dence, and the patient suffered from slight fever at night, followed by perspirations. The case was said to be one of phlegmonous congestion and incipient suppuration in the broad ligament. Leeches and tepid baths, poultices, and enemata were prescribed. A few days afterwards, the patient being better, another examination was made, but in this instance, by the vagina and by the rectum simultaneously, which had not been done previously. It then became

evident that the womb was not to be felt in its right place; and that it had been diverted to the left side, thus simulating a tumour of the broad ligament. The patient recovered from this attack of pelvi-peritonitis, but the deflection of the womb remained, on account of the firm adhesions which bound it down, and for a long time walking was painful.

I took the minutes of the following case in Dr. Rayer's ward at La Charité, in Paris, and adduce it, to show, that if the double-touch had been performed, the tumour, without doubt, would have been detected, and the patient's life, in all probability, would have been saved.

CASE 3.-A woman, aged forty-five, had been long suffering from some undefined abdominal complaint before entering La Charité, on February 15th, 1848. The abdomen was uniformly enlarged, and tender when pressed; there was also retention of urine; and on introducing the catheter the instrument took a perpendicular direction against the pubes, and only a few ounces of urine were voided, though, on percussion, the bladder still sounded as if full. The male catheter was then substituted for the female, and Dr. Blanche, with some trouble, and by exercising a moderate degree of force, penetrated into a second portion of the bladder, and evacuated from two to three pints of urine, which operation was daily performed, with the same difficulties. All this was esteemed by Dr. Caseau to be the result of an ovarian tumour; in Professor Velpeau's opinion, it was caused by an uterine tumour; but Dr. Rayer prudently forbore giving any diagnosis. The patient lingered for several days with increased abdominal pain, fever, weakness, and then died. There was general peritonitis, with considerable effusion, the bladder was enlarged, and presented traces of chronic inflammation, and a few gangrenous spots; the uterus and ovaries were without adhesion.

To explain the peculiarity of the patient's symptoms, a globular tumour, about the size of a cocoa-nut, was found between the bladder and the rectum. The walls of the tumour were very thin, firm, and fibrous; it contained a yellow fluid of the colour and fluidity of ordinary urine. This tumour had pressed on the bladder against the pubes, and so divided it into two cavities, that on sounding the woman it was not difficult to penetrate into the smaller cavity, but it required great force and a longer instrument to enter the second portion. The woman had been carefully examined by some of the most eminent men in Paris, yet the explorations per rectum and per vaginam separately did not lead to the detection of the tumour, perhaps on account of its uniform elasticity; but had the double-touch been put in practice, the tumour would have been detected before the supervention of general peritonitis, and the patient's life might have been prolonged. I may remark, that if the patient had fallen into inexperienced hands, force might have been employed in the usual direction of the female urethra, the cyst would have been perforated, its contents evacuated, and looked upon as urine. One of two things would then have occurred-the inflammation of the cyst, as a consequence of the ingress of urine to its cavity, and ultimate death; or adhesive inflammation might have taken place, and the patient have been cured without the nature of her complaint being ascertained. A case of an ovarian cyst was cured by Professor Bennett, of Edinburgh, after the emptying of its contents through the bladder, and Mr. Curling has published another.

OCULAR EXAMINATION OF THE WOMB.

The practical turn of the Roman mind may to a certain extent explain the finding of a speculum-uteri amongst other surgical instruments at Herculaneum. Judging by the following extract from Morgagni's forty-sixth letter, some kind of ocular examination of the womb was occasionally made in the seventeenth century. Refuting Naboth's assertion that the structure of the os-uteri is as difficult to make out as the diseased state of the ovula themselves, Morgagni observes that " he ought to have known that every day skilful

