The obstetric memoirs and contributions of James Y. Simpson
kf ?. n u r ■* '* -*'«<’ * * OBSTETRIC MEMOIRS AND CONTRIBUTIONS. • • ■ -V*- THE OBSTETRIC MEMOIRS AND CONTRIBUTIONS JAMES Y. SIMPSON, M.D. F.R.S.E. l'ROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF EDINHURGH. ETC. ETC. ETC. EDITED BY W. 0. PRIESTLEY, M.D., EDINBURGH, AND H.ORATIO R. STORER, M.D., VOLUME I. BOSTON, U.S. EDINBURGH: ADAM AND CHARLES BLACK, NORTH BRIDGE. MDCCCLV. ©binbnrgh : ^.lrintfb bu tf 3SI. <£(arlu TO DR. MAGNUS C. RETZIUS, PROFESSOR OF MIDWIFERY IN THE UNIVERSITY OF STOCKHOLM, PHYSICIAN TO THE ROYAL FAMILY OF SWEDEN, ETC. ETC. ETC. MY DEAR DR. RETZIUS, As I have reserved the right of dedicating these volumes, I beg to have the pleasure of inscribing the following pages to you. And pray accept of the offering as a slight tribute, on my part, to your profound professional acquirements — as a mark of my sincere esteem for your persons?! friendship — and as a small memento of the delightful weeks which we spent together in the summer of 1852. I feel deeply that I owe many apologies to you, and to my other professional brethren, for the publica- tion of the Memoirs and Contributions of which these volumes consist, in so unusual and crude a form. Believe me, no one can be more sincerely impressed with their great and numerous imperfections, than I VI DEDICATION. am myself. Most, if not all, of these Communications were, as you well know, written hurriedly and amid the incessant distractions of practice. If 1 had at- tempted to remodel, extend, and correct them, in the manner and to the amount which I have sometimes anxiously desired, they would, I fear, never have been published in a collected form. In this view, my friends and assistants, Dr. Priestley and Dr. Storer, were right, I believe, in urging the sheets through the press as rapidly as possible, after they had them- selves arranged and annotated them. And for the great care and toil which they have expended upon the task thus voluntarily assumed, I cannot possibly feel too grateful. Allow me to add, that I sometimes venture to look forward with hope and pleasure to the possibility of the renewal of our personal intercourse ; nor, though far separated from you, are you ever allowed to be long absent from my thoughts, for one merry face around my hearth — that of your little namesake — is ever reminding me and mine of your happy sojourn among us. — Believe me, with heartfelt regards, Ever faithfully yours, J. Y. SIMPSON. Edinburgh. 16 th April 1855. EDITORS’ PREFACE. The greater portion of tlie following pages lias appeared at various times in the British Journals of Medicine, as occasional contributions to Obstetric Pathology and Practice. The object of the Editors has been to present these to the Profession in a more readily available form, believing that such compilations have at least the merit of greatly facilitating the study of any special inquiry — an object of no slight importance to most Medical Men engaged in active practice. In reprinting Dr. Simpson’s Obstetric Memoirs and Essays, the Editors moreover believe that they will be the means of supplying many of his former pupils with papers they have vainly striven to possess themselves of, inasmuch as they were published originally in journals which are now out of print. Most of the Contributions thus scattered over many years and Vlll editors’ preface. many volumes, while they do honour to the literature of the Profession, bear the impress of an almost unlimited practical knowledge and experience. The evidence of the latter appears to us especially to enhance their value, and it seems but justice to Dr. Simpson’s acknowledged reputation as an Obstetrician, that some more tangible and permanent form should be given to his works. Several of the Memoirs included in these volumes have been deemed of sufficient value, by our Conti- nental brethren, to be translated into their own languages, and many of them have likewise been reprinted in American journals. Besides those already published, the present volumes contain a number of entirely new contributions, and Dr. Simpson has him- self revised two or three of the older papers, which hence appear in an almost re-written form. We believe that Dr. Simpson, after repeated requests from his professional friends and pupils, has only been prevented from, himself, republishing these Essays and thus presenting them to the public in a more valu- able form, by an impression that one or more of them must necessarily be finished, and many others elabo- rated and re-written ; while the little leisure time at his disposal seemed entirely to preclude the accom- plishment of so much extra labour. We may, however, state that Dr. Simpson, after assenting to our request to allow these papers to be republished, has, whenever we needed it, given his cordial co-operation in our editorial labours; and that, editors’ preface. IX while he is not responsible for the appearance of these volumes in their present form, he has most kindly placed at our disposal such of his papers as we desired, and has at all times been willing to assist us in any difficulty which presented itself during the pre- paration of the work. The nature of the papers, from the mode of their