^r—2Pj? /o^f'L. ■■ ^ m ^ 1 d i CS3 ' rll j,, J^| ©n some forms of Disease of tl)e (Henri* Uteri THK ANNUAL ADDRESS UEFORK THK CONNECTICUT MEDICAL SOCIETY, MAY 1848. w BY B. FORDYCE BARKER, A. M. M. I). Pl'BUSllED BY THE COHECTKTT MEDICAL SOCIETY. Wi sic P. C.b.: I ES3 Wl id p CO si & NORWICH: J. UUMIAM'S PBKSS, SHETtJCKET / 6% *J;*<(//l REMARKS ON SOME FORMS OF DISEASE OP THE CERVIX UTERI. BY _ ^'" B. FORDYCE BARKER, M. D a- Mk. President and Gentlemen r In offering for your consideration a few observations on some forms of non-malignant disease of the cervix uteri, I hope to call the attention of the medical practitioners of this State to a elass of diseases, the pathology and appro- priate treatment of which, have been, until very recently, entirely misunderstood. From their very great frequency, and their vast importance as affecting the comfort and hap- piness, noti only of the individual suffering, but that of her family and friends, this class of diseases merits the most at- tentive study, the most patient and careful investigation. The progress which has been made in physical diagnosis- and acGura'te pathological knowledge, during the last half century, is truly wonderful. At the present day, almost every physician avails himself, (or professes to,) of. the im- portant, I may say indispensable aid furnished by ausculta- tion and peicussion in diagnosing disease of the lungs and heart. Even the non-professional public have become so fully alive to the great advantages to be gained by these methods of examination, that the quack and the ignoramus are compelled to thump the chest and apply the stethescope in order to retain the confidence of their deluded victims. Equally great have been the improvements made in the di- agnosis of uterine disease and its true pathology. But the profession as a class, both in this country and in Great Brit- ain, have not. been equally ready to reap for themselves, or. to confer upon their patients, the advantages to be gained from these new diseeveries. Even practitioners who are familjar by their reading, with the progress which has been made in uterine pathology, have been restrained by an al- most criminal fastidiousness and a perverted sense of deli- cy, from using the necessary means of exploration, and as a 4 natural consequence, when their services are sought for, orn account of a leucorrhea, or menorrhagia, or a prolapsus, they; have contented themselves with the old routine of tonics,. astringents, injections, or worse yet, have ordered an abdo- minal supporter, or applied a pessary. Sometimes the poor patient has been, undoubtedly, benefitted by even this rou- tine of practice ; sometimes, beneficent nature has taken the case into her own hands, and affected a cure, but more gen- erally the unhappy sufferer has been eompelled to drag out in patient endurance, years of misery and weakness, worn down by a Leucorrheal discharge, or a uterine hemorrhage,. wretched in body and in mind ,- peevish, irritable and hys- terical, a burthen to herself and a " thorn in the flesh'1 to' her immediate relatives and friends, and m many, very ma^ ny cases, bitterly disappointing family hopes in wanting the blissful anticipations of a mother's joys, on account of ob- stinate sterility, or oft repeated abortions. This is no fancy sketch, but many such, I have no doubt, are within the' knowledge of every medical man engaged in active prac- tice, in this State. Ail writers, who have made this class: of diseases a subject of special investigation, speak of their very great frequency. It has been supposed that nearly one-half of the married females suffer to a greater or less; degree from some form of uterine disease. I propose to speak of some forms which, from my own experience, I am satisfied are of frequent occurrence with us, but which are hardly alluded to in our systematic works on female diseases. I would call your attention first to Granulations of the Cervix uteri. I am not aware of any work in the English language, which gives a description,. sufficiently full or accurate for the practitioner to recognize or understand this affection. In the excellent work of Dr. Churchill, there is a meagre and imperfect sketch of it. 5 Dungl'ison,. (Practice of Medicine;) devotes one-third" of as page to it as a sequela of acute and chronic inflammation of; the uterus. It is not mentioned by Ashwell.or Lever. In, the work of Colombat de L'Isere, (translated by Dr. Meigs,), there is a very brief, imperfect and erroneous description of it, evidently hastily copied from Boivin and Duges, and con- founded with, inflammatory affections of the cervix. It was, first, as I think, correctly described by Mad. Boivin, (Mal- adies de l'uterus par Boivin et Duges.) It is briefly al- luded to by Duparcque, but more fully described in the Bib- liotheque du Medecin-Praticien. I hope to be pardonedi for saying that it seems to me, all the writers above refer- red to have been in error as to the true pathology of this af- fection. I heard a most excellent clinique on the subjecti by M. Chomel, at the Hotel Dieu, and have often seen this: form of disease,, both, in the Parisian Hospitals, and in pri- vate practice within the last two years and a half. Granulations of the cervix uteri seem to consist of an hy- pertrophy of the mucous membrane, or of the numerous fol- licles which exist in the thickness, of this membrane, more- abundant in the uterine orifice than every where else. The- French in describing it, have used the term framboisee from the little hard fleshy elevations on the os tinese, resembling the distinct elevations of the raspberry. So also, some of them speak of it as a granulous or raspberry-like inflamma- tion. (Inflammation granuleuse ou framboisee.) But this is incorrect; it is not an inflammation but an affection suk generis, peculiar to this organ. The only part of the sys- tem in which analagous granulations are found, is the pha- rynx, as the