surgeons investigate the state of the neck of the womb, when the patient is in the erect posture, and when the patient is placed in the posture which is necessary for the introduction of the speculum uteri, the orifice of the womb can be seen. I have even more than once seen this orifice, when the vagina was short, without using the speculum, but by means of an ivory or glass tube, of sufficient length and diameter to permit the free ingress of light." From which it may be inferred, that the speculum uteri was some old complicated machine, and that the glass tube resembled what is now called Fergusson's speculum, without its reflecting power. When the speculum was, as it were, discovered by Recamier, its novelty was not contested by Boyer, Chaussier, or Dupuytren, who, actuated by a true conservative spirit, at first opposed it. I shall refer the reader to Dr. Bennet's and other classic works for an account of all the specula that have been invented, as well as for other valuable information upon the subject. Each writer praises some particular instrument-Dr. Bennet prefers Jobert's bivalvular, Scanzoni, Fergusson's; Becquerel, one invented by Mdme. Boivin, consisting of three valves laterally articulated. All these different kinds are useful to those who see much of uterine practice. Jobert's bivalvular speculum is indispensable to well separate the lips of the os-uteri, so as to see as far as possible into the cervix; but a beginner will find himself lamentably at a loss to discover more than a fold of the vagina on first attempting to use this instrument, and for the majority of cases Coxeter's bivalvular is perhaps the best speculum. With this instrument, or Fergusson's, nothing is easier, when the womb is well placed, than to discover its orifice, and to fix the vaginal portion of the cervix between the valves of the instrument, but when the womb is anteverted or retroverted, as it often is in cases of long-protracted uterine disease, the practitioner will frequently find it most difficult to reach the osuteri, and to place it so as to render it amenable to surgical applications.

Injections, repose, and other treatment, often so improve the position of the womb as to permit the os-uteri to be brought in view, but this will be sometimes found extremely difficult. I almost always place the patient on her back,

because it incontestably affords the best view of the reproductive organs. I cannot understand the objections raised in this country against this mode of examination, for, by throwing a cloth over each lower limb, it is attended by less uncovering of the patient, and does not hurt her feelings more than lying on her side. In introducing the speculum it is well to press it, gently but firmly, against the rectum, so as to avoid a thick, sensitive, transversal fold of the vagina near the vulva, for should the speculum hitch upon this it may cause bleeding, and give unnecessary pain. In different cases, one mode of exploration will be more advantageous than another. Compared with the finger, the speculum is of little use to decide whether organic disease of the womb be inflammatory or cancerous, but in many inflammatory affections of the womb the finger only reports chronic inflammation, without informing one whether caustics are required to cure the patient; information which can only be acquired by the use of the speculum. It is not, however, a question of choice between several modes of investigation; we want them all, and have none to spare.

PART I.

PHYSIOLOGY AND DISEASES OF MENSTRUATION.

66

CHAPTER I.

NATURAL HISTORY OF MENSTRUATION.

Cujusque morbi tanta est magnitudo, quantum a naturali statu recedit, quantum vero recedat is solus novit, qui naturalem abitum adamussim tenuerit."-GALEN.

DEFINITION.-Menstruation is an ovarian nisus, manifested by nervous symptoms, relieved by critical discharges, principally from the internal surface of the womb, and recurring according to a monthly type, during the reproductive period of the lifetime of woman.

Besides experimental researches on the remote causes of menstruation, the subject may be studied like any other natural phenomenon. This has been partially done by numerous authors, and in a very satisfactory manner by my friend M. Brierre de Boismont. I have also devoted much time to this inquiry, and shall detail some of the results I have obtained in the following portion of this work. I shall first point out the law and rule of each of the phenomena of menstruation, and then follow out the deviations from the rule during the whole extent of that period of life which is bounded by the first and last menstruation, thus connecting physiology with pathology in accordance with the intricate union of the two in diseases of women; and although the utility of treating the subject in this systematic manner does not seem, as yet, to have struck other observers, the plan will be found replete with interesting and practical results.

The following table will show how each symptom of menstruation may be perverted, so as to assume the character of disease:

D