original publication, was necessarily desultory, but we have endeavoured to arrange them in different parts, according as they seemed to belong, more espe- cially to the Diseases of Women, Natural and Morbid Parturition, &c. &c. We have thought it better so to classify, than to arrange them chronologically, in order to give the book a more systematic form, and to facilitate reference ; while it may thus be of more use to Students who are attending Dr. Simpson’s Midwifery Class. We have, at Dr. Simpson’s special request, en- deavoured to avoid as much as possible entering into the controversies which have occurred on more than one occasion — always in self defence on his part — on the subject of some of the Memoirs here republished, and we have only extracted from such correspondence those portions which seemed to throw light on the subject under discussion. Our object has been to re- present fairly the opinions of Dr. Simpson, written or spoken, on many important Obstetric matters ; and we would refer our readers who may desire to see the controversial correspondences (more especially those with Dis. Dee and Radford on Placenta Prsevia, and with Dr. Collins on Hospital Statistics, and the X editors’ preface. Effects of the Duration of Labour), to the Journals in which they were respectively published. It will be found, we believe, that we have given all of Dr. Simpson’s Obstetric writings, up to the pre- sent date (April 1855), with but a single exception. We refer to a series of short articles on some of the most common diseases of women, written many years ago for the Library of Medicine. These are regarded by Dr. Simpson as of little value ; and they would only have been a needless repetition of some of the pages in the first volume. Many will ask, as has already been done, why we have not also published in the present work Dr. Simpson’s more general Medical writings. Others will be surprised to learn, that a man not yet forty -four years of age, with such engrossing practice, and who has accomplished so much in his own peculiar field, should have yet found time for other subjects of thought. We subjoin a list of the more important of Dr. Simpson’s general Essays and Papers: — 1. “ The Contagiousness of Cholera.” Ed. Med. and Surg. Jour., April 1838. Also a Paper containing further evidence. (Read to the Medico-Chir. Society, Dec. 13, 1848.) Ed. Monthly Jour, of Med. Science, Feb. 1849. 2. “ Antiquarian Notices of Leprosy and Leper Hospitals in Scotland and England.” (Three papers read before Med. Chir. Society, March 3, 1841.) Ed. Med. and Surg. Journal, Oct. 1841, and Jan. and April 1842. editors’ preface. XI 3. “ The Conduct and Duties of Young Physicians.” Edinburgh Graduation Address, 1842. 4. “ Description of the Bones of the Distorted Foot of a Chinese Woman.” (Read before Med. Chir. Soc., 4th June 1845.) Northern Journal of Med. Aug. 1845. 5. “ Solutions of Gun Cotton, Gutta Percha, and Caoutchouc as dressings for wounds, &c.” (Read before Med. Chir. ►Society, May 1848.) Ed. Monthly Journal of Med. Sc., July 1848. 6. “Ancient Roman Medicine Stamps.” Three papers. Ed. Monthly Journal of Med. Sc., Jan., March, and April 1851. 7. “ Repudiation of Mesmerism.” Ed. Monthly Journ. of Med. Sc., May 1851, and Lancet, Sept. 1851. 8. “ Was the Roman Army provided with Medical Officers?” Printed and privately circulated, 1851. 9. “ Notes on some Ancient Greek Medical Vases for contain- ing Lykion ; and on the modern use of the same drug in India.” Ed. Monthly Journ. of Med. Sc., Jan. 1853. 10. “ Modern Advancement of Practical Medicine and Surgery.” (Inaugural Address as President of Med. Chir. Society, 5th Jan. 1853. Ed. Monthly Journ. of Med. Sc., April 1853. 1 1. “ Homoeopathy ; its Tenets and Tendencies.” Edinburgh, 1853. (3d Edition. Now out of print.) These would of themselves have formed a large volume. We could not, properly have embodied them X11 editors’ preface. with the papers we now present, to the collection and arrangement of which we have devoted several months. For valuable aid in procuring papers out of print, we are indebted to Drs. Malcolm and Wm. Ziegler, and to Messrs. Carmichael and Hunter Adam ; and for opportunities of consulting the MSS. Records of the Obstetric Society, we are under obligations to its Secretary, Dr. Keiller. 52 Queen Street, Edinburgh, 10 th April 1855. CONTENTS. ♦ PART I. SPECIAL PATHOLOGY OF THE UNIMPREGNATED FEMALE. Page General Remarks on Uterine Diagnosis .... 1 On the Position of the Patient for the Use of the Speculum . . 31 Memoir on the Uterine Sound ..... 33 Antiquity of Uterine Sounds and Pessaries ... 93 On the Use of the Exploring Needle .... 94 Anaesthesia as a means of Diagnosis ..... 96 Inflammatory Eruptions upon the Mucous Membrane of the Cervix Uteri 97 Medicated Pessaries ....... 98 Chloride of Zinc in Ulceration of the Cervix . . . 100 Potassa fusa in Inflammatory Induration of the Cervix Uteri . 101 Morbid Deviations of Involution of the Uterus . . . 103 Terminations and Treatment of Fibroid Tumours of the Uterus . 114 Artificial Removal of a large Uterine Fibrous Tumour . . 118 Diagnosis of Polypi growing from the Lips of the Cervix Uteri . 120 Detection and Treatment of Intra-Uterine Polypi . . . 