Class / Book-Lil GqpyrigtoN?- COPYRIGHT DEPOSIT. \ FEMALE PELVIS. irl TREATISE fikl- F MEDICAL AND SURGICAL DISEASES OF WOMEN, WITH THEIR ELOMCEOPATHIC TREATMENT. gully Illustijatefl. - BY MORTON MONROE EATON, M. D., Cincinnati, Ohio. BOERICKE & TAFEL, NEW YORK, PHILADELPHIA, 145 Grand Str. 635 Arch Str. TRUBNER & CO., Ludgate Hill, E. C. LONDON, ENG. 1880. i> Copyright Secured, AND ALL RIGHTS UNDER IT RESERVED, BY THE AUTHOR. PREFACE In conformity to custom, the Author presents some of the reasons which have induced him to present this work to the homoeopathic medical profession. First. Because he has been for several years repeatedly urged to do so, by prominent homoeopathic physicians of several States, including representative men in the cities of Chicago, St. Louis, New Orleans, Boston, Louisville and Cincinnati. Secondly. Because homoeopathic colleges have been obliged to recommend, and homoeopathic physicians and students have been obliged to provide themselves with, allopathic works upon these diseases ; thereby giving a certain amount of sanction to the treatment therein advocated, and causing the use (among otherwise good homoeopathic phy- sicians) of caustics, scarifications, etc., applied to the uterus, to become so common among them as to bring a blush of shame to the face of the true homoeopath. In the use of pessaries and drugs, the homoeopathic profession have also inadvertently been following, in part, their old-school breth- ren's treatment ; because they largely have been obliged to IV PREFACE. study the description, etiology, diagnosis, pathology, and prognosis of these diseases from their books. The homoeo- pathic books which we have had upon the diseases of women, though written by gentlemen of high standing, do not seem to meet all the requirements of the profession, though excellent, so far as they go. Thirdly. Because it seems time that homoeopathists should have complete text books on all branches of medical education ; the large increase in the number of homoeopathic physicians from year to year justifying the expectation, that erelong we may rival the old school in numbers, as we now do in the intelligence and wealth of our patrons. Fourthly. Because the homoeopathic physicians of Illinois and Ohio, in their State societies, and of the North-west, in the Western Academy, have honored him with their con- fidence, and shown their respect by giving him prominence in regard to these diseases, and because he has had a large experience in their treatment for over twenty years, in hospital and private practice (allopathic and homoeopathic). He has endeavored to make this work as complete as possible. How far he has succeeded, the profession must judge. He believes the works upon the diseases of women, by Thomas and Emmet, of the old school, are ordinarily considered complete; but he finds that Prof. Thomas* omits in his index, Lacerations of the Cervix Uteri; and Prof. Emmet f omits Areolar hyperplasia of the uterus, Hydatids of the uterus, Rectocele, Sterility, Inflammation of the uterus, in all forms, except as he refers to congestive hypertrophy, Abor- tion, Pudendal hemorrhage and Pudendal hematocele. And * Thomas' Diseases of Women. t Emmet's Prin. and Prac. of Gyn. PREFACE. both Profs. Thomas and Emmet omit Hysteralgia, Puerperal fever, Puerperal phlebitis, Mammary Abscess, Cervicitis, Sympathetic Affections, and Nymphomania, as well as Puer- peral mania. He is hopeful that this work will not be found less complete. Neither Dawson's improved Sims' speculum nor Wocher's bi-valve speculum are mentioned in either of these works, or those of any other author on Diseases of Women (so far as he is aware), and they need but to be seen to be appre- ciated as decided improvements. Cutler's suture cutter and forceps, his own improvement of the London Abdominal Supporter, his needle holder, and wire holder and twister, for vaginal fistulse, have not heretofore been presented to the profession. He has spared no pains or expense to have his illustra- tions perfect and complete. In this he is greatly indebted to Mr. John H. Bogart, designer and engraver, of this city. He has not attempted to make a Materia Medica, but has named such remedies as he has found beneficial, and given the prominent homoeopathic indications for their use in each disease, gleaning somewhat from other authors, as well as his own experience. The Author, in conclusion, would express his thanks to Drs. S. R. Beckwith, of Cincinnati; W. H. Hunt, of Cov- ington, Ky. ; M. B. Pearman, of St. Louis; T. P. Wilson, of Ann Arbor, and others, for valuable suggestions. Respectfully, M. M. EATOX Cincinnati, O., U. S. A. TABLE OF CONTENTS. CHAPTER I. Page. Introduction, 17 CHAPTER II. General Diagnosis, 21 CHAPTER III. Normal Menstruation, and Amenorrhcea, 31 CHAPTER IV. Menorrhagia and Metrorrhagia, 41 CHAPTER V. Dysmenorrhcea, or Painful Menstruation, 46 CHAPTER VI. Vicarious Menstruation, 56 CHAPTER VII. Inflammation of the Female Genitalia, 60 CHAPTER VIII. Metritis, 77 CHAPTER IX. Areolar Hyperplasia of the Uterus; or, Chronic Parenchyma- tous Metritis, 87 VIII TABLE OF CONTENTS. CHAPTER X. Page. Peri-Metritis — Pelvic Cellulitis— Pelvic Abscess, . . . 110 CHAPTER XL Child- bed Fever — Puerperal Peritonitis, Puerperal Metritis, Metro-Phlebitis, and Peritonitis, 126 CHAPTER XII. Homoeopathic Remedies, . . 137 CHAPTER XIII. Instruments, 142 CHAPTER XIV. Induration and Hypertrophy of the Cervix Uteri — Vaginismus and Dyspareunia, • . . 162 CHAPTER XV. Ulceration of the Os Uteri, . . . . . . . .179 CHAPTER XVI. Vaginitis— Adhesions in the Vagina from Inflammation — Diph- theritic Inflammation of the Vagina — Peri- Vaginitis Phleg- monosa Dissecans, 186 CHAPTER XVII. Imperforate Hymen — Atresia of the Hymen (Congenital and Acquired) — H^matometra, Etc., . . . • . . . 197 CHAPTER XVIII. Uterine Hemorrhage, 201 CHAPTER XIX. Cervicitis and Endo-cervicitis, or Catarrh of the Cervix, . 211 CHAPTER XX. Endo-Metritis, 218 CHAPTER XXI. Leucorrhcea— Whites, 240 TABLE OF CONTENTS. IX CHAPTER XXII. Page. Barrenness and Sterility, .249 CHAPTER XXIII. Diseases of the Ovaries, 265 CHAPTER XXIV. Ovarian Tumors, 275 CHAPTER XXV. Ovariotomy, 312 CHAPTER XXVI. Uterine Fibroma — Myoma — Fibrous Tumors of the Uterus, . 342 CHAPTER XXVII. Uterine Polypi — Vegetations of the Endometrium — Uterine Hydatids —Vascular Polypi — Placental and Granular Pol- ypi, Etc., 352 CHAPTER XXVIII. Moles in the Uterus, 375 CHAPTER XXIX. Catarrh of the Uterus and Vagina, 380 CHAPTER XXX. Hernia of the Ovary— Hernia of the Uterus, or Hysterocele, 385 CHAPTER XXXI. Prolapse of the Vagina, Cystocele, Rectocele, Enterocele, and Ovariocele, 389 CHAPTER XXXII. Papillary Tumors of the Uterus and Ovaries, and Coccygodynia, 395 CHAPTER XXXIII. Cancer and Cauliflower Excrescence of the Uterus — Carci- noma, Sarcoma, Etc., 400 CHAPTER XXXIV. Femoral Hernia, Inguinal Hernia, Labial Hernia, Vaginal Hernia, and Hydrocele, . 404 X TABLE OF CONTENTS. CHAPTER XXXY. Page. Hydrometra — Pruritus Vulvae— Abscess of the Labia — Cysts of the Vagina— Fibroids of the Vagina— Polypi of the Vagina- Prolapse of the Ovaries, 406 CHAPTER XXXVI. Abortion, .' 42i CHAPTER XXXVII. Cysts of the Broad Ligament and Diseases of the Fallopian Tubes, 437 CHAPTER XXXVIII. Diseases of the Urethra— Urethritis, Caruncles of the Ure- thra, Irritable Urethral Caruncul^e, Ulceration, Fissures of the Neck of the Bladder, or Meatus Urinarius Internus, Lacerations of the Urethra from Dilatation, Prolapse of the Urethra, Urethral Polypi, Etc., 445 CHAPTER XXXIX. Tuberculosis of the Vagina— Stenosis of the Uterus, . . .451 CHAPTER XL. Cystitis in Women, 455 CHAPTER XLI. Stone in the Bladder and Ureters, 462 CHAPTER XLII. Sympathetic Effects of Diseases of the Uterus and its Append- • ages, . . . 472 CHAPTER XLIII. Pudendal Hemorrhage — Pudendal Hematocele — Thrombus — Rup- ture of the Bulbs of the Vestibule, 490 CHAPTER XLIV. Puberty — And the Climacteric Period, 494 CHAPTER XLV. Atresia of the Vagina, and Cervix Uteri— Hematometra, Etc., 502 TABLE OF CONTENTS. xr CHAPTER XL VI. Page. Fistula— Vesico-vaginal Fistula — Recto- vaginal Fistula— Recto- vesical Fistula — Vesico-cervical Fistula — Urethrovaginal Fistula— Intestino- vaginal Fistula — Ureto- vaginal Fistula— Vesico-uterine Fistula — Peritoneo- vaginal Fistula — Perineo- vaginal Fistula— Blind Vaginal Fistula— Fistula in Ano, . 511 CHAPTER XLVIL Lacerations of the Cervix Uteri, 539 CHAPTER XLVIII. Displacements of the Uterus, ........ 552 CHAPTER XLIX. Different Forms of Displacements of the Uterus— Inversion of the Uterus, 563 CHAPTER L. Retro-version and Retro-flexion of the Uterus, . . . 578 CHAPTER LI. Ante-version and Ante-flexion of the Uterus, . 598 CHAPTER LII. Prolapsus Uteri and Procidentia, 605 CHAPTER LIII. Laceration of the Vagina — Laceration of the Perineum — Ulcer- ation (Tuberculous, Cancerous, and Syphilitic), . . . 629 CHAPTER LIV. Extra-uterine Gestation, 642 CHAPTER LV. Strangury, Dysuria, Ischuria, Retention of Urine, Suppression of Urine, Enuresis, Etc., 646 CHAPTER LVI. Gonorrhoea in Women, 650 CHAPTER LVII. Syphilis in Women, 655 CHAPTER LVIII. Diseases and Difficulties of Pregnancy, 660 XII TABLE OF CONTENTS. CHAPTER LIX. Page. Vomiting in Pregnancy, 672 CHAPTER LX. Puerperal Mania, 688 CHAPTER LXL Diseased and Deformed Nipples — Milk Fever — Abscess of the Breast — Tumors of the Breast, Cancer, and Amputation of the Breast, . . . . . ' 692 CHAPTER LXIL Phlegmasia Dolens — Puerperal Phlebitis, or Milk leg, . . 705 CHAPTER LXIII. Hypertrophy, and Sub-involution of the Uterus, . . . 709 CHAPTER LXIV. HEMATOCELE, PELVIC HEMATOMA, THROMBUS, ETC., . . . 716 CHAPTER LXV. Elephantiasis, or Hypertrophy of the Clitoris, Labia Majora, and Labia Minora, Hermaphrodites, Nonentities, Tumors of the Labia, Etc., 723 CHAPTER LXVI. Extirpation of the Uterus — Ablation of the Uterus, Hyster- otomy, Etc., 727 CHAPTER LXVII. Hysteralgia — Neuralgia Uteri — Irritable Uterus — Ascites in Women, 736 a* CHAPTER LXVIII. Bathing — Vaginal Washes— Stomatitis Materna, . . . 744 CHAPTER LXIX. Nymphomania ( The " Fureur Uterine " of the French) — Atrophy and Hyper-involution of the Uterus — Absence of the Uterus — Malformation of the Uterus — Anaesthetics, .... 750 CHAPTER LXX. Hysteria, 757 ILLUSTRATIONS Alphabetically Arranged. Page. ABSENCE of the uterus, .... opp. 723 Ante-version of the uterus, . . . " 598 Ante-flexion " ■' ..." 599 Antiseptic spray apparatus, . . " 150 Applicator sponge tent, 36G " uterine, Emmet's, .... 3G6 " . " Palmer's, . . . .715 Artery forceps, 322 Ash ton's perineum needle, . . . opp. 150 Aspirator, Tiemann & Co.'s, . . " 153 " Dieulafoy's, " 154 Atresia of the vagina, 503 BABCOCK supporter, ..... opp. 140 Battery, Faradic, 38, 160, 714 " combination, 38 Bed swing, 339 Bi-valve speculum, vaginal, . . opp. 143 " " urethral, .... 446 Bony pelvis, female, . . . opp, title-page. Bozeman's tenaculum, opp. 158 " curved scissors, 523 " straight scalpel, 636 CALLENDER'S drainage canula, opp. 158 Canula drainage, . . . 333, and " 158 Catheter, reversible, 457 " self-retaining, .... opp. 158 Cervix uteri, hypertrophy of, ... . 162 " " elongation of, . . . opp. 609 " " amputated (two tigs.), 169 " double, 755 Chair examination, 22 Civiale's lithotriptor, opp. 147 Page. Clamps for pedicle of ovarian tu- mors, opp. 161 Clamp, Tliomas', il 161 " Dawson's improved, 321 " Spencer Wells' original, opp. 161 " " " new (three figs.)," 161 Clitoris, hypertrophy of, ... . " 723 Combination battery, 38 Complete procidentia uteri, . . opp. 611 " inversion of the uterus, " 563 Counter pressure hook, 521 Curved scissors, 530 " " Bozeman's, 523 " " long, 146 " Emmet's, 726 Cutler's suture cutter and forceps, . . 535 DAWSON'S pedicle clamp, improved, 321 " Sims' speculum, . . opp. 142 Depressor, vaginal, 522 Dieulafoy's aspirator, opp. 154 Dilator, uterine, "147 " sponge tent, " 153 " vaginal, " 145 Double tenaculum forceps, 323 " uterus, 754 " cervix uteri, 755 " uterus and vagina, 503 Drainage tubes, .... 333, and opp. 158 Dressing forceps, uterine, . . . . *' 144 EATON'S needle-holder in use, . . .527 " " " ... opp. 145 " wire holder and twister, . " 145 XIV ILL USTRA TIONS. Page. Eaton's wire holder and twister, applied, opp. 145 " improved London sup- porter, " 157 Ecraseur, Edwards', 869 Edwards' Ecraseur, 369 Elastic pessaries, 149 11 abdominal supporters, . opp. 157 Electrode, intra-uterine, 714 Electrolysis needles (one fig.), . . . 160 " " (seven figs.), . . 370 Elevation of the uterus, . . . . opp. 718 Elevator, Elliott's uterine, ..." 159 Elliott's uterine elevator, ..." 159 Elongation of the cervix uteri, . " 609 Emmet's sponge tent applicator, 597, 366 " curved scissors, 726 " sponge dilator, .... opp. 153 holder, 326 " counter pressure hook, . . . 521 " speculum, • . . 635 Enlargement of the clitoi-is, . . opp. 723 Enucleators, Sims' (three figs.), . . . 365 Endoscope, urethral, 446 Examination chair, 22 Exploring trocar, opp. 154 Extirpated uterus, 733, 734 FARADIC batteries, ... 38, 160, 714 Female form, opp. title page. " pelvis, bony, . . " " " Fibroma of the uterus, . . . 343, 352, 354 " " cervix, 343 " uterine, subserous, 343 " " submucous, .... 343 " . . 352, 354 Fibroids, syringe for injecting, . . . 171 Fistula, vaginal, 524, 526, 527 " " opp. 535 Forceps, vulsellum, " 154 " Nelaton's tumor, . . . ,; 156 " " pedicle, 365 " straight lithotomy, . . opp. 147 " « needle, 526 » artery, 322 " double tenaculum, 323 " uterine dressing, 184 " " ... opp. 144 « Greenhalgh's, 208 " Cutler's suture, 535 Page. Front view of uterine organs, . opp. 17 Furguson's mirror speculum, . . " 143 GREENHALGH'S forceps, 208 HEMATOCELE, recto-vaginal, opp. 718 Haematometra (two figs.) 503 Hermaphrodite, opp. 723 Hypertrophy of the uterus, 710 " of the clitoris, .... opp. 723 " u labia majora, . " 726 " " « minora, . " 725 " " cervix uteri, .... 162 Hysterotome, White's, opp. 144 " Simpson's. .... " 144 IMPROVED London abdominal sup- porter, opp. 157 Imp'd Peaslee perineum needles, " 145 Inflatable pessary, 149 Inhaler, Lente's modified, . . . opp. 156 Intra-uterine electrode, 714 Inversion of the uterus, .... opp. 563 LACERATION of the perineum, . . 635 u of the perineum, adjusted, 638 " " " sutures placed, 635 Lente's inhaler, opp. 156 Ligature cutter, 535 Ligatures, 169, 346 Lithotomy forceps, opp. 147 Lithotriptor, " 147 Little's antiseptic spray apparatus, " 156 '' trocar, " 159 London abdominal supporter (old), {i 157 " tl " improved, " 157 Long curved scissors, 146 " " trocar, 125 " " " (uterine), . . . .510 M'INTOSH'S supporter, 150 Mirror speculum, opp. 143 Mucous polypi, uterine, 352 NEEDLE HOLDER, Eaton's, 527, opp. 145 " " Sims', 526 tl " curved, . . opp. 145 " " straight, .... 526 Needles, Pease's, 148 " suture, curved, .... opp. 158 ILL USTRA TIONS. XV Page. Needles, suture, full curved, . . " 158 " perineum, " 156 " " Ashton's, . ..." 156 " " Peaslee's improved, " 156 " open-eyed, 326 " electrolysis, 160 " " (seven figs.), . . 370 Nelaton's pedicle foi*ceps, 365 " tumor forceps, .... opp. 156 Nelson's tri-valve speculum, . . " 143 Nonentity "723 Nott's depressor, 522 OLD WOMAN'S uterus, 27 " " vagina, 27 Old London abdominal supporter, opp. 157 Open-eyed needle, 326 Operating tables, 319, 703 Operation for lacerations of perineum, 635 " " vesico-vaginal fistula, opp. 535 " 524, 526, 527 Original speculum, Sims', . . . opp. 142 " clamp, Spencer Wells', . " 161 " London supporter, ..." 157 Os uteri, virgin, 26 " '* old woman's, 27 PALMER'S uterine dilator, . . . opp. 147 " applicator, 515 Peaslee's perineum needles, . . opp. 156 Pease's needle (perineum), 148 Pedicle clamps (four figs.), . . . opp. 161 " " Dawson's improved,. .321 Pelvic lisematocele, opp. 718 Pelvis, female, bony, . . . opp. title page. Pessary, inflatable, 149 " elastic ring, 149 Perineum, operation for restoring lac- eration of, 635 " restored after laceration of, 638 Polypi, mucous uterine, 352 " fibrous uterine, . . . 343, 352, 354 Procidentia uteri, opp. 609 " complete, . . . " 611 Prolapsus uteri, .... opp. 605 and 710 " " opp. 606 "608 QUILL, suture, adjusted, 038 Page. RECTO- VAGINAL hematocele, opp. 718 Repository White's uterine, 573 Retractor, Emmet's vaginal, .... 635 Retro-version of the uterus, . . opp. 578 Retro-flexion " " ..." 580 Reversible catheter, 457 Round elastic pessary, 149 SCALPEL, Bozeman's, 636 Scissors, " 523 curved, 530, 726 Self-retaining catheter, .... opp. 158 Side view of uterine organs, . . opp. 21 Sims' uterine elevator, " 159 " enuclcators (three figs.), .... 363 " needle holder, ......... 526 " original speculum, .... opp. 142 " folding " . ..." 142 " Dawson's imp. " . . . . " 142 " vaginal dilator, " 145 " sponge holder, 326 " sponge dilator, opp. 153 '* enucleators, 347 Simpson's sound, opp. 144 " hysterotome, . . . . " 144 Skene's sound, " 144 " urethral endoscope, 440 Sound, steel, opp. 144 " Simpson's, " 144 * Skene's, " 144 Speculum, urethral bi-valve, .... 446 " Skene's, 446 " Sims' (three figs.), . . opp. 142 " Wocher's bi-valve, . . " 143 " Nelson's tri-valve, . . " 143 '' Furguson's mirror, . . " 143 " Emmet's vaginal, .... 635 Spencer Wells' trocar, 320 " " artery forceps, 322 '' lt pedicle clamp (orig'l), opp. 161 " " " " new, (three figs.), " 161 Sphygmograph, 161 Sponge tents, 150 Sponge tent applicator, 366 " " holder, 597 " " dilator, opp. 153 " " sponge holder, 326 Subserous fibi'oid of uterus, 343 Submucous " " " 343 XVI ILLUSTRATIONS. Page. Swing, bed, 339 Sub-involution of the uterus, .... 710 Supporter, Babcock's, opp. 14G t( old London abdominal, . . " 157 " impr'd Lond. abd'l, Eaton's, " 157 " silk elastic, " 157 » M'Intosh's, 150 Suture cutter and forceps, 535 " needles, curved, .... opp. 158 " " half curved, . . " 158 Sutures in cervix uteri (two figs.), . . 169 Syringe for injecting uterine fibroids, 171 TABLES, operating, 319, 703 Tenaculum, Bozeman's, .... opp. 158 " double, 323 Thomas' pedicle clamp, .... opp. 161 Tiemann & Co.'s aspirator, . . . " 153 Trocar, common, 391 " exploring, opp. 154 " long curved, 125 " " " uterine, 510 » Spencer Wells', 320 " Little's, opp. 159 Tri-valve speculum, Nelson's, . . opp. 143 Tumor forceps, Nelaton's, 3G5 « " " .... opp. 150 UTERINE organs, normal posi- tion, opp. 17, 21 " dressing forceps, . . 184, opp. 144 « elevator, Elliott's, ... " 159 « " Sims', " 159 " repositor, White's, 573 " fibroids (three figs.), .... 343 " " syringe for injecting, .171 Page. Uterine polypi (mucous), 352 " (fibrous), .... 352, 354 . " dilator, Palmer's, .... opp. 145 Uterus, hypertrophy of, ... . 162, 710 " sub-involution of, 710 " virgin, 26 " old woman's, 27 " double, 503, 754 " extirpated (two figs.), . . 733, 734 " elevation of, opp. 718 " prolapse of, . . opp. 605, 606, 609 " " " opp. 710 '* versions of, . . . . opp. 578, 598 " flexions of, .... " 580, 599 " procidentia of, . . . " 609, 611 " absence of, opp. 723 " drawn out in sight, ..." 535 VAGINA, old woman's, 27 " atrophy of, opp. 723 " atresia of, 503 " double, 503 Vaginal dilatoi-, opp. 145 " pessaries, 149 '* specula (three figs.), . . opp. 142 u u a « ; . . « 143 Virgin os uteri, 26 Vulsellum forceps, .... opp. 154, 535 WELLS' artery forceps, 322 il pedicle clamps (4 figs.), opp. 161 " trocar, 320 White's uterine repositor, 573 Wire holder and twister, Eaton's, opp. 145 " « " applied," 145 Wocher's bi-valve speculum, ..." 143 Plate I. FRONT VIEW OF UTERINE ORGANS IN THEIR NORMAL POSITION. THE DISEASES OE WOMEN CHAPTER I. INTRODUCTION. To-day the diseases peculiar to women are daily brought to the attention of the general practitioner of medicine. It is a fact that these diseases are on the increase to an alarming extent, and bid fair to seriously affect coming generations, physically and morally. The world has a right to look to the members of the med- icnl profession for advice on matters of this kind, and I judge the profession would come short of its duty did it fail to point out, and seek to remedy, the causes which have led to, and are increasing, this great amount of female suffering and dis- ease, thereby enfeebling the offspring which are to come for- ward on the stage of action, in a few years from now, as the business men, statesmen, and those who must fill the posts of responsibility. May we not, then, in view of the necessities of the times, spend a short time in consideration of the causes that have produced this increase of the diseases peculiar to women ? First, the advancements of civilization, so called, have caused a life of luxury and ease to supplant that of toil and exercise. The necessity of exercise is as imperative with the female as the male. Strong muscle, active digestion, and as- similation are not the result of indolence, but of activity. Again, our food of late years has been too fine. Pastries, 18 EATON ON DISEASES OF WOMEN. fine flour, and highly seasoned food have driven out of use, almost, the plain bread and milk and mush and milk of our fathers. Again, the fashion of lacing the chest and upper part of the abdomen has been, perhaps, the most fruitful cause of the long train of women's ailments and weaknesses. By con- tracting the thorax the action of the heart is impeded, the lungs are prevented from a full expansion, the blood is con- tinually charged with too large a quantity of carbonic acid gas. Oxygen is not received into the blood in sufficient quan- tities to stimulate healthy nerve action, and the result, of course, is lassitude, debility, and disease. Another injury resulting from lacing the upper part of the abdomen is, that the abdominal organs are thereby displaced downwards, and press heavily upon the uterine organs. These are thereby displaced and inflamed, producing not only the symptoms resulting directly from these conditions, but an immense amount of trouble through reflex action on the cer- ebrospinal and sympathetic nervous systems, thereby derang- ing all the normal functions of the body, and sometimes the mind as well. The wearing of clothing suspended from the hips aids in producing all the ills just mentioned, as resulting in greater or less degree from lacing. Thin clothing, especially upon the extremities, in winter, conjoined with the previously men- tioned customs, is not to be forgotten as one cause of female suffering. And, finally, the cause Avhich, we must recollect, is the in-eat curse of the American ladies is to be found in those means used to prevent pregnancy and produce abortion. The disinclination of so many married ladies to become moth- ers has led them to adopt means for the prevention of concep- tion that have had the effect of producing diseases in them- selves of a serious nature. The various means used to pro- duce abortion have entailed on many a lady life-long suffering. IN TR OD UCT10N. 1 9 These remarks may be sufficiently explicit in this connection. (See chapter on Abortion.) These causes have led to so many ailments, directly and through reflex action, that the general practitioner seems obliged to become conversant with the diseases of women, and we think he should be better informed in regard to these ailments than any other, because they are more delicate to manage, and it is not always that the patient will volunteer information in regard to them. And when investigation is thought to be necessary by the physician the patient shrinks from it, and purposely misleads ihe physician in describing her symptoms, so as to convince him that the difficulty is in the head, liver, back, or stomach, when it is clear that all the symptoms are due to uterine disease or displacement. Let me recommend that the student, before entering upon the study of diseases of women, become very familiar with the anatomy of the female genitalia, and the arrangement of the sympathetic ganglia throughout the entire system. Let him read well the physiology of the healthy female, that devia- tions from health may be readily recognized, recollecting, however, that there are some exceptions to general rules. That some women may normally menstruate every two or three or five weeks; that the flow may with some be three times in amount of what others would discharge, and still they might only have this idiosyncrasy, and be not diseased at all. By the study of the healthy subject he will learn that owing to the varying lengths of the vagina, in different women the position of the uterus that would in one case be partial prolapse would in another be normal. Hence, it will be seen, that the greater the knowledge we have of the peculiar- ities of different women, as well as the general knowledge of the normal conditions, the greater will be our opportunities to judge correctly of the cases we may have to treat, and the more correct will be the diagnosis which we will form (if the diagnosis of the case is all that is asked of us). 20 EA TON ON DISEASES OE WOMEN. It may be well to mention that the early introduction into society of girls of tender age, the desire of mothers to make young ladies of their girls when they should be considered children, requiring them to refrain from that active exercise that is so necessary for the full development of muscle and strength; the early marriages so frequently consummated, together with the constitutional debility inherited from moth- ers already affected with weaknesses dependent upon errors of their diet, clothing, and exercise in early life, — all tend to enfeeble the constitution and develop special weaknesses and diseases. Plate II SIDE VIEW OF FEMALE PELVIC ORGANS IN NATURAL POSITION. GENERAL DIAGNOSIS. 21 CHAPTER II. GENERAL DIAGNOSIS. It is not every patient with uterine disease that will come to the physician and announce that she is suffering with such an ailment; that is, they do not go to the general practitioner in this way (though the acknowledged gynaecologist has the advantage in this respect, as the patient's presence in his office is an announcement of some such ailment, and he is at liberty to suppose his patient has been convinced that she is suffering from some disease of the female generative organs, and has come for examination and advice) ; hence, it becomes necessary that the general practitioner look for indications of these ailments among the symptoms given by the patient. Some of these symptoms, that may point to uterine difficul- ties, are, pain in the occiput, or top of the head, burning heat in top of head and soles of feet, hot flashes of long standing, too frequent or painful micturition, persistent constipation, bleeding piles, pain in small of back and thighs, nausea, loss of appetite, indigestion, etc. Either of these symptoms, alone, would not assure you of uterine disease; but either of them gives you cause to investigate further. First, note how long these symptoms have existed, how much treatment they have had with a failure to obtain relief; inquire further, and ascer- tain if we have two or three, or more, of these symptoms in the same case ; also, if there is dysmenorrhoea, amenorrhoea, menorrhagin, or leucorrhcea — if so, of how long duration, noticing all the peculiarities of each case in these regards. Take into account the age of the patient, whether married or single, widows or spinsters, mothers or barren. When all these things are considered, and the difficulty 22 EATON ON DISEASES OF WOMEN. has been of long standing, and we feel assured that our patient's sufferings are caused from uterine disease, we are justified in requesting a physical examination, per vaginam. This does not contemplate any exposure of the patient, and consists of a digital examination, and taking note of the dryness or moisture of the vagina, heat, size of neck of uterus, whether smooth, nodulated, or fissured; also, its posi- tion in the vagina, etc., — all this may be determined with the patient standing. jSssP Fig. No. 1. — Examination Chair. (Mitchell, Rammelsberg & Co., Cincinnati, O.) Very chronic and severe cases, of course, will demand more careful examination with the uterine sound, and some- times we may need the aid of the vaginal speculum as well, in aid of diagnosis. I value the uterine sound much more highly than the vaginal speculum. In many cases, as I have hinted, neither of these instruments is needed. Introducing the vagi- nal speculum in all cases, as has become the routine habit of some gynaecologists, is not to be commended or followed. Its use may be required in treatment much more frequently GENERAL DIAGNOSIS. 23 than in diagnosis. To make a vaginal examination I prefer to have the patient sit in a regular examination chair. (See Fig. No. 1.) It is less embarrassing to the patient; it seems more modest; it is more convenient for the physician. Let the cover be thrown over her lap while sitting in the chair, and then gently tip the chair backwards. The patient is thus placed in the reclining posture without scarcely realizing the fact. Some gentle examination of the size of the abdomen, with slight percussion external to the cover, to ascertain if there is much tympanites or tenderness, tends to assure the patient, when we may gently slip the clothing upwards with- out disturbing the cover, and pass the extended palm of the hand over the abdomen, first over one or two thicknesses of clothing, then in direct contact with the flesh. By this exam- ination we have determined the presence or absence of ten- derness, heat, and tympanites and have, in many cases, deter- mined whether or not we have ovarian tumors of large size, pregnancy of several months' duration, or any large fibroids of the uterus. I do not mean to say that this external examination will be conclusive as to the diagnosis of any of these conditions, except regarding tenderness, tympanitis, and heat; but I do say that this manipulation will materially assist in the special diagnosis which I will explain in detail under the proper special heads. This examination gives further advantage, viz., that our patient has by this time become somewhat accustomed to manipula- tion, and, being assured by this method of examination under the cover, that she is not to be exposed or rudely handled, we will have little difficulty to proceed in making a digital examination per vaginam, following that by examination with the uterine sound, and finally with the speculum, if need be. Gentleness, and the most respectful demeanor, will win the confidence of our patient, and greatly promote the success of the treatment used; for, without the confidence and respect of his patient, the physician will fail in receiving that careful 24 EATON ON DISEASES OF WOMEN. attention to his directions and co-operation in the treatment which is so essential for success in any disease, but more es- pecially in those peculiar to women, as, owing to their deli- cacy, it is necessary that much of the treatment be carried out by themselves. The physician has not the opportunity to frequently examine the case, or apply treatment, as in other ailments. The general appearance of the patient is to be studied, and the diathesis noted. The cancerous cachexia, which is indi- cated by the sallow, brownish yellow complexion, combined with the anxious, wearied, sunken countenance, is to be rec- ognized at a glance. The tuberculous cachexia is indicated by the shrunken features, the bright, glassy eye, the hectic cheek, emaciation, with the hopeful condition of mind of the patient, conjoined with the slight or severe cough, which the patient always insists is but a slight cold. The location of the tuberculous matter may be in the lungs, liver, bowels, brain, or other parts of the system. But if we have the tuberculous or cancerous cachexia clearly defined, we must, of course, address the treatment to the general condition of the patient, being assured that unless we are able to bring the system to a better standard of health we will have little reason to hope for a favorable termination of the case, what- ever special ailment the patient may have. To what extent these conditions or diatheses may be removed with proper remedies I will state under their proper chapters. A question may arise in the mind of the physician as to the propriety of suggesting a physical examination in case the patient is an unmarried lady. Some seem to think these cases should never be subjected to physical examination, and let them suffer on. Now, while I would not propose a phys- ical examination of the virgin as soon as I would in the case of a patient that had been married, and Avould try to avoid the necessity of making an examination, still, if the case seemed to require it very urgently, on account of the long GENERAL DIAGNOSIS. 