pharynx alone possesses the same follicular dis- position. Neither is it, as some have supposed, a result of inflammation. Inflammations have a period of increase, a period of statu quo,, and a period of decrease, to which sue- 6 eeeds the euro. Affections which do not present these three periods, may, it is true, offer inflammatory symptoms, but they are not veritable inflammations. Inflammations are those diseases which exciting agents exasperate, antiphlo- gistic means moderate. But this disease has not this cha- racter ; antiphlogisties do nothing for it. Again the terms,. granulous excoriations, granulous ulcerations, have been employed to designate this disease, but they are equally improper. In ulceration there is always a loss of substance more or less extensive. But in the granulated state of the neck of the uterus, there is always a relief, a projection, an increase of substance; the prominence is perfectly appre- ciable to the touch. Furthermore, the granulous state is. accompanied by an excretion of glutinous, tenacious, semi- transparent, or sometimes slightly opaque and puriform mu- cus. Ulcerations on the contrary, present the veritable pus at the surface without mixture of mucus of any sort. Gran- ulations of the cervix uteri have also, no doubt, been con- founded with carcinoma, but they have nothing in common with cancer. Carcinoma uteri commences by the develop- ment of globulous tumors upon the neck, which the touch may signalize, but which frequently cannot be seen by the speculum. The granulations, on the contrary, commence in the interior of the neck, and extend by degrees from with- in to without. Carcinomatous tumors commence external- ly, going from without to within. Chomel* has never known but one female, who commenced by having granu- lations, in whom it degenerated into a cancer. Causes. These are so very obscure, that it is very diffi- cult, not to say impossible, to determine them. Some have said that abuse of venereal pleasure, the repeated contact of the male member was one of the most frequent. But wo* *MSS. Notes. 7 men of pleasure are not more subject to it than other wo- men. Those who have had children present this affection more frequently, but it often occurs in those who have nev- er borne children. So one may consider pregnancy as a predisposing, but not as an exciting cause. There is one circumstance which the French pathologists have found frequently allied to the existence of these granulations, that is anterior chronic affections of the skin. A great number of patients in whom these granulations are found, have been formerly affected with those diseases of the skin, con- founded under the name of tetter. This fact has been ob- served at the Hospital St. Louis, where cutaneous diseases are specially treated. They have found that herpetic af- fections have preceded the development of uterine granula- stion in women ; in men, granulations of the pharynx, which have been mentioned above as having some analogy with granulations of the neck of the uterus. So it would not be too much to suppose, that there exists between them, some- thing in common, having the relation of cause and effect. Symptoms. The existence of this disease can only be absolutely recognized with the sight, by the aid of the spe- culum and by the touch. But there are various functional symptoms which would draw the attention of the observ- ing physician to the uterus. There are some derangements in the functiofls of this organ, or in the groin, pains more or less severe in the side, (most commonly, I have observed, under the false ribs in the left side,) leucorrhea more or less abundant, a derangement of the menstrual evacuations, so that the physician is induced to examine the genital organs. There is no heat of the parts, no exaltation of the sensibil- ity. Although there is pain in the parts above-mentioned, yet rarely is the suffering augmented by coition, or by the touch. The leucorrheal discharge is sometimes moderate s \n quantity, consisting of a thick, tenacious, semi-transpa- rent mucus, resembling the white of an egg. a little beat up. In other and perhaps a majority of these cases, the discharge' of albuminous mucus is very abundant, running down the thighs at times when the patient walks, producing a sensa- tion of chilliness. Hemorrhages are very common in this affection, and they may consist either in an abnormal aug- mentation of the menstrual flux, or in a proper hemorrhage between the menstrual periods. The debility and emacia- tion resulting from the menorrhagia are perhaps the most frequent cause of the patient's seeking medical aid, unless at an earlier period, she has been led by the old women learned in these matters, to believe that the vague pains in the groins and lumbar regions, and the dragging sensation at the lower part of the abdomen are caused by falling of the womb. There is another symptom so common as to merit atten- tion, that is, sensations or pains at the pit of the stomach, which patients frequently describe as " pulling or dragging of the stomach." These sensations, as remarked by Cho- mel,* have this important particular for their diagnosis; as they are sympathetic with the morbid state of the uterus, the presence of aliment in the stomach effects no change in them ; while in pains of the stomach, which are idiopathic, the presence of aliment is not at all indifferent. Another phenomenon which coincides frequently with this disposi- tion of the cervix uteri, is the absence of conception, a sort of accidental or symptomatic sterility. It is said that this is not a constant phenomenon, but that there are some who become pregnant not only during the course of the disease, but also during the course of the treatment: but neverthe- less in a great majority of cases, there is sterility, and in ex- *MSS. Notes, 9 amining with the utmost care, nothing is found in the ute- rus itself which explains the absence of conception. The