122 (Note on Uterine Hemorrhoids.) Excision of large Pedunculated Uterine Polypi . . . 150 Amputation of the Cervix for  Uterus .... 226 Gout of the Uterus ....... 230 Fistulm as the Results of Pelvic Abscess .... 232 Position of the Patient for Tapping in Ovarian Dropsy . . 239 XIV CONTENTS. Page Plaster-belt in Abdominal Tumours .. - . . . 246 Inflammatory and Non inflammatory Ruptures of Ovarian Cysts . 247 Injections of Iodine into Ovarian Cysts  Dysmenorrhcea . . . 282 Dilatation and Incision of the- Cervix Uteri in Dysmenorrhcea . 288 Retention of Menstrual Secretion . . . . 292 Gallic Acid in Menorrhagia ...... 293 Direct Application of Remedies to the Cavity of the Uterus . . 295 Therapeutic Action of Furfurine, Nickel, &c. . . . 296 Spurious Pregnancy ....... 300 Fatal Venous Hemorrhage from Pudenda .... 305 Ball Valve Obstruction of the Rectum .... 306 Peritoneal Hydatids in Fluid removed by Tapping . . . 307 Eruptions on the Intestinal Mucous Membrane . . . 308 Therapeutic Action of the Salts of Cerium .... 312 Alleged Infecundity of Females born co-twin with Males . . 314 PART II. PHYSIOLOGY AND PATHOLOGY OF PREGNANCY. Duration of Human Pregnancy . . • • • 329 Appearance of the Areola as a Sign of Pregnancy . . . 345 Influence of the Death of the Foetus on its Retention or Expulsion . 346 Treatment of Hemorrhage in connection with Abortion . . 348 Inhalation of Laudanum for the Vomiting of Pregnancy . . 349 PART III. NATURAL AND MORBID PARTURITION. The Determining Cause of Parturition • Sound heard during Detachment and Expulsion of the Placenta Mechanism of Natural Labour • Laceration of Perineum and Cervix Uteri during Natural Labour . 367 Inefficiency of Uterine Action as a Cause of Tedious Labour CONTENTS. XV . Page “ Fulvis ad Partum ” of the First Edinburgh Pharmacopoeia . 378 Indian Hemp as an Oxytoxic . . . . 374 Influence of Galvanism on the Action of the Uterus . . . 375 Sex of Child as a Cause of Difficulty during Parturition . . 394 Irregularities of Head Presentations ..... 454 Treatment of Face Presentations ..... 482 Dystocia from Displacement of the Arm .... 488 Mode of Application of the Long Forceps .... 492 Tho Air Tractor ....... 498 Turning as a substitute for Craniotomy and the Long Forceps .  Pulse of Danger to the Child . . 627 Transverse Presentations ...... 628 Spontaneous Evolution or Expulsion of the Foetus . . . 645 Vaginal Hysterotomy in Obstruction from Carcinoma Uteri . . 648 Danger of Rupture of the Uterus from Hydrocephalus . . 653 Case of Malacosteon — Indications for Caesarean Section . . 656 On the Separation of the Placenta before  836 Report of Edinburgh Royal Maternity Hospital . . . 844 I. PART I. SPECIAL PATHOLOGY OF THE UNIHPREGHATED FEMALE. GENERAL REMARKS ON UTERINE DIAGNOSIS. (from EDINBURGH MONTHLY JOURNAL OF MEDICAL SCIENCE, FEBRUARY 1851, p. 155.) I shall begin these Lectures1 with the consideration of the • diagnosis of the diseases of the uterus and its appendages ; and it is the more necessary in this respect, that, in studying these affections, you enter upon a field of practice in which the means of diagnosis are peculiar in various respects, in consequence of the anatomical and other peculiarities of the organs themselves, the diseases of which it is our object to investigate. But you must permit me to make one or two preliminary remarks. And first of all, I would earnestly beg you to hold this important fact in view — namely, that the diseases of the uterus do not essentially differ, in their principles of pathology and treatment, from the diseases of other individual organs of the body. The uterus is liable, for example, to be the seat of con- gestion, inflammation, carcinoma, &c., like any other organ of the body which you can name. It may be, and certainly is, more liable than other organs to some morbid states and actions ; but what I wish to impress upon you is, that its diseases are 1 This lecture is the first of a series on Uterine Diagnosis, given annually by Dr. Simpson, when treating of the Diseases of Women. It is the only one of the course which he has published. — (Ed.) n 2 ON THE DIAGNOSIS OF THE DISEASES OF generically the same as the diseases of other organs ; and the general principles of their treatment are also the same, the special modifications of management which they require not being greater than the special modifications that must be attended to in apply- ing any general principles of cure to any other individual organ, or set of organs. You treat and cure, for example, an attack of acute inflammation of the uterus, or a chronic inflammatory ulcer of the cervix of the organ, as you would treat an acute inflam- mation or a chronic inflammatory ulcer of the cornea, or of the pharynx, or larynx, or of any other part of the body — with this difference, that you can apply local antiphlogistic and other cura- tive measures much more readily and easily to the uterus than to many other more internal organs. In fact, you may, if you deem it necessary, apply lotions and dressings to an ulcer, for example, of the cervix uteri, with as much certainty and precision as if you applied them to an ulcer on the external surface of the body; you can thus almost reduce the organ, in relation to treatment, to the facilities presented