25 duration of the difficulty, or the intensity of the suffering, I would proceed to make the examination without hesitation. I will relate two or three cases only, as examples of many that have come under my notice and treatment, that will show how great the necessity for an examination that some- times exists in these cases, that the patient's life may be saved, not to mention the saving of suffering and impairment of constitution by neglect. In 1870 a young lady from a town some thirty miles dis- tant, whose age was about twenty-eight years, consulted me about a persistent ague, as she called it, of two years' dura- tion. On inquiry, I learned that her chills were nervous, clearly; that she had hot flashes at irregular intervals; had much back-ache, constipation, severe dysmenorrhoea, with much nausea and excruciating headaches, heat in the top of her head, cold feet and hands. She had taken every medicine that three physicians of different schools could suggest, and found no relief. I suspected uterine displacement as the cause of her ailments; made an examination per vaginam at once, found retroversion of the uterus, restored the organ, gave her Nux 3 X three times a, day, and she was soon well, every symptom having disappeared. Case Second. — A young lady, aged about thirty years, was brought to me, four years since, by her sister, whom I had previously treated, and I found her complaining of a, fish-bone in her throat. I examined carefully, even using the probang, and finding no obstruction in the throat or oesoph- agus ; and, learning that the trouble had existed over three years, and had been treated by several good physicians with- out benefit, I concluded this symptom must result from reflex uterine irritation, though the patient would acknowl- edge no other symptom to corroborate my diagnosis. I asked for, and insisted upon, a vaginal examination, which was re- luctantly consented to, when I found a prolapsus almost amounting to complete procidentia! I restored the organ by 26 EATON ON DISEASES OF WOMEN. appropriate treatment, and within three days she ceased to complain of the fish-bone in her throat. Some little attention to maintain the womb in situ was all the case required, and a complete cure was the result. Case Third. — A miss, aged about twenty-three years, con- sulted me, about four years since, as to her cough, that had existed some three years, and resisted all treatment. On inquiry, I found that menstruation had been getting more and more scanty for three or four years, until it was entirely absent for some six months past. I made, or rather at- tempted to make, a vaginal examination, and found an imper- forate hymen completely closing the vaginal orifice. (There must have formerly existed a small opening, that had grad- ually closed by adhesive inflammation.) I operated on the case, assisted by the late and honored Dr. Troyer, of Peoria, 111., removed a small amount of retained menstrual flow (the Fig. No. 2. — Virgin Os Uteri. small amount being due to her emaciated condition), and suc- ceeded, by proper remedies, in restoring normal healthy men- struation. In a few months my patient was fully recovered from her cough, and had become rosy and fleshy. I might go on relating numbers of cases as striking as these occurring in my private practice ; but I do not think a work on diseases of women should be very much cumbered GENERAL DIAGNOSIS. 27 with the detail of cases, and should be only mentioned in sufficient number to demonstrate the principle under con- sideration. It will be seen that we fully believe that it is sometimes imperatively necessary to make vaginal examinations in virgin patients. In examining the virgin per vaginam, we can gen- erally introduce but one finger. This should be well smeared with some oily substance. I prefer vaseline, as its healing properties make it desirable in case of some slight laceration of the hymen, which will usually occur. The virgin os uteri is small, round, and smooth, projecting into the vagina, about an inch. (See cut No. 2.) It should be found a little posterior to the center of the vagina, about three or three and a half inches from the hvmen, or mouth of the vagina. The opening into the virgin uterus is so small it may require careful feeling to detect the dent or fissure. In case of those ladies who have borne children the vagina, is capable of receiving two fingers, and we can make a much more satisfactor}- examination with two than with one. In these cases we find the neck of the uterus larger, the opening more distinct. In the aoed the os is sit- uated normally at the upper extremity of the vagina, and projects into the vagina little or none at all. The anterior, posterior, and sometimes the Fig. No. 3.— Old Woman's Os Uteri. lateral walls of the vagina are shrunken into bands or tendon like cords, that give the upper portion of the vagina a rough, irregular, tendonous feel, which we might mistake for dis- 28 EATON ON DISEASES OF WOMEN. ease did we not know this change was peculiar to women after the climacteric period has been passed several years. Finally, I will agree with Professor By ford in saying that a tender uterus is a diseased uterus. Normally, it is not tender. It should give no pain to make a thorough examina- tion, either digital or with the speculum or sound. If a care- ful examination gives pain we may be assured that something is wrong; that is, always understanding that a suitable sized speculum is used. A speculum of no considerable size should, of course, be introduced into the virgin vagina. For these examinations I prefer the uterine sound in- vented by Simpson, though I desire two or three sized probes always at hand. The bi-valve speculum manufactured by Max Wocher & Son, of Cincinnati, is the speculum I gen- erally use; but in some cases we must have the tri-valve. Nelson's is, perhaps, the best. I find little use for the com- mon glass instrument recommended by Furguson. Occasion- ally a case can best be examined with the aid of Sims' slit speculum, but its use requires the aid of an experienced assistant. (See chapter on Instruments.) The diagnosis of diseases of women has been greatly aided during the past twenty-five years by our distinguished coun- trymen, Drs. Ludlam and By ford, of Chicago ; Sims' of New York; also, Simpson, of England; Kiwisch, in Germany; Huguier, in France; and Ziemssen, of Bavaria; though the uterine sound and vaginal speculum were known to the ancients, Soranus having mentioned their use. Conjoined manipulation seems to have been well under- stood by Puzos, as far back as 1750. In the excavations of Pompeii a speculum was found, the three blades of which were expanded by a screw ; but, so far as we can learn, its use was not appreciated until within the last quarter of a century. Anaesthesia is to be employed in cases that can not be well diagnosed without its use — such cases are those who GENERAL DIAGNOSIS. 29 suffer from extreme tenderness of the vagina or abdomen, and where we feel in doubt of the existence of ovarian tumors or tumors of the uterus, owing to the rigidity of the abdom- inal muscles. Schroeder* mentions two cases which were sent him for ovariotomy, where he found not only no ovarian disease, but did not even find a circumscribed abdominal tumor. A lady was sent me from Kentucky, last year, for ovari- otomy, Avho had no disease of the ovary, but a dead foetus in the uterus, which I removed, though it presented many symptoms calculated to lead one to suppose she had disease of the ovary. These mistakes might have been avoided by placing the patient under an anaesthetic while making the examination. I need scarcely remark that in examinations, as well as operations, a competent assistant should administer the anaesthetic. No physician should be so careless of his reputation as to attempt to administer any anaesthetic to a patient without the presence of a friend. A lady's imagination is so much affected, in some instances, by the anaesthetic that the physi- cian might be accused wrongfully by her of improper familiar- ities, had he not a friend present to prove his innocence. In conclusion of this subject I will say, that in case the patient refuses to submit to as thorough an examination as the physician thinks necessary, he is perfectly justified in not prescribing for the case. By attempting to prescribe for cases with an imperfect knowledge of them, the physician is almost sure to lose reputation, and the patient loses valua- ble time in many cases By being decided about the matter, the physician generally commands the respect of the patient, and his success will be the means of more extended usefulness. Conjoined manipulation, previously mentioned, is made by introducing one or two fingers of one hand into the va- gina until the cervix uteri is felt, and then pressing the * Ziernssen's Cyclopaedia, Vol. X. 30 EA TON ON DISEASES OF WOMEN. fingers of the other hand down into the pelvis from above, pressing just above the pubis, and carrying the abdominal walls downwards before the fingers into the pelvis. In this way the position and diseases of the uterus may sometimes be diagnosed. In cases of enlargement of the uterus from tumors, or in pregnancy, the extended palm of the hand is laid upon the hypogastric region, in making this examination, instead of pressing down into the pelvis. Rectal examination is some- times necessary to determine the diagnosis of disease in the pelvis. This is especially the case in the diagnosis of retro- version, cellulitis, recto-vaginal hematocele, and some of the diseases of the ovary. The student should also bear in mind that hemorrhoids, fissures of the anus, tumors in the rectum, prolapsus of the bowel, etc., may simulate uterine disease or displacement. The second finger should ordinarily be used in making a rectal examination, as it is longer than the other fingers and consequently enables us to reach higher up in the bowel. The finger should, of course, be well smeared with vaseline or some oleaginous substance, as in making a vaginal examination. In making a rectal examination the patient should lie upon her side, with the thighs flexed upon the abdomen. Over the patient should be thrown a cover. There is no need of any exposure of the person in these examinations unless we have reason to suspect fissures of the anus from having hemorrhage from the rectum and finding no hemor- rhoids, and then the parts can be seen through the slit in the cover. In the office we have a cover always- at hand about two-thirds as large as a sheet, with a slit about five inches long in its center. A slight opening may be made in a sheet and be kept, at the house by the patient when Ave make visits to her there, in cases requiring frequent examination. An ordinary sheet may be used for a cover in an emergency. MENSTR UA TION. 31 CHAPTER III. NORMAL MENSTRUATION, AXD AMENORRHEA. The term amenorrhoea signifies the absence of the usual monthly menstrual flow in women of proper age. where the suppression is not due to pregnancy. The menstrual flow, or catamenia, commences with girls in this country usually from the fourteenth to the sixteenth year of their age. though some instances of the appearance of the flow at ten or twelve years of age are observed, especially in the Southern States. Isolated cases have occurred of menstruation at even an ear- lier period. The age when the menses cease is called the climacteric period, and occurs at about forty or fifty years of age, though exceptional cases have been known of their cessation permanently as early as twenty-eight or thirty years of age — these cases of early cessation being those who com- menced exceptionally early. Still, as a general rule, the girl commences to menstruate at about fourteen years of age, and continues to menstruate each twenty-eight days till reaching the age of about forty-five or forty-eight years. Sometimes the commencement of menstruation is delayed till the age of seventeen or eighteen is reached ; seldom, however, without showing evidences of impaired health, causing the propriety of denominating the case one of amenorrhoea. It may com- mence at the proper time, and continue for months or years regularly, and cease from various causes. This complete amenorrhoea usually produces grave effects on the system. Again, we may have only a slight show at each monthly period. This condition is called partial amenorrhoea. The quantity of menstrual flow and its duration varies greatly in different women, some only soiling three or four 32 EATON ON DISEASES OE WOMEN. napkins, others ten or twelve ; some have the flow to last only two or three days, others six or eight; hence, a condition that would be amenorrhoea in one woman, would be a full menstruation in another. The physician should learn the peculiarity of his patient in this regard at first, if possible, that he may better judge the proper amount that should be discharged. The interval also varies much; some menstruate every three weeks, others every six weeks, and are healthy; but these are exceptional cases. Another class of exceptional cases are those Avho never menstruate, and are still in good health. This class is exceedingly small. Symptoms. In addition to the absence of the usual menstrual flow, we have various symptoms manifesting themselves in amenor- rhoea. First, pain in the back and loins at about the time the menses should occur; nausea, produced from sympathetic nerve action, occasioned by the congested condition of the uterus, resulting from the failure of menstruation; acute or chronic inflammation of the uterus; anaemia, sometimes result- ing from the vitiated sanguification produced from the general derangement of the digestive and assimilative process ; head- ache, dizziness, lassitude, the white tongue, palpitation of the heart, shortness of breath, loss of appetite, and a general atonic condition of the system. This latter condition is known as chlorosis. Another symptom which has been too little recognized by authors is congestion of the kings, and is so frequently a con- dition resulting from amenorrhoea, that I am surprised that more has not been written on the subject. I have frequently been consulted in cases that were supposed to be phthisis, without any doubt (cases Avhich had been so diagnosed by sev- eral physicians), where the cough and emaciation had gradually increased for two or three years, and, in one instance I recall now to my mind, over six years, where I found the history AMENORRHEA. 33 of the case showed that amenorrhea had been the cause of all this trouble, and not a result of this cough and chlorosis; and I believe, in every case of this kind that I have had the treatment of fully, I have succeeded in establishing men- struation, and obtaining entire relief from the cough, with great increase in flesh and an entire restoration of strength and health. Hence, I would be emphatic in calling the atten- tion of the physician to the congestion of the lungs as one of the prominent symptoms of amenorrceha. I believe many a young lady has filled her grave prematurely for the want of proper attention to the cause of her ailments, where they have been supposed to be constitutional, and were really caused from amenorrhoea. Why authors have failed to make more prominent this resultant symptom of amenorrhoea is more strange from the fact that many physicians, in conversa- tion and in society meetings, have expressed the same expe- rience. The length of time that is necessary for the amenor- rhoea to exist before these symptoms of the general system, lungs, and stomach manifest themselves varies greatly in dif- ferent cases. Some will manifest active symptoms of this kind at once on the suppression of the discharge, while with others the symptoms are delayed several months. More generally we have, within a few weeks, backache, pain in the iliac and hypogastric regions, loss of appetite, dullness, languor, sometimes extreme nervousness, fever, etc., indicat- ing active inflammatory action. This is more likely to be the case if the suppression has been the result of cold at or about the last menstruation. A sense of weight in the pelvis is complained of, with tenderness over the lower part of the abdomen in some instances. In other cases the symptoms are not active, but more moderate in their manifestation. We have the headache and backache only, or dizziness is complained of, with torpid bowels and want of appetite. Other cases show congestion of the lungs as one of the first symptoms, being decided at first and gradually becoming less 3 34 EA TON ON DISEASES OF WOMEN. severe, and still some irritation remaining, with some cough and slight expectoration, increasing from month to month. In cases of entire absence of menstruation, where the flow has never been established and the patient has reached the age of maturity, we usually have the symptoms of general decline well marked, with less prominent symptoms in the pelvis. The digestion and assimilation generally are most impaired in this class of cases, and a general anaemia is often diagnosed carelessly, when the true understanding of the case shows that the retention in the blood of the menstrual fluid, with the consequent irritation in the ovaries and uterus, have caused this apparent anoemia, and the true treatment is to bring on the menstrual flow — not filling the system with iron, how- ever, as has been the practice of the old school for a century past. Absence of menstruation during lactation is not con- sidered amenorrhoea,, but is a normal condition. Anomalous cases, where menstruation is entirely absent, and no injurious effect is produced on the general system, are to be let alone as a general rule. Loewy relates a case where a woman had six children previous to her menstruation, which first appeared at the thirty-first year of her age. We have in these cases, generally, all the external evidences of puberty, with the exception that the breasts are rudimentary ; but, as this is also observed in many who menstruate regularly, it is not peculiar to this class of women. We sometimes have what is termed vicarious menstruation, which indicates a flow of blood from some other part of the body, as the nose, stomach, or bowels. Again, we have a copious leucorrhoeal discharge, which seems to take the place of the regular catamenia. Etiology. The most frequent cause of amenorrhoea is doubtless cold. Getting the feet wet, or being exposed to cold with insufficient clothing at about the time of the menstrual flow, will often cause amenorrhoea, from a sub-acute inflammatory action set AMEXORRHCEA. 35 up in the uterine organs, especially the lining membrane of the uterus. This may cause suppression by means of the temporary occlusion of the neck of the uterus, from the swollen condition of its lining membrane; or the inflammatory action may cause an indurated or thickened condition of the endometrium, or the exudation of a semi-plastic material may prevent the menstrual flow. Doubtless, an anaemic condition sometimes causes delayed menstruation in the young, and may cause suppression as well, as Ave see in cases of typhus and typhoid fevers, and other diseases of debility tending to impoverished blood — especially is this the case in advanced stages of tuberculosis. Psychical influences sometimes produce amenorrhoea. Thus great mental depression or great fright may produce suppression. (See Parviri on the "Influence of the Mind over Menstruation.") Rnciborski and Bohata mention cases of amenoiThoea which may occur from great fear of preg- nancy, in cases of unmarried girls, or women who have been led astray or forcibly violated, and have reason to stand in extreme dread of pregnancy. Again, as Ziemssen mentions, (on page 328, Vol. X), it seems possible for the period to be delayed or fail altogether in women who eagerly desire the occurrence of pregnancy, and who look for the appearance of the menses with great mental agitation, from fear of being barren. Some cases of amenorrhcea seem to result from an en- tire absence of sexual strength, there being no sexual passion. This want of strength, or torpidity, of the sexual functions seems to result from close confinement in convents, the asso- ciation with females only, hard study, so as to divert all the nerve force to the head at the expense of the sexual system. The imperforate hymen, atresia of the vagina, or cervix uteri, absence of vagina, uterus, and ovaries, of course would prevent menstruation. These malformations and accidentally acquired or congeni- tal deformities may exist, and the physician be in ignorance of 36 EATON ON DISEASES OF WOMEN. them for a time, as he is not justified in making a physical examination of a young lady patient suffering from amenor- rhoea, until some remedies have been used to establish the function. After they fail to produce menstruation when given for a considerable length of time, and the health of our patient is greatly impaired, we may proceed to make a phys- ical examination of the generative organs. Some patients suffering from this difficulty are troubled with severe neu- ralgia, not only affecting the uterus and ovaries, but the head, face, and sometimes the stomach ; and some have hysterical convulsions. These conditions are usually considered results of the amenorrhoea; but the nerve symptoms, as well as the amenorrhoea, may be due to spinal difficulty, meningeal or otherwise. Prognosis. The prognosis of these cases is usually favorable, though it is grave and unfavorable when occurring in connection with a case of phthisis. We are to bear in mind, however, that the symptoms of phthisis are sometimes resultant from the amenorrhoea, and may disappear by curing the suppression, if there be not actual disorganization of the lung substance. If the case show's only chronic bronchitis, we make a favor- able prognosis if the amenorrhoea preceded the cough. Much must depend upon the complications of the case as regards prognosis. Treatment. The treatment of amenorrhoea must be adapted to the va- rious conditions of the particular case in hand. Recent cases of suppression, caused from cold, generally require Aconite. Bell, is indicated if there is much weight and pressure in the lower abdomen. Arsenicum Alb., if there is alternating heat and chilly feelings, with thirst. Puis., if there is pain in the uterus and ovaries of an intermittent character. AMENORRHEA. 37 Cimicif., if the pain is in the ovaries or runs down the thighs. Bryonia, if the pains are sharp and darting, and worse on motion. These remedies, conjoined with the warm foot and hip bath, repeated daily, are generally efficient in restoring the flow. Cases that exhibit great debility, especially after severe illness, will generally require China, Merc, Nux, etc. Macrotine is sometimes useful in chronic cases. Where the difficulty has been of several months' standing in married ladies, and also in case we may have any reason to suspect pregnancy, in married or unmarried, the physician should be careful to make a clear diagnosis of the absence of this condition before continuing treatment. When fully con- vinced there is not pregnancy, we may proceed to use elec- tricity, placing the positive electrode over the pelvis, and the negative to the spine, passing it up and down the lower part of the back for five or ten minutes, using only a, mild current; or we may introduce directly into the uterine cavity a me- tallic electrode, made much like the ordinary uterine sound of Simpson, to which is attached the positive pole of the bat- tery, the negative applied to the spine as before. (See cut of uterine electrode, in chapter on Hypertrophy of the Uterus.) This may be repeated, if necessary, in three or four days, using always a very mild current of electricity. Mustard sinapisms to the small of the back and over the hypogastric region are often very efficient. In those cases that are obstinate I would rely upon Puis. 3 X or Macrotine 3 X every three hours, giving occasionally, for a day or two, China, Merc., or Ars., while w T e interrupt the Puis, or Mac. for that length of time. Cases caused by fright, I may say, always demand Aconite, except in a few that show decided tendency to twitching of the muscles and restlessness, where we may find Ignatia, or Verat. alb., indicated. In case of imperforate hy- men, of course, we should proceed to make an incision, and 38 EATON ON DISEASES OF WOMEN. evacuate the menstrual blood that has accumulated in the vagina. This is a simple operation, and requires no special remarks, except, perhaps, that we must remember to insert into the opening we have made a wad of lint or cotton smeared with vaseline, so as to prevent the reuniting of the Fig. No. 4.— Combination Battery. This is a combination of ii thirty-cell Galvanic Battery ami a No 3 Faradic Buttery. The above cut shows the method of putting the Battery in action by raising the cells. In application, either the slow or the rapid interrupter of the Farndic apparatus can, by simply moving a switch, be made to act as an Automatic Rheotome, for interrupting the Galvanic current. In certain in- stances this combination of the two Batteries in one case is of great advantage. incised hymen. The adhesions in the neck of the os uteri may sometimes be broken up with the uterine sound. When this can not be done, we may insert into the neck of the uterus, through the os, if it is perceptible, or, if not, then where it should be, a curved trocar, passing it in till we are AMENORRHEA. 39 sure we have reached the cavity of the body of the uterus, being careful not to go too far, when, upon withdrawing the stylet, we will generally have a flow of menstrual fluid through the canula. I would advise the leaving of the canula in the uterus two or three days, having the patient main- tain the recumbent position. The canula may be retained by means of a wad of cotton placed against the end of the canula in the vagina, and retained with a T bandage. Of course, these wads of cotton should be removed, and replaced with fresh ones, three or four times a day. In about three days remove the canula, and daily pass the uterine sound through the opening, having it well smeared with vaseline before it is introduced. This should be continued a week or so. In case of absence of the uterus, or ovaries, w r e can do nothing. Fortunately these cases show small indications of woman- hood, being angular in build, w 7 ith rudimentary breasts, a. coarse voice, and generally suffer little, or none at all, from the absence of menstruation ; but in cases of well-formed uterus and ovaries, with occlusion of the neck, attresia of the vagina, or imperforate hymen, it is quite different. Some cases of delayed menstruation show no signs of general derangement of the system. On the contrary, they appear as healthy as any one ; and we are consulted by the mother for fear of serious consequences. Generally, in such cases, I would recommend Puis. 3 X , a powder three times a day, with horseback riding, change of air, etc., which generally will set the matter right in a short time. Should there be any serious symptoms arising — such as slight cough, shortness of breath, dyspeptic symptoms, and the like — the ca&e should receive careful attention till the menstruation is established; for until then our patient is in imminent danger. The prepa- rations of iron I would not recommend, as I have found the remedies already suggested much the more efficient. In fact, I never observed good effects from Iron in these cases. The 40 EATON ON DISEASES OF WOMEN. leucorrhcea, that sometimes seems to take the place of the menstruation, is not to be stopped by astringent vaginal injec- tions, as is so often done by the allopaths ; but we are to consider that the leucorrhcea is a symptom of the inflamed condition of the endometrium, or vagina, and that remedies to relieve the inflammation will not only restore the mens- trual flow, but will also cure the leucorrhcea as well. Warm clothing, especially to the lower extremities, is to be insisted upon; suitable bathing and exercise are not to be forgotten. Going into society is sometimes beneficial. Changing the res- idence from city to country, or vice versa, stopping hard study, using sea-bathing or rowing, and having cheerful company, etc., with assurance of speedy relief, will do much to restore the normal flow. In those cases where the fear of pregnancy seems to be the cause of the suppression, I know of no rem- edy more efficient than blanks of sugar of milk, with the assurance of the physician that they will certainly bring on menstruation (if the patient has confidence in her physician, and pregnancy does not really exist). Hysteria in these cases is treated as in others, coupled with the proper remedies to relieve the suppression. Caiitliarid.es is sometimes a useful remedy in amenor- rhoea, given in low dilutions. The indications for its use in these cases are weakness, irritation of the bladder or urethra, and especial weak sexual strength, absence of all sexual desire, stinging pain in micturition, etc. MENORRHAGIA AND METRORRHAGIA. 41 CHAPTER IV. MENORRHAGIA AND METRORRHAGIA. The excessive loss of blood at the menstrual period is called menorrhagia. In these cases we have, generally, not only an excess of quantity, but also excess in the duration of the flow. It comes on usually without pain; but if the patient is much exposed to cold during the first part of the flow, we may have a temporary cessation, followed by some forcing-down pains to expel clots that have formed in the uterine cavity. The patient is generally much exsanguined, and shows evidences of debility. In menorrhagia we may have, and usually do have, vari- ous complications, such as tenderness over the hypogastrium and one or both iliac regions, a sense of weight in the pelvis, pain in the small of the back, nausea, headache, etc. These symptoms are common, however, to most uterine difficulties, and are not pathognomonic of this particular disease. Here the excess of flow at the menstrual period is almost the only distinctive pathognomonic symptom. If the flow occurs at short, irregular intervals, occurring between the periods of menstruation, it is termed uterine hemorrhage, or metror- rhagia — a difference of name, with no great difference of con- dition ; but it is well always to draw careful lines in medical nomenclature, as it is only in this way that one physician can, by a name, communicate to another the condition of his patient. We must bear in mind that a free menstrual flow is a conservator of health, and realize that nature is a wise physician, and makes no mistakes, and always tries to rectify those of others. Hence, we should be slow to interfere with active agents to suppress the discharge that is, at best, but a 42 EATON ON DISEASES OF WOMEN. symptom of other ailments, though given, by common con- sent, a distinctive name. Htiologjr. The excessive flow in monorrhagia is due, in some in- stances, to overwork ; again, from a too sedentary life, caus- ing impoverishment of the blood. An inflamed condition of the uterus, in its sub-acute form, tends to promote this difficulty. This is favored by miscarriages, and we often find this disease as a sequela of abortion. Neglected catarrh of the vagina and uterus also favors monorrhagia. Small granula- tions in the neck of the uterus, as well as all forms of uterine polypi and uterine fibroids, tend to produce excessive flow at the regular period. The an semi c condition of the blood, as well as great fatigue of body or mind, may greatly aggravate the difficulty. My esteemed friend, Prof. Ludlam,* says : "In the early stages of phthisis we sometimes meet with cases of troublesome, and sometimes dangerous, monorrhagia. As a rule, however, it is more liable to occur in the advanced stages of the disease." This does not accord with my experience, and I have taken some pains to obtain the experience of others, and they agree with me that, in the advanced stages of phthisis, we uniformly have amenorrhoea, instead of monorrhagia ; and we think that if a profuse menstrual flow should be present in any excep- tional case of the advanced stages of phthisis, it would proba- bly be due to uterine polypus or cancer. We have never seen this complication of a case of phthisis. The capillary congestion that is necessary to the produc- tion of monorrhagia may be produced from such a variety of causes that we always have to go back of the excessive flow to the undue capillary congestion, and again back to the cause of this congestion. The cold, that in the first instance produced amenorrhoea, * " Clinical Lectures on Diseases of Women," R. Ludlam, p. 48. MENORRHAGIA AND METRORRHAGIA. 