question then arises whether these granulations have not something to do with the sterility. When the mucous membrane, which covers the internal surface of the orifice, is tumefied, this tumefaction diminishes by so much, the diameter of the orifice, and may oppose the penetration of the semen into the cavity of the organ. Then the viscous, glutinous character of the discharge from this orifice, its physical properties are opposed to fecundation, as the mu- cus is often so tenacious that it is difficult to raise it with the speculum forceps. Furthermore, it has been remarked by several observers, that women who have been married several years, and who were found to be affected with this disease, have become enciente after having been subjected to the appropriate treatment, followed by a cure. Three such instances have occurred in my own practice, two of whom are now happy mothers, and the third soon hopes to be. Diagnosis. This is not usually difficult if we resort to the touch, and the aid of the speculum. By the touch we find a portion of the mucous membrane of the cervix uteri feeling softer than usual, something like velvet; and in this portion the granulations are very distinct, as if millet seeds were imbeded in the mucous membrane. Sometimes they attain a size nearly as large as a small pea. The surrounding healthy portion feels smooth, firm, and polish- ed. As this disease always preserves the same disposition, commencing at the centre of the orifice as the point of de- parture, and extending towards the external circumference of the orifice as it progresses, we shall invariably find the softening and the granular elevations near the centre of the orifice, while the external circumference will retain its nor- 10 mal firmness and smoothness. I believe that this affection never implicates the whole of the cervix. By the touch alone we can then recognize this affection, but as the spec- ulum is absolutely essential to its appropriate treatment, we can then avail ourselves of its important aid in confirming our diagnosis. Indeed, without the speculum, we can nei- ther limit nor define its extent; and even the existence of this state was entirely unknown previous to the invention of the speculum, which permitted one to see a very marked change between the portion around the orifice, and the ex- ternal circumference. The latter offers a pale rose tint, like that of a healthy mucous membrane of the mouth ; while, on the contrary, the diseased portion near the orifice, is of a reddish violet eolor, with the unequal granulated surface very apparent. This is sometimes seen within the orifice itself, extending by degrees to the neighboring parts. Its progressive development is not constantly the same. Some- times it extends only to one lip, sometimes to both. Its form also is variable. So then, the two pathognomonic signs of granulation of the cervix uteri are redness, and a granulated, unequal surface, appreciable both to the touch, and to the sight. It happens frequently that when the speculum is introduced, one can distinguish but imperfectly the spots of which we have spoken, because a certain quan- tity of the mucus covers the neck and conceals the granu- lations. It is neeessary then to wipe it away by means of long straight-handled forceps, with a dossil of lint or cotton; and this should be sufficiently large to accomplish the ob- ject quickly, and sufficiently soft not to wound the neck of the uterus. It is not always easy to wipe from the neck the mucosities that cover it, they are so viscious, thready, and adherent. By touching with the nitrate of silver, an artificial coagulation is produced, rendering their removal easy. II Treatment. General or constitutional measures exert no» influence over this disease ; and, as has been remarked a- bove, antiphlogistics are of no avail. Of all therapeutic means, cauterization is the only one which has been em- ployed with success. This should always be effected by substances of medium energy; as, when these are used, the physician can always see the diseased part in its nor- mal aspect, and natural condition. Jobert de Lamballe, at the Hospital St. Louis, generally makes use of the hot irony the actual cautery; Lisfranc, the acid nitrate of mercury; but Chlomel and others prefer the nitrate of silver in the solid state ; and it has this advantage—that we are ena- bled to touch the projecting portions first with the point of the caustic. It has been objected to the nitrate of silver, that in mixing with the vaginal mucosities, it determines a discharge which turns the linen black when suppuration of the eschars takes place, and that it sometimes produces a little discharge of blood. But this sanguinolent dis- charge is entirely insignificant and without value. Some have recommended injections after the cauterizations, to to raise the superfluity of the caustics; but this method is bad, instead of which, we should very gently wipe it off with the dossil of lint. The cauterizations should be re- peated a great number of times, or, at least, until the gran- ular surface has entirely resumed its normal aspect. The day one practices cauterization, the patient should remain some time in the horizontal position, in absolute repose.— This may be repeated every sixth or eighth day, unless, from the effects of the disease and the treatment, the pa- tient becomes so nervous and irritable, as to make a longer delay necessary. During the whole period of treatment. such means should be used as the state of the general sys- tem may demand. 