in treatment by an external as compared with an internal organ. Modern pathology has made great advances in the manage- ment of uterine diseases. These advances, however, have not, let me repeat, consisted so much in finding out that the uterus is the seat of any new, or any peculiar affections, as by finding out means and methods by which we can detect and diagnosti- cate the affections that are actually present in it. Here, as else- where, after being enabled to discover what its diseases really are, the chief difficulty of the physician is removed ; for, as I have stated to you, the same principles of treatment apply to the treatment of specific morbid actions in the uterus as apply to the treatment of the same specific morbid actions in other organs. Indeed, if you will attempt to analyse what the great progress in the medicine of modern times has actually consisted of, you will, I believe, find that it has consisted, not so much in the detection of any new principles of therapeutic treatment, as in the detection of appropriate means for enabling the practitioner to detect and discover in different individual organs what the actual diseased actions are, in those organs for which his aid may be required. The treatment, for instance, of inflammation, ulceia- tion, and most other morbid states, was perfectly well known and established hundreds of years ago ; but, to take our example from the uterus itself, it was not till of late years that we had THE UTERUS AND INTERNAL FEMALE ORGANS. 3 certain means and measures of knowing when inflammation and when ulceration, &c. &c., were present in this organ. The study and practice of medicine has confessedly made, within the last fifty years, enormous advances ; but these advances have been advances in pathology and diagnosis, much more than advances in therapeutics. And yet, what we still wish and desi- derate in actual practice are still greater advances in our diagnostic means ; or, to state the same circumstance in other words, at the hed-sides of our patients we find that it is in diagnostic means, and not in therapeutic resources, that our existing knowledge is most frequently deficient. Every medical man is constantly meeting with difficulties in practice, and would often gladly avail himself of an opportunity of resolving these difficulties by appealing to the judgment of some older and more experienced practitioner. Ask the medical practitioner what the nature of the difficulties is which he most frequently encounters in practice. If he will properly analyse the subject, he will confess to you that his difficulties most usually consist in exactly determining what the special disease, or diseased action, in his patient may be ; not in determining what he should employ for its cure, provided he were once perfectly certain of its precise nature, and precise seat and extent. The real difficulties of the practitioner do not commonly consist of doubts about the nature and details of the therapeutic measures which he ought to use ; but they consist of primary doubts and uncertainties as to what the diseased action is, against which he is to turn his diver- sified therapeutic resources. They are doubts, not about thera- peutics, but about diagnosis. Since the diseases of the uterus and its appendages have of late years attracted so much more the attention of the profession than they formerly did, one grievous error has been committed in their study and investigation. It is an error which has been committed often in the study and investigation of the diseases of other organs, before we arrived at a sufficiently full and sufficiently comprehensive view of the morbid affections of these organs. The error I allude to is the error of exclusiveness. Formerly many practitioners seemed to look upon all diseases of the uterus as diseases indicative of debility; and they treated almost everyone of them with miniate of iron and other chalybeate preparations ; sometimes adding, where there was any discharge, the local employment of astringent or tonic injections. I fear that even 4 ON THE DIAGNOSIS OF THE DISEASES OF yet you will find some old practitioners treating their uterine cases upon this sole principle. Then a second set of pathologists would, if we may judge from their writings, seem to suppose that all diseases of the uterus are marked by, if they do not consist of, congestion and engorgement of blood ; and that they are to be remedied by the remedies applicable to this state. A third set, again, look upon the general run of uterine cases as almost invariably inflammatory in their nature, and imagine that we are sure, or almost sure, to find in every case inflammation, or some of its results ; as ulceration, purulent discharges, &c. A fourth set would seem to fancy all uterine ailments to be produced by some mechanical displacement or dislocation of the uterus, and to consist of prolapsus, versions, and flexions of this organ upon itself, and upon the neighbouring parts. Again, there are some practitioners — one, in particular, in immense practice in America — who would appear to believe that the affections of the uterus are fundamentally nervous or neuralgic disorders, and that they are always to be treated by the local inunction upon