43 may secondarily produce monorrhagia, from the irritation which is left in the mucous membrane of the uterus in some instances. Treatment. The first point in the treatment of monorrhagia is to enjoin and insist upon absolute rest, in the recumbent posture. This will greatly aid us in the treatment, and without it we will generally fail. Cold compresses, in the form of cool, wet cloths, applied to the hypogastrium, and frequently changed, and cool water vaginal injections, may be used with benefit in some cases. The tampon in the vagina may be demanded in those cases that resist ordinary treatment, still it will be seldom that we will see cases of such severity as to demand it, unless the cause is uterine polypi, or a single polypus. We are not to expect to very often see cases that demand these severe measures, and, if the history of the case shows us that the flow has been coming on at times in the intervals of the reg- ular periods, we may know that we have something more se- rious to attend to than ordinary excess of menstruation. The flow should not be arrested simply because it is large, for some plethoric, full-blooded women lose a large amount, and find it consistent with good health. Treatment is only to be used when the general health seems to be seriously affected, or the exhaustion at each flow is so great as to necessitate remedial measures. In the treatment we have also to bear in mind that the excessive flow coming on for the first time may indi- cate a threatened abortion. The particular condition of the general system, and the local condition of the womb, in each particular case, are to be studied in the treatment of each case, Very often cases, following after confinement or abor- tion, have a relaxed condition of the uterus and uterine ves- sels, which require Secale cor., in twenty-drop doses of the fluid extract, given in a drink of warm water, and repeated every twenty minutes till three or four doses have been v 44 EA TON ON DISEASES OF WOMEN. taken. This treatment is applicable also in those cases where polypus is present. This remedy (which to my mind is much preferable to ice in the vagina, or ice to the back or abdomen) may act suffi- ciently in one dose, and, if so, no more need be given. Should a threatened abortion be suspected, and there be present some labor-like pains, Secale 3 X or 6 X will generally stop the contractions of the uterus and moderate the flow. Viburnum Prunifolium l x , given in tea-spoonful doses every half hour, is an efficient remedy in true menorrhagia. Ipecac, China, Ferrum, Nux, are remedies that are calcu- lated to relieve the case if due to debility, general atony, or anaemia. Aconite, Gelsem., or Ars., are the remedies to be studied and used, according to the totality of the symptoms, in those cases, of a congestive or inflammatory character, which are acute. We will do well, in all cases of menorrhagia, to be sure of the nature of the case. A thorough examination is often necessary, though we are justified in omitting it, in recent at- tacks, in some instances. We find the sponge tent to be of great service in some cases. It acts as an efficient tampon, arresting the flow, and, by dilating the cervical canal, we may find the cause to be a polypus, or small granulations in the neck of the uterus. If granulations, their vitality is destroyed by the tent, and they generally will fall off with the use of very little force, and sometimes with none at all. This effect of the sponge tent is very evident in those cases where it is allowed to remain for eighteen or twenty hours, and another immediately inserted and allowed to remain for the same length of time. The tampon most convenient to be used in the vagina I have found to be the elastic rubber bag, with tube and stop-cock (English or French manu- facture). The American rubber has very often disappointed me in leaking the air and collapsing. Of course, the vagina MENORRHAGIA AND METRORRHAGIA. -45 may be tamponed with old cloths or wads of cotton, but the rubber big, or colpeurynter, is much the most convenient and desirable. The use of the colpeuiynter, or air bag, is called colpeu- rysis. Dr. Carl Braun,* assistant physician at the lying-in clinic at Vienna, is the inventor of this tampon. The colpeu- iynter, as invented by Dr. Braun, consisted of a vulcanized gum elastic bag, fitted into a small, hollow cone of horn. It has since been modified so that the elastic bag is attached to and is continuous with a tube of the same material 18 inches or more in length. To this tube a stop-cock is attached, which retains the air. The length of the tube makes it more easily inflated, and more convenient than the original instrument. Merc, Iod., Br?/., Cal. carb., Cimicif., Hamamel, Phos., Trillium, etc., may sometimes be homoeopathically indicated in menorrhagia or metrorrhagia. (See works on Materia Medica for special indications.) Uterine polypi, if present, must, of course, be removed. *"Klinik der Geburtshilfe and Gynsekologie, " Vol. I, page 126. 46 EA TON ON DISEASES OE WOMEN CHAPTER V. DYSMENORRHEA, OR PAINFUL MENSTRUATION. Dysmenorrhea is a term used to signify painful men- struation ; but it is not all pain occurring at or about the menstrual period that should be called dysmenorrhcea. Neu- ralgia of the ovaries is a notable instance ; here we have severe pain in the ovaries, one or both ; it occurs in some instances only at the menstrual epoch, still is neuralgia, and should be so designated. The true dysmenorrhceal pain is in the uterus, coming on in paroxysms, as a general rule, simu- lating the pains of threatened abortion, while the ovarian neu- ralgia is continuous and darting. The throbbing, tense pain is indicative of ovaritis, and is located in the iliac regions. Authors generally seem to consider that the condition of the uterus in dysmenorrhcea is one of inflammation, either in the uterine muscular tissues or in the internal membrane. I differ somewhat, and claim that more cases of dysmenorrhcea are caused from retro- or ante-flexion, stenosis, or partial atresia of the cervical canal, than from any other causes; though it is true that the inflammation in some cases, without doubt, pro- duces the pain in the expulsion of the menstrual flow. It also tends to the formation of false membrane, that is formed in some cases, and thrown off at each menstruation from the mu- cous membrane lining the uterus, called nidation. Generally, the pain commences several hours, and in some cases two days, before any flow is established. The agony suffered in some of these cases is terrible. Besides the severe pains in the uterus, we may have, in addition, pain in the ovaries, great tenderness over the hypo- gastric region, and sometimes this tenderness extends over the entire abdomen. This is the case where there is present DYSMENORRHEA. 47 peri-metritis. The poor patient can not sleep or eat. If food is taken into the stomach, it is generally rejected very soon. The headache accompanying these cases is very distressing. Pain in the back is also often a distressing symptom. Cold hands and feet, with great restlessness and an irritable tem- per, are generally symptoms in these cases. Dysmenorrhoea is peculiar to women who are sterile or unmarried, except in a very few instances, and in those ex- ceptional cases it is less severe than in the barren woman ; for after the uterus has contained a child or foetus of consid- erable size, it is more tolerant of the presence of the effused fluid, and the stricture produced in the neck of the uterus by flexions is not so tight. The nervous symptoms are more prominent in some cases than others, but are doubtless de- pendent upon the temperament of the patient, and are not to be considered as a separate or peculiar form of the disease, if I may so speak, for I consider dysmenorrhoea only a symp- tom of other difficulties causing these peculiar symptoms. Differential Diagnosis. The only troubles likely to be confounded with dys- menorrhoea are, threatened miscarriage and some cases of uterine polypi. The history of the case will generally show, that the menses have been suppressed for a time, wholly or in part, in cases of pregnancy. This suppression, however, may have been months before, and may have continued three or four months, and the flow become again established and appear regularly, though usually too profuse and long contin- ued, till the seventh or ninth month arrives from the time the suppression commenced, or, in other words, till complete ges- tation would have been accomplished had the foetus lived. But the history of the case shows that a partial detachment of the placenta had occurred early in the pregnancy, causing the death of the foetus, but that it was retained in the uterus till full term had arrived. 48 EA TON ON DISEASES OF WOMEN Such cases may have a history of pain similar to that our patient is now suffering, at a few preceding menstrual periods; but we will note that it was not so, previous to the suppres- sion. Some uterine polypi cause much suffering at the men- strual period. These cases may be recognized by having had easy menstruations at some early period of their lives, gener- ally up to within two or three years, and by physical examin- ation we discover the presence of the polypi, and clear up the diagnosis. Etiology. It is probably a fact, that a less number of cases of dys- menorrhoea are cured than of most other ailments peculiar to women. This is accounted for, in my mind, from the fact that I have found the cause of this pain in menstruation to be flexions of the uterus, or stenosis, in many cases. They may be either ante- or retro-flexed ; either condition may cause the difficulty. This is explained in the fact that the flexion causes almost the closure of the cervical canal at the point where the flexion is most abrupt. There is generally a point in these cases of flexion where the canal turns almost at right angles. Flexion also tends to produce irritation, tenderness, and abnormal congestion at the menstrual period. I say abnormal, because a slight increase of the turgescence or vas- cularity of the endometrium is a normal condition at the menstrual epoch. But when this normal congestion is increased by previ- ouslv existing increased vascularity, we have, as a result, considerable thickening of the mucous membrane of the uter- ine canal, and this tends to obstruct more fully the cervical canal at the point where the flexion had nearly closed it. Consequently, when the body of the uterus becomes filled with menstrual flow, the uterus naturally takes on contractile action, and we have the intermittent pains of true dysmen- orrhoea. These contractile pains of the uterus that is flexed, tender, and congested, are very severe, and continue, till the DYSMENORRHEA. 49 constriction is forced open, and the contents of the uterus is forced out. This consists often of clots (the retention of the effused blood having caused them to form), and their presence adds to the necessity for severe expulsive pains to force them out. So we may see that the process corresponds very nearly to that of ordinary miscarriage, and is often more severe. Again, in the membranous form, the cause of the pain we have, is the necessity of severe enough uterine contractions to rup- ture the membrane, and peel it off from the intra-uterine surface; this process is termed denidation, or nidation. The student will readily comprehend the cause of the severe pain previous to the discharge of any menstrual fluid in these pa- tients. In some cases the flow commences moderately, with little pain, and, after a day or so, the pain commences severely. These pains are produced by the contractions necessary to expel the membrane, the blood in the slight amount that has been already expelled having passed out between that portion of the membrane already detached and the intra-uterine surface. The investigations of Engelmann* show that this mem- brane is the upper layer of the proliferated mucous mem- brane in a state of fatty degeneration, that is exfoliated, and thereby a hemorrhage is occasioned ; hence we have more liability to the formation of clots in these cases than in nor- mal menstruation. This process is termed denidation by Dr. Aveling,f and he compares it to parturition, and terms the membrane thrown off the nidal decidua. Chronic ovaritis may be a cause of pain at this period, producing not only more sensitiveness in the organs, but from slow inflammatory action causing a thickening and tough- ening of their fibrous coat, and consequently more difficult ovulation. Or we may have a rheumatic condition of the general system, which may so affect the ovaries as to pro- *Strickler's "Med. Jabrb," page 135. tObstet. Jour, of Great Britain and Ireland, July, 1874. 4 50 EATON ON DISEASES OF WOMEN. duce painful menstruation; but I am inclined to the belief that in the great majority of cases displacements of the uterus, with some degree of endo-metritis and stenosis of the cervical canal, are the main causes of dysmenorrhea. Prognosis. This must depend much upon the willingness of the pa- tient to submit to proper treatment. As the patients usually feel tolerably well during the interval between the men- strual periods, they are very often disinclined to pursue the necessary treatment. In this case an unfavorable prognosis is the best we can make. But, in case we may have several months to treat the case, the prognosis may be favor- able. We are usually justified in prognosing sterility, if let alone, in cases that are severe; with proper treatment we may, in most cases, expect that pregnancy will be possible. Treatment. Whoever achieves success in the treatment of this diffi- culty, may feel that he is equal to the task of treating almost any of the diseases of women, for to be successful, the phy- sician must show power of careful discrimination in diag- nosis, decision of character and will, in proceeding to do that for the case which it seems to demand. Perseverance in treatment, proper encouragement to the patient (that he may have her full co-operation), is necessary. This is all impor- tant, as it is generally the case that the patient enjoys quite a good degree of health in the intervals between the men- strual periods, and it is absolutely necessary that the treat- ment be continued thoroughly during these intervals. Much care and judgment need to be exercised in the selection of the remedies, and in the surgical or mechanical treatment used. Hence I deem the skill demanded in these cases equals any that is required in any case of gynaecology. These cases are the more embarrassing on account of their being found DYSMENORRHEA. 51 mostly in those women who have either never been married, or have never borne children, and hence are more averse to the making of the necessary vaginal examination, and are much more troublesome to treat, even if they consent to an examination. They are likely to be careless about regular calls upon the physician, and as this class of patients are usually desirous of concealing from the public," and some- times even from friends, the fact of their having any ailment whatever, they are very annoying, and, as I said before, require all the skill at any one's command to carry them to a successful issue. Remedies During: the Attack. When called to a case of severe dysmenorrhoea the in- tensity of the sufferings demands something that will at once relieve the pain and vomiting. For this purpose, perhaps the most efficient remedies are the inhalation of Sulph. Ether, or Chloroform, with warm foot and hip baths — of course, using the Ether or Chloroform after the patient has taken the bath, and is nicely wrapped in bed, as anaesthetics are never to be given to any one while in the erect or semi-erect posture. The hypodermic injection of pure water in the arm or limb will sometimes give instant relief, and is prefer- able to the use of Morphia in any manner. Sometimes Puis. 3 X gives relief; again, Secede 3 X , or Vi- burnum l x , will be most efficient. Secale or Viburnum being indicated for those pains that are entirely confined to the uterus, of an intermittent character, while Puis, is indicated in cases where the ovary is also largely affected. Cimicif. Rac. gives, usually almost instant relief to the ovarian pains and tenderness, which sometimes continue after the contractile pains of the womb have ceased, and the flow has been established. These remedies, as indicated, will re- lieve, giving Aconite, Ars., or Bell., according to their general indications so well understood, in these cases, which are clue, 52 EATON ON DISEASES OF WOMEN. evidently, from their history, and all we can learn, to an acute congestion of the uterus, which sometimes occurs, and produces severe menstrual colic ; but they are not cases of true dys- menorrhea as generally understood, any more than a slight cold in the head is catarrh. Attacks of menstrual colic, from acute congestion, will be cured with these remedies, the same as such cases are cured where there is no menstrual colic, and we may expect little trouble with this class of cases. If the history of the patient shows the attack to be probably due to acute congestion, we may have no occasion to make a physical examination. The remedies I have indi- cated will cure the case promptly and efficiently. But the case whose history shows years of monthly suffering, will not be cured with these remedies; we must use other measures and remedies, or have a failure. If flexion of the uterus is the cause, we will only be able to detect it, in most cases, with the uterine sound. When discovered, of course, it is to be rectified as in other cases of flexions, but in these dysmenorrhoeal patients we have more trouble in introducing the sound, as here we will find a narrowing of the neck of the uterus at some point, generally at the internal os. Much patience may be neces- sary to accomplish the introduction of the sound, and, in some cases, it will be found impossible. The next thing to do, on failing to introduce the sound, is to introduce into the cervix uteri a sponge tent, and follow by another in about six hours, keeping the patient in bed. In introducing the tents press upon them for some minutes, that they may follow the crooked canal, and as they dilate expand the portion that is constricted, and enable us on the removal of the second tent, to introduce the sound into the body of the uterus, and detect the flexion, if one exists; and, if there be no flexion, and we find the uterus in situ, we will have prepared the uterus for further treatment in the way of curing the dis- ease of the internal surface of the organ that has caused the D YSMENORRHCEA. 53 dysmenorrhea, by exfoliating the dysmenorrhoeal membrane, or obstructed the natural outlet of the body of the womb by the congested condition of the endometrium. This diseased condition of the endometrium is usually present and needs treatment in these cases, whether we have a flexion or not. Hence, it will be seen that I consider the use of tents to be very necessary in the treatment of most cases of true obstructive dysmenorrhoea. The incision of the neck of the uterus, as some recom- mend, is to my mind very objectionable, and as I have never found it necessary in over twenty years of practice in this line, during which time it has been my lot to treat very many cases, I feel that possibly incisions of the cervix uteri may be abandoned. Incisions, in order to be successful at all, must be followed by dilatation by some means ; if not by tents, then forcibly and abruptly, by means of in- struments. It seems our Creator has made the cervical canal in such a manner as to be expanded without danger, even to immense proportions, as seen in parturition. In abortion it also has to dilate, which it often does with but little pain. The sponge tent seems to me to act the most in confor- mity to the process nature has established ; that is, it causes gradual dilatation. Should we incise the neck of the uterus, and simply leave it to heal without any attempt at dilatation, the circumference of the canal will be lessened instead of increased ; its dilatability will be diminished on account of the cicatrix left. From the wounds made by incision we have danger of the absorption of pus or muco-purulent matter, which is abun- dant in some of these cases. Besides, I see nothing to be gained by incisions, and much greater danger is incurred than with the use of the sponge tent. 54 EA TON ON DISEASES OF WOMEN. Subsequent Treatment. After a good degree of dilatation of the entire cervical canal is accomplished, I proceed to apply directly to the intra-uterine surface a Solution of Iodine, making it with five grs. Iod. Res., fifteen grs. Potass. lodid., to one oz. of water. This should be further diluted with Avater if it produces any considerable amount of smarting. This is conveniently ap- plied with Palmer's uterine applicator. These applications I repeat once in three days, keeping the cervix dilated by passing a large bougie daily through the cervical canal. Omit the treatment four or five days previous to the time for the commencement of the next menstrual period. Vaseline, or Bell, ointment, may be used through the applicator in some cases with advantage. Internal Medication. Probably there is no remedy so efficient as Phos., given in the 2 X or 3 X attenuation twice a day, and continuing the treatment for several months ; especially is this efficient in the membranous form of dysmenorrhoea. Prof. Carl Schroeder, of Bavaria, says : * " The fact that membranous dysmenorrhoea has been observed in poisoning by phosphorus, favors the view that a profound fatty degen- eration, even in a normal mucous membrane, may bring about the membranous exfoliation." Cat. carb.y Graf., Iod. of Merc., Phytolac., Cocculus, or Caidophyllum, etc., may sometimes be of much service, when used in accordance with the totality of the symptoms. Treatment of Rheumatic Dysmenorrhoea. In the rheumatic condition of the system we will do well to try the effect of Bry. or Rhus, Colch., Kali hyd., etc., according to the peculiarities of the case and the homoeo- pathic indications for their use. * Ziemssen's Cyclopaedia, "Diseases Female Sex. Organs," p. 335. DYSMENORRHEA. 55 Besides giving Phos. in the membranous variety of dys- menorrhea, we must bear in mind that the exfoliation of membrane is the result of inflammatory action, and endeavor to rectify any cause producing this irritation, and treat the case very much the same as we would if purely a case of chronic endo-metritis. Remedies Occasionally Indicated. Bell., Coff., Cham., Coloc., Graph., Plat., Sulph., Ignat., Nux v. Belladonna is indicated in dysmenorrhoea with flushed face, dullness of the mind, fullness over the eyes, intolerance of light, pain in moving the eye-ball, feeling as if the contents of the pelvis would pass out of the vagina, severe bearing down in the pelvis, etc. Coff., where the flow is full but painful; loss of appetite, sleeplessness, nervousness, irritation of the bladder, etc. Cham., where there is colic in the bowels, as well as pain in the uterus ; discharge comes in clots, restlessness ; breasts are tender and swollen. Graphites, where there is chilliness, with dull headache, heartburn, constipation before, and diarrhoea after, the menses. Platina, where the ovaries are enlarged or tender, with extreme nervousness, depression of spirits, severe cutting, labor-like pains, dark-colored menstrual flow, etc. Sulphur. The catamenia are too profuse, with pain in the small of the back; at times the flow ceases, and again comes on profusely ; burning in the vagina, etc. Ignatia, where the menses are scanty and dark-colored ; the pain amounts almost to spasms ; palpitation of the heart, fain tn ess, etc. Nux Vomica. Severe pain in the back, constipation, want of appetite, cramping pains in the abdomen. 56 EATON ON DISEASES OE WOMEN. CHAPTER VI. VIC A RIO US MEN ST R UA TION. By vicarious menstruation is meant the discharge of blood from some of the mucous surfaces other than the uterine, at somewhat regular intervals, accompanied with arrest of the normal catamenial flow. These hemorrhages sometimes take place from the nose, called epistaxis ; from the stomach, called hematemesis ; from the lungs, called hemoptysis ; or from the bowels, either with or without the presence of hemorrhoids. (Leucorrhoea, diarrhoea, etc., also sometimes seem to be vica- rious of menstruation.) These discharges seem to relieve the system, so that the patient suffers much less than she otherwise would from the suppression of menstruation. These hemorrhages, of course, occur at other times and from other causes, and are only con- sidered vicarious menstruation when occurring in connection with suppression of the regular flow. When coming on from other difficulties or diseases, they are ordinarily to be ar- rested, while in the case troubled with suppression they are rather to be encouraged (within reasonable limits), and viewed as conducive to health rather than disease. The patient is often greatly alarmed at these hemorrhages, until they are explained to her. These discharges greatly relieve the hypersemic condition of the circulation induced by the retention in the system of the material usually cast off at the menstrual flow; and, if not relieved in some way, would soon manifest the more dangerous symptoms of congestion of the brain, lungs, stom- ach, pelvic organs, or bowels. Frequently, in these cases, the uterus appears torpid, showing no increase in size, no VI CAR 10 US MENSTR UA TION. 57 heat or congestion, showing that the fault lies in the normal periodical nerve excitement in these parts, which invites the excited circulation of the blood to them. In other cases, the congestion, heat, and enlargement of the uterus is marked, showing that there is a normal excitement of the circulation ; but the flow is absent through some abnormal condition of the endometrium, generally that of thickening, by exudation of a plastic material on its inner surface, causing the obstruction of the flow, from its close adhesion to the interior surface of the uterine mucous membrane. This condition is not of very infrequent occurrence, as a result of mild inflammatory action, as shown by the throwing off of stringy, semi-organ- ized, membranous material, from cases affected with a mild endo-metritis not always being highly enough organized, or not adherent enough, to prevent the menstrual flow, but peeling off and being discharged at the flow and during the interval. This, of course, might as well be explained under the head of Amenorrhoea. In some cases an indolent ulcer on the leg or other part of the body seems to act as a vica- rious menstruation, so that the patient is relieved from con- gestive symptoms resulting ordinarily from suppression. Why it is that in one case the discharge takes place in one patient from the lungs, in another from the stomach, bowels, or nose, we can not explain, unless it be that these membranes are, in the particular patient, in a condition of slight irritation, and the blood oozes through the minute capillaries more readily, on this account, in this particular locality. Vicarious menstruation has been known to take place from the skin, gums, nipples, etc.* (See Edinburgh Med. Journal, 1866; London Lancet, 1872; and Transactions Med. Society Bombay, 1872.) These instances are, however, of extreme rarity, and are only worthy of remark on account of their possible occurrence in the practice of any physician. * Barnes on "Diseases of Women," p. 182. 58 EATON ON DISEASES OF WOMEN. Treatment. As stated before, the discharge of blood vicariously of menstruation is a relief to the system if within moderation, still it may be so profuse as to constitute a hemorrhage, and be dangerous to life if not restrained. Continual conges- tions and effusions of blood, occurring in those membranes not normally so affected, may develop serious ulceration, and it becomes the physician's duty to carefully diagnosticate between the discharge which is vicarious, and that which is pathognomonic of disease in the part or organ from which it is effused. In the case of the vicarious discharge it is advisable to first establish the normal function before doing more than to restrain the discharge within the bounds of moderation. This treatment may be found under the head of treatment of amenorrhoea, and consists of remedies and means to invite the circulation and nerve force to the generative organs. This is accomplished with Puis., Canth., Macrotis, etc., the use of warm foot and hip baths, electricity passed through the pelvis, or directly through the uterus, by means of the uterine electrode, exercise on horseback, etc. But there are cases where menstruation is arrested from causes somewhat out of the ordinary line, like atresia of the cervix, the presence of large intra-mural fibroids, pregnancy, etc. Atresia of the cervix will, of course, be discovered in an attempt to pass the uterine electrode, which must not be done, however, if there is a possibility of pregnancy. The condi- tion of pregnancy sometimes develops vicarious menstruation ; but not often. It is well to be on the alert to recognize this condition, as active interference would be likely to induce an abortion. We may, however, seek to equalize the circulation of the blood by warmth to the extremities, and using some effort to restrain the hemorrhages by giving Aconite or Ipecac. I am aware that these cases are not recognized by VICARIOUS MENSTRUATION. 59 some gynaecologists as vicarious menstruation, on account of the pregnancy present. If the flow was from the uterine surface or cervix, and occurred regularly each month, it would be menstruation, though pregnancy did exist at the same time, and I see no impropriety in calling a flow from other mucous surfaces vica- rious menstruation, if it occurs at regular intervals, although pregnancy exists. The treatment must be modified, how- ever, as has been suggested. Some cases of this kind may be so difficult of diagnosis as to baffle, for a time, the most skilled physician, owing to the peculiarities in the particular case ; still, the more thoroughly the subject is studied, the less likely will the physician be to fall into errors in treatment. Atresia of the cervical canal, of course, demands an oper- ation ; stenosis requires dilatation. These conditions, as well as those where uterine fibroids are present, must be treated as will be stated under these special heads. Remedies indicated in amenorrhea are usually demanded in these cases. (See Chapter III.) The remedies must act to stimulate strength and activity in the ovaries and uterus in atonic conditions, and to allay irritation when these organs are inflamed. 60 EATON ON DISEASES OF WOMEN. CHAPTER VII. INFLAMMATION OF FEMALE GENITALIA. Etiology. The female genital organs are probably more subject to inflammation than other parts of the body. This is owing to various causes, some of which I will mention. The most prominent one that suggests itself is cold. The open cloth- ing so commonly worn by women offers little protection to the pelvic organs from severe changes of temperature. Especially is cold injurious at or about the menstrual period. The ovaries, uterus, and vagina are at this period congested, so to speak, though the function of menstruation is a physio- logical one, and one that is necessary to the health of the female. Still we may speak of the congestion of the parts occurring at this period, and generally a few days previously. This congestion especially affects the mucous membrane lining the uterine cavity. Cold baths, taken by girls and ladies while menstruating, have often caused inflammation of the uterine organs. I have seen the inflammation of so high a grade from these causes as to endanger life. I have seen it also produce paraplegia, hemiplegia, as well as hysterical convulsions. Sexual Intercourse, which is resorted to by the lower animals solely for the purpose of reproduction, except in one or two species, is resorted to by man as the most common indulgence of his nature, and is frequently the cause of inflammation of the uterus, and, from the irritation and excitement produced, causes also the effects of cold to be more severely felt. The reading of lascivious books, the nature of the asso- INFLAMMATION OF FEMALE GENITALLA. 61 ciations of many of the amusements of society, constipation which is due to not attending to the evacuation of the bowels at proper intervals, tend to produce inflammation of the uterus. This is particularly the case with teachers and schol- ars, who delay the calls of nature for a more convenient op- portunity ; and they soon lose the inclination to evacuate the bowels, and the retention of the fecal matter causes the hard, constipated stool, requiring straining in its expulsion, produc- ing hemorrhoids, and general congestion of blood in all the pelvic viscera. Constant standing, distress of mind, self- abuse, falls, jolts, heavy lifting, careless management after abortions, or confinement at term, lacerations of the cervix uteri, etc., all tend to produce inflammation. It is a fact to be borne in mind that causes which might produce severe in- flammation in one, might not affect another ; but this is also true throughout the whole range of physical ailments affecting mankind. Hence, because one woman, or possibly a class of women, may not receive injury from a particular cause, it does not disprove the possibility of others being affected seriously by it. There is much in the constitution of women, as well as men, to withstand or predispose to disease. The girl of ro- bust parentage, brought up to active exercise suitable for her years and strength, using suitable food and clothing, till she is twenty years of age, will ordinarily endure five times the fatigue that one could endure reared under opposite circumstances, and having parentage broken in health and constitution. Symptoms. The term inflammation indicates heat, or burning, in itself, and the term is used in medicine to indicate a high tempera- ture, tenderness, generally swelling of a part, tissue, or organ. This is true of acute inflammation, and is as applicable to in- flammation of the female genital organs as to any other part of the body, and no more so. 62 EA TON ON DISEASES OF WOMEN. But we have a sub-acute form of inflammation affecting these organs more frequently than other parts of the body, and these sub-acute forms are characterized by a train of symptoms quite different from those produced by acute in- flammation. We will, for convenience, make the following divisions of inflammation as effecting the female genitalia : 1. Acute Inflammation. 