12 I would next ask your attention to the subject of In- flammation, Ulceration and Induration of the cervix uteri. Recent investigations have proved that this class of affec- tions are exceedingly common, and that they are the cause, in a large majority of cases, of the various functional de- rangements, as menorrhagia, dysmenorrhea, leucorrhea, pro- lapsus uteri, &c. which have usually been studied and treat- ed as distinct diseases. There is, probably, no branch of pathology which has been so little understood, no class of diseases which have been so badly treated. Every practi- tioner is aware of the extreme prevalence of the function- al disorders above-mentioned, and of their intractable character under the ordinary routine of treatment. A recent writer of ability, (Whitehead) believes that scarcely less than one half of all married women between the age of twenty and forty-five, are constantly suffering under the influence of uterine disease, and his researches have demon- strated that besides these functional disorders, it is the most frequent cause of sterility and abortion. I shall endeavor to give a resume of the present state of our knowledge of these affections of the cervix, for which we are indebted principally, to the labors of Boivin and Duges, Duparcque, Lisfranc, Emery, Jobert de Lambelle & Castilhes, in France, Bennet, Montgomery, Kennedy and Whitehead, in Great Britain. Inflammation of the cervix, with its sequela?, ulceration and induration, may occur in the virgin and in the married, who have not borne children, but it is much more frequent in those who have borne children. The character of the disease is essentially the same in the three classes, arising from similar causes, producing similar symptoms, and re- quiring similar treatment in all. I have had no experience in the disease occuring in virgins. I will only say in re- 13 gard to it, that Dr. Bennet has found it the most frequent cause of the severe dysmenorrhea and inveterate leucor- rhea, connected with great general debility and prostration, which occur occasionally in the virgin female; and that from the increased volume and weight of the cervix, a part tial prolapsus is sometimes produced, as in the married fe- male, the treatment of which by pessaries, is not only of no benefit, but productive, oftentimes, of the most disas- trous results. Causes. In brief, the most frequent causes of this dis- ease, are supposed to be labor and abortion. To these may be added, sudden suppression of the menses, or of the lochia, the irritation arising from sexual congress, or pro- duced by the use of pessaries, apthous inflammation of the vagina propagated to the os. tincee, and metritis localising under a chronic form in the cervix. Symptoms. I will mention only those which may be regarded as characteristic of this disease, omitting entirely those which occur in common with other local inflamma- tions. Painful and difficult menstruation conjoined with a. permanent leucorrheal discharge, may be regarded as al- most pathognomic of this affection. Dysmenorrhea alone may exist without disease of the cervix. There are some who from a peculiar organism, suffer pain during the cata- menial period from the first appearance of this function, and this may arise from mechanical obstruction or from a neuralgic condition, developed by the uterine excitement which exists during menstruation. The previous uterine history of the patient should then be carefully learned, and if it is found that the menstruation became painful and difficult, for the first time, after a sudden suppression of the menses, or after marriage, or after labor or an abortion, we have strong presumptive evidence that inflammatory dis- 14 ease of the cervix is tne cause, and this diagnosis is Con- firmed if the dysmenorrhea be accompanied by a constant leucorrheal discharge. The abscence of all leucorrheal discharge does not positively prove that there is not in- flammatory ulceration and induration of the cervix, because the secretion from the ulcerated surface may be so small in quantity, that the surrounding tissues may completely ab- sorb it, so that no discharge is observed. Many females have a leucorrheal discharge two or three days previous to the menstrual discharge, and also two or three days af- terwards, it being entirely absent in the intermediate peri- ods, and may be regarded as their normal state. But if there is a constant, white starch-like or yellow vaginal dis- charge, and this is associated with dysmenorrhea, continu- ing through the whole menstrual period, we may be near- ly certain that this disease of the cervix exists. The men- struation may be scanty under these circumstances, or it may be profuse, constituting a menorrhagia. The patient ordinarily suffers from a constant " aching pain " in the hy- pogastric, inguinal and lumbar regions. The pain is usu- ally increased by pressure made just above the pubis, but relieved by pressure in the inguinal regions. But this is not always the case, as there is sometimes very great ten- derness over the whole of the .lower part of the abdomen. If the disease has been of long standing, the patient suffers from " beating and throbbing " in the back, and sometimes excrutiating pain directly over the coccyx. The digestive organs become deranged, there is a bad taste in the mouth, a coated and flabby tongue. Not unfrequently, pulmonary symptoms appear, attracting more attention both from the physician and the patient than those which indicate the real cause of her ill health. In many, the moral nature is remarkably changed, the patient becoming capricious and 15 Unreasonable, peevish and despondent, and tortured by a thousand nervous symptoms. The hysterical phenomina are ordinarily very much aggravated during the menstrual period, occasionally inducing cramps and convulsions.