the cervix uteri, of morphia, aconite, and similar sedatives. Another section of pathologists imagine the so-called uterine diseases are, after all, not uterine, but ovarian ; and that ovarian irritation and inflam- mation is actually the source and origin of much of the suffering that is imagined to be uterine in its seat. All of these views are correct in one respect, that they are all founded partially, though only very partially, upon truth. For, no doubt, the uterus is in practice seen to be liable to one and to all of these morbid states. Thus it is liable to congestion, to inflammation and its consequences, to displacement, to neu- ralgia, &c. ; and the ovary is liable also to ovaritis, &c. But all these opinions are excessively unsound and excessively wrong in another point of view, viz., from their having been in practice pushed by those who have adopted them, to such an extreme and exclusive length, as to amount in some instances to a practical THE UTERUS AND INTERNAL FEMALE ORGANS. fallacy and a practical error of the greatest possible magnitude. It shall be my earnest endeavour to prove to you that in relation to the uterine, as in relation to other organs, all such extreme and exclusive views are ever erroneous views. The diseases of the uterus are not always of one kind and of one character; they are of many different kinds and different characters, and require in consequence many different modes of treatment; and we should place ourselves under the most foolish and fatal fallacy, if we supposed that there was only one series of morbid actions liable to go on in the uterus and its appendages, and only one method of treatment applicable to all their diseased states. N o doubt all such errors in pathology and practice as I have just now adverted to, will gradually die away, as medical men become more intimately acquainted with uterine affections, with their pathology and treatment, and above all, as they become more intimate with the proper means of making a diagnosis of the affections of the internal reproductive organs in the human female. Certainly such errors will he best corrected in each of you, by each of you studying earnestly and carefully the means of diagnosticating the different morbid states and morbid actions to which these organs are subject. And, as I have already men- tioned, it is my main object at present to point out to you by what different means the diagnosis of uterine and ovarian diseases may be effected, and to state to you the general principles of diagnosis which we can apply to their detection and discrimination. In doing so, I shall enter into no historical details; the knowledge I wish to impart to you is that kind of practical knowledge which we constantly require to use and apply at the bed-side, and which we must be able to employ in the daily and hourly exercise of our profession. In attempting to make a diagnosis of the diseases of the uterus and its appendages, as in attempting to make a diagnosis of the diseases of most internal organs, the physician calls in to his aid two sets of symptoms, viz. first, the Rational, Dynamic, or Func- tional Symptoms, as they have been termed ; and secondly, the Physical or Anatomical Signs and Symptoms. Let us first note the very marked and important difference which exists between these two sets of diagnostic phenomena — since we thus may have the 6 ON THE DIAGNOSIS OF TIIE DISEASES OF SYMPTOMS OF UTERINE DISEASE, EITHER 1. DYNAMIC, OR 2. PHYSICAL. Under the Dynamic, Rational, or Functional Symptoms are included all those lesions, deviations, or derangements in the functions of the affected organ, in the functions of other organs that sympathise with it, and in the functions and state of the system generally, that can possibly be excited by the disease or diseases that we may happen to be investigating. On the other hand, the Physical Signs or Symptoms consist of those means of diagnosis, and particularly of those exercises of the senses of touch, sight, hearing, &c., by which we can attain a knowledge of the anatomical structure, form, density, colour, position, &c. &c., of the organ which is diseased. By this latter set of symptoms or signs — the Physical — we attempt, in fact, to read and discover within the living body the actual morbid anatomy of the organ or organs that are affected. We endeavour by them to study and to ascertain, as exactly as pos- sible, upon the living patient, those anatomical lesions and changes which we should expect to detect on the post-mortem examination of that patient, provided the disease proved fatal. In detecting and diagnosticating the diseases of the different organs and parts of the body, the practical medical man has recourse sometimes more to one of these sets of symptoms, some- times more to the other. A diagnosis always becomes more and more accurate, the more we can conjoin both means of investigation, and draw our deductions from both sources of evi- dence. Of the two sets, the rational or functional symptoms are the least to be depended upon 5 or, at all events, our diagnosis is always the less accurate, the less we can take advantage of the physical or anatomical signs. Surgical diagnosis is, as a whole, more accurate than medical diagnosis. But why is the surgeon more accurate in the discri- mination of the affections which he treats than the physician ? Merely because he can, and does, found his diagnostic deductions far more upon physical symptoms ; while the physician is of necessity driven to depend more upon the rational or dynamic symptoms. In fact, in making a diagnosis of the diseases sub- mitted to his care, viz., those placed upon the external surface of the body, the surgeon relies almost entirely upon physical THE UTERUS AND INTERNAL FEMALE ORGANS. 