2. Sub-acute Inflammation. 3. Chronic Acute Inflammation. 4. Chronic Sub-acute Inflammation. Acute Inflammation. — This sometimes commences with a distin.ct rigor or chill; but this is not always well marked, and in some instances entirely absent. This cold stage varies in duration from an hour or two to ten or twelve hours, when reaction comes on, and Ave have increase of heat, much thirst, dryness of skin, and general symptoms of fever. So far the symptoms might be present in any inflammatory attack, pre- ceded by some congestion, in any part of the body; and even in the various forms of intermittent fever we have a similar array of symptoms as we have in the outset of an attack of acute inflammation of the genital organs in the female. After the lapse of about twenty-four hours we have additional symptoms that characterize this disease, which are not pres- ent in ordinary fevers, or in congestive or inflammatory at- tacks of other parts of the system. These are pain, heat, and tenderness of the vagina and uterus, and, in some cases, fre- quent desire to urinate, accompanied with pain in the urethra of a burning character. If the ovaries are affected, we will have tenderness, with some swelling, of these organs. These urgent, active symptoms are present in cases of acute inflam- mation of any, or all of the genito-urinnry organs, and are present, I may suggest, also, when the inflammation is caused by specific poison (i. e., gonorrhoea!) ; but, in the acute in- flammation of the gonorrhoea! case, these symptoms may be three days or more from the time the first intimations are ACUTE INFLAMMATION. 63 noted till the full development of the inflammation, when we have also the symptoms of a copious yellowish white dis- charge from the vagina, with great swelling of the labia majora and minora. But I will not enter more into detail in the matter of gonorrhoeal inflammation, as its importance merits an entire chapter, and I prefer to give a full descrip- tion of the disease under the proper heading, where it will be found in connection with the homoeopathic treatment for its cure. In the acute inflammation caused from colds, exposure, and, I may mention, sometimes the suppression of eruptions on the skin, we have active symptoms, as I have described, and they point to this disease unerringly. There is no chance to be misled. Soon, in addition to the symptoms of heat, pain, tenderness, swelling, etc., just enumerated as affecting the labia, vagina, uterus, ovaries, etc., we have, within two or three days, a profuse discharge, generally acrid in its character, light yellow, or milky, and in no way to be recog- nized by its appearance from the discharge produced from gonorrhoeal inflammation. There is no way at the present day, so far as I know, to determine by its appearance whether or not the vaginal discharge in such cases is gonorrhoeal or not. We have to note other symptoms than the discharge, to make up a diagnosis. Of course, gonorrhoeal discharge some- times follows impure connection, and, did we know of this exposure, we might be the more read}' to call the disease gonorrhoeal. But let the physician be cautious; much trouble might result to him and others by giving such an opinion. The non-specific inflammation comes on, ordinarily, much more suddenly than the specific; but the symptom of painful micturition is not very prominent unless the disease affects the bladder mainly ; in which case we have none of the ten- derness, heat, and pain in the vagina, nor much of the vaginal discharge just mentioned as occurring when the vagina has been inflamed for any length of time. Hence, this case would 64 EATON ON DISEASES OF WOMEN. be diagnosed as cystitis, and not as acute inflammation of the geni to-urinary organs. We will also have nausea present, in many instances, produced by sympathy with this acute in- flammation of the pelvic organs in the female. Treatment. The treatment of acute inflammation (non-specific) should, in the first instance, be rest for the entire body, warmth to the extremities, a warm full bath, or sitz bath, for ten or fifteen minutes, and when taken from the bath the patient should be rubbed dry, and well wrapped in warm blankets; and repeat these baths once a day as long as the urgent, active symptoms show themselves. The first remedy to be given, and I may say the last also, in many cases, is Aconite nap. This remedy alone usually controls all these symptoms, and will ordinarily carry the case through to a favorable termination, unaided by other reme- dies. We will very often find this remedy to cut short every symptom, and restore to a state of health almost as if by magic, stopping the disease before any discharge has made its appearance. If w 7 e were so fortunate as to be called in the first stage, or rather when we had congestion present, cold- ness, etc., I would prefer Gelseminum or Arsenicum alb., the Ars. being indicated if nausea and vomiting, with thirst, were prominent symptoms, otherwise give Gelseminum. When the second stage is established give Aconite. After the acute stage is passed and we have not succeeded in curing the case, and it passes into a chronic, active inflammation, or a chronic sub-acute form, I would use other remedies, which we will designate under the treatment for those conditions. Sub- acute Inflammation. — The term sub-acute inflamma- tion indicates a grade of inflammatory action that is more mild in its symptoms than acute inflammation. The sub- acute form of inflammation may come on so insidiously as to be scarcely noticed until the disease is thoroughly estab- SUB- ACUTE INFLAMMATION. 65 lished and the patient is much broken down in health, and perhaps consults the physician on account of this general debility, or under the impression that the difficulty is some- thing entirely different from what is really the matter. Etiology. The causes of this disease are somewhat similar to those which produce active inflammation, but owing to the good constitution of the patient, or the small amount of exposure a very acute inflammation is avoided, and in its stead a sub-acute form is established. The sub-acute form is often caused also by the use of cold vaginal injections to prevent conception, and by acid injections for the same purpose. Fre- quent child-bearing is also a fruitful cause of this sub-acute form; neglect of cleanliness, as well as too frequent bathing, may produce the disease. The wearing of hard vaginal pes- saries, as well as rough, brutal copulation by the husband, or promiscuous sexual intercourse, sub-involution of the uterus, and lacerations of the cervix uteri in confinement, also tend to cause this disease. Symptoms. The symptoms of sub-acute inflammation may not mani- fest themselves in the parts affected to any great extent, and in some instances there may be no symptoms that point directly to the difficulty, unless we are aware of the fact that the symptoms indicating sub-acute inflammation are generally in some part of the body somewhat remote from the pelvis, and are caused by reflex nerve action. True, we may some- times have slight tenderness of the vagina or os uteri, or slight tenderness in the ovarian region; but often we have no tenderness. Sometimes we have a slight vaginal dis- charge and sometimes none. On making a physical exami- nation we find the vagina warmer or colder than natural. The secretion instead of being oily and slippery to the feel is often tenacious, and the odor of the vaginal secretion 66 EA TON ON DISEASES OF WOMEN. is nauseous. The os uteri is found enlarged, the length of the uterus, as found by introducing the uterine sound, indi- cates considerable increase of size, sometimes measuring, from os to fundus, four or four and a half inches. Some tenderness is found to be present in some cases, and in rare instances a complete hyperesthesia of the parts is caused from sub-acute inflammation. Still in these cases of ncute sensibility, we have absent those general symptoms of ex- treme heat, swelling, and general fever we have in the acute form. Sometimes we have hot flashes, as the patient de- scribes them. The symptoms that we may expect the patient to com- plain of in sub-acute inflammation of the genital organs in the female are backache, pain in small of back, sometimes at the extremity of the coccyx, pain under the left breast, palpitation of the heart, various dyspeptic symptoms, tym- panites, etc.; with pain in the occiput, heat in top of head, sci- atic pains, general lassitude, weakness of the limbs, sometimes a feeling of weight in the pelvis, sometimes not. It will be appreciated that these symptoms, though more moderate in their action, are nevertheless wearing on the patient, and though the disease might kill slowly, it might kill just as surely as the more active form of inflammation. This sub-acute form of inflammation, when affecting the ovaries or uterus, is one of the most prominent causes of tumors in these organs. Generally we have sterility as another symptom of this disease, and it will probably con- tinue till the disease is cured ; and possibly barrenness may result, and remain after all other evidences of disease have disappeared. Treatment. Aconite, so useful in the acute form of inflammation, is of little use in the sub-acute; here we need Br?/., Bell., Ars., Ars. iod., Merc, iod., Rhus, Ignatia, Nux, Puis., Sepia, etc. These should be selected according to the homoeopathic indi- CHRONIC ACUTE INFLAMMATION. 67 cations in each particular case. (Consult works on Materia Medica.) As to local applications, I will say, my experience justi- fies the use of some local treatment; but not such as has been in use by all gynaecologists of the old school, and, I blush to say, some of our own. I refer to nitrate of silver, nitric acid, strong chromic acid, tincture of iodine, leeches, etc., ad infinitum. We discard all these, in treatment of these diseases. I sometimes, however, apply the Solution of Iodine locally to the os externum and internum, and even to the intrauterine surface. This solution is to be prepared with water and the addition of Kali iodatum in the proportion of three grs. of the latter to one of the former. I usually use the strength of about three or five grs. to the ounce, ap- plied with a camel's-hair pencil every three days. Some cases of sub-acute inflammation of uterus and vagina are greatly benefited by the ball of cotton (to which is attached a string for its easy removal), saturated with equal parts of Tr. Hydrastis and Glycerine, placed in the vagina, well up against the os uteri. It may be noticed that I am not entering into the description of the special inflammations or their treatment, this chapter being intended as general in its application to de- scription and treatment. A more minute description of the treatment of special inflammations of particular parts may be found under the chapters on Vaginitis, Metritis, Ovaritis, etc. \ Warm Water. — The warm water vaginal injection and warm sitz bath are quite generally useful, and, I believe, can in no instance do harm in any form of pelvic inflammation, when used properly. Chronic Acute Inflammation. — There are some cases of inflammation of the pelvic organs that go on actively for a considerable time, having a tendency to progress to the extent of the formation of an abscess or ulceration, in spite of the most active measures we may use to subdue them. The allo- pathic profession have tried the antiphlogistic treatment, have 68 EA TON ON DISEASES OF WOMEN. bled and leeched, physicked, and given remedies the most powerful in depressing the activity of the circulation; and still active inflammation has continued till abscess resulted. The homoeopathic treatment of active inflammation has not al- ways been successful, though much more frequently so than the allopathic. Hence, we have a class of cases to which it seems to me appropriate to apply the term chronic-acute inflammation. Symptoms. The exact time at which an acute inflammation becomes chronic, we are not able to specif}' in hours or days. The symptoms will be a better guide to the proper nomenclature to be applied than the expiration of any particular length of time. I am inclined to draw the line at such time as the general symptoms of fever, general heat, and extreme rapid- ity of the pulse subside in part, and, if it be a week or so after the onset of the active symptoms, and still we have the tenderness and heat of the pelvic organs remaining, the vagina tender to the touch, the labia swollen, tenderness of abdomen in hypogastric or iliac regions, the patient, unrelieved hy proper medication, continuing to present these symptoms with depressed general strength, pulse weak, though often as high as 100 to 120 per minute, temperature indicating from 101° to 103°, tongue generally coated light brown or brownish white, with red tip and edges, papillae elongated, we denomi- nate the case chronic-acute inflammation. Following on in the progress of the disease, we have, in the next stage, those symptoms that are indicative of the formation of pus; such as slight rigors, throbbing sensation in the pelvis, some in- crease of heat, etc. On vaginal examination, we may feel fluc- tuation, usually in the posterior portion of the vagina, the os tender and swollen, the heat of vagina much above the natural temperature, generally accompanied with a copious mucopuru- lent discharge from the vagina. The patient complains of great pain at stool; the most careful manipulation causes great CHRONIC ACUTE INFLAMMATION. 69 suffering. We do not wish to be understood as saying that all cases of chronic-acute inflammation always result in abscess ; but we say that there is a great tendency to the formation of abscess. We also have a class of cases which may be consid- ered chronic in that they are subject to frequent attacks of active pelvic inflammation, they being really cases of sub-acute inflammation, that, owing to cold or exposure of some kind, has caused the acute for a time to supplant the sub-acute, then under treatment; ordinarily, by the natural restorative powers of nature, active inflammation subsides, and leaves the sub-acute form in its stead, there being enough irritation re- maining to attract towards the parts all the impurity of the blood, retard and retain all the degenerated blood corpuscles, thereby aiding in the development of malignant disease, or, perchance, only hypertrophy or areolar hyperplasia of the uterus. The most frequent seat of abscess, when it does form from general pelvic, chronic, acute, or active inflammation, is in the cellular tissue, generally posterior to the vagina and uterus. I can only account for this from the fact that the position of the patient on the back, with the thighs semi-flexed on the abdomen, which is the position usually voluntarily as- sumed by the patient in acute pelvic inflammation, allows the uterus, with weight of bladder and its contents, to press more heavily against the cellular tissue posterior to these organs, and tends to retard more fully the circulation there, and, of course, on this account, gives greater tendency to the forma- tion of abscess in this locality than in the anterior or lateral portions of the pelvis. Abscess forming anterior to the uterus, between it and the bladder, is usually caused from circum- scribed inflammation in this particular location, induced by anteversions of the ,womb, direct injury, peri-metritis, etc. Treatment. We must not allow the bowels to become charged with fecal matter, and thus press upon the inflamed tissues. The 70 EA TON ON DISEASES OE WOMEN. most suitable means to prevent this is the regular daily use of warm water enemse, with plenty of soap dissolved in the water. Never let the solicitations of the patient or friends induce you to allow the administration of purgative medicines. The increased peristaltic action of the bowels that they would occasion would be more injurious than to allow the bowels to remain inactive. Still there is no need of their remaining overloaded, and it is better to insist on their being moved with enemse than to neglect them. Warm vaginal injections of castile-soap and water, used several times a day, with warm fomentations with hop-bags applied to the perinseum and over the hypogastrium, are to be used, with warmth to feet and sustaining diet of beef-tea, egg-nog, and the like. Milk will be well borne and easily digested, if to it is added a small quantity of salt. Let this hint be ever remembered. Milk often disagrees with the stomach of patients because of too much acidity there ; but if we correct this acidity with a little lime-water or a little salt added to the milk, we chemically overcome the acidity, and our diet of milk is very acceptable and satisfactory. Should all means fail of accomplishing reso- lution of the inflammation and absorption of the matter, we may have to evacuate the abscess. This is much better prac- tice than to allow it to go on to spontaneous evacuation, as it may form an opening in an inconvenient locality, and, besides, be much more difficult to heal than when evacuated artificially. As to methods of operating, we refer the reader to the chapter on Cellulitis, where he will also find some general directions as to the after treatment of the abscess. The remedies most frequently indicated are Bell., Merc., Hyos., Bry., China, Sepia, Cimicif., Can. ind., and Hamamelis, internally and externally. Chronic Sub-acute Inflammation — Description. — We find in practice that there are cases where there is present a sub- acute inflammation, not only of the cervix uteri, but also of the endometrium, the ovaries, bladder, vagina, and cellular tissue CHRONIC SUB-ACUTE INFLAMMATION. 71 surrounding the pelvic organs as well, often implicating the peritoneal covering, so that it may he considered, as a whole, under the name of chronic sub-acute, pelvic inflammation. The patients in these cases may be able to go about their usual avocations a considerable part of the time, though suf- fering much pain. This pain is in the organs themselves, and also in the back, loins, thighs, occiput, top of the head, and under the left breast. Digestion is generally impaired, much flatus in the stomach and bowels is generally pres- ent; and palpitation of the heart and fainting spells are frequently symptoms of this difficulty. Etiology. The cause is often obscure. These cases generally come under our care with a history often so long that we need to make a special appointment of an hour to hear it, and, when we learn it all, we generally find that the array of treatment, and the names of different physicians who have from time time treated the case, will occupy no small part of the recital; and as several years have generally elapsed since the patient has been a sufferer, we often find it extremely diffi- cult to decide what was the cause of her trouble in the first instance. Sometimes it is clear that a miscarriage, or con- finement badly managed, was a prime cause, in other cases that a cold taken and neglected at the menstrual period seems to have laid the foundation for the long train of suf- ferings that the patient has endured. Again, injudicious treatment, especially with pessaries, caustics, frequent cold baths, the continuous use of cathartics, etc., seem to have kept up the irritation. Again, unsatisfied sexual passion, as in the case of those ladies who have married men many years their senior (whose sexual vigor was inadequate to satisfy the wife, though sufficient to excite her) ; entire continence, in cases of the unmarried, at ages ranging from thirty to thirty-five years, has seemed to me to tend to pro- 72 EATON ON DISEASES OF WOMEN. cluce this condition. My experience would lead me to believe that the two latter classes of ladies are rather more subject to this difficulty than any other. This condition may be, in some instances, caused by uterine displacements and the accompanying ovarian displacements, producing irritation of the organs themselves and the surrounding parts as well. Diagnosis. In these cases it is not hard to see that the patient is ill, as the constitutional disturbance generally present will clearly indicate it; and, did we fail to see at a glance that something was the matter, the patient will not long allow us to remain in ignorance that she is a great sufferer. Doubtless these patients have much real suffering, but the gravity of the prognosis should not be measured by the extent of the patients' complaints, as we Avould be led to believe from them that dissolution was imminent. They do not always, however, refer their sufferings to the part dis- eased, but often to the stomach, back, or head, and fre- quently to the liver, which does become torpid in some in- stances, it is true, by reason of the depressed nerve strength of the system, tending to torpidity of the glandular system in general, thereby producing a condition of imperfect secre- tion and excretion. This tends to emaciation, and to pro- duce that swarthy, yellowish color of the skin we so often see in this class of cases. The long train of symptoms pro- duced from dyspepsia — the depression of mind, the unrest, the dissatisfied disposition — will lead us to be on the alert to investigate the condition of the pelvic organs. The exami- nation will disclose similar symptoms as in case of sub-acute inflammation; and these, conjoined with the grave constitu- tional symptoms just mentioned, together with the great length of time the patient has been in ill health, will give us reason to diagnose the ailment, chronic sub-acute inflam- mation. We will generally find hypertrophy of the uterus in CHRONIC SUB-ACUTE INFLAMMATION. 73 these cases, though occasionally in the. patient of fifty years of age and upwards — sometimes in those of thirty-five or forty years of age, who have remained virgins — we have an atrophied condition of the organ; but in the case of atrophy we generally have increased sensibility, amounting to great tenderness. The ovaries are usually enlarged and tender, sometimes only one is affected; if so, it is generally the left. There is a sense of weight and bearing down in the pelvis while in the erect posture. The chronic yellowish leucor- rhoea, often acrid, is frequently a persistent symptom. Pain in the small of the back or in the sacroiliac articulation, sciatic pains, burning in palms of hands and soles of the feet, heat in the top of the head, palpitation of the heart (though the rhythm remains normal, and no abnormal sounds are to be observed by stethoscopic examination), tenderness in epigastric region, coated tongue, loss of appetite, restless sleep, bad dreams, etc., are symptoms we find in most cases. Chronic constipa- tion is almost always present; spasmodic stricture of oesopha- gus, and the globus hystericus, are often complained of. Para- plegia, of almost any part of the body, may result from this disease. The menstrual function is usually deranged in those ladies who have not passed the climacteric period. Some- times we find scanty and sometimes profuse menstruation, sometimes too frequent and sometimes delayed menstruation. The sympathetic symptoms are almost endless, and when we find a lot of obscure symptoms in a patient, who has also a considerable number of the symptoms just enumerated, we are generally right in supposing they are caused from this chronic sub-acute inflammation of the pelvic organs. Mu- cous polypi, hydatids, and, in fact, all the forms of polypi, as well as fibroids of the uterus, ovarian fibroids, and fibro-cysts and vaginal cysts, are caused largely, in my opin- ion, from this condition of chronic sub -acute inflamma- tion. Acute inflammation may attack a case previously suf- 74 EATON ON DISEASES OF WOMEN. fering from chronic sub -acute inflammation, and the sub- acute is often left after the subsidence of the acute form. Treatment. First, I will recommend in these cases, as of the utmost importance, some form of abdominal supporter, to lift and hold up the abdominal organs, so that they do not press upon the irritated pelvic organs. I can not be too emphatic upon this point. Without the aid of the abdominal supporter, I would not expect to be successful in curing these cases, and, with its use, we have trouble enough. I generally use my Improved London Abdominal Supporter (see plate No. 12), or one made of silk and elastic; but every physician should use judgment and ingenuity in adapting the support to each individual case. T think no set rules need be laid down, except to use a support that is efficient, and at the same time comfortable to the patient. Where we have severe peri-metritis in the case, we may have to enjoin perfect rest in the recumbent posture, till we get this condition somewhat relieved by remedies ; but very long- continued decubitus is objectionable, in that it tends to debil- ity, and seriously interferes with the process of digestion. It is better, therefore, to hold up the abdominal organs with suitable support, and not only permit, but enjoin, exercise of a moderate character. I am so impressed with the necessity of exercise, and at the same time keeping the tender parts from suffering irrita- tion from the superincumbent weight of the abdominal organs, that I prefer the abdominal supporter to all the reme- dies that can be given in the treatment of this disease. Doubtless remedies are beneficial, and do cure, when we have suitable conditions and accessories. The frequent use of the tepid, salt water, hip bath is very beneficial. Let the patient sit in the bath ten or fifteen minutes, twice a day. Sponge CUR ONIC SUB- AC U TE INFLAMMA TION. 75 off the hips well with alcohol and water, equal parts, after each bath. The following preparation of watery Solution of Iodine may be applied freely over the os every two or three days, and also to the intra-uterine surface in obstinate cases. If it becomes necessary to apply it to the endometrium, it will be generally necessary to dilate the cervical canal with a sponge tent or two, and then use a soft brush or the uter- ine applicator to apply it. 1^. — Iodine, res., grs. v. Potass., iodide, grs. xv. Aqua, 3 1 "I- Et. sig. Solution Iodine. This solution can be further diluted with water to any extent desired. We can not do this with the Tr. of Iodine. When much water is added to the Tr., the solid Iodine is deposited and becomes a caustic. The dilution of Tr. Iodine with alcohol is objectionable, in that the alcohol smarts too much. The use of Tr. Iodine to the os uteri, or "applied to the intra-uterine surface, is not desirable because of its caustic properties. The usefulness of the solution of Iodine. as I recommend, is to promote absorption of the serous infil- tration in the tissues, which is so commonly present, and to allay the unhealthy action we call by the name of chronic sub-acute inflammation. The daily use of this remedy is not beneficial. It would be like the administration of the prop- erly selected homoeopathic remedy in too low an attenuation. It might aggravate the difficulty. The introduction of this solution directly into the substance of the uterus or ovaries, in cases of enlargement that resist all other measures, is useful and to be recommended. This is accomplished with a large syringe with a long, stout tube. (See syringe for inject- ing uterine fibroids.) This may be repeated once in three or four days for two weeks, when it is best to wait two or three weeks and watch results. There is, perhaps, no one remedy that exerts so beneficial an effect upon this disease as Phy- 76 EA TON ON DISEASES OF WOMEN. tolac. dec., in the l x or 2 X attenuation, given every three or four hours. China, Ars. tod., Bry., Nux, Sepia, Cimicifuga, Bell., Cal. carb., Ignatia, Cantharis, Hepar sidph., Cham., etc., are the remedies to select from in each particular case, as the totality of the symptoms seem to indicate. If we have uter- ine hemorrhage, or absence of menstruation, polypi, cysts, or tumors, we must treat them on the principles laid down under these diseases, which will be treated of specifically under their proper heads. Attention to the administration of suitable diet, that is nourishing and still easy of digestion, is always to be remembered. Cheerful company, change of scene and climate, will sometimes aid materially ; and, if the patient has lived in a malarious district, we must recollect how much this tends to lower the strength of the nervous system, and produce a condition of chronic congestion, and apply our remedies accordingly. METRITIS. 77 CHAPTER VIII. METRITIS. The term metritis signifies inflammation of the uterus as a whole, including its muscular tissue, serous covering, lining membrane, and sub-mucous and cellular tissues. In a case of metritis we have, then, peri-metritis, endo-metritis, and cer- vicitis combined. There is generally sympathetic inflamma- tion of the ovaries and broad ligaments in a case of metritis. The inflammation may extend to nil the pelvic and some of the abdominal viscera, or it may remain confined to the uterus. When the pelvic cellular tissue is invaded by inflam- mation, the disease is called cellulitis, which may also com- plicate a case of metritis. Generally, we have an active inflammation to contend with in these cases, which will require skill and firmness in treatment, though the diagnosis is easy. The disease in its acute form runs a rapid course, either to destruction of the patient or ends in restored health within a few weeks, and sometimes in a few days. When the disease extends to the abdominal organs, the case is grave. Puerperal metritis I will not discuss at this time, as a separate chapter is required for its full explanation. It being best discussed in connection with puerperal peritonitis, and having so much in it depend- ent upon the condition of the lying-in state, I prefer to speak of it separately. I will, however, include in this chapter in- flammation of the uterus following abortion, which is some- what allied to puerperal peritonitis, with much less of involu- tion requisite in the uterus, but, at the same time, perhaps the more dangerous of the two. The fatality in metritis following 78 EATON ON DISEASES OF WOMEN. abortion I will explain in this chapter, as it is more like the cause which produces mortality in ordinary metritis. Diagnosis. The diagnosis of metritis, as I mentioned before, is not difficult. The patient complains of great pain and heat in the uterus. There is soreness and tenderness of the entire organ. Generally, the acute attack commences with a chill, or at least chilly sensations, followed by a fever, often of a high type ; generally some nausea, and, in some instances, frequent vomiting. The fever continues, or intermits for a short time, and returns as severely as ever; the pulse is fine and wiry; tongue generally coated white, sometimes white or brown coat in center of tongue and red around the edges; enlarged papillae here and there project through the coating of the tongue, and are extremely red; considerable headache and backache is complained of; constipation is common, though diarrhoea is sometimes present. There is little or no tenderness of the vagina in the recent uncompli- cated case, but it feels hot to the touch, and the uterus is found hot, swollen, and tender. Pressure made just above the pubis causes much pain. As the disease progresses the tenderness extends over the lower abdomen, showing peri- toneal complication. In this case (peri-metritis) gentle pres- sure over the hypogastrium produces pain. It is to be dis- tinguished from enteritis in that we require deep pressure to produce pain in the latter disease. There is a, profuse discharge of matter, mingled with streaks of blood, in the severe form of this disease, after it has lasted a few days. The introduction of the uterine sound, and sometimes even digital examination, produces a free flow of pure blood, even if gentleness is used in the examination, owing to the extremely congested condition of the lining membrane of the uterus, and also that portion of the vaginal membrane reflected over the neck in the vagina. METRITIS. 