college. The following is the history of the case, as drawn up by Dr. Yardley himself, who allows me to publish it here.

CASE. "Mrs. N became my patient in the spring of 1840. I visited her on account of a diarrhoea, which had continued for some time, and which was attended with distressing pain in the left side.

"A regulated diet, saline frictions of the skin, which was cold and dry, together with small doses of mass. hydrargyri, opium, and ipecacuanha, soon cured the diarrhoea; but as the pain in the side and other symptoms of disease still continued, I was induced to investigate the case more fully. I then learned that since her marriage, about three years previously, she had had two attacks of uterine hemorrhage, which were pronounced by her physician to be abortions, though nothing like an ovum had ever been detected, and he had never examined the state of the uterus.

"The first attack came on on New Year's day, 1838, after taking a very long walk, and though the hemorrhage was not profuse, it was attended by such excruciating pain in the side on being moved that it was necessary to bring her bed into the parlor, where she remained several weeks. The hemorrhage and pain gradually subsided, and by the 1st of June she appeared to have regained her usual health.

"The second attack took place April 12th, 1839, and came on suddenly when making some unusual exertion while engaged at her toilet. The pain was so severe as to cause fainting, and was attended by vomiting, diarrhoea, retention of urine, tenesmus, severe bearingdown efforts, and slight uterine hemorrhage. These symptoms were mitigated by general treatment, without resorting to the catheter, or making a vaginal examination. She was confined to her chamber nearly three months under this attack, and was still suffering from its effects when I was consulted in her case. Her menses were irregular; her bowels frequently disordered; she was unable to take her accustomed exercise on account of a bearing down pain and distress in the pelvic region, which was increased by exertion of any kind. Her husband informed me that since her last attack, she had always suffered severely from sexual intercourse.

"I considered these symptoms sufficiently indicative of disease or displacement of the uterus to call for an examination of the state of the parts. I found the uterus low in the pelvis, hot and swollen, and so sensitive as to preclude further exploration. Rest in a recumbent position, bleeding, cupping over the sacrum, and general antiphlogistic treatment, in ten days produced so much relief that the patient declared. herself better than she had been for more than a year. I then made

a second examination, and found the engorgement, heat, and tenderness much diminished; but there was considerable prolapsus, and the uterus and vagina were morbidly sensitive.

"I was desirous that the patient should remain longer in the recumbent position, but the weather being warm, and confinement very irksome, I introduced a gilt-ring pessary, and sent her into the country.

“Mrs. N———————— returned about the middle of September. She informed me that for three weeks after the introduction of the pessary, she felt unusually well; she was able to stand and walk without suffering, and the distress in the pelvic region was much mitigated; but about that time, when using considerable exertion, she felt the instrument move, and it continued to trouble her until it came away. After the displacement of the instrument, her old symptoms returned, though for a time she was better than before its introduction.

"After keeping the patient quiet a few days, I made another examination; all morbid sensibility of the parts had now subsided, so as to admit of a full exploration, and, for the first time, I detected in the hollow of the sacrum a round, hard body, with a deep indentation between it and the lower part of the neck of the uterus.

"It was difficult to decide whether this was a tumor, or the fundus of the uterus bent down in that position; but after a careful examina tion, I was disposed to regard it as the latter, though it was much lower and more prominent than I should have expected from the situation of the os tince, which was not more anterior than is usual in simple prolapsus of an equal degree.

"After pressing up the uterus as far as I could, I introduced a giltglobe pessary under the fundus, hoping it would gradually restore the organ to its proper position, and that, if it came away, the patient could replace it herself, which was important, as these repeated examin ations were very disagreeable to her.

"The globe pessary was retained but a short time, and as it caused considerable pain and uneasiness during its retention, the patient was unwilling to have it again introduced.

"At the suggestion of Professor Horner, of the University of Pennsylvania, I next placed the patient on her knees in the bed, with her head and shoulders as low as possible, and introduced an instrument into the rectum, under the fundus of the uterus, and, by that means, assisted by its own gravitation, endeavored to dislodge it from its position. In this manner, I succeeded in pressing the uterus up much higher than before, and after again introducing a ring pessary, requested the patient to remain quiet for a few days. This ring kept

I

its position two weeks, and was productive of much relief; but it then came away, and the unpleasant symptoms returned.

"This process of pressing up the uterus, and introducing a pessary, was repeated several times; and it was found that a ring pessary was the only kind that was of any advantage, for, while a ring retained its proper position, the patient was comparatively comfortable. This relief, from the use of a ring pessary, appears remarkable, when, after death, it was discovered in what manner the uterus was bound down to the rectum; there is, however, no doubt of the fact, and it may be explained, by supposing that the anterior wall of the rectum was pressed forward and upward, or the adhesions stretched.

"The difficulty of retaining the ring in its proper position, however, seemed to increase; rings of silver gilt, glass rings, ivory rings, rings of hard wood, such as ebony and lignum vitæ, and rings of gum elastic, were all tried, but the gilt rings were found much the best.

"Discouraged by my want of success in the treatment of the case, I sought further counsel, and Professor Hodge, of the University of Pennsylvania, saw her with me, July 10th, 1841. On examination, he readily detected a retroflection; a displacement of the uterus with which he was familiar, and which he calls a retort uterus, from the fact that the uterus is bent on itself in the form of a retort.