7 diagnosis alone, because he can handle and examine the diseased parts by direct tactile examination, and by direct visual inspec- tion. Deprive a surgeon of these means of physical diagnosis, and throw him back merely upon the functional or dynamic symptoms that may be present, without allowing him to exercise his sense of touch, or sight, or hearing, in the discrimination of the cases submitted to him, and you will find him as much or more at fault than the physician sometimes is. Take, for example, a case of any disease of the eye, leading on to imperfection and dimness of sight. No surgeon would venture to make a decided diagnosis of what that dimness or blindness was produced by, provided he were allowed to appeal to the dynamic or functional symptoms only. He might be told fully as to the mode and manner in which the blindness came on, as to its varieties under different circumstances, as to its being accompanied or not with pain or lachrymation, &c. &c. ; but these and other circumstances would often be inadequate to enable him to decide whether the imperfection of vision arose from an affection of the cornea, or of the iris, or of the lens, or of the retina, or of some other parts ; or by what particular affection of these parts it wras pro- duced ; while an inspection of the diseased eye itself by the sur- geon— that is to say, a glance at the physical symptoms or physical diagnosis — would probably enable him to resolve at once all these difficulties, and to ascertain determinately and unequivocally what the diseased state of the organ really was. It is very different with the physician, in reference at least to some classes of affections. For in some he cannot avail him- self of any of these measures of physical diagnosis which the surgeon finds to be so absolutely necessary to enable him to come to a correct decision in surgical cases. In affections, for example, of the brain and spinal cord, and of their membranes and component parts, the physician can, with a few rare excep- tions, make use only, in his diagnosis, of the dynamic or functional symptoms. It is only these symptoms that he can reach in this class of diseases. For we have no means as yet, and, in all probability, will never have any, in this special class of affections, of ascertaining, in the yet living subject, what the special anato- mical lesions are, that may be present in the encephalon or in the spinal canal. We cannot reach and search these cavities and their contents by any modification of hearing, or touch, or sight. We can ascertain the morbid derangements that may 8 ON THE DIAGNOSIS OF THE DISEASES OF take place in them only by studying the changes and derange- ment ol function to which their presence gives rise in the nervous system generally, in the different parts of this system, and in the functions of those organs which are liable to be more directly or indirectly influenced by that system. In other classes of disease, the physician, however, has for- tunately the power of appealing to physical signs as well as to rational symptoms. He can derive his deductions of the diseased states of the organs themselves from both classes of proof ; and you will always find that in medicine our practical knowledge of these diseases has progressed proportionally with the amount and extent to which physical diagnosis has been applied in their discrimination. There is no set of organs, for example, the pathology and practical knowledge of which has advanced more in modern times than that of the organs contained within the chest. If you look into any work on the affections of the heart or lungs, written thirty or forty years ago, you will find a strange contrast between its contents and those of any modem work written on the same subject. Formerly, physicians were often in error in regard to their cases, as to what this or that thoracic affec- tion might be ; and their true nature was often only accurately detected after death. The modern physician has almost always the power of discovering what the affections of the heart and lungs are, even during the life of the patient; and can trace, usually with great accuracy, their morbid anatomy while the patient is still alive. Mark what this difference between thoracic medicine, thirty or forty years ago, and that department of medi- cine now, is to be attributed to. It is entirely attributable to the fact, that while in former times physicians were obliged and neces- sitated to attempt the diagnosis of these diseases by functional symptoms only, they have now the power of aiding and correcting that method of diagnosis by ascertaining a series of physical signs appertaining to almost every disease of the heart and lungs, through the instrumentality of auscultation and percussion. No careful or judicious physician depends now for the diagnosis ol these chest affections upon functional symptoms only ; but he appeals constantly, in aid of his diagnosis, to the more certain signs which may be derived from the pleximeter and the stethoscope. I might safely repeat the same remark, and with nearly exactly the same degree of truth, with regard to the affections of the uterus and internal female organs. Formerly, and even in our THE UTERUS ANI) INTERNAL FEMALE ORGANS. 