79 The sub-acute chronic form of metritis I will speak of as areolar hyperplasia of the uterus. Strictly, any inflamma- tion of the uterus is metritis ; but special names are given to the disease when only a portion of the uterus is affected. Some writers divide metritis into two forms. — that which affects the cervix mainly, terming it cervical metritis; and that which affects the fundus, giving to it the name of me- tritis. In chronic cervical metritis we have a mild inflamma- tion of the sub-mucous tissue, which first tends to effusion in this tissue of a fibro-plastic material, which organizes after a time, to produce the indurations of the os found in these cases, if of long duration. To what extent the muscular tissue is involved in chronic metritis we are unable to say, but probably very slightly; and we have no evidence, in most cases, that the peritoneal coat is much affected, except in cases of the acute form of this disease. In metritis of an acute character there is usually con- siderable tympanites; but this does not distinguish it from inflammation of either of the internal female genital organs, or of the cellular or peritoneal tissues, as this symptom is common to all of them, both in their acute and chronic forms. Acute metritis may result in hypertrophy, softening, or gan- grene of the organ, but usually, under homoeopathic treatment, terminates in resolution. Etiology. Acute metritis results from cold taken at the menstrual period, first causing arrest of the flow, secondarily, inflam- mation; or it may attack a lady who has had some operation performed upon her for the removal of a, uterine polypus or has had the sponge tent used without having taken suit- able care of herself; or it may be caused from hard work and some exposure while very warm ; or it may result from excessive coitus, or cold vaginal injections, or the use of in- struments to prevent conception or produce abortion ; or su- 80 EA 7' ON ON DISEASES OF WOMEN. pervene on a chronic endo-metritis or endo-cervicitis; or it may follow an abortion, from want of care, and rising too soon, with exposure to cold ; or from a retained placenta, or a part of one ; or a cold taken at this time ; or from lacerations of the cervix uteri in labor. After a miscarriage or premature labor, women are liable to be very careless, as they imagine little care is necessary. This want of care and caution tends to produce the acute attack of metritis. The re trover ted state of the organ pre- disposes to inflammation, especially the chronic variety; retro- version or retroflexion sometimes exists in girls, caused from jumping or a severe lift, and as puberty comes on the uterus becomes unduly congested, and an inflammatory condition is set up. This gives rise to severe suffering at the menstrual period, and is often a cause of the non-appearance of the flow, although monthly pains come on with regularity, and the general health is much affected. Constant standing, as in case of clerks and teachers, is frequently a cause of the sub-acute inflammation, which readily becomes acute and act- ive from taking a, cold, as this class of women are likely to do from exposure in all kinds of weather. Treatment of Acute Metritis. The first requisite in treatment is perfect rest in the recumbent position. If there is any peritonseal complication, placing the knees and thighs in a semi-flexed position gives some relief. The warm sitz bath, warmth to the feet, warm wet compresses over the hypogastrium, are all beneficial. Aconite should be given till the pulse is under control, be- comes soft, and the general fever subsides ; after which Bell., Bry. : Sepia, or Sidph. are frequently indicated. Injections of Hydrate of Cloral into the vagina are useful in soothing the irritation, tenderness, and pain. Do not be tempted into giving allopathic doses of Morphia or Opium \ though they give temporary relief, they derange the action of the stomach METRITIS. 81 and bowels, arrest healthy secretion, benumb the system, and prevent the proper action of other remedies. The same remarks apply with equal force to the hypo- dermic use of Morphia. Its use has become shamefully frequent with some practitioners, and should be discounte- nanced, because we can relieve our patients in a short time without it; and because it so seriously interferes with the natural process of digestion and assimilation; and, worst of all, establishes in many the opium habit. The alarming increase of the habit of opium-eating in this country should cause us to be active in suppressing it, and careful not to aid in its spread. The import duties on opium paid the United States government for the year ending June 30, 1877, were $1,778,347. This gives some idea of the great amount of the drug consumed by opium-eaters in the United States. Cool lemonade is a means of great relief to the fever, and is much relished by most patients. Cold water may be drank with freedom in small quantities, often repeated. The diet should be very plain, consisting of gruel of corn or oat- meal, toast, with a little milk. The entire surface of the body should be frequently sponged with tepid water. Ca- thartic medicine must be positively forbidden, and tepid soap and water enemae used to move the bowels, in case of want of action in them. I speak of this, not that I expect any homoeopathic physician will prescribe a cathartic in these cases, but knowing that we sometimes have patients who have previously had allopathic treatment, and that they may take a cathartic without asking the physician's advice. From the swollen condition of the uterus and its pressure against the rectum in these cases, as well as some degree of irritation of the bowel from the spread of the active inflam- mation in the uterus, the patient feels a constant ineffectual desire to evacuate the bowels, which tempts her and her friends to use a cathartic. Hence, I make the su^estion to the student to forbid them, unless he knows his patient well 6 82 EATON ON DISEASES OF WOMEN. enough to be sure she will not take them unknown to him. The enema of water will unload the rectum if any fecal matter is lodged there ; and, besides, it serves to soothe the irritation in the bowel, while the cathartic increases the irri- tation, and may change a mild case into one of great severity. Remedies. In addition to Aconite, Bryonia, Bell., Sulph., and Sepia, already mentioned, Verat. alb., Verat. viride, Ignatia, Hyos., Puis., China, etc., will be sometimes indicated. (See works on Materia Medica for indications.) Treatment of Chronic Metritis. The student is requested to read the treatment of endo- metritis, as being largely applicable to cases of chronic metritis, excepting some complications more likely to arise in metritis than in endo-metritis. (Also, see Areolar Hyper- plasia of the Uterus.) Complications in Metritis. — In metritis we are liable to have some inflammation of the bladder as a complication. This is due, in some cases, to the pressure of the womb upon the bladder, from its increase of size, and sometimes to a par- tial ante-flexion or retro-version of the organ. In other cases, a continuation of the inflammation from the peritoneal cov- ering of the uterus to that covering the bladder, and thence to the muscular, and even the mucous, lining. This gives rise to a desire for frequent micturition ; in fact, we may have all the symptoms of cystitis, including a great amount of mucous discharge, which adheres to the bottom of the vessel with great tenacity. I know of no better remedies for this condition than Can. ind., Cantharides, Uva Ursi, Aeon., Bell., or Cubebs. Tendency to Dropsy. — In some cases we have a tendency to dropsy ; but it is generally manifested as ascites. This is produced from the peritoneal irritation causing an effu- COMPLICATIONS IN METRITIS. 83 sion of serum into its cavity in excess of what is normal. The student will understand that, in the healthy condition of the peritonaeum, a small amount of serum is thrown out in its interior to lubricate it, and we may readily see how an irritation of the membrane may cause an excess of this secre- tion; and this accumulation of fluid in the cavity of the abdo- men is termed ascites. Ars., Merc, iod., Digitalis, China, Apoc?/niim, etc., are the remedies to be studied for this complication. Cellulitis as a Complication. — General pelvic cellulitis may complicate these cases ; for the treatment of which see chapter on Cellulitis. General Effects of Chronic Metritis. — It is readily un- derstood how the increased weight and size of the uterus would tend to produce displacements of the organ. In con- nection with displacements we would have, not only the reflex symptoms in ordinary displacements, but they are likely to be intensified, from the fact of having the irritable condition of* the organ, produced by the sub-acute inflamma- tion, in addition to the ordinary nervous effect in displace- ments. Hence, we are more likely to have hysterical spasms, a greater amount of brain symptoms, more derangement of digestion, etc., than in ordinary recent displacements without metritis. The Eyes are sometimes affected, so as to produce various forms of amaurosis, and sometimes much inflammation, as a result of these conditions of the uterus. The oculist needs to be thoroughly conversant with these facts, as otherwise his treatment would be calculated to give, at best, only tempo- rary relief. Sterility, Abortion, Etc. — Sterility is a common result, though in rare instances, where the irritation is slight in the endometrium, pregnancy may take place ; but as the uterus enlarges in pregnancy, it is liable to contract (owing to- its irritable condition), and expel the foetus prematurely. 8£ EATON ON DISEASES OF WOMEN. Copulation Injurious. — Copulation should be interdicted in these cases, as it can hardly be otherwise than harmful by producing greater irritation, temporarily at least ; and as con- ception is likely to be followed by abortion, it is better it should not occur till a year or so after the patient appears well ; otherwise Ave may have a relapse. Tumors. — Metritis tends largely to the growth of tumors of the uterus, especially fibroids and fibrous polypi. It also tends to the development of cancer of the organ. Menstrual Derangements. — We also have menstrual de- rangements in metritis. More frequently than otherwise the flow is increased in duration, quantity, and frequency. This drain upon the system, in connection with the excessive leu- corrhoeal discharge and the pains she has to endure, with the poor nourishment she gets by reason of the disordered stom- ach generally present in these cases, tends to seriously exhaust the patient to an extent which may threaten her life. The development in the uterine cavity of vegetations of the endometrium, hydatids, or polypi, or granulations of the cervix, may cause this hemorrhage ; and it may be best to at once insert the sponge tent, dilate quite fully the cervix, and ascertain what the trouble is, if possible, in chronic cases, where uterine hemorrhage is present. The tent will tempo- rarily arrest the flow, and aid us in finding out what the real trouble is in the case. Remedies in Metritis. Remedies necessarily take a wide range in cases of me- tritis, on account of the various conditions present and the various constitutions of women. We have mentioned a few remedies in connection with the treatment, and will add some few indications for remedies in a more compact form. Aconite. — Fever, wiry pulse, dry skin; nausea; great tenderness of uterus, fear, restlessness, and despondency. METRITIS. 85 Bell. — Dull, heavy headache; tenderness; pain in fore- head just over the eyes. Bry. — Stitches, cutting pain, fever, pulmonary compli- cations. Cal. Carb. — Light complexion, with profuse leucorrhoea; general irritation of the mucous membranes ; scrofulous pa- tients, with leuco-phlegmatic temperament, cold feet, vertigo, fear of impending evil, supra-orbital neuralgia, sour taste in the mouth, involuntary emissions of urine, bearing-down pain in the uterus ; especially useful with fleshy people. Ferrum. — Menorrhagia in women with red face; great weakness ; menses stop and return again. Gelsem. — Hysterical symptoms; hyperesthesia of a part of the body; tendency to hemiplegia ; confusion of the mind; sleeplessness; hysterical spasm; fever without thirst; the fever intermits; great nervous exhaustion. Graphites. — Profuse leucorrhoea, coming in gushes ; in ladies inclined to obesity, affections of the ovaries, severe bearing-down pain, constipation, the leucorrhoeal discharge is tenacious, excessive sensitiveness to cold, etc. Ig'iiatia. — Uterine cramps and stitches ; chlorosis ; much pain in rectum; excessive flatulency; incontinence of urine; restlessness ; changeable mood ; hysterical manifestations ; excessive yawning. Borax. — White, thick leucorrhoea; menses too profuse and too frequent. Cimicif . Rac. — Chorea ; great pain in the uterus or ova- ries; tendency to rheumatism; has hysterical tendencies; rheumatic or neuralgic pains in the uterus. Caiilopliyllum. — Insomnia; paraplegia; atony, and re- laxed condition of the uterus; hysterical spasms; irregular menstruation ; excessive uterine hemorrhage. Carbo. Veg*. — Great weakness; tympanites ; cardialgia: eructations of glairy mucus ; acrid leucorrhoea ; heat, redness, itching of the labia and vulva ; voluptuous thoughts. 86 EATON ON DISEASES OF WOMEN. Conium Mac. — Swelling of the breasts ; stitches in the breast, mostly at night; induration of the cervix uteri, with sharp pain in the part; acrid leucorrhoea; prolapsus uteri. Colocyiithis. — Flatus ; rolling pain in the bowels ; agon- izing pain in the bowels; blood flows from anus; urine is thick, foetid, scant; restlessness, with great anxiety; sci- atic pains. Verat. Viritle. — Congestive state of the pelvic organs; tenderness of the uterus; fever; heat; restlessness; palpita- tion of the heart; local or general hyperesthesia. Verat. Alb. — Hyppocratic countenance ; excessive sexual passion; tendency to diarrhoea; despair; hysterical or puer- peral convulsions ; fretful disposition ; nervous headache. Patiiiuin. — Depression of spirits ; excessive sexual de- sire ; excessive uterine hemorrhage ; much bearing down pain in pelvis ; ovarian tenderness ; indurations of the uterus ; albuminous leucorrhoea; useful in hysteria. Rhus Tox. — Numbness of feet and limbs;, rheumatic complications ; takes cold easily ; white sediment in urine ; uterine hemorrhage. Secale Cor. — Bearing down pain in uterus ; uterine hem- orrhage; has cold perspiration; flabby condition of the mus- cles; menses profuse; relaxation of the uterine tissues. AREOLAR HYPERPLASIA OF THE UTERUS. 87 CHAPTER IX. AREOLAR HYPERPLASIA OF THE UTERUS; OR, CHRONIC PAREN- CHYMATOUS METRITIS. Areolar hyperplasia of the uterus has been, until of late, described as chronic metritis. Professor Thomas, of New York, has taken great pains to elaborate this disease in his work on "Diseases of Women," fourth edition. I shall take the liberty to quote considerably, at length, from him, as his views regarding this disease are so fully in accord with my own, I feel that in all respects, save a part of his treatment, I can fully agree with him; the objectionable points (in my mind) in his treatment being scarifications and blisters locally to the cervix uteri, and his drug medication, which is, how- ever, in accord with the school of medicine to which he belongs, and is, I believe, as good as any which has been proposed by any one of that school. I am convinced of the more satisfactory results of homoeopathic drug medication, and one of the best wishes I could ask for man, as well as woman kind, would be that the old school might, in a body, embrace and practice the principles of homoeopathy. As I turn to Professor Emmet's new work on "Diseases of Women" to learn what he says upon this disease, I am sur- prised to find he has omitted it entirely, and find, on further search, that he has said but a few words upon hypertrophy of the uterus, and nothing under the heads of either metritis or chronic parenchymatous metritis, though his Avork is so very elaborate and excellent in many respects. I had pre- viously noticed that in his index I could find no mention made of puerperal fever, puerperal phlebitis, mammary ab- scess, hydatids, hysteralgia, cervicitis, rectocele, sterility, etc., 88 EATON ON DISEASES OF WOMEN still I was unprepared to find that he gave but a page or so to the consideration of all the forms of inflammation of the womb. Inflammation of the uterus, in its various forms, we have considered of the utmost importance, and we have attempted to describe and give the treatment of metritis, endo-metritis, cervicitis, endo-cervicitis, and peri-metritis, and still we could not feel our work complete, or up with the onward progress of medical discovery, without giving some time to the consider- ation of areolar hyperplasia of the uterus. This is rather a result of disease than a disease per se. The connective or cellular tissue, situated between the endometrium and mus- cular tissue, between this muscular tissue and the outer cov- erings of the uterus, and also connecting the fibers of the muscular tissue of the organ, is the part affected in this dis- ease, which results as a consequence of long continued irritation of some part or the whole of the organ. In the outset the disease of the uterus may have been endo-metritis, cervicitis, or even endo-cervicitis only, and still the connective tissue may have become, after a time, affected so as to produce hyperplasia of this tissue. The condition is similar to that found in cases of chronic cervicitis. There is engorgement of the cellular tissue, from effusion of serous fluid into its interspaces. This effusion, resulting from chronic irritation, may some day be discovered to contain material which is not always so mild in its effects as serum; and I suspect that herein may be found, at no distant day, an explanation of the develop- ment of carcinoma of the uterus. In hypertrophy of the uterus all the tissues of the organ are enlarged, especially its muscular tissue. In areolar hyper- plasia the muscular tissue may be atrophied instead of en- larged, although the organ as a whole is enlarged, owing to the distension of the connective tissue from the effusion mentioned. AREOLAR HYPERPLASIA OF THE UTERUS. 89 This effusion in time becomes organized, forming new areolar tissue, or distending the minute cells of this tissue so as to appear increased in its substance. Following this con- dition, further effusion may take place into this tissue of sero-plastic lymph, or of abnormal cell plasma, which may cause induration, or cancerous degeneration of the tissues ; or the hyperplasia may remain (for a long period at least) without resulting in induration or carcinoma. In these cases the uterus is found enlarged, somewhat patulous, often displaced, espe- cially downwards, and often retro-verted or flexed. Constipa- tion is an almost constant symptom in these cases, vesical irritation, strangury, ischuria, etc., being frequent; pain in the loins, back, or thighs, pain at the base of the brain, or on the top of the head, gastric derangements, nervous or hyster- ical manifestations, etc. This is the train of symptoms point- ing to this condition, especially when the history of the case shows that these symptoms have been present for a long time. Pain in the pelvis is not very frequently complained of in these cases, and the absence of this pelvic pain is the very point likely to mislead the physician in diagnosis. The symp- toms are largely sympathetic, and embrace, at one time or another, about all the sympathetic effects manifested by any uterine disease. (See Sympathetic Affections.) Of this dis- ease Dr. Thomas * says : " One of the most common pathological combinations which confront the gynaecologist is that which I here endeavor, in as concise a manner as possible, to picture. A patient calls upon us for relief of backache ; pelvic pains ; dragging sen- sation about the loins; 'bearing down pains;' leucorrhcea; menstrual disorder, tending chiefly to excessive flow; throb- bing sensation about the uterus ; general feeling of despond- ency, malaise, and weakness ; and irritability about the blad- der and rectum. All these rational signs pointing to the uterus as the probably delinquent organ, a physical explora- *Thomas's "Diseases of Women," p. 274. 90 EA TON ON DISEASES OF WOMEN. tion is made, and furnishes the following results : The uterus is usually discovered to be in the condition of descent, retro- version, or ante-version; it is voluminous, tender to the touch, and evidently engorged with blood; from the cervical canal a leucorrhoeal matter pours; the probe carried to the fundus finds it tender, and creates the flow of a little blood; the cervix is often in a condition of granular or cystic degenera- tion; and a low grade of vaginitis exists. "To this pathological combination the more superficial diagnostician will often apply a name which announces one only of the existing conditions ; as, for example, uterine ca- tarrh, ulceration of the cervix, or retroversion or prolapse. The more reflective and intelligent examiner will ordinarily group the coincident morbid states together under the name of ■ chronic metritis.' "The latter would be fully sustained in his position by authority as abundant as it is orthodox, for by systematic writers, since the days of Recamier, this uterine state has been described as one of ' chronic parenchymatous metritis.' Only within a very recent period have the pathologists of the German school begun to question the validity of this conclusion, which, taking its origin in France, was spread through England and America chiefly by the writings of Dr. Henry Bennet. According to this view, the following patho- logical changes were believed to be those resulting in the condition just described. In the first stage the parenchyma was regarded as gorged with blood, a state of active conges- tion existing. This was supposed soon to pass into the sec- ond stage, consisting in an effusion of lymph, when, unlike a similar process in other parts, the morbid action ceased, or rather did not advance, and, unless relieved by treatment, continued stationary for a length of time. The third stage of inflammation in other parts, that of suppuration, was ad- mitted to occur rarely here, or in the parenchyma of the body, but in time, all inflammatory action ceasing, the cervix AREOLAR HYPERPLASIA OF THE UTERUS. 91 remained large and indurated without sensitiveness, or the effused lymph might be absorbed, and great diminution in size occur with induration. Were this really the case the condition would constitute one of inflammation, even if we restricted ourselves in the use of that ambiguous term to the narrow and precise limits prescribed by Dr. J. Hughes Ben- nett, when he says : ' It should be applied only to that per- verted alteration of the vascular tissues which produces an exudation of the liquor sanguinis; it is this exudation alone which can be held to unequivocally characterize an in- flammation.' '•Examined more recently, however, by the more certain and less theoretical processes of modern science, all this has come to be looked upon as erroneous. Cases which were formerly regarded as instances of inflammation — on account of the existence of enlargement, congestion, and tenderness upon pressure — the microscope now proves to have been instances of excessive growth of the connective tissue of the uterus, with congestion, and resulting hyperesthesia of its nerves, i; It may result from three entirely different pathological states : first, from interference with retrograde metamorphosis of the puerperal uterus from any cause ; second, from conges- tion long kept up by mechanical causes, such as displace- ment; third, from a formative irritation or state of hyper- nutrition excited by endo-metritis, or the existence of fibrous tumors. Whatever be the originating pathological condition, that which results and which we are now considering con- sists in hyperplasia of connective tissue as its most marked feature, and of congestion and nervous hyperesthesia as im- portant accompaniments. " Every-where throughout the recent and progressive lit- erature of gynecology the foreshadowing of the advancing change in views with regard to this subject will be recog- nized. The pendulum, swung too far by the hand of Dr. Henry Bennet, is making its inevitable return. That it may 92 EA TON ON DISEASES OF WOMEN. stop on safe middle ground must be the hope of all. 'The determination of blood to a part here noticed, characterized by dilatation of the arteries, with increased flow of blood through the capillaries, must be distinguished from the con- gestion of inflammation, characterized by the accumulation and stagnation of red and white corpuscles in the vessels, tending to be abnormally adherent to each other and to the vessels,' says Dr. H. G. Wright,* quoting from Dr. Aitken. ' Tested by this standard ' (that of Dr. J. Hughes Bennett, already quoted), says Dr. Graily Hewitt,f 'the uterus is cer- tainly very little liable to "inflammation;" exudation, and transformation of such exudations, purulent and otherwise, similar to what may be witnessed in other organs of the body, being very rarely witnessed in the parenchyma of the uterus. The morbid processes with which we are familiar as affecting the tissues of the uterus are, for the most part, alterations of growth, irregularities in growth, slight modifi- cations, in fact, of the processes which follow each other in due succession in the natural condition of things. The word "inflammation," used in Dr. J. Hughes Bennett's sense of the word, certainly fails to convey an adequate idea of the modifications observed under such circumstances.' 'Diffuse growth of connective tissue,' says Klob,J 'constitutes the so-called induration, hitherto considered as a result of par- enchymatous inflammation of the uterus. . . . For rea- sons mentioned I would also advise a disuse of the term "chronic inflammation.'" In a discussion || upon chronic metritis, before the New York Academy of Medicine, Dr. Noeggerath limited the disease to 'growth of cellular tissue, both of the body and neck, occurring only during the puer- peral state.' Dr. Peaslee preferred 'to call the disease under consideration congestion, rather than inflammation, because it has none of the events of inflammation;' and Dr. Kam- * " Uterine Disorders," p. 218. t " Dis. of Women," p. 363. t a Op. cit.," p. 129. II " Med. Record," No. 92, p. 475. AREOLAR HYPERPLASIA OF THE UTERUS. 93 merer expressed the view that 'chronic inflammation of the substance of the non-puerperal uterus is never met with ; what has been described as such is hypertrophy of connec- tive tissue, resulting from long continued hypersemia.' " These views, which, among men who are in the advance in gynaecology, are rapidly gaining ground, are not sustained by analogical reasoning, but by anatomical proof. I know of nothing which will more surely convince the reader of the necessity for an alteration in our nomenclature concerning this condition than a perusal of Scanzoni's* article upon it. This author, after heading his chapter 'Chronic Parenchy- matous Inflammation of the Womb,' goes on to say : ' The nature of the disease would then be, in an anatomical point of view, a hypertrophy of the cellular tissue.' Certainly the 'anatomical point of view' is an important one, and it is supported by what we observe from a clinical stand-point. " So much evil has arisen for pathology and treatment from the use of the term chronic metritis, and so clear a demonstration has been made that the condition so called is not one of true inflammation, that some other appellation is not only desirable, but has become absolutely essential. It is incontestable that there is a peculiar condition that affects the uterus which is characterized by distention of blood-vessels from vital or mechanical cause, effusion of the serum of the blood, and hypergenesis of connective tis- sue. To denote this state, gynaecologists have long required a name, for medical nomenclature is as necessary as it is faulty. Lisfranc felt this need when he styled it 'engorge- ment ;' Hodge, when he entitled it ' irritable uterus ;' Bennet, when he called it 'metritis;' and others have also acknowl- edged the necessity; Klob, for example, in 'habitual hyper- aeinia' and 'diffuse proliferation of connective tissue;' and Kiwisch, in 'infarctus.' " The appellations infarctus, engorgement, and hyperaemia *" Diseases of Females," Aui. ed., p. 181. 94 EATON ON DISEASES OF WOMEN. only convey a partial idea of the truth; they only announce one element of the condition — congestion — while that of irritable uterus ignores all structural change in announcing another element — nervous hyperesthesia. At the same time that the phrase, ' diffuse proliferation of connective tissue, due to hyperemia/ which is employed by Klob, clearly de- fines the pathological condition, it is too long and burdensome to answer the purpose of a name to be conventionally em- ployed. If there be a term now in existence which does really convey the idea truly and completely, it should surely, in the interests of pathology and treatment, as well as out of consideration for the overburdened student of medical nomenclature, be employed in preference to the adoption of a new one. Enlargement of an organ, due to the formation of new cells similar to those of the tissue in which they are developed, has been styled, by Yirchow, hyperplasia, in con- tradistinction to hypertrophy, which consists in increase of size from distension of cells already existing. As the con- dition of the uterus now under consideration is one arising from over-excitation of the vaso-motor and excito-nutritive nerves, a ( formative irritation,' as Klob styles it, and result- ing in a numerical hypertrophy, it appears to me that the term areolar hyperplasia would more correctly designate it than any other with which I am acquainted. With a sincere desire to lessen, and not to increase, the labors of the stu- dent and the perplexities of the gynaecologist, I shall, there- fore, replace the confusing term, chronic metritis, by that of areolar hyperplasia of the uterus. " If the disease really consists in a proliferation or hyper- trophy of the areolar or connective tissue of the uterus, and not in chronic inflammation, it would certainly be advan- tageous to apply to it some name which would signify that fact. 'Areolar hyperplasia'* expresses this fact concisely, * Hypertrophy signifies excessive growth of the elements of a tissue already existing; hyperplasia signifies the development of new tissue. AREOLAR HYPERPLASIA OF THE UTERUS. 95 and hence I have employed it. But the only proof of the appropriateness of a newly applied term is its general adop- tion. If this be accepted, I shall feel that good has resulted from my effort; if its approval be not implied by adoption, I shall admit, with regret, that I have only helped to render confusion worse confounded. "Pathology of Areolar Hyperplasia. — The vast majority of cases are due to interference with that retrograde meta- morphosis occurring in the puerperal uterus, styled involu- tion. To comprehend the pathology of cases thus arising, it will be necessary to consider the physiology of that process as well as the pathological conditions which may affect it. "It is only within the last quarter of a century that we have understood the process by which the uterus, an organ measuring three inches, in the short space of nine months enlarges so as to contain a child, or even two or three chil- dren, and then, within two months after delivery, undergoes so rapid an absorption as to return to its original size. The credit of elucidating the subject belongs chiefly to Germany, for it is to Virchow, Franz Kilian, Heschl, Kolliker, and Retzius that Ave are most indebted. "The important pathological fact, that arrest in a disturb- ance of this process constitutes a condition of disease, ema- nated from Sir James Simpson, who, in 1852, published the first article which drew especial/attention to it. His article was entitled, 'Morbid Deficiency and Morbid Excess in the Involution of the Uterus after Delivery.' Since that time, the condition which now engages us has become generally recog- nized as a uterine state of great frequency and moment. "To fully comprehend this part of our subject, it is nec- essary to bear in mind the component parts of the healthy uterine parenchyma. It consists of five elements : 1. Fusi- form fiber cells, or, as they are termed, the smooth muscu- lar fibers; 2. Round and oval nuclei, which are supposed to be elementary fusiform fiber cells; 3. Amorphous or homo- 96 RATON ON DISEASES OF WOMEN. geneous connective tissue, which permeates the parenchyma and binds together the fiber cells and nuclei; 4. Fibrillated connective tissue or white fibrous tissue; and, 5. Elastic fibrous tissue. These elements, together with nerves, blood- vessels, and lymphatics, make up the tissue of the uterus, which is covered by a serous membrane externally and a mucous membrane within. "No sooner does this structure feel the stimulus of con- ception than it develops rapidly, partly by growth of already existing structures, and partly by new formations. The round or oval nuclei rapidly develop into fusiform cells, and these as rapidly grow into colossal cells, which grow longer and more powerful as pregnancy advances. 'A new forma- tion of muscular fiber also takes place,'* the connective tissue elements grow proportionately, and the blood-vessels enlarge. "Parturition occurs, and almost immediately a retrograde evolution begins to restore the uterus to its original constit- uency. The fully developed fibers undergo a fatty degener- ation; the fat thus formed is absorbed, and the organ rapidly diminishes in size and weight. This fatty degeneration affects the organ after the fourth day subsequent to delivery, and, according to Heschl, the commencement of a new formation of muscular fibers is recognized in the fourth week after labor, in the form of nuclei and caudate cells. At the end of the eighth week the uterus has returned to its nor- mal state. " Certain untoward influences may retard or check this process, and the uterus remain flabby and large, when it is said to be in a state of sub-involution, or arrested retrograde evolution. " Thus far we have been dealing with facts thoroughly ascertained by histological investigations and fully established by evidence yielded by the microscope. But from this point the pathology of sub-involution is not so satisfactorily settled. * Arthur Farre: "Cyc. Anat. and Phys.," Article Uterus. AREOLAR HYPERPLASIA OF THE UTERUS. 