— When the disease has become inveterate, the sense of weight and bearing down in the pelvis, induces the patient and oftentimes her medical attendant to believe, that she has prolapsus uteri, and an abdominial supporter or a pessa- ry is applied. While I regard these troublesome and in- convenient appliances as absurd and unphilosophical in all cases, and productive of positive injury in many, yet I have no doubt that the abdominal supporter, for example, often relieves the patient from the pains over the pubis, in the groins and in the back, by its pressure upon the integu- ments and the uterine ligaments, thus interrupting the communication between the uterine and the spinal nerves distributed to the surrounding viscera. But it never cures, it only conceals. Although the symptoms above enumerated, indicate with a great degree of probability, the disease of the cervix now under consideration, yet we must resort to the touch and to the speculum, for absolute proof of its existence. By the touch, we easily recognize the increased size and density of the cervix, and the abscence of the unctuous, greasy feel of the os. If inflammation of the cervix exists without ul- ceration, the mucous membrane will feel smooth and equal, and the tissue of the cervix will be found more elastic than when in its normal condition. The sensation produced by the ulcerated surface has been compared to that of velvet, and if the tissue beneath be indurated, to that of velvet covering any hard substance, as a table for example. Some- times fissures are distinctly felt subdividing the cervix into lobules, the tubercles of the older writers. The cervix is 16 found lower down in the pelvis than natural, constituting a greater or less degree of prolapsus, aud generally direct- ed backwards towards the concavity of the sacrum. From the induration which exists in some cases, one might be led to suspect a cancerous deposit, but the error will be corrected if the history of the case is carefully sought for, and by observing the freedom of the vagina at its union with the neck, and the movability of the uterus within the pelvic cavity, which is not the case in cancer. The os u- leri is ordinarily more or less open, sometimes admitting with ease the first phalanx. The presence or abscence of pain from the touch cannot, I think, be regarded as a means of diagnosis. On examining with the speculum, there is always seen more or less of the muco-purulent matter around and cov- ering the os. On removing this with a dossil of lint, the tumefied cervix is seen, sometimes so much enlarged, that both lips cannot enter at the same time the speculum.— " When inflamed the tumefied cervix presents a more or less intense red, glistening hue, instead of the pale, dull whitish color, which is natural to it."—(Bennet.) If ulcer- ation exists, the ulcerated surface may offer all the varieties of appearance, common to suppurating surfaces in other parts of the body, from a slight abrasion, to the large flab- by bleeding granulations. From the different appearances which these ulcers present, some have described the gran- ular ulcer, the fissurated ulcer, the varicose ulcer, the "cock's-comb granulation,"—(Kennedy, Dublin Q,uar. Journ. of Medical Science,) &c; but these divisions seem to me, to have no practical value except as facilitating de- scription. The character and treatment are essentially the same, varied only as the discriminating, well iead physi- cian, would vary it on general principles. 17 Treatment. As my design in this dissertation is simply to call the attention of the profession in this State to this important class of diseases, not to arrogate to myself the of- fice of a teacher, I shall mention in the briefest manner, the treatment which I believe to be inculcated by the best au- thorities, and by which I have been governed in my own practice, omitting entirely all discussion of the various nov- elties now proposed in Europe. If there is simply conges- tive engorgement or acute inflammation of the cervix uteri, leeches, applied by means of the cylinder speculum to the diseased part, constitute the most essential part of the treat- ment. Even one application of a half dozen of leeches, I have known to produce a wonderful change in the general condition of the patient. The leeches may be encouraged to bleed, by a continued irrigation of the cervix, with as warm water as can be borne, and this may be accomplish- ed either by the syphon proposed by Dr. Kennedy, or by the ordinary self-injecting apparatus now in so common use. The patient should preserve as much as possible the recum- bent posture, for several days after the application of the leeches. Lying in a warm bath, if practicable, for an hour or more every day, is, I think, of very great service. Coun- ter irritations, as Granville's lotion, sinapisms, &c, applied over the pubis, often seems productive of great relief. If to the above be added a saline purgative every other day, and colchicum and camphor every few hours in the inter- mediate period, I think a cure will ordinarily be effected in a very short period. If the disease of the cervix has as- sumed the chronic form of ulceration and induration, cau- terization constitutes the most essential part of the treat- ment. For this purpose the nitrate of silver, the acid ni- trate of mecury, the potassa fusa, the Vienna paste, and the actual cautery have been used. Without entering into any IS -discussion in regard to the comparative merit of each of these different articles, I will merely say that in my own practice, I have made use of only the nitrate of silver, the acid nitrate of mercury, and the actual cautery. The prin- ciples which govern me in selecting the agent to be used are the following : if there be only simple ulceration, with- out much induration of the tissue beneath, the nitrate of silver is to be preferred. If the ulceration is somewhat ex- tensive, with partial induration, I prefer the acid nitrate of mercury. If the ulcerated surface presents a fungous ap- pearance, and is accompanied with deep seated induration, I resort at once to the actual cautery, as it seems to me more manageable, and less liable to produce injury to the sur- rounding parts than either the Vienna paste or the potassa fusa. It produces not the slightest pain at the time of the application. Whatever may be the agent that is used, no pain is caused by the operation, but the general symptoms are