9 own days still far too frequently, the physician has been led to suppose that he could make a diagnosis of diseases of the uterus by depending and relying upon functional symptoms only. A little practice will, however, I believe, readily convince you, that in most cases we are necessitated to have recourse to a phy- sical diagnosis in order to obtain anything like an accurate know- ledge of the diseases under which our patients are labouring. Do not suppose that, in making this remark, I mean to imply that the functional symptoms are of no value. Nothing could be farther from my belief and conviction. I by no means wish to state that they are of no value ; all I mean to state is, that they are not of sufficient value to make a sufficient distinction between the different individual or special diseases of the uterus and uterine appendages. And now, having made these too diffuse introductory remarks, let me call your attention to what the functional and what the physical symptoms of the diseases of the uterus and ovaries really eonsist of. And first, let us consider THE RATIONAL OR DYNAMIC SYMPTOMS OF UTERINE DISEASE. The uterus performs at different times different functions. During menstruation its lining membrane forms and exudes the so-called menstrual fluid. In the intervals between menstruation we have merely a mucous secretion flowing from the same tissue. And again, it performs from time to time a variety of important functions connected with conception and pregnancy. Under different states of disease, one or more or all of these functions may become perverted. In other words, the first division of dynamical symptoms liable to occur in uterine disease consists of — I. Derangements in the Functions and vital Condition of the Uterus itself. — Thus the function of menstruation may become irregular in regard to the time of its occurrence, or the duration of its appearance ; — or the quantity of the menstrual fluid which is thrown oft’; — or the nature of that fluid may vary ; and it may or it may not be accompanied by pain and suffering ; — and pain, if present, may be constant, or it may be spasmodic or paroxysmal. The mucous secretion may be increased or diminished in its quantity or quality, or it may become occasion- ally or constantly mixed with blood or pus. The function of 10 ON THE DIAGNOSIS OF THE DISEASES OF conception may be interfered with, so that sterility is the result ; or the uterus may not have the power of carrying the foetus beyond the second, fourth, or sixth month, the patient being sub- jected to a series of abortions or premature labours. The natural states of sensation of the uterus and its appen- dages may also be altered and perverted. They may be decreased, but this is rare. Far more frequently they are increased to a degree amounting to actual pain ; and the pain may appear under very different modifications. It may be continuous or intermit- tent ; it may be dull and aching, or pulsative, or lancinating, and extremely severe. Often when it is present, it is accompanied with a feeling of heat and tension ; and far more frequently still, with a feeling of weight and bearing down. Almost all these pains, resulting from diseases of the uterus, or its appendages, are diminished by the reclining position, and increased by two circumstances, — by a long continuance in the erect posture, and by the active and congested state of the organs, which accom- panies the secretion and elimination of the catamenial discharge. Most of the so-called local pains of the uterus are not situated in the position of the uterus itself, or at least in the central part of the pelvis ; but the patient more frequently complains of them as located in one or other of the sides of the pelvis ; most generally in the left side, in consequence, no doubt, of the left side of the uterus and left broad ligament and ovary being more liable to be irritated than the right, by the varying condition of the rectum, which enters the pelvis towards the left ; and the distensions and accumulations in this portion of the intestinal canal are certainly often the more immediate exciting causes of uterine and pelvic pains, if the uterus and its appendages are tender and predisposed to suffer pain, in consequence of any diseased condition existing in them. At present it would be out of place for me to dwell upon the irregularities and deviations which we meet with in practice, in these functional symptoms of the uterus in uterine diseases gene- rally, and in different cases of the same disease. But let me make this one remark as a caution to you, I shall insist upon it more afterwards, viz., that identically the same pathological affection does not always affect identically in the same way the functions of the uterus. You may have, for instance, fibrous tumours in the walls of the uterus, one of the most frequent organic diseases in this organ, producing, as local functional symptoms, THE UTERUS AND INTERNAL FEMALE ORGANS. 