97 Prof. Simpson declared that the disease was due to the fact that 'this retrograde metamorphosis of the uterus has not taken place during the puerperal month, or has taken place only to such an imperfect degree that the uterus is of the size we usually see it have at the end of the first week or so after delivery;' but he entered, if I may judge from the posthumous volume of his work upon Diseases of Women, upon no detailed account of the existing pathological defect in the organ. Since his writing, it appears to have been agreed upon that this consists of persistence of the muscular fibers, characterizing pregnancy, in a state of fatty degener- ation. Thus Dr. Wright * says : ' Pathologically, it closely corresponds with that state of the heart structure so admir- ably described by Dr. Richard Quain, and commonly known as fatty degeneration.' Dr. Westf expresses himself thus: 1 Though fatty degeneration of the tissues takes place, yet the removal of the useless material is but imperfectly accom- plished, while the elements of the new uterus are themselves, as soon as produced, subjected to the same alteration.' I search in vain the literature of the pathology of this subject for a basis for these hypotheses. That literature is scanty in the extreme as yet, and the subject awaits extended re- searches before we can speak intelligently of it. The day has passed, however, when we can let probabilities in pathol- ogy pass current for facts. " The best, indeed I may say the only, detailed account of this condition studied by the microscope, which I have been able to obtain, is one by Dr. Snow Beck,J of London. ' The enlargement of the uterus did not depend so much upon an increase in the size of the contractile fiber-cells as upon an increased amount of round and oval globules, with amorphous tissue in the uterine walls. . . . The essential condition of the organ consisted in the elements of the different tissues * "Uterine Disorders," p. 221. t "Dis. of Women," 3d Eng. ed., p. 89. t" London Obstetrical Trans.," Vol. XIII, p. 239. 7 98 EATON ON DISEASES OF WOMEN. retaining a portion of the natural enlargement consequent upon impregnation. But this enlargement was more due to the increased size and amount of the soft tissue present in the walls of the uterus, as well as at the internal surface, than to the increased size of the contractile fiber-cells.' Marked congestion existed, the blood-vessels being large and forming a complete and continuous system with the capillary network on the inner surface of the uterus. No allusion to prepon- derance of muscular fibers is anywhere made, and no mention of fatty degeneration occurs. "The condition of the uterine cavity is important. It is always enlarged, the glands of the cervix are usually en- larged, and upon the lining membrane of the cavity fungoid growths are commonly developed. " This is all that can with positiveness be said of the pathology of the early periods of sub-involution in the pres- ent undeveloped state of the subject. " The uterus, the study of the tissues of which gave Dr. Beck's results, measured 3i inches in length, 21 inches across the fundus, the walls were II inches thick, and the uterine canal was 3 inches deep. "As time passes the uterine walls diminish in size, their tissue grows less vascular, the blood-vessels become smaller, and the uterine cavity assumes smaller dimensions. But the organ does not assume its original size; it remains large, dense, firm, and sensitive, for years presenting the character- istic appearances of the so-called chronic parenchymatous metritis. Although taking an entirely different view of the pathology of chronic metritis, Dr. West* signalizes almost the same fact in the following words : ' It must, however, be at once apparent that after inflammation has passed away, its effects may remain in the larger size and altered structure of the womb, and that the very nature of these changes will be such as to render the repair of the damaged organ both un- *"Op. cit.," p. 89. AREOLAR HYPERPLASIA OF THE UTERUS. 99 likely to occur and slow to be accomplished, and must leave it in a condition peculiarly liable to be aggravated during the fluctuation of circulation and alternations of activity and re- pose to which the female sexual system is liable.' This is just the state to which I allude at the commencement of this chapter, as one existing years after labor, and which, attended by congestion, displacement, catarrh, and granular degenera- tion, is styled chronic metritis. It is, I think, this state which most frequently furnishes instances of areolar hyperplasia to the microscope. "Let any one patiently and faithfully watch a case of sub- involution for a year or two with reference to this point, as I have repeatedly done, and I can not doubt that he will have the same evidence which makes me so strong in my present belief. Lastly, let it be remembered that, by the French school, no condition of arrest of development is recognized as accounting for it ; these are cases of : post-puerperal metritis,' metritis, according to M. Gallard,* without symptoms, 'chron- ique d'emblee.' "Does any one claim that between this condition and chronic metritis a difference should be made ? Let him tell me by what means he can at the bedside distinguish one from the other, and I may agree with him. There are no means for such differentiation. If the uterus be very large and the patient recently delivered, the case is termed sub-involution by English writers ; if its dimensions have diminished, years have elapsed since parturition, and the almost universal ac- companiments of the condition, leucorrhoea, granular degen- eration, and displacement be present, it is styled chronic metritis. "Arrest of involution of the puerperal uterus is an occur- rence of very great frequency. It constitutes the chief cause of all chronic uterine disorders, and for this reason its impor- tance can not be overestimated. Until this subject receives *"Op. cit.,"p. 372. 100 eaton on Diseases of women. the attention which it deserves, the present confusion as to the causes, pathology, and general features of chronic metritis, which helps to weaken uterine pathology, must continue. "In the first stage of the disease the hypertrophied areolar tissue is congested, containing absolutely more blood than normal, and the whole of the affected part, neck, body, or entire uterus, is greatly increased in size and weight. As time passes, the second stage of the disorder supervenes, and an opposite state of things is set up. Klob describes it in these words : ' The parenchyma on section appears white or of a whitish-red color, deficient in blood-vessels, from com- pression of the capillaries by the contraction of the newly formed connective tissue, or from partial destruction or oblit- eration of vessels during the growth of tissue ; the firmness of the uterine substance is also increased, simulating the hardness of cartilage, and creaking under the knife.' This constitutes a true sclerosis * of the uterus. "Every practitioner must have met with cases in which a large, red, engorged, and soft uterus, examined after an interval of several years, has been found, to his surprise, to have become small, densely hard, white, and anaemic, and its cavity diminished in size. Such an organ removed from the body cuts like fibrous tissue, and appears when cut almost as dense and bloodless. "Course and Termination. — The length of time which this condition may last is very uncertain. After the con- nective tissue once becomes thoroughly affected by the dis- ease, it rarely returns to its original condition; but so complete is the relief which may be afforded the patient by removal of those concomitant conditions that attend upon it and in- crease the discomforts which are due to it, that she will often, for years, imagine herself well. Very suddenly, however, imprudence during menstruation, the act of parturition, over- * The term sclerosis was, I believe, first applied to this condition by Skene, of Brooklyn. Subsequently Gallard likewise employed it. AREOLAR HYPERPLASIA OF THE UTERUS. 101 exertion, or some other influence creating congestion, will produce a relapse which will convince her of her error. It is astonishing to what an extent enlargement of the cervix as a result of areolar hyperplasia will go. Sometimes this part will equal in size a very small orange, and, filling the vagina, will compress the rectum to such an extent as to interfere with its functions. Uninterfered with by art, the disease has no fixed limits. The increase of uterine weight which it induces usually results in displacement. This increases already existing congestion, and the patient suffers, until the menopause at least, from endo-metritis, granular cervix, and the ordinary symptoms of displacement. " In some cases contraction of the exuberant tissue oc- curs, and uterine atrophy, with its accompanying symptoms, takes place. "Frequency. — This affection is one of great frequency, and as it was formerly universally regarded as chronic paren- chymatous metritis, this is one great reason why inflamma- tion of the structure of the uterus was thought to be so common. This fact makes its careful study a matter of great moment to the gynaecologist. I do not hesitate to declare that he who fully masters it, and thoroughly appreciates its frequency and influence, will possess a key to the manage- ment of numerous cases which would in vain be sought for elsewhere. "Predisposing Causes. — These may be enumerated as — "A depreciation of the vital forces from any cause; "Constitutional tendency to tubercle, scrofula, or spa- nsemia ; "Parturition, especially when repeated often and with short intervals ; " Prolonged nervous depression ; "A torpid condition of the intestines and liver. " The Exciting Causes are the following : "Overexertion after delivery; 102 EATON ON DISEASES OF WOMEN. " Puerperal pelvic inflammation ; " Laceration of the cervix uteri ; " Displacements ; " Endo-metritis ; " Neoplasms ; "Cardiac disease; "Abdominal tumors pressing on the vena cava; " Excessive sexual intercourse. "After delivery many of both these sets of causes are developed by the pernicious system of management which nurses frequently adopt. The nerve and blood states of the woman are depreciated by starvation, impure air, and disturb- ance of sleep by attention to the wants of the child, while the enlarged uterus is forced into retroversion, and the con- gestion which it induces, by a very tight bandage, rendered still more hurtful by a thick compress over the uterus. The practitioner who regards delivery of the placenta as the end of the third stage of labor furnishes a marked predisposing cause. The third stage of labor consists in complete and per- manent contraction of the uterus, and may not be accomplished for hours after the expulsion of the placenta. No obstetrician has done his duty who leaves his patient before its accom- plishment. " Symptoms. " It is impossible to present the symptoms of this condi- tion entirely separated from those of complications which very commonly attend it ; such, for example, as displacement, laceration of the cervix, ovarian congestion, granular cervix, etc. These states, of course, produce symptoms of their own, which mimxle with those of the main disorder. The symptoms, then, which are due to areolar hyperplasia, and its almost inevitable complications, are the following. If the cervix alone be affected, there are : " Pain in back and loins ; " Pressure on bladder or rectum ; AREOLAR HYPERPLASIA OF THE UTERUS. 103 " Disordered menstruation ; " Difficulty of locomotion ; " Nervous disorder ; "Pain on sexual intercourse; " Dyspepsia, headache, and languor ; " Leucorrhoea. " If the affection be general or corporeal, graver symptoms manifest themselves/ 1 ' Chief among these are : " A dull, heavy, dragging pain through the pelvis, much increased by locomotion; " Pain on defecation and coition ; "Dull pain beginning several days before menstruation, and lasting during that process ; " Pain in the mammae, before and during menstruation ; " Darkening of the areolae of the breasts ; " Nausea and vomiting ; " Great nervous disturbance ; "Pressure on the rectum, with tenesmus and hemorrhoids; " Pressure on the bladder, with vesical tenesmus ; " Sterility. " Physical Signs of Cervical Hyperplasia. — Vaginal touch will generally discover that, the uterus has descended in the pelvis so that the cervix will rest upon its floor. The cervix will be found to be large, swollen, and painful, and the os may admit the tip of the finger. If the finger be placed under the cervix, and it be lifted up, pain will be usually complained of, and if it be introduced into the rectum so as to press upon the cervix as high as the os internum, it will often reveal a great degree of sensitiveness. Under these circumstances, the direction of the uterine axis will generally be found to be abnormal. The cervix will, in some cases, have moved for- * It must not be supposed that all these symptoms occur in all or even in the majority of cases. In many cases few, and in some almost none of them, will be recognized. 104 EATON ON DISEASES OF WOMEN. wards and the body backwards, or the opposite change of place may have occurred. " Physical Signs of Corporeal Hyperplasia. — If. two fingers be carried into the vagina, and placed in front of the cervix so as to lift the bladder and press against the uterus, while the tips of the fingers of the other hand be made to depress the abdominal Avails, the body of the uterus will, unless the woman be very fat, be distinctly felt, should the organ be ante-flexed. Should it not be detected, let the two fingers in the vagina be now carried behind the cervix into the fornix vaginae, and the effort be repeated ; if the uterus be retro-flexed or retro-verted, or even in its normal place, it will be detected at once. By these means we may not only learn the size and shape of the organ, but its degree of sensitive- ness. This may likewise be accomplished, to a certain extent, by rectal touch. The uterine probe may then be introduced, the cavity measured, and the sensitiveness of the walls care- fully ascertained. "A point which should be settled before the diagnosis can be considered complete will be whether the cervix alone is affected, or whether its enlargement is only a N part of a general uterine development. To determine this question, two means are at command : First, the examiner, introducing one or two fingers under the body of the uterus, and depress- ing the abdominal walls by the other hand, so as to clasp the fundus, ascertains whether it is larger than it should be, or of normal size, and free from sensitiveness. He then passes the uterine probe into the cavity of the body, and measures it. If the uterine cavity be increased in size, the evidence is in favor of the disease having extended to the tissue of the body. Should its size be normal, this is prob- ably not the case. This sign is not, however, to be entirely relied upon. " Sometimes, suspicion of scirrhous cancer in an early period being entertained, it becomes necessary to decide AREOLAR HYPERPLASIA OF THE UTERUS. 105 between its existence and that of the second stage of areolar hyperplasia, or sclerosis. Scanzoni doubts the possibility of deciding, but it appears to me that the investigator will usually succeed in doing so by the following comparison of signs and symptoms : In Cervical Sclerosis. In Scirrhous Cancer. "The patient shows no cachexia. She often does. "There is tendency to amenorrhea:!. There is tendency to hemorrhage. "The history usually points to parturition. It does not. "It has been preceded by symptoms of It has not- uterine enlargement. "The cervix feels like dense fibrous tissue. It feels almost like cartilage. "The body is, perhaps, implicated. It is very rarely so. "A sponge-tent softens the tissue.* It leaves it hard and dense. " Prognosis. " The prognosis in hyperplasia of the entire uterus, or of the body alone, is unfavorable with regard to complete cure, though highly favorable with reference to great relief of symptoms and to danger to life. Should the patient be approaching the menopause, it is possible that, after the functions of the uterus cease, atrophy may occur, and relief be obtained. But one can not be sure even of this, for the monthly discharge may give place to metrorrhagia, or all the symptoms may continue, in spite of the menstrual cessation. Under a course of local treatment, combined with one con- ducted with special reference to the general system, hope may always be held out that, although restoration of the uterus to its normal condition may not be effected, the evils result- ing from the complications of this disease can be so fully controlled that comfort will be obtained. When the neck of the uterus alone is affected, a favorable prognosis may always be made, for here there are fewer grave complications to be encountered; such, for example, as corporeal endo-metritis, menorrhagia, etc. The diseased part is likewise more access- ible to local treatment, and is also a much less sensitive and * This test originated with Spiegelberg. 106 EATON ON DISEASES OF WOMEN. important part of the organism; I might, indeed, almost say a less important organ, so distinct are the uterine body and neck, physiologically and pathologically. As I have else- where stated, the prognosis will depend, in a great degree, upon the patient. If she be unwilling to sacrifice her incli- nations and pleasures, but half fulfill the directions of the attending physician, and clandestinely expose herself to prejudicial influences, the treatment will accomplish nothing. In the case of a reasonable patient, who appreciates what is at stake, and is anxious to regain her health, it may be regarded as favorable. " Treatment. "Rest. — The patient should be instructed to take much less exercise than usual, to lie upon her bed or lounge for an hour every day, about midday, and to be especially quiet during menstrual periods. It is highly improper to confine her to bed, for many women become restive under the con- finement, and suffer both in mind and body, the sanguineous and nervous systems being impaired by want of fresh air. If the connective tissue be so much affected that the cervix is very painful upon pressure, absolute rest upon the back may become necessary, but my impression is that deprivation of fresh air and exercise ordinarily does more harm than is compensated for by the advantages arising from quietude. Every day she should go, unless deterred by some special cause, into the open air; and a limited amount of exercise should be inculcated, as a means of keeping up the general health. "The uterus should be placed at rest as much as possible. Its natural tendency, under these circumstances, is to fall from its position; consequently, all pressure should be re- moved from its fundus by the use of a skirt-supporter and a well-fitting abdominal bandage." The use of the abdominal supporter I have found of the AREOLAR HYPERPLASIA OF THE UTERUS. 107 utmost benefit; in fact, Ave doubt if these chronic cases can be successfully treated without its use. We would not dispense with them on any account. They need to be used with care and judgment, however. They must be made to fit so as to be really supporters of the abdominal viscera, and not compressors of the abdomen. (See improved London Supporter, Plate XII.) Sexual Intercourse. — Sexual intercourse is harmful in these cases as a rule, and should be prohibited in most cases. Diet. — The diet should be nourishing, but not stimulat- ing. It should be easily digested and taken in moderation, and at regular times only. Remedies. Ars. iod., Merc, iodide Phytolac. dec, Ferrum, Merc, cor., Kali idro., Nux, Ars. alb., Secale, Ignatia, Iris vers., Hyosc, Verat. vir., etc., are indicated remedies in this dis- ease, and the sympathetic affections dependent upon it. Special indications for these remedies may be studied best in works on Materia Medica. Remedies in Homoeopathic practice are not given according to the name of any disease, and must always be selected ac- cording to the pathogenesis of the drug, and we simply men- tion here the remedies most likely to be indicated to facili- tate the selection of the appropriate one, by the study of each individual case. I have named the remedies in the order in which they are prominent in regard to the fre- quency of their being indicated. Local Treatment. Some gentle local treatment we have found useful. The warm vaginal injection of water, using a large quantity, with a Davidsons syringe once a day, is of service. We think when there is a displacement of the uterus its reten- tion in situ is usually the thing to attend to at first. The 108 EATON ON DISEASES OF WOMEN. displacement, though it may have been in a measure caused from this disease, may be a cause of its continuance. The malposition of the uterus tends to keep up an irritation of the nerves, and to cause an increase of the circulation in the parts. Displacements can not always be relieved at once, on ac- count of the tenderness of the parts. In such cases, we must direct the patient to take rest in the recumbent posi- tion, use warm vaginal injections of water, and take reme- dies for the relief of the tenderness. These remedies indi- cated by the tenderness are, Bell., Arnica, Aeon., Gelsem., or Verat. viride. We may also apply a wad of cotton saturated with glycerine to the cervix uteri. As soon as the uterus is sufficiently free from tenderness to allow of it, we should proceed to rectify the displacement. (See Displacements.) Now, in addition to the use of the homoeopathically indi- cated remedies given internally, we may use some local treat- ment. The object to be obtained is, absorption and con- traction. The local application to the cervix uteri, externally and internally, of a solution of Iodine, is the most efficient rem- edy we have found, using the solution of the strength of about ten grs. of Iod. res., and Potass, iodid., 3ss. to Aqua 3i; applying this to the cervix with a soft brush, and to the cervical canal with a small uterine sound wrapped with cotton. These applications we would not make oftener than once in three clays. During treatment the daily use of the warm water vaginal injection is advisable. Scarifications of the cervix, blisters, and caustics we do not use, and can now say (after ten years of experience with- out them, and having had more than that number of years of experience in their use in hospital and private practice while in the old school), that we feel sure their use is harmful. Our experience is decidedly in favor of leaving them entirely alone. AREOLAR HYPERPLASIA OF THE UTERUS. 109 Sponge Tents. — A sponge tent covered with glycerine, and placed for about six hours in the cervical canal, is often very useful. First, it dilates the canal so as to make it easier to apply the Iodine. It compresses the tissues so as to temporarily impede the capillary circulation, and the local application of the glycerine is also of service. In using the sponge tent caution must be exercised that the patient does not take cold. It better always be done at the patient's home, and the sponge should not be allowed to remain more than six or eight hours in this class of cases. 110 EATON ON DISEASES OF WOMEN. CHAPTER X. PERI-METRITIS— PELVIC CELLULITIS— PELVIC ABSCESS. Peri-metritis indicates, strictly, an inflammation of that portion of the peritonaeum attached to and covering the uterus ; but, by common consent, it is applied to the inflam- mation of the peritonaeum situated within the pelvis. It is a frequent complication of cellulitis, and, when existing inde- pendently of cellulitis, has many symptoms in common with it. In a case of pure and primary peri-metritis we have not the effusion which takes place in cellulitis, and the tender- ness in the vagina is confined to the upper portion entirely. After the lapse of several weeks, we may have effusion of serum into that portion of the peritonaeum lining Douglas's cul-de-sac, and the case then may resemble recto-vaginal haema- tocelej though it is much smaller in size and is not so diffuse. Symptoms. The symptoms of peri-metritis are much like cellulitis. There is the stage of congestion, followed by fever and reac- tion, with the wiry, rapid pulse ; acute pain in the pelvis just posterior to the pubis. Vaginal examination does not reveal any evidence of inflammation in the cellular tissue. Slight pressure upon the uterus upwards produces no pain, but hard pressure causes much suffering ; the pain and tenderness being referred to the lower portion of the abdomen, just above or posterior to the pubis, about the fundus of the womb, and in the region of the bladder. There is not, how- ever, the frequent desire to pass water which we have in cystitis, as the lining membrane of the bladder is not affected. PERI-METRITIS. Ill There is some little pain from distension of the bladder, but the sensation is more often described as an uneasy feeling. Slight pressure in the lower portion of the hypogastric region produces pain, while in metritis, endo-metritis, etc., slight pressure causes no pain, but hard pressure can not be en- dured. Generally, in a few days, and sometimes in twenty- four hours, the inflammation extends over the peritonaeum, and we. have a case of general peritonitis. In some cases, however, the disease is arrested at once, and no extension of inflammation occurs. The disease may exist as a primary difficulty, or may exist as a complication of, or in connection with, the inflammation of some of the pelvic organs or vis- cera. The disease may be acute, chronic, or sub-acute. The acute form, though more dangerous, is not so likely to produce effusion as the chronic. ' Etiology. It is probable that most primary cases of peri-metritis are the result of cold, generally taken at the menstrual period, or following surgical operations. But peri-metritis very frequently results from extension of inflammation in the uterus, ovaries, or cellular tissue, and occasionally the bladder. Treatment. The treatment must be in accordance with the stage of the disease and the special indications in each particular case. In the early part of the disease Ars. alb.. Aeon.. Br?/., or Arnica are indicated, while later in the disease Merc, cor., Merc, iod., Kali iod., China, Cimicif., Colocynth., or Nux are the remedies. Rest is necessary. The recumbent posture should be maintained, and warm applications be made to the feet and limbs. Cool, acidulated drinks are often grateful to the patient. The diet should be mild and non-stimulating. Fomentations of hops, or the hop or warm water compress, 112 EATON ON DISEASES OE WOMEN. may be applied to the hypogastrium, and the warmth main- tained by coverings of dry flannel. Great industry should be exercised to arrest the inflam- matory action, by promoting the action of the skin and secre- tions generally, in this way establishing an equilibrium in the circulation, relieving the congestion and inflammation. Cathartics, anodynes, or the hypodermic syringe, are to be strictly prohibited. Meddling friends Avill often be suggesting these things, as well as turpentine externally ; but there is no way that proves satisfactory but a firm though kind re- fusal to allow of their use. Teach the people that benumbing the system is not curing the disease ; show them the bene- ficial effects of homoeopathic treatment by giving a single dose of Colocynthis (which is very often indicated in this dis- ease), and let them observe its effect, and then notice the freedom from nausea, constipation, and loss of appetite, pro- duced by opiates, to say nothing of the terrible effects of the opium habit, so often resulting from the administration of the drug, allopathically, for the relief of pain. Sequelae. The result most to be feared after peri-metritis is effusion of serum into the peritonseal cavity. If it does occur, Apis met, Ars. alb., China, Dig., Can. hid., Merc, iod., etc., are usually indicated. Sterility may be looked for as another sequel of peri-metritis, though it is not a certain result. This is owing to the thickening of the peritoneal covering of the ovaries from inflammatory action, and the consequent preven- tion of the escape of the ovum from the ovisac ; hence, it becomes impossible for the ovum to enter the fallopian tube or the uterus, and become impregnated. The retention of the ovum may cause the development of ovarian cystoma or fibroma; hence, we see that peri-metritis may be a cause of ovarian tumors. pelvic cellulitis. 113 Pelvic Cellulitis. Cellulitis, Para-metritis, Pelvic Abscess, etc. — These terms indicate inflammation of the cellular tissue surrounding the uterus, vagina., fallopian tubes, ovaries, etc. The cellular tis- sue serves to fill up the interspace between the rectum and vagina; and, in fact, is a connective tissue which connects, and still separates, all the pelvic organs, and serves as a bed, in which are located the blood-vessels and nerves as well. This tissue is more liable to inflammatory action than is generally supposed, and many cases of cellulitis are over- looked and misdiagnosed, being denominated inflammation of the womb, neuralgia of the womb, irritable uterus, etc. Too much stress can hardly be put upon the necessity of more care in the diagnosis of female complaints, and espe- cially cellulitis. Many a patient suffers greatly and loses her life from a want of proper attention to the diagnosis and proper treatment of the diseases of her generative organs ; and perhaps no disease is more frequently unrecognized than cellulitis. The cellular tissue, being sponge like or honey- combed in structure, is adapted to the uses for which it was intended, allowing of the elevation of the uterus in gestation and its depression in prolapse. Cellulitis may affect the entire cellular tissue of the pel- vis, or it may be circumscribed and confined to a small space. In making a vaginal examination of a patient for the first time, we should always be careful to note any evidence of cellulitis, for otherwise we might use treatment which would be injurious. For instance, if we found a displaced uterus, and at once proceeded to replace it without any reference to the cellulitis already present, we would probably find great increase of pain, and the development of inflammatory symp- toms which might be severe and alarming. Cellulitis may develop as a, primary affection, or it may result from the 114 EATON ON DISEASES OF WOMEN. extension of inflammation from some of the pelvic organs or from the peritonaeum. It was formerly claimed by authors that cellulitis only occurred as a result of displacement of some of the pelvic organs, or the extension of inflammation from some of them ; but it is now admitted to exist as a, pri- mary affection, although the pathology of the disease is not as well understood as could be wished, and it is hoped that more light will be found ere many years have passed, and we shall soon come to understand more thoroughly the pa- thology of this important disease. Prof. Emmet* claims that "cellulitis mod frequently exists as a primary affection, and that affections of the ovary, uterus, etc., are due, very often, to some previous lesion in the cell- ular tissue. He holds that the uterus is entirely dependent upon the blood which is distributed through the cellular tissue, and that, as the nerve filaments reach the uterus by the same route, the connective or cellular tissue is the first and most exposed to the influences exerted through the blood- vessels, and, consequently, is more liable to become inflamed, as he who transports nitro-glycerine is more exposed to dan- ger than he who is to receive it." Women are most liable to this disease during their period of menstrual activity, though it occurs occasionally after the cessation of the catamenia (probably about five per cent). Quite young girls are stated by Prof. Emmet to be liable to the disease. How he goes to work to make up a diagnosis in their cases he does not tell us, and I can not imagine. True, we might diagnose general pelvic inflammation in case of young girls; but I judge it is impossible for any one to very satisfactorily differentiate, in their cases, as to the particular part affected, and I do not think it important, as treatment should be very similar in their cases, whichever organ or part in the pelvis is affected. * Emmet, "Prin. and Prac. of Gynaecology," p. 260. PELVIC CELLCLITIS. 