usually aggravated a few hours afterwards, continuing sometimes for two or three days. In the five cases in which I have made use of the actual cautery, I have thought the subsequent symptoms were much less severe than in those cases, where I have used the nitrate of silver or the acid ni- trate of mercury. The only other local treatment necessa- ry, is the frequent use of weak astringent injections, as alum, tannin, sulphate of zinc, &c. As a palliative, I have found the injection of cold water into the rectum, night and morn- ing, more satisfactory than any thing else. I shall not oc- cupy your time with any remarks in regard to the necessa- ry constitutional treatment, as the practitioner will be guid- ed by the general indications of the case. I believe that the mistake that I have made the most frequently, has been in resorting too early to the use of tonics. However weak and anemiated the patient may have been, tonics have 19 seemed to do harm, while the patient was subjected to deep1 cauterizations. When the tissue of the cervix has recover- ed its normal condition, then tonics judiciously prescribed, seem to buildup the patient at once. Pregnancy has been formerl y regarded as an indication that, the local treatment should be discontinued. But the observations of Bennett and Whitehead prove that not only is it safe and free from1 danger of producing abortion, but that it is the most certain means of preventing this occurence; diseases of the cervix being by far the most frequent causes of abortion. In 318 ca- ses of abortion, Mr. Whitehead (on the causes and treatment of sterility and abortion) found the disease of the lower part of the uterus to be the cause in 275. The other causes which he mentions, are, accidental agencies in 44; placen- ta previa in 8 ; constipation, 3 ; retroversion, 3 ; incurable: disease, 1 ; vascular congestion, 15;; obscure causes, 29. More than seventy per cent, of the abortions arise from dis- eases of the cervix. We can easily conceive then, that the successful treatment of the disease, will be the most effect- ual means of preventing the abortion. I have never been' called to treat a patient during pregnancy, but I should re- gard its existence as a more urgent reason for subjecting the patient to the appropriate treatment. I will submit to you an abstract of the more important symptoms attending thirty-three cases which have come under my care, as I should exhaust your patience, were I to give a detailed report of each. All were or had been married. Twenty-one had borne children, and of the re- maining twelve, seven had aborted; one, four times, three twice, and three once each. A constant leucorrheal dis- charge was a symptom in every case. This discharge was in some white, in others yellow, and in five it was frequent- ly sanguinolent, particularly after connection. Dysmenorr- 20 hea (I restrict the term to those cases where the pain Con- tinues severe through the whole catamenial period,) existed in nine cases. In all, the first day of the menstrual dis- charge was attended with a good deal of pain. Menstrua- tion was profuse in thirteen, scanty in three, irregular as to its appearance and sometimes profuse and sometimes scanty in five. The " bearing down" symptoms were the most prominent in thirteen, eight of whom had worn abdominal supporters, four had worn pessaries, the other was accus- tomed to wear a belt of her own construction, which she thought relieved her. Two patients had no suspicion that they were subjects of uterine disease, but sought medical advice on account of some pulmonary symptoms, which a- larmed them extremely. These however entirely disap- peared when the disease of the cervix was cured. I think the above analysis embraces all the important general symp- toms, except those which may be regarded as purely nerv- ous. These were so numerous, and presented such a vari- ety of characters, that it would be impossible either to an- alyze or to classify them. I will ask your indulgence while I give a somewhat de- tailed report of three cases, which I think offer some points of peculiar interest. #Sept. 6, 1846, I was called in great haste to see Mrs. —*-—, who was represented to be in a dy- ing state. I found her in a violent hysterical paroxysm, really alarming to her friends, as they never had seen her in such a state before. She was of a florid complexion, very full plethoric habit, and had always been in perfect health, the bystanders stated. But on visiting her the next day, I learned the following history. Up to the time of her marriage, which was five years before, she never had had an ill day to the best of her recollection. Five weeks after she was married, she was attacked with what her physician 21 called "inflammation of the bowels." Soon after her re- covery, she first observed a leucorrheal discharge. It was sometimes white, sometimes yellowish, and at other times greenish, but she "did not thyik there had been a single day that she had been free from it, except when she was unwell." She had aborted three times, the last time, (in Jan. 1845) she was obliged to call in medical aid " after she got all through," on account of the flowing, which was Very excessive. Since that time menstruation had been growing more and more painful. She could not recollect that she had suffered during the catamenial discharge pre- vious to the last abortion. Coition had been painful and disagreeable to her since she had " inflammation of the bow- els." More than a year ago it became so extremely painful and intolerable, that she "had been compelled to live like a nun ever since." These were her exact words. The menses had been diminishing in quantity for the last six months. The two periods previous to my being sent for, had continued but two days each, which she had been obli- ged to pass upon her bed on account of the severity of the dysmenorrheal pains, and a most distressing vertigo. She was perfectly willing to submit to any treatment which would offer a prospect of cure, on account of the unhappy coldness existing between her husband and herself, which she de- scribed as amounting to absolute hatred on his part, which was breaking her heart, but which had been most studious- ly concealed from her most intimate frieuds, as they erro- neously supposed. At this time her skin was hot and dry, pulse quick and hard, pain in the head, back, and along the thighs. No satisfactory information could be obtained by the touch, on account of the extreme tenderness of the cer- vix uteri, except that it was very low down in the pelvis * These cases are related by permission. 