11 increased menstruation, or menorrhagia ; — increased mucous secre- tion, or leucorrhcea ; — pain during menstruation, or dysmenor- rhoea ; and, in the intervals between the menstruations, constant uterine pains and bearing down, and irritation of the bladder and surrounding parts. But in other cases of exactly the same organic disease, more or fewer, or indeed all of these symptoms, may he entirely wanting. Anatomists tell us that the cerebro-spinal nerves which come to the uterus are principally distributed to the cervix uteri ; — and hence it has been considered by some pathologists, that the dis- eases of this part of the organ ought to be accompanied with pain, although the maladies of the body and fundus of the organ may not necessarily give rise to this symptom. But the results of practice by no means bear out this theory. The two most common affections of the cervix uteri are, — 1. Chronic inflammation and its consequences — hypertrophy, ulceration, &c.; and, 2. Carci- noma of this part. In practice, cases of both of these diseases from time to time occur, in which, though the disease has pro- gressed far, yet the patient has not been made aware of its pre- sence by any increased tenderness or pain in the part sufficient, at least, to attract her attention ; and it is frequently very difficult to persuade the patient — nay, sometimes difficult to persuade the me- dical attendant — that such serious affections are present, because they incorrectly believe and argue that such affections could not exist without the accompaniments of local pain and suffering. II. Dynamic Symptoms in other neighbouring Pelvic Organs. — Dynamic symptoms often exist, in connection with uterine disease, not in the uterus or its appendages, but in the parts and organs in their more immediate vicinity. There may be pains, for example, about the bladder or rectum ; about the coccyx or sacrum ; in the groins ; or along the crest of the ilium, and, what is exceedingly frequent, down the limbs, along the course of the crural or sciatic nerves. Pains running from the lower lumbar region, or from the groins, down along the limbs, are felt, and often felt severely, by females even during common menstruation ; and intermittent pains in the lower part of the abdomen, or uterine colics, as they have been termed, are com- mon under the same circumstances, as well as in different varieties of morbid uterine irritation. The functions of the rectum or bladder may be interfered with. Defecation may be difficult or 12 ON THE DIAGNOSIS OF THE DISEASES OF painful. Often in uterine diseases there is constipation ; and sometimes a want of power to expel the feculent matter, as if there was a kind of paralysis of the rectum ; this last occurs not unfrequently in cases of retroversion of the unimpregnated uterus. In many cases the functions of the bladder are more or less affected. Micturition may he too frequent — a symptom that is common to many uterine diseases ; or there may be great dysuria, as is often seen in cases of pelvic cellulitis, &c. ; or there may he complete retention, as from the pressure of Uterine tumours ; or the result may be incontinence and impossibility of retaining the urine. These various pelvic symptoms are, in some instances, mecha- nical in their pathology ; in other instances they are sympathetic results. In other words, they are occasionally the direct result of the physical pressure of the enlarged or displaced uterus upon the rectum, or bladder, or trunks of the affected nerves. But, again, they may be present, and equally strongly marked, although the uterus is not unnatural in size, or unnatural in position ; and, consequently, when the origin of these symptoms cannot be mechanical. In these last instances, and perhaps they are the more numerous class, we speak of the resulting disturbances of function and increased sensations, as sympathetic or reflex — that is, as originating in an irritation primarily seated in the uterus and uterine nerves, but terminating and felt, secondarily, in the sensitive nerves of those other neighbouring parts which are affected. This last remark leads me next to show you, that, in diseases of the uterus and its appendages, we have often the prin- cipal pains and sufferings of the patient not located in the uterus or in the pelvis itself, but located in other parts of the body ; or we have a third series of dynamic symptoms, consisting of — III. Sympathetic Pains in different and distant parts of the Body. — This important class of reflex sympathetic pains or neuralgias is often so marked and severe as to draw away the attention of the patient, and even of the practitioner, from the real nature and seat of the original and primary malady. Of late years, much important physiological and pathological information has been laid before the profession regarding what are termed reflex motions. ^ ou are all well acquainted with the nature and mechanism of the motions that are designated by THE UTERUS AND INTERNAL FEMALE ORGANS. 