115 Etiology. The causes which produce cellulitis in the female are, cold taken at or about the menstrual period, produced or acci- dental abortion, constipation, displacements of the uterus, cold taken after severe physical labor while in a perspiration, means used to prevent conception, severe and protracted labor, lacerations of the cervix uteri, the use of pessaries too Ions; continued, strong vaginal injections, excessive coitus (especially soon after marriage), allowing of the too great and protracted distension of the bladder; pelvic, ovarian, or uterine tumors, etc. The tubercular diathesis, conjoined with some local irritation, the climacteric period, gonorrhoeal infec- tion, local phlebitis, etc., may produce this disease. Unsat- isfied sexual passion in widows of full blood may also cause this disease ; as it may also, in the case of the married, where the passion is excited but not satisfied, owing to incapacity on the part of the husband. Fruitful married women are less liable to cellulitis than the sterile or unmarried. During the last quarter of a century the almost indiscrim- inate use of caustics to the os and internal surface of the uterus, by the allopathic medical profession, has been a fruitful source of cellulitis, which even their own authors are now willing to concede. How any body of intelligent, scientific, professional gentlemen could have adopted such a routine practice as this, causing such sad results in some cases (as they now freely acknowledge), and being of so little benefit in most cases, is truly astonishing. Too great faith in their leaders, and a blind following of their example, produced this unfortunate result, just as it did in the use of venesection and antiphlogistic treatment, so-called, almost universally used for many years by them, and now entirely, or almost entirely, abandoned for the tonic or the expectant treatment, which means stimula- tion, or the use of placeboes — or, as we say, blanks — and wait- ing for nature to accomplish a cure; the latter of which is cer- 116 EA TON ON DISEASES OF WOMEN. tainly commendable, in that it shows either a great respect for nature and nature's God; or a distrust of the efficacy of their established routine, double-distilled, scientific treatment. Symptoms of I»elvic Cellulitis. The acute attack of cellulitis is usually ushered in with a chill, or at least chilly sensations, for a period varying from a few moments to several hours, when reaction sets in, and fever rises, with considerable pain in the pelvis. Sometimes the pain is sharp and piercing, at other times sore and aching — the sore, aching pain being most prominent in cases arising from excessive coitus or severe labor, while the darting, lan- cinating pain accompanies an attack caused from cold, either general or local. The general symptoms of an acute attack of cellulitis are similar to those in acute attacks of vaginitis, ovaritis, metritis, cystitis, or peritonitis. In cellulitis a vaginal examination will generally reveal tenderness on all sides of the vagina, although the vagina itself is but slightly increased in tem- perature or color. There is an absence of the intense redness and spasmodic tenesmus, usually present in vaginitis ; pres- sure upon the uterus produces little increase of pain, while in metritis this pressure could not be endured. The func- tions of the bladder are little disturbed, micturition being accomplished with tolerable ease, in great contrast to the extreme pain in this act accompanying cystitis. It will be understood I am now speaking of the recent attack of cellu- litis, for, in some instances, when the disease is not arrested, the inflammation extends to all the pelvic viscera, and we have a case of general pelvic inflammation, as well as cellulitis. Cellulitis may also be circumscribed. In this case it is somewhat more difficult of diagnosis. We then have local tenderness at the inflamed point, in connection with the gen- eral symptoms enumerated. Defecation is usually painful, PELVIC CELLULITIS. 117 and constipation a prominent symptom. In the early stages the blood vessels, being full in the cellular tissue, and the circulation obstructed, a condition of congestion is present, which not only gives rise to the pain, as well as the tender- ness on pressure, but soon causes effusion of serum into the cellular tissue, giving rise to a feeling like the vagina was sur- rounded with cotton batting, pressing it inwards and decreas- ing its size. We must be careful not to confound this narrowing of the vagina with recto-vaginal hematocele, as we may distinguish it by its presence in the posterior part of the pelvis entirely, and not affecting the anterior portion at all; besides, in recto-vaginal hematocele the size of the effu- sion (or the apparent tumor caused by the effusion) is much greater in the same length of time than is present in cellu- litis. After two or three weeks we may have an abscess form posterior to the vagina, and greatly resemble in its physical features a recent hematocele; so time must be an element in making up the diagnosis, as also must the history of the case. Nausea and vomiting are often symptoms in these cases, as well as severe headache. Perhaps headache is the most constant symptom with which we meet in chronic cellulitis, though backache and a. sense of weight in the pelvis are very common. Hysterical symptoms of almost any form are liable to be manifested in this disease. There also exists, in a great many patients, a chronic form of cellulitis, where the symptoms of the acute attack have never been experienced, cellulitis being, in these cases, the result of the extension of inflammation from some of the pelvic organs or viscera, the symptoms of tenderness and effusion having been so moderate as to have been overlooked or ascribed to some other ailment. The pain in these chronic cases is usually of a burning character. The patient is often tortured with hot flashes, becomes easily fatigued, is very nervous, and complains of all manner of absurd and conflicting symp- toms ; is usually peevish, fretful, notional, and whimsical. 118 EATON ON DISEASES OF WOMEN. Sometimes she is emaciated, but is often of full habit, having a good appetite and digestion. In these cases a sense of weight in the pelvis and bearing-down pain is usually com- plained of, and pain in the back as well, especially after exercise. A physical examination, however, reveals no pro- lapse or version of the uterus, although there is a supersensi- tive condition of the entire pelvic contents, and often the tenderness is greatest in one or both iliac regions. In cellulitis the passing of the sound into the uterus, even to the fundus, would produce no special pain, while in endo- metritis the pain would be intense from its introduction. This is an important point in differential diagnosis between endo- metritis and cellulitis. In the introduction of the sound for the purpose of diagnosis great care should be exercised that no vio- lence is done the mucous membrane. In fact, this care is always necessary in making an explorative examination for the purpose of differentiating in a case where we find that pressure upon the os causes pain to be felt higher up, and pressure above the pubis causes some pain, and there is apparently some supersensitiveness on the sides and upper portion of the vagina, with only mild symptoms of inflam- matory action, without hemorrhage. The use of the speculum is hardly ever required in making the diagnosis of an acute attack of cellulitis. By separating the labia we may see enough of the vaginal mucous membrane to satisfy us, in connection with the digital examination, whether the case is one of vaginitis or cellulitis. In either vaginitis or cellulitis, the speculum causes too much pain in its use to cause it to be recommended, even in diagnosis of these cases ; for I take it for granted that a, digital exam- ination should always precede a specular examination in all cases, in making an examination for the purpose of diagnosis ; and we can learn enough by the introduction of the finger to assure us of heat and tenderness, the location of the tender- ness and its extent, the amount of effusion and congestion PELVIC CELLULITIS. 119 of the tissues, the position of the pelvic organs in the main; and. in the few cases where we are not satisfied there is not a flexion of the uterus, with digital examination, we can gently introduce the sound, and clear up that much of the diagnosis. I lay it down as a general principle of gynaecolog- ical practice that we should never attempt to introduce the speculum when a digital examination gives any considerable pain. (The tenderness should be first removed by suitable treatment.) Prognosis. The prognosis of cellulitis will be favorable, in most cases, of acute attacks, if treated promptly and rationally, terminat- ing generally in resolution, leaving the uterus less movable than normal, however, oAving to adhesions which usually form at some part of the location of the inflammation. We may also detect the band-like or corded feel of the folds of some portion of the vagina, generally its upper part. These are also caused by adhesions, and may offer considerable resistance to the advancement of labor, should gestation occur. In some instances, however, suppuration develops, and a pelvic abscess is formed, and may point in the vagina or find exit through the rectum, the opening of the abscess into the rectum being the more common. Or the abscess may open into the bladder in rare instances (only one case of this kind has come under my personal observation); or we may have blood poisoning from the absorption of the pus, in which case we have rigors and fever, with great nervous prostration, and death may result. In occasional instances the pus has found exit through the small intestines, owing to adhesions between them and the sac of the abscess; and the pus may follow down the psoas muscle, and open in the groin; or it may pass through either sciatic foramen, and burrow under the glutei muscles, or it may become sacculated, and remain for years, causing a diagnosis of fibroid to be made; or it may be 120 EATON ON DISEASES OF WOMEN. entirely overlooked until, for some reason, some inflammatory action is set up, and even then it may be mistaken for a recent attack of cellulitis. Generally the abscess discharges voluntarily, or is evacuated artificially, at its most depend- ent portion, and the pus is very thoroughly drained off, leaving the sides of the sac of the abscess in contact, causing adhesions and a cure of the whole trouble with little treat- ment except of a general character. In chronic cellulitis we may look forward to a protracted, if not an incurable, case; for generally the ovaries and uterus are more or less involved, and the nervous irritability is such that the patient suffers much from prostration. The symptoms being someAvhat obscure, the patients are said to go into a decline, which simply means they run down, and no one knows what is the matter with them. Sterility is a common result of pelvic cellulitis, which is caused from the organization of the plastic material thrown out around the ovaries, making it impossible for the ovum to escape from the ovary; or sterility may, in these cases, be caused from the adhesion of the fallopian tube in such a way as to prevent its receiving the egg" at all. Hence, we see that cellulitis may be a prime cause of ovarian inflammation and tumors, in that it may prevent the escape of the ovum, and it may prove the nucleus of a cystic or fibro-cystic growth. Cases which early come under homoeop- athic treatment are usually relieved without the formation of pus, and chronic cases are relieved with homoeopathic reme- dies which have bidden defiance to old-school treatment. Occasionally, however, chronic pelvic cellulitis may take on active inflammatory action, and pus may form as in acute attacks, which go on rapidly to suppuration. One attack of cellulitis offers no immunity from subsequent attacks, but rather predisposes to them. Complications in Pelvic Cellulitis. — The extension of inflammation from the cellular tissue to the peritonaeum is PELVIC CELLULITIS. 121 the most common complication in this disease, although me- tritis, cystitis, and rectitis are not of infrequent occurrence. If we do not see the case till several days after the attack, and fully developed peritonitis has resulted, we will have only the history of the case to aid us in diagnosing it from ordinary attacks of peritonitis. We have the tenderness on slight pressure over the abdomen, the tympanitic condition, wiry pulse, great prostration, constipation, loss of appetite, fever, frequently accompanied with profuse perspiration, as in ordinary attacks of peritonitis; but the history of the case will show that the pain in the pelvis was manifested one or more days before it occurred in the abdomen. A vaginal ex- amination will show the tenderness of the connective tissue, and will probably indicate some effusion into this cellular tissue, showing that the origin of the disease was in the cellular tissue of the pelvis, and consequently the case is one of cellulitis complicated with peritonitis, and should be so desig- nated. The gravity of this case is much greater than ordi- nary peritonitis, which is always serious. The symptoms of rectitis, as a complication, are those present in dysentery in connection with those in pelvic cel- lulitis. There is diarrhoea, tenesmus, ineffectual urging to stool, with no operation, save a little mucus ; or blood; while in peritonitis, as a complication, there is no urging to stool, not even a desire for stool, although the pain in the abdo- men may be of great severity. When cystitis complicates a case of cellulitis, there is the frequent desire to pass water, accompanied with pain in the effort and a sensation as if there was more urine to pass, which can not be discharged. This is owing to the presence of mucus in the bladder, which is very tenacious, and difficult to dislodge, and its par- tial entrance into the urethra, as well as the inflammation in the bladder, causes the feeling of frequent desire to mic- turate. The presence of the urine in the bladder, even in small quantities, in its inflamed condition, tends to produce 122 EATON ON DISEASES OF WOMEN. this feeling also. These symptoms, taken in connection with (hose of cellulitis, clearly show cystic complication. The pain is not so much in these cases at the time of the flow of the urine through the urethra, as in urethritis, but follows the flow, as a sort of straining, or tenesmus. Urethritis may, however, be present, due to extension of the inflammation from the cellular tissue or otherwise, and in that case we will have the scalding, burning pain in the urethra while the water is passing. Treatment. In the first stage, or that of chill, Arsenicum is most prominently indicated, with the warm foot bath, and warmth to the limbs. The full warm bath, succeeded by a warm pack in a warm wet sheet, with the administration of large draughts of moderately cool water, will frequently establish the equilibrium of the circulation. In this case the disease is aborted in its first stage, and we can only denominate it as congestion of the pelvic organs. It is not often, however, that we are called to a patient in this stage, and Ave usually find that reaction is fully es- tablished in the general system, and fever, with a rapid, wiry pulse, is present, although there is still evidence of conges- tion in the pelvic cellular tissue. The remedy indicated in this case is generally Aconite, although, if the cause is from excessive coitus or protracted and severe labor, Arnica should be alternated with the Aconite, and followed in a day or two with Bry. or Mercurius, if there is a tendency to suppuration. Bell., Hyos., Plat., Cimicif., etc., are sometimes indicated. (See their pathogenesis in works on Materia Medica.) The hygienic measures necessary are, first, perfect rest in the recumbent posture, with the thighs partially flexed upon the abdomen. The patient should be enveloped in flannels from neck to foot. Warm vaginal injections with an elastic syringe should be used freely, with the patient recumbent, a bed-pan being placed under her to receive the water as it passes out PELVIC CELLULITIS. 123 of the vagina. Warm injections per rectum are also of great service. The food should be very light and non-stimulating. Cold water may be drank freely. The vaginal and rectal in- jections of warm water should be used every three or four hours for some time, till the evidences of active inflammation subside. Should pus form, I prefer to evacuate it artificially in the vagina, if possible, as its opening into the rectum, colon, small intestines, or bladder, or even into the groin, makes a more troublesome case, and there is very much more danger of fatal results. Some cases result favorably, how- ever, when the pus escapes through these outlets by ulcer- ative action. Some cases of chronic cellulitis, sub-acute in character, as all cases of chronic cellulitis are (unless, from some exciting cause, acute inflammation supervenes upon the chronic sub- acute inflammation), will nearly baffle all the remedial measures and remedies we can employ. Here it is necessary to look well over the general system, and ascertain the functional derange- ment or organic lesion, if any there be, which may so affect the system as to keep up the disease or prevent its cure. Sometimes it will be found to be a displacement of the uterus, sometimes disease in the rectum; at other times we find its explanation in the tubercular diathesis of the patient, impu- rity of the blood, or some disease or tumor of the uterus or ovaries. Sometimes these difficulties can be relieved and removed, and sometimes not. If possible, we must, of course, remove the cause of the irritation, which, if we can accom- plish, will enable us to get relief from the tenderness, back- ache, weight in the pelvis, etc., by the use of Nux, Rhus, Ars., China, Bryonia, or Pulsatilla. When the disease is depend- ent upon impoverished or impure blood, w T e find great benefit from Iod., Ars., Phytolac. dec, China, Merc, Thuja, etc., as indicated. The application of a Solution of Iodine, ten grs. to the ounce, to the vaginal mucous membrane, by means of a brush, used through the speculum once in three days, with the 124 EATON ON DISEASES OE WOMEN. external application of Colorless or Tr. Iodine above the pubis, together with attention to the movement of the bowels resru- larly, will greatly aid in the cure of these cases. Supporting the abdominal viscera by an abdominal sup- porter is often a great relief to the patient, and a measure calculated to be of service in the cure, as it relieves the tender parts from being pressed upon by the weight of the abdominal organs when in the erect posture. In the chronic form of cellulitis attention must be paid to the promotion of healthy digestion and assimilation, as well as the general nervous recuperation. Generous, easily digested diet, with moderate exercise and pure air, as well as medicine, are necessary. The exercise must be moderate, however; hard labor, or riding in a hard vehicle, over a rough road, could not be tolerated. Even sweeping carpets and making beds must be prohibited. Sexual connection must be forbidden. The tepid sitz bath, daily, is of much service, as is also a general sponge bath, followed by active friction to the ex- tremities and back. Do not be inveigled into the use of anodynes, either by the stomach or by the use of that con- temptible little instrument, the hypodermic syringe, which has done more harm than decades can eradicate, in the establishment of the opium habit. We, however, withdraw objection in case of cancerous disease (which is hopeless), and, perhaps, some other hopeless cases, as mangling from external violence of such severity as to preclude the hope of recovery. Listen not to the importunities of patient or friends; do for the patient what your judgment dictates. Cheer the patient with all the hope you can honestly give her, and explain the injurious after-effects of anodynes, and help her to be brave by your own tranquillity, and have firm faith in the remedies and means used. The complications of cellulitis must be treated on the general plan laid down when they occur as separate diseases, using remedies singl}', however, and not making a mixture PELVIC ABSCESS. 125 of remedies because you have a complication of diseases. If two or three remedies seem to be about equally indicated it is well to give one for a few days, then omit it, and use another for a time. We then get a better action of the remedy, and Ave also learn something for our own, or some one's, future use. Pelvic Abscess. Abscess in the pelvis, resulting from pelvic cellulitis, is not of very infrequent occurrence. We know of its forma- tion by the occurrence of rigors and the soft, fluctuating feel. When we are certain that an abscess has formed, it is best to evacuate it if possible through the vagina with the long curved trocar. Fig. No. 5.— Long Curved Trocar Allowing the pus to remain can do no good, and it may do much harm by its absorption into the circulation, or it may point and cause ulceration in very inconvenient locali- ties, as into the bladder, intestines, or peritonaeum. Usually draining the abscess with the trocar allows the sides of the walls of the sac to come together and adhere, and causes a cure of the abscess ; but if it does not, and more pus forms, we may evacuate it again in the same way, and folloAv the evacuation of the pus with injections into the interior of the sac of a Solution of Iodine, ten grs. to the ounce. Instead of the curved trocar, we may evacuate the pus with the Aspi- rator. (See chapter on Instruments, and Plates IX and X.) 126 EATON ON DISEASES OF WOMEN. CHAPTER XL CHILD-BED FEVER. PUERPERAL PERITONITIS, PUERPERAL METRITIS, METRO-PHLEBITIS, AND PERITONITIS. This disease, occurring as it does after parturition, is treated of in some works on obstetrics, but not in all, and, as it is one of the diseases peculiar to women, I deem it properly considered in a treatise upon " Diseases of Women," although very generally omitted in these special works. Puerperal fever indicates something more than a fever occurring after delivery. It consists of an inflammation of the womb, gener- ally accompanied with peritonitis and following delivery but a few days. By some, the term has been restricted to the malignant, epidemic form of the disease. It is essentially an inflammation, accompanied with a severe fever, and it is more. It includes a blood poisoning, also. The inflamma- tion may be seated mostly in the muscular tissue of the uterus ; or it may be in the uterine veins, being then a uterine phlebitis ; or it may mainly affect the peritonaea! tissue ; or it may affect all the pelvic organs, and extend to the abdominal viscera as well. The nervous system does not escape in this disease, and we have extreme prostration of strength very much like that which we have in typhus fever. Unfortunately, the writings of authors of eminence upon this disease have been so conflicting, not only regarding its treatment, but also its symptoms and pathology, that the term "puerperal fever," unexplained and unqualified, conveys to the mind of the experienced, thorough physician no assur- ance of the real nature or severity of the complaint, unless he is aware of the ideas entertained by the speaker upon PUERPERAL PERITONITIS. 127 this disease. During the last few years those of the profes- sion Avho exercise most care in nomenclature and diagnosis have discarded the use of the term puerperal or child-bed fever, and use the terms puerperal peritonitis, or puerperal metritis, instead. This is much the more satisfactory method of nomenclature. A few years since it seemed to me to be my duty to criticise the remarks of a prominent author, made to a large number of medical gentlemen of the North-west, in the par- lors of the Grand Pacific Hotel, Chicago, upon puerperal fever, he including phlebitis of the extremities, milk fever, pneumonia, and intermittent fever (occurring in the puerperal state), as well as abscess of the breast, septiccemia as well as pycemia, under the general head of puerperal fever. He had the perception and manliness to acknowledge the justice of the criticism I made, and expressed the hope that hereafter the profession would be more careful in medical nomenclature. On the one hand, it might be considered that partu- rition, being a physiological process, it should not very materially tend to disease. On the other hand, when we consider the large dimensions to which the uterus attains at full term of natural gestation ; the consequent displacement of the abdominal viscera ; the pressure to which the kidneys, liver, and stomach are subjected; the obstruction offered to the free action of the bowels ; and the consequent derange- ment of digestion and assimilation, we may wonder that disease is not a constant effect of this process. When we consider the violent straining and tension to which the muscles of the body are subjected in the process of the expulsion of the child, both in natural and abnormal deliveries; the depression and exhaustion to the nervous system, caused by this process, we Avonder more and more that the recoveries from confinement are as favorable as they are. 128 EATON ON DISEASES OE WOMEN. Any student, by making a careful study of puerperal peritonitis or metritis, will, from the history and description of the disease given by different authors, become convinced that it sometimes occurs epidemically, sometimes sporadically, and sometimes as the result of contagion or infection; and that it sometimes follows the easiest as well as the most severe labors; that it occurs in the robust as well as the weak; that there is generally .evidence of blood poisoning; but whether it be from atmospheric conditions, or from the absorption into the system of poison from the person of the accoucheur, or the putrid matter within the uterus from decay of a portion of retained placenta, or from cold and the arrest of the natural secretions, he will not be prepared to say. He will feel sure, however, that either of these causes may develop the disease. He will be convinced that the accoucheur can not, with safety to the patient, attend cases of confinement while he has in charge a case of puerperal peritonitis, and that he can not safely dress suppurating wounds and then attend cases of confinement. He will also be convinced that a case of puerperal peritonitis may arise in the practice of any physician, in spite of the utmost care and caution on his part. The nervous system is claimed by some to be the seat of all the derangements of the system, and especially puerperal diseases. M. Flourens* says: " The form of the nervous system determines the form of the entire animal, and the reason why it is so is plain; it is because, in fact, the ner- vous system constitutes the entire animal, all the other sys- tems being added merely to serve and maintain it." Meigsf says : "That the nervous system is the only part or element upon which medicines, miasms, or contagions can act." (This theory should make a homoeopathist of him, as in it is found one explanation of the perceptible action upon the system * Analyse Raisonnee des Travaux de Georges Cnvier, page 88. t Meigs's "Obstetrics," page 642. PUERPERAL PERITONITIS. 129 of the minute dose.) But, however we may theorize, we may as well, first as last, admit that all cases of puerperal peritonitis do not result from the same cause ; but to one thing we can adhere, that in every genuine case of puerperal peritonitis there is blood poisoning and nerve depression, and that a certain train of symptoms are necessary to indicate the disease. Symptoms. The first symptom which presents itself in an attack of puerperal peritonitis or metritis is a chill, either affecting the whole or a part of the body, and varying in severity from mild, chilly sensations to severe rigors, causing shivering and chattering of the teeth. This chill comes on generally with- out premonition, often occurring in those cases which have for two or three days, and sometimes a week after delivery, seemed to be doing well. In some cases, however, there is some premonition of the attack in an increase of the rapidity of the pulse previous to the chill, with a feeling of exhaus- tion or excitement. The occurrence of a chill does not, however, indicate with certainty the attack of peritonitis, as it may be due to the secretion of the milk or the commencement of an ordi- nary intermittent or bilious attack of fever. In the attack of puerperal peritonitis there is fever following the chill, so there is also in intermittent and bilious attacks ; but in the attack of peritonitis we have tenderness over a portion or a whole of the abdomen, generally commencing in its lower portion and extending upwards; we also have a wiry pulse, which Ave do not have in intermittent or bilious fever. Pain in the abdomen and pelvis is another symptom in- dicative of this disease. This pain is greatly increased by pressure, even very gentle pressure often producing acute pain — sometimes the weight of ordinary clothing can scarcely be endured. The patient draws up the limbs 1 30 EA TON ON DISEASES OF WOMEN. and flexes the thighs upon the abdomen. Great thirst is complained of, and the swallowing of cold water often causes vomiting. In some cases the mind wanders, in others, the patient insists that she is getting along nicely, seems uncon- scious of her condition, and does not seem to suffer pain except when some pressure is marie over the abdomen, or she attempts to move in bed. Tympanites over the entire abdomen is soon manifested ; though percussion is very painful we may use it enough to satisfy ourselves of the actual condition present, though it would be very unwise to subject the patient to frequent examinations by percussion. The tongue, at first red or furred in the center, with red edges and tip, becomes dry and fissured. There is inability to obtain rest in sleep in most cases, though sometimes an almost constant drowsy, semi-comatose condition is present. Profuse perspiration is sometimes a constant symptom after the first few days of the disease, although the pulse remains frequently up to 130 or 140 beats per minute. It becomes softer in favorable cases, and gradually diminishes in frequency. Sometimes the skin remains dry and hot. The temperature of the body is high, ranging from 103° to 105°. As a gen- eral rule, the higher the temperature the more grave the case. Dr. Blundell * has given the term hidrosis, or hidrotid fever, to this disease, when characterized by very profuse perspira- tion. He divides these cases into seven varieties, " the ultra malignant, the malignant ', the acute, the lingering, the mutable, the fugacious, and the remittent" (which is splitting hairs when we have no use for the hair). It amounts to no practical ad- vantage, but would tend to make more intricate that which is poorly enough understood at best when made as plain as pos- sible. The secretion of milk is generally arrested, and the child has to be fed artificially. The bowels are usually con- stipated. This is a more favorable symptom than diarrhoea, as diarrhoea in this disease indicates that the peritonitis has * " Obstetricy," by Costle, p. 770; Ramsbotham, p. 545. PUERPERAL PERITONITIS. 131 enteritis as a complication, greatly increasing the gravity of the case. There is great prostration of strength, with entire loss of appetite. The breath is offensive. The lochia is gen- erally arrested, and the odor of the vaginal discharge (if there is any) is very putrid and nauseating. The eye looks glassy and inexpressive. The countenance is sallow, dejected, and ghastly. Sometimes a metastasis of the inflammation takes place, and the disease suddenly seems to leave the perito- naeum and attack the pleura; but in these cases there are not all the symptoms of puerperal peritonitis fully developed, and the case is one which some authors, especially Professors Iiamsbotham and Keating, have denominated false peritonitis, which is more of a neuralgic than inflammatory condition, though it manifests many symptoms indicative of genuine puerperal peritonitis. Sometimes pain in the back is more complained of than any thing else. Frequently there is almost an entire arrest of the secretion of urine, and in these cases the pain in the back is doubtless due to congestion of the kidneys, causing the arrest of the natural secretion. Cold hands and feet I may also mention as generally present in this disease, although the body is unnaturally warm. Blue- ness of the skin, with obstructed respiration, may be some- times noted. Etiology. Upon the cause of puerperal peritonitis there is a great diversity of opinion. From my own experience, and all I can learn from authors and the experience of my brethren, I am of the opinion that the causes are various, but producing a uniform effect upon the nervous system through the agency of the blood, sometimes by inhalations of poisonous gases, sometimes by absorption of poisonous gases, or matter in the uterus, and sometimes from cold. The arrest of the process of involution of the womb after labor, on account of lacera- tions of the cervix, makes it requisite that there should be 132 EA TON ON DISEASES OF WOMEN, considerable discharge per vagina m; An irregular contraction of the womb, so as to cause retention of this effete matter, may cause the generation of such poisonous gases as might develop the phenomena we witness in this disease. The re- tention and putrefaction of a bit of placenta may produce the same result. The removal of so much pressure as has been exerted upon the abdominal viscera by the gravid uterus tends to render the parts liable to congestion and subsequent inflammation. Doubtless epidemic influences are such, in some instances, as to merit the term contagion, though it is clear that contagion is not necessary to the development of the disease. The coincident occurrence of epidemics of ery- sipelas and puerperal fever have led some to suppose the dis- eases were interchangeable ; bat this manifestation is doubt- less simply the effect of the atmospheric conditions which have favored the development of these diseases, the nature of these conditions of the atmosphere being as yet unknown. Prognosis. Sporadic cases will usually terminate favorably under proper treatment; but in severe epidemics a considerable number will be lost under the best treatment. The disease, when terminating favorably, generally results in resolution, but sometimes leaves an effusion of serum in the peritonaeal cavity, called abdominal ascites. This may be absorbed by the powers of nature, assisted by remedies, or require artificial evacuation by tapping. Complications. The extension of the inflammation from the uterus and peritonaeum to the cellular tissue, ovaries, etc., is not infre- quent, and sometimes causes sterility, from the effusion of plastic lymph around the ovaries, as in pure cellulitis; or pus may form in the cellular tissue, or between the layers of mus- cular tissue, in the uterus, or in the peritonaea! cavity. In PUERPERAL PERITONITIS. 