22 and much enlarged. I therefore directed her to remain hi bed, and to take the following medicine, viz: Pulv. Rad. Colchic. one drachm, Pul. Gum Camphor, two scru- ples, Ext. Hyoscyamus, one scruple, M. Div. in chart No. 10. S. One every fifth hour. If there was no movement of the bowels, she was to take on the next day Sulph. Magnes. one ounce, Tart. Antimonii et Potassae, gr. i. Suc- ci Limonis, Aq. Puras, aa two ounces, M. Sept. 10. The general appearance of the patient had very much improved. The mixture had operated freely, both as an emetic and ca- thartic. I did not attempt to examine by touch, but intro- duced the speculum, with some pain, for the purpose of ap- plying leeches to the cervix. There was an abundance of muco-purulent secretion in the upper part of the vagina, on removing which with a dossil of lint, a part of the anterior lip was seen, of a deep red color, but no ulceration was vis- ible. Eight leeches were applied. She was directed to in- ject into the vagina, four or five times a day, a warm de- coction of poppy leaves, and a pint of cold water into the rectum every morning. Sept. 18. The patient so much better, that I was able to get a good examination. The cervix is low down, en- larged, offering to the finger very distinctly, the velvety sensation around the orifice, and well marked lobulated in- durations. By the speculum, the orifice was about a half inch in length, somewhat patulous, from which I wiped nearly a teaspoon-full of a muco-purulent secretion, when an ulceration was distinctly seen, occupying both lips. The ulcerated surface was of a bright red color, and did not bleed. Cauterized with the acid nitrate of mercury. In the eve- ning, ten hours after the cauterization, she had a second hysterical paroxysm, more violent than the first. The suc- ceeding two days her symptoms were all aggravated :but 23 after that she improved so much, that it was with difficul- ty she could be persuaded to remain in bed. Weak injec- tions of sulph. zinc and alum, were substituted for the de- coction of poppy, she continuing the ct»ld water enema ev- ery morning. Sept. 26. The cauterization was repeated, the immedi- ate effects of which were much less severe than before. The menses appeared on the 30th, nearly a week earlier than she anticipated, lasting three days, but attended with a good deal of pain. Cauterized again Oct. 8th. On the 15th, the induration was entirely gone, and the ulcerated surface completely healed, but as purulent matter was seen issuing from the orifice, I introduced nearly an inch into the cervix, the solid nitrate of silver, and again on the 20th.— The menses appeared on the 24th, continuing for five days, and without pain, except just before their appearance. I then permitted her to resume her ordinary habits. Nov. 12th. On an examination with the speculum, and by the touch, no appearance of disease was discovered. The patient de- scribed herself as being perfectly well, and it was sufficient- ly evident that connubial harmony was restored. Dec. 15th. A speculum examination was made, as the patient had some symptoms which led her to fear that the disease was returning. An irregular erosion with some increased red- ness was visible on the anterior lip; the solid nitrate of sil- ver was applied, a temperance lecture was given to the hus- band, and the patient has had no occasion for medical aid since, except on one occasion, when the squalling of a fine baby was deemed delicious music by at least three persons, the parents and the accoucheur. Case II. The patient in this case was forty-two years of age, the mother of eight children, the youngest eight years old, since the birth of which she had never been preg- 24 nant. She was very pale, extremely emaciated, and years before, she had worn out the patience of every regular prac- titioner in the vicinity, since which she had tried every itinerant quack, and every patent medicine that she could hear of. I shall not attempt to give a history of the case as it was related to me, as it was the most tedious that I was ever compelled to hear, she seeming to fear all the time that I should not attach sufficient importance to every ache and ail she had suffered since her childhood. Among other complaints, according to her opinion, she had " two con- sumptions," "liver complaint," "the gravel awfully," and "falling of the womb." She asserted, that many years, she had had a constant leucorrheal discharge, but that she had been "flowing" every day for the last five months, which statement was confirmed by her husband's sister, who was present. The discharge had never been fetid. On a digital examination, the ulcerated surface was distinct- ly felt, the anterior lip seeming shorter than the posterior, indurated and voluminous. The touch was not painful, and the uterus was perfectly movable. On introducing the speculum, it was half filled with a blody, sanious discharge, on removing which, a fungous ulceration was distinctly vis- ible, completely lining the field of the speculum. On va- rying ihe direction of the speculum, so as to bring into view the other parts of the cervix, about one-third only of the posterior lip was found free from ulceration. The diagno- sis was extremely doubtful in my mind, whether it was a corroding ulcer, an