"He proposed the introduction and persevering use of a pessary of a peculiar form, which he has successfully used in many cases of the kind; I had an instrument made after his pattern, and introduced it; but it was not of the proper size, and caused considerable discomfort, which the patient attributed to the form of the instrument, and, to my regret, was unwilling to have another one of the kind used.

"During the following five years, she pretty much abandoned medical treatment, except that, whenever her sufferings became unusually severe, she applied to me, when, by pressing up the uterus and introducing a ring, she would be much relieved for a time. Several other physicians were consulted in the case, but nothing important or novel was suggested.

"Her symptoms gradually grew worse, and, in July, 1847, I visited her, and found her confined principally to her bed; she appeared slightly emaciated; her brilliant color was gone, and she suffered severely from sickness of the stomach. She informed me that, after passing her monthly period about three weeks, she had had a slight show, which had returned every few days for the last two weeks; making about nine weeks from her last regular monthly period. On making an examination, I found the uterus occupying the same posi

tion it had heretofore done, and somewhat larger than before, but apparently not larger than an ordinary unimpregnated adult uterus.

"I declined adopting any active treatment without assistance, and suggested Professor Meigs, of the Jefferson Medical College, who saw her, with me, on the 17th of July. Dr. Meigs was sanguine, after examining the state of the parts, that the uterus could be restored to its proper position, notwithstanding the length of time it had been displaced.

"He came next day, prepared with an instrument to press up the fundus of the uterus, and with some small gum-elastic bottles, of the kind recommended by Hervez de Chegoin, in the hope that by gradual pressure in this manner we might succeed in restoring the organ to its proper position.

"The patient complained of much pain when the doctor attempted to press up the uterus, though but moderate force was used. I filled the bottles with curled hair, which I found to answer admirably on account of its elasticity, and introduced one of them carefully between the perineum and the fundus of the uterus. It gave no pain, and was retained without inconvenience, and appeared as though it would fulfil the indication.

"I kept her in her bed a few days, after which she rode out occa sionally, and once walked several squares.

"On the evening of the 5th of August, after using much more exertion than she had done for several months, the ball was forced away, and she was attacked with severe bearing-down efforts, so that it was a considerable time before she could be removed to her chamber. After she had been carried to her bed, I made an examination, and found the uterus at the os externum, and the bearing-down pains so severe as to threaten its expulsion from the vagina.

"After administering an anodyne enema, and in some measure tranquillizing her system, I succeeded in pressing the uterus up to its former position, and introduced the gum-elastic ball at her own request, as she said she felt safer and more comfortable while it was in sitû.

"The patient was unable to leave her chamber, and seldom her bed, from this time; and she often passed whole days and nights in the most awkward positions, because the least motion increased the pain beyond endurance. Her stomach became so irritable that it was seldom anything would be retained in it even for a single hour. She became weak for want of nourishment. The most excruciating neu ralgic pains pervaded every part of her abdomen, so as to preclude

the possibility of any examination either externally or per vaginam; and, to increase the difficulty of diagnosis, she became tympanitic.

"The wise women of the neighborhood said she was in the family way; but of this we were not satisfied; and Dr. Meigs, who placed considerable reliance on the appearance of the nipple, examined her breasts carefully, and there was not the slightest change of the areola.

"An anodyne enema was administered every evening, but her nights were generally sleepless, and she gradually grew worse till the 19th of August, when I was obliged to leave the city for a few days. My friend Dr. Jewell attended her for me, and has furnished me with the following notes of the case:"—

"My first visit to Mrs. N. was made on Thursday, August 19th, at the request of my friend Dr. Yardley, who was to be absent from the city for several days.

"Her condition, when I saw her, was anemic; countenance thin, pale, and sallow, expressive of long-continued and wasting disease; pulse sharp and frequent; abdomen tympanitic and exceedingly tender to the touch; tongue clean and moist; stomach so exceedingly irritable as to reject all nourishment and medicine, craving only ice, which, however grateful for a moment, afforded no relief. All her suffering was directed to a most excruciating pain in the left iliac region, accompanied with extreme gastric distress, which symptoms had been in existence, and increasingly so, for several days.

"Fomentations of brandy and spices were applied to the abdomen, and various anti-emetics and sedatives were ineffectually tried for the vomiting.

"In the afternoon, the symptoms being more aggravated, twentyfive leeches were applied over the stomach, and an enema of forty drops of laudanum in a gill of warm flaxseed tea thrown into the rectum. In the course of the night, the gum-elastic ball pessary, which had been introduced by Dr. Yardley for the retroversion of the womb, came away during an effort to vomit, and was not replaced.

"Friday, 20th. Found her very weak and exhausted, with some slight relief from pain and vomiting; expressed herself to be easier, but dreaded the return of the severe suffering she had experienced the day before. Was troubled with flatulency and slight oppression at the præcordia. Directed the effervescing draught, with thin arrowroot, in small quantities, and to be frequently repeated. The fomentations to be continued as yesterday.

"In the afternoon, was sent for in haste-that Mrs. had convulsions. On my arrival at her bedside, I found her in a collapsed