133 the latter case it is rapidly fatal. Cystitis, pleuritis, puer- peral mania, or cerebral meningitis sometimes complicate the case. Post-mortem Appearances. — These are quite uniform. The abdomen is large and tense. On opening it, there is an escape of fetid, nauseous gas. The peritonaeum is found highly vascular, with discolored patches, and some evidence of pus at these points. The omentum is thickened, and a considerable quantity of turbid serum is found in the perito- neal cavity. The womb is sometimes found to be normal in appearance ; at others so soft as to allow of being easily torn to pieces with the fingers. Treatment. If we are so fortunate as to see the patient during the onset of an attack while there is coldness or rigors, Ars. alb. is indicated, administered in the 3 X trituration, in the dry state, upon the tongue, every quarter or half hour. Place the feet in a very warm foot bath. This is best done in this case by allowing the patient to lie upon her back in bed, with the limbs drawn up, and the feet placed in the small foot bath-tub, which can be slipped under the bed- clothins;. The tub should be well warmed before being used, so as not to chill the patient should she chance to nit her limbs against its edges. As soon as reaction is established, Aconite in low dilution, alternated with Sulph. is demanded, and should be continued until free diaphoresis is established. In place of Sutyh, Kali chlo., l x trituration, given every two hours, is of great serv- ice. After the perspiration has continued for several hours, blanks should be used for a time, to allow us to see the condition of the patient when -not taking medicine; if fever is found to be mostly gone for a few hours, and the case shows clearly that the attack was not due to the secretion of milk (it having been secreted before the chill or it is 134 EATON ON DISEASES OF WOMEN. too early for the milk to come), we do well to give one gr. doses of Sulph. Quinia every two hours for a day or so, especially if we have a white coating upon the tongue, and aching of the limbs is complained of. If nausea is a promi- nent symptom, together with general aching, Ars. alb. should take the preference of the Sulph. of Quinia. In case fever returns, there is no further use for Quinia. We must use either Kali chlo., Sulph., Carbol. acid, Iodine, or Ars. iodid., with intercurrent remedies, as indicated. They will be found among the following: Bell., Aconite, Bry., Rhus tox., Apis mel., Verat. viride, Merc, etc. When convales- cence is established, China, Nux, Puis., etc., are useful according to their most prominent homoeopathic indications. During the greatest activity of the fever, Aconite low has served me well, generally in alternation with Iodine 6 X or Sulph. 30 x . Bell, takes preference of Aconite if the dullness of the sensibilities is the most prominent symptom. Verat. viride, so useful in pleuritis, I haA^e not found satisfactory in peritonitis, though some have claimed to obtain excellent results from its use in this disease. Beef tea is the most satisfactory diet; cool water may be given freely;' hot teas and stimulants are hurtful; warm compresses to the abdomen are used by many, but, on account of their dampness, are not very desirable. Where there is extreme tenderness the compress should be wet with warm hop water, and kept in situ with a flannel bandage. In most cases the dry flan- nel bandage, evenly applied, is all the local application nec- essary. Vaginal injections of tepid water and castile-soap, followed by an injection of Liq. Soda chlo., one part to six of water, are of service — using the injection of a tempera- ture high enough not to chill the patient. Intra-uterine injections of Solution of Iodine, two to five grs. to the ounce, are sometimes promptly beneficial in very bad cases, espe- cially when the evidence is clear of the suppurating condition in the interior of the womb. PUERPERAL PERITONITIS. 135 Good air is another necessity in the successful treatment of puerperal peritonitis, or metritis. The old style of keep- ing the patient in a small room, with every crevice carefully closed to prevent the ingress or egress of a breath of air should never be followed; but, on the contrary, see to it that a free supply of fresh air is admitted to the sick-room, and abundant means are secured for the passing out of the impure, poisonous gases, which are always present in great amount. Do not be satisfied with a small opening for the ingress of fresh air ; but have two openings so the air in the room may circulate, taking care that the patient is not in a draft. Let her be well protected with warm coverings, and let these, as well as her personal clothing, be changed often. There is no good, but a positive harm, in allowing the bed- ding and patient's clothing to remain days and weeks with- out change. Let the patient be bathed often, and wiped or sponged off frequently, also, using a little soda in the water when the fever is high, and a little Bay-rum when there is less fever. Keep most visitors out of the room, and, if possible, away from the house. They often are a positive injury by disturbing needed rest, and exciting alarm by unwise though well-meant solicitude. The complications of this disease must be treated accord- ing to the peculiar conditions present, and the urgency of the symptoms, taking care not to compound the remedies, using one for a few hours or a day, singly, and then changing to another, which the complication seems to demand; the al- ternation which I have already mentioned being in the giv- ing of some antiseptic remedy in alternation with the one, especially indicated in that particular case. I am well aware that some homoeopathic physicians believe nothing in anti- septic treatment. So far as I can get at their objections to it, they are due to the fact that the term has been used by allopaths. Now, the reason for the faith which is in me is 136 EATON ON DISEASES OF WOMEN. this : I believe that in the genuine case of puerperal peri- tonitis we have a blood poisoning which has a tendency to develop a pysemic condition of the blood and the conse- quent depression of nervous strength, which develops the Diathesis sen Infectio purulenta. Now, if this is not indica- tion enough for the giving of antiseptic remedies, then there are no indications for remedies. If we can not give anti- septics, neither can we use any kind of antidotes to poisons, and really an antiseptic is an antidote. If it can be ex- plained in any way which does not show its antidotal quali- ties, I am mistaken. I will digress just here to remark that in the treatment of Scarlatina Maligna, Diphtheria, and Epidemic Cerebro- spinal Meningitis, the need for antiseptics is equally great, and they prove as eminently beneficial. Without their use I would not take the responsibility of a case of either disease. HOMCEOPATHIC REMEDIES. 137 CHAPTER XII. HOMCEOPA THIC REMEDIES. Desiring to condense as much as possible, we make a few suggestions regarding homoeopathic remedies. We do this, not to interfere with works upon Materia Medica, or Therapeutics, but that the reader may understand the opin- ions we entertain regarding them and their action on the system. Having used them now over ten years, and having previously graduated in allopathy, and practiced it for up- wards of a decade, we may, perhaps, offer some practical hints, and Ave say, unhesitatingly, that we consider homoeop- athic medication the more speedy and certain curative treat- ment, and we offer our understanding of its modus operandi. Attenuation. — This term has been so often confounded with potency that many have come to use the two terms as synonymous. This seems to me to be a grave error, and has led to much hard feeling on the subject of high and low potencies. As I understand Hahnemann, in his work on " Chronic Diseases," Vol. I, when specially teaching the preparation and nomenclature to be used, and as I find Jahr and Griiner's " Pharmacopoeia," as edited by Hempel, contains the same directions verbatim,* I must conclude there was in the early days of homoeopathy no idea that attenuation and potency were synonymous terms. There, we learn in plain English that the l c trituration is to be called the 100 th potency; that the 2 C attenuation is to be called the 10,000 ,h potency; and that the 3 C attenuation is to be called the 1,000,000 th potency. * Jahr and Griiner's Pharmacopoeia, by Chas. J. Hempel, pp. 4, 5, 6, and 7. Also see tables on pp. 32, 33 r ibid. 138 EATON ON DISEASES OF WOMEN. There is no chance to deny that these were the plain instructions of Hahnemann, and were quoted and appropriated as authority by Jahr and Griiner and Hempel. If these were the plain instructions of these fathers of homoeopathy, why should we not adhere to this nomenclature still ? If we did, we would hear no one speak of the 200 th potency, as there is no intimation in the works quoted that it is possi- ble to make any attenuation that should be called 200 th po- tency. The 30 th potency sometimes mentioned is probably intended to mean the 30 th attenuation. Trituration, attenuation, or dilution may be used as synonymous, as regards strength of medicine (trituration is attenuation with sugar of milk ; dilution is attenuation with alcohol), but potency is quite different, as I have shown from Hahnemann's own teachings. The 10,000 th potency, as I understand it (and as Hahnemann, Biichner, Griiner, and Hempel teach), indicates the 2 a attenuation on the centesi- mal scale, and the 4 th on the decimal scale. On account of the confusion of the terms potency and attenuation, much controversy has arisen in the profession as to the comparative merits of high and low potencies, which need not have existed had it been understood as Hahnemann taught in his work on "Chronic Diseases," just quoted, for all would have seen that the low trituration or dilution was the same as the high potency. After having given much time to the study of this matter I am fully convinced that Hahnemann never conceived of using remedies carried above the 30 th attenuation. The late lamented Dr. Carroll Dun- ham, of New York, carried up several remedies by dilution to the 200 th attenuation and claimed excellent effects from their use, as have several other excellent gentlemen. Drs. Swan and Finkie have claimed to make high dilu- tions, which they have called potencies, by a process of math- ematical calculation as to the attenuation produced by means of a certain amount of running water through a tube, in HOMOEOPATHIC remedies. 139 which had been placed a small amount of medicine. Allowing the water to flow through the apparatus a certain number of hours, they have calculated that a certain attenuation was reached. They call the manufacture of remedies in this way the fluxion process. They, and many others, have reported cures with these high dilutions, the height of the potency of which is beyond human calculation. I will not deny the efficacy of these preparations, but will say they doubtless would have astonished Hahnemann had they been invented in his life- time; and if it is given to disembodied spirits to scan the acts of those below, what must be the emotion of Hahne- mann's spirit at the heights of fancy, imagination, and credulity reached by some of his disciples ! We have found, from our own experience, that from the 2 X to the 6 X attenuations, or, if you please, from the one hun- dredth to the one millionth potencies (which is saying the same thing in different language), is the strength of medicine we find acts satisfactorily to us. Sometimes mother tinctures may act better ; sometimes it may be best to use potencies higher than the one millionth. Did we know the strength of the medicine used in the provings, we might better select the attenuation in treating cases of disease. The 3 C being suited to overcome symptoms indicated by provings with the first on the centesimal scale, while the first attenuation will overcome those provings, not toxicological, made with mother tinctures ; and mother tinctures are to be used in the treatment of those toxicological symptoms produced from poisonous doses of the remedy, when, of course, these symptoms are produced from disease. To overcome toxicological symptoms while the drug is still acting, of course, antidotal treatment is to be at once used. We feel convinced that the minute quantity of a given remedy produces on the system effects directly opposite to those produced by that remedy in large quantity. Hence, we have an explanation of the action of the properly selected homoeopathic remedy in any given disease. The remedy is 140 EATON ON DISEASES OF WOMEN. selected because of the similarity of the symptoms we have in the case to those we know the remedy produces when given in considerably greater quantities than we use in the cure, the curative action being that of correcting these symp- toms, or, in other words, antagonizing them. The giving of a single remedy should be the rule, avoiding all alternation of remedies. I have known a physician to give five different remedies in the same case at the same time. Though he gave- them separately, the intervals were sometimes only ten min- utes, and the people found it impossible to keep the run of the remedies, and they changed physicians. Success never perched on that physician's banners, though he was educated in Germany, and talked learnedly of symptomatology, and ignored pathology. Every physician should seek to add something to the general stock of knowledge possessed by the profession. To do this it is important, at this age of the world, that we learn more of individual remedies, given singly, without alternation. The affinities which remedies possess for some particular parts of the body, or some particular organ of the body, can not be explained. We only can observe that it is so. We can no more tell why it is so than we can explain the law of gravitation or cohesion. We may observe the phenomena, but at last we have to say, God made it so. Why opium in minute doses is a stimulant, and in large ones is a seda- tive, can we explain, more than to assert, it is so? We learn, however, how to apply the remedy from our knowledge of its action. Homoeopathists use remedies for their primary action, or the action produced by the minute dose, while allopathists use remedies for their secondary action, in a large dose. Hahnemann discovered the law that the minute dose cured symptoms produced from disease which were characteristic of the remedy in large doses when given to the healthy man; hence we have a law 7 to guide us in the selection of a remedy, while the allopathist has none. HOMCEOPATHIC REMEDIES. 141 Does any allopathist dare say our theories are unphilosophical or untenable ? Does he call a homoeopathic physician a quack because he has adopted an exclusive dogma, as he says? Then let him seek light in his own U. S. Dispensatory, where I found mine. Let him note the action of the small dose, and compare with the action of the large dose, as there laid down, and he will find enough to convince him of the universality of the law just mentioned. Then let him try in practice the application of this principle, and he will soon be able to declare that he, too, has found, not only joy in believing, but joy in practicing as well. 142 EATON ON DISEASES OF WOMEN. CHAPTER XIII. INSTRUMENTS. The use of instruments has been sadly abused by the profession in the diagnosis and treatment of the Diseases of Women, to the extent of causing some thoughtful medical gentlemen to condemn their use in toto. We do not go this far, and still we are free to condemn many of the instruments in frequent use, especially most pessaries, and also the con- stant use of the speculum, uterine dilators, hysterotomes, etc. These instruments are occasionally useful; but probably not one-fourth as often as some have been in the habit of em- ploying them. We shall present only those instruments in this work which Ave can recommend (about eighty in num- ber), and we devote one chapter exclusively to their con- sideration, that the student may learn something of the uses and advantages of them, as well as be cautioned against their abuse. There is no work on Diseases of Women now published (1880) which, in our opinion, is fully up with the times in the matter of gynaecological instruments. This is strikingly evident in the matter of speculums, Cusco's being the best bi-valve published, and Sims' original speculum be- ing the best one presented as a retracting speculum — all ex- cept Richardson having omitted Dawson's improved Sims' speculum. (See Plate III.) This has one of the blades slit in two, and fixed with a screw so they may be separated, which is a great improve- ment in enabling us to bring into view the walls of the vagina or the cervix uteri. If we desire to use the instru- ment in its original form, we have but to screw the divided blade together and we have it. This instrument we ordi- Plate III SIMS' ORIGINAL SPECULUM. SIMS' FOLDING SPECULUM. DAWSON'S SIMS' IMPROVED SPECULUM. Plate IV. NELSON'S TRI-VALVE SPECULUM. FURGUSON'S MIRROR SPECULUM. WOCHER'S BI-VALVE SPECULUM. INSTRUMENTS. 143 narily only use in operations for the treatment of vaginal fis- tulse, uterine polypi, or lacerations of the vagina, or cervix uteri. Whenever we do need to use a Sims' speculum the advantage of the divided blade is obvious, as it can be opened or closed during the operation at our pleasure. The speculum which we use for ordinary vaginal exami- nations, when they appear necessary, and for bringing the os and cervix uteri into view for ordinary treatment, is the bi-valve made by M. Wocher & Son, of this city. (See Plate IV.) This speculum combines the advantages of disco's han- dles, Higbee's screw on the side, and Taylor's blades, with the wide crest on the upper blade, to keep the flesh and hair of the labia out of the way. In our experience the advan- tage of having the upper blade shorter than the lower, as in Taylor's instrument, is very great. Taylor's speculum has to be opened with the screw, which is not so convenient as the handles of Cusco's, but Cusco's blades are of equal length, and it has not the wide crest on the upper blade. Wocher seems, in his instrument, to have combined the best parts of all the others, and left out their objectionable ones. The instruments are made of three sizes. Nelson's tri-valve speculum — Plate No. IV — is a very con- venient instrument, especially in those cases where the vagina is very large, loose, and flabby, as it distends the anterior walls of the vagina in a lateral direction. It is very good in office treatment, but can not be carried in the pocket so conveniently as Wocher's bi-valve, or Sims' folding speculum. (See Plate III.) Furguson's round mirror speculum is convenient to have at hand, to examine partially a suspected case of gonorrhoea or syphilis where we do not wish to introduce those we daily employ. The instrument is cheap, and is universally known. We also put them to a different use from that of making vaginal examinations. We employ them as vaginal 144 EATON ON DISEASES OF WOMEN. dilators, and to admit the atmospheric air in cases of pro- lapsus, or a tendency to this displacement, having the patient recline, with the hips elevated, while it is inserted. (See chapter on Prolapsus Uteri.) Sims' vaginal dilator, Plate VI, is all right in cases of vaginismus, or a contracted vagina, first smearing the vagina with Belladonna ointment before its introduction; but in cases where we wish to dilate the vagina to admit atmospheric pressure direct to the uterus they are useless, as they are closed at one extremity. UTERINE SOUNDS. The uterine probe, or sound, is a useful instrument in diagnosis of uterine disease and displacement. It should always be used with skill and care. No considerable force should ever be used in its introduction, or any manipulations with it after it is introduced. Used carelessly, it may be a cause of much evil; but, if used with care, it is not inju- rious. Simpson's uterine sound has been much used, but it is too stiff. The steel sound, which can be easily N bent with the fingers, is to be preferred, as it is often of great advan- tage to be able to change its curve. The steel sound should not be larger just at the point (see Plate V), as uterine sounds are usually made ; neither should it be sharp or more pointed at the end, but should be of uniform size* for four or five inches from its extremity. It is well to have notches in the sound, at intervals of one-half inch, that we may note more readily the length of the uterus. Dr. Skene has invented a very good sound for measuring the length of the uterine cavity (see Plate V). It has a slide which is drawn back when the sound is introduced, and, when fully inserted, the slide is pushed up against the os, and we can determine by it just how far the sound has entered the womb. Hard rubber uterine sounds should never be used unless Plate V. TlkWANN&CO Fij.l SKENE'S SOUND. Plate VI. SIMS' VAGINAL DILATOR. cc dl H co £ H i Q ij 2 cc < p cr; • J w o P 2 1 1 1 i ffi J s x 11 ! o o W PC n 1 s Ml p p DJ 3 ! w K ** II w £ w 1 a 1 2 Cfl O n Ij Z g " o LO p I- H P 1 i : < fe II | O J Q 1 O DC H W S INSTR UMEN TS. 145 great care is taken to warm them by putting them in warm water. When cold they are liable to break, even from slight pressure. Caution. — The physician should always be sure pregnancy does not exist before he attempts the introduction of the uterine sound. Cellulitis also contra-indicates its employment, even for purposes of diagnosis. The use of the sound, or even any considerable manipulation with the ringer, in cases of cellu- litis, is very likely to awaken an increase of the inflammation. The use of the sound gives us information of the pres- ence of stenosis of the uterus, tenderness and flexions of the organ, the size and attachment of fibrous polypi, and some information regarding intra-mural fibroids, etc., etc. HYSTEROTOMIES. The hysterotome is an instrument for incising the interior of the cervical canal. It is occasionally needed in stenosis of the cervix; Its use must, in these cases, be followed by the daily introduction of the bougie smeared with vaseline to prevent the adhesion of the cut surfaces, and the consequent diminution of the size of the cervical canal. I prefer Simp- son's or White's. (See Plate V.) eaton's needle holder. In addition to the straight needle holder already mentioned for sewing up longitudinal lacerations and fistulre of the vagina, the gynaecologist needs an instrument for placing sutures in a transverse laceration or fistula. This is accomplished with my needle holder, as can be readily seen from the cut, Plate VI. It enables us to insert the needle into the vaginal tis- sues from above downwards with the same facility with which we use the straight holder in stitching from side to side, for which purpose my holder may also be used by grasping the needle further down on the blades. 10 146 EATON ON DISEASES OF WOMEN. To fasten or twist the wires after the sutures are placed in a vaginal laceration, or either form of vaginal fistulse, we use our wire holder and twister. (See cut of wire holder and twister, Pate VI.) Pass the ends of the wire through the two holes in the end of the holder, make traction on the wires with one hand, and slide the instrument up to the lacerated tissues with the other — this approximates their edges. We then give the instrument two or three turns, with the fingers holding if, and the wire is twisted and the suture secured. We now slip the twister off the wires and cut Fig. No. 6. — Long Curved Scissors. them with the long, curved scissors. This instrument makes the twisting of the wires high up in the vagina a very easy operation. We present Palmer's uterine dilator (see Plate VIII), not to advocate its frequent use, but because rapid dilatation of the cervical canal of the uterus is sometimes necessary ; and when so, we prefer to use "Palmer's Uterine Dilator." With it we can make the dilatation as gradual as we please, and still, with the aid of the screw in the handle, maintain an even and regular expansion, and increase or diminish it at will. The blades which are inserted into the os are slender and slightly curved, and still not too pointed nor too blunt, as are some others. Rapid dilatation is most frequently called for in cases where women have passed a piece of a hard rubber probe or a stick into the uterus and broken it off; or have passed in short pieces of whalebone and lost hold of them. I have been called to remove foreign substances of this character from the uterus in several instances where dilatation of the Plate VII. BABCOCK'S SUPPORTER. Plate VIII. INS 7 'A' UMEN TS. 147 os uteri internum, as well as externum, had to be ac- complished rapidly. Occasionally its use facilitates the getting at an internal uterine polypus, where we have but a short time at com- mand. Very rapid dilatation is in most other cases objec- tionable, in that it lacerates the tissues, and, in their healing, causes somewhat of a cicatrix, which interferes with the re- laxation and dilatation of the os in labor subsequently, and may cause stenosis, or even atresia of the cervical canal, and prevent impregnation, arresting the menstrual flow, and producing hsematometra. Hence, whenever rapid dilatation is used, care should be taken to keep up some degree of expansion till the tissues are healed. Passing into the cervix every two days a bougie smeared with Vaseline, is a good way to accomplish this. PERINEUM NEEDLES. In operating for lacerated perineum it is most convenient to use Peaslee's improved perineum needles and holder shown in Plate VI, whether we wish to use the quill or ordi- nary interrupted suture. The needles fasten into the han- dle with a thumb-screw, and the eye of the needle is near the point as shown in the cut. This is much more convenient than having the needle screw into the handle. Having the three needles threaded before commencing the operation there is no delay in placing the sutures, as one needle can be taken from the handle and another, all threaded, inserted almost instantly. (See the old form, Plate XI.) In an emergency the largest sized surgeon's curved needles may be used to place interrupted sutures in the lac- erated perineum; but the regular perineum needle is much to be preferred, when Ave can have it, and in placing the quill sutures this, or a similar needle, is absolutely neces- sary. (See chapter on Lacerated Perineum.) 148 EA TON ON DISEASES OF WOMEN. Pease's staphylorraphy needle represented by Fig. No. 7, was invented by Gr. M. Pease, M. D., of San Francisco. Fig. No. 8.— Pease's Needle. This needle is described in the proceedings of the Pacific Homoeopathic Medical Society, 1874-6, and in the proceed- ings of the American Institute, 1871. The needle is useful in operations for vaginal fistulse, as well as cleft palate. The silver wire is propelled through the needle (which is conula shaped, with the eye near the point), by means of the little wheel on the side of the handle. PESSARIES. I am well aware that medical gentlemen of high standing advocate the use of pessaries, even those of hard rubber ; but they have to acknowledge that, unless used with skill and judgment, they may do much harm, and that the physician must have experience, as well as a mechanical talent, to ad- just and select them properly (see Emmet's "Prin. and Prac. of Gynaecology," one of the most prominent of the old school books, which acknowledges all this, and still advocates their use very strongly). Now, how many medical men have skill, judgment, experience, and mechanical talent ? Can we say that more than one in ten have all these ? If not, then must we recommend the other nine- tenths to use pessaries indis- criminately to the injury of their patients ? Simply introducing a pessary into the vagina is not using it with skill, even if it be so small as to cause no pain. Besides, the use of them, as has been the custom, and the theory regarding their beneficial effects, have been en- INSTR UMENTS. 149 tirely erroneous and founded upon . erroneous ideas of the etiology of displacements, as we will more fully show in the chapters upon Displacements of the Uterus. While we condemn pessaries from a conviction of the in- jury they have done and a belief that they may, in nearly all cases, be discarded, I am aware that, in some few cases, where we can not mannge the patient or obtain her co-oper- ation, and where a patient is obliged to be con- tinuously traveling or standing, and in the case of old women, where we can not hope for a cure, some form of soft pessary may be ad- visable. In these exceptional cases we use the inflatable rubber pessary or the elastic ring. The abdominal supporter must always Ring pessary. be used in connection with even these pessaries, as otherwise the uterus is placed between the pressure of the bowels from Fig. No. 8.— Elastic Fig. No. 9. — Elastic Rubber Pessary, with Tube and Stop-cock. above and the pessary from below, and injury readily results in the way of flexions of the uterus, or inflammation of this organ, the cellular tissue, or the ovaries. Before inserting a pessary of any kind, the bladder and bowels should be evacuated, and the patient should recline with her hips elevated, with the body low, and the uterus should be replaced before the pessary is introduced into the vagina. Then an abdominal supporter should be applied before the patient rises. The pessary should be removed and cleansed at least once a week. It should not be worn, in any case, but a few weeks, as a rule. The Babcock Supporter holds the womb up in a cup- 150 EATON ON DISEASES OF WOMEN. shaped instrument. (See Plate VII.) It is objectionable in retaining the secretions and in being too stiff. The cup is sup- ported by a steel shaft, which is held in position by a belt around the lower portion of the abdomen. The shaft of steel may be moulded to the form somewhat. In some old women suffering with prolapse this instrument is worn with comfort ; but ordinarily it is found that it causes pain and irri- tation. It will sometimes answer a good purpose where the atonic condi- tion of the system is marked, and where we can not' do better. The in- strument, if used, should be often re- moved and cleansed. The different Fig. No. 10 — M'Intosh's Uterine supporter. shaped cups make it adapted to varie- ties in the shape and location of the os uteri. (See Plate VII.) M'Intosh's Uterine Supporter and Abdominal Sup- porter Combined is sometimes found useful ; but internal sup- port is to be avoided in all cases where it is possible to do so. (See Treatment of Prolapsus Uteri.) SPONGE TENTS. The uses of sponge tents we mention in connection with the conditions and diseases for which we recommend them. They should be solid and smooth, and fye furnished with a strong cord to aid in their removal; and should have an opening in their larger end to insert the end of the sponge holder, which it is advisable to use in the introduction of the sponge into the cervical canal. The best of the sponge tents now in use are carbolized in their manufacture ; still it is well to dip them into carbolized glycerine just before we insert them. Fig. No. 11— Sponge Tent. INSTR I T ME NTS. 151 Dr. Emmet, of New York, has invented a sponge dilator, as he calls it, which is advantageous in some instances. The advantage of this dilator (see