ulcerated cancer, or an inflammatory ulceration. It was impossible for me to decide satisfactorily whether the increased size of the cervix was due to engorgement or to morbid deposition^ the part. But the uterus was mova- ble, and the discharge had never been fetid, two facts op- 25 posed to the idea of carcinomatous ulceration, and the fun- gous granulations appeared too large for corroding ulcer. On suggesting, with a good deal of hesitation, that there was a bare possibility that some benefit might accrue from cauterizing with a hot iron, to my utter astonishment, she at once insisted it should be done, evidently from a morbid desire for sympathy on account of being the subject of such a terrific operation. Not to weary you with a minute de- tail of the case, I will say in general terms that the cervix was cauterized with the hot iron three times, and with the nitrate of silver twice, the intervals between each cauteriz- ation varying from eight days to three weeks, and that a perfect cure was the result. It is now more than a year since she lias had any uterine discharge, either sanguineous or leucorrheal, and her general health is now excellent. A little of the old spirit however remains, as the last time I saw her, some two months sinee, she was *rery much afraid that her flesh was bloat and her color hectic. Cask III. I shall reflate in very brief terms this case, solely for the purpose of showing how easy it is to be mis- taken, and of enforcing the importance of caution in prog- nosis. The patient was pale, feeble and emaciated from a menorrhagia of three years standing. It had been several times arrested for a short period, only to mem again with increased violence. She was the mother of three children, the youngest six years old, since the binh of which she had never conceived. The slightest exertion, as going up stairs or riding in an easy carriage, woti'ld frequently bring on a sudden and profuse discharge of blood. I will do myself the justice to say, that in the outset I suspected a polypus, but on making a most careful examination. I found nothing to confirm my suspicion. The cervix was moderately ten- der to the touch, the orifice open, admitting the ungueall 26 portion of the finger, with apparently a very superficial in- duration of the anterior lip. The vaginal portion of the cervix seemed to me full two inches in length, but not en- larged to any considerable extent. From the result of this examination and a full history of the case, I was induced to urge upon my patient a specular examination, which she with some reluctance consented to. On discovering a su- perficial ulceration of some extent, involving both lips of the cervix, I was stupid enough to promise a very speedy cure. The ulceration was soon cured, but not so the ute- rine hemorrhage. This continued, although not the slight- est disease of the cervix could be discovered by repeated and careful examination both by the touch and with the speculum. Every known remedy was resorted to, with but yery little benefit, until at last I lost all confidence in my- self, and plainly told my patient so. She became subject to repeated attacks of hemorrhage from the nose, and her general health was fast breaking up. Thus the case went on, for nearly four months, when in October last, I read an article by Dr. Bennet, in the London Lancet for August, 1847, on ulceration of the cervix uteri, accompanying ute* rine polypi. Another specular examination was made, sep- arating the lips of the cervix with the speculum forceps, so that a portion of the cavity of the cervix was distinctly vis* ible, but nothing could be detected indicating the existence of a polypus. On attempting to examine with a probe, so much hemorrhage came on that I was obliged to desist from farther exploration. She was so much exhausted by this examination that she kept her bed for a week, and three weeks were allowed to pass before she was again subjected to another examination. At this time a sponge tent was introduced into the cervix, and retained in its place by fill- nig the vagina with old linen, and this was allowed to re* 27 main, she keeping her bed for two days. The last day she suffered from pains which she described as being exactly like labor pains, only more severe than she had ever expe- rienced. On removing the tampon and sponge, a profuse discharge of blood took place, obliging me to wait nearly two hours before I judged it proper to proceed farther. On introducing the speculum, and separating the lips of the cervix, the cavity of which was a good deal dilated by the sponge, the cause of all her trouble was apparent, although imperfectly so from the constant oosing of blood. With a good deal of difficulty I succeeded in twisting and pulling off with the forceps, the polypus which I now exhibit to you. Symptoms of acute metritis, requiring active treat- ment for a few days, came on directly after the operation, followed again by ulceration of the cervix, which yielded readily to cauterization with the nitrate of silver. Her restoration to health was slow but complete. It was my intention to have added a few observations on some of the functional disorders which occur so frequently, as symptoms of the diseases which we have been consider- ing, but I have already taxed your patience too severely.— Allow me in conclusion to state my conviction that a large majority of the cases of prolapsus, dysmenorrhea, menor- rhagia, and leucorrhea, which the medical man is called up- on to treat, arises from organic disease of the cervix uteri. Dr. William C. Roberts,' in by far the very best paper I have read on the subject of leucorrhea, (New York Journal of Medicine for May and July, 1845.) demonstrates, most satisfactorily to my mind, that this is the true pathology of leucorrhea, and I have no doubt that future investiga- tions will establish the fact, that the other affections refer- red to above, are rarely idiopathic diseases.