:......  400
        nerves  of................................ .....................  ......................  399
        nourishment of........................................................................  399
        structure of..........................................................................398, 389
        section showing nerves in, (wood-cut).................................................  39*
        substance of...................  ....................................................  399
        vertical section of, (wood-cut).........................................................  39m
Constitutional  treatment  of herpes of cornea........................-..........................   109
Chronic granular conjunct ivitis................................. ...............................  410 
                                               430

                                                                                             Page.
Eye and ear, department of diseases of.........................................................   394
            introductory' remarks...;............ ............................................   395
            tabular report of cases of diseases of..............................................   397
Herpes of the  coruea..........................................................................   402
                    causes of.................................................................   405
                    herpetic efflorescence in.............~.....................................   402
                    relapses of.................................................................   406
                    symptoms of first stage of___..............................................   403
                    symptoms of second stage of...............................................   404
                    sequele to................................................................   404
                    table of cases of...........................................................   402
                    treatment of..............................................................   406
'■ Lunar-caustic" ophthalmia...................................................................   414
Mercury, ointment of the yellow  oxide.........................................................   408
Paracentesis of the cornea iu herpes............................................................   409
Phlyctenular ophthalmia.................»....................................,...............   402
             corneitis.........................................................................   402
Protective bandage............................................................................   407
Rupture of both eyes, case of..............................................................___   39;i
Sequele of trachoma..........................................................................   413
Strumous ophthalmia.........................................................................   402
Symblepharon posticus...........................................................7............   413
Trachoma.....................................................................................   410
          causes..............................................................................   414
          classification........................................................................   411
          clinical history......................................................................   413
          complications.......................................................................   419
          diffuse..............................................................................   413
          mixed..............................................................................   412
          papillary............................................................................   412
          pure granular  or vesicular...........................................................   411
          prognosis............................................................................   416
          relative frequency of.................................................................   410
          table of cases..................................  .....................................   410
          treatment...........................................................................   417
Trachoma follicles.............................................................................   411
                  analogy of, to closed follicles of small intestine...............................   109
Ulceration of coruea in herpes.................................................................   412
o 
ERRATTA.
Page 78, line 32, read "scybale" for "scyballe."
Page 79, line 20, read "three-fourths'" for "three parts."
Page 82, line 28, read "vagine" for " vaginoe."
Page 90, line 4, read "size is represented," etc.
Page 90, line 4, read "plate 8" for "plate 7."
Page 90, line 9, read "plate 8" for "plate 7."
Page 96, line 14, read "plate 9" for  "plate 8."
Page 102, line 23, omit the dash between "Tissue" and "Tumors."
Page 228, line 17, read "Multilocular" for " Mutilocular."
Page 251, line 13, read "caruncula" for "caruncle."
Page 251, line'22, read " galactocele " for " gallactocele."
Page 253, line 7, read "adjacent" for "adejacent."
Page 254, line 2, read " fecal" for "foocal."
Page 259,-line 9, read "upon" after  "insist."
Page 259, line 36, read "wall" after "posterior."
Page 260, line 14, read "soluble" for "soluable."
Page 260, line 17, read "the disease" for "it."
Page 264, line 27, read "Pessary" before "figure 1."
Page 267, line 11, read "wall" after "posterior."
Page 267, line 35, read "rectal" for  "bladder."
Page 268, line 9, read "fecal" for "fecal."
Page 270, line 21, read "infarctus" for "iufractus."
Page 309, line 22, read "appear" for "commend itself."
Page 311, line 2, read "resulted" for " proceeded."
Page 332, line 14, read "Pediatricar" for "Pediatrica."
Page 346, line 14, read "Pediatrica" for "Pediatricas.''
Page 356, line 29, read "fecal" for " freca-1."
Page 328, line 35,read "Menstruum" for "Menstrum."
Page 390, line 34, read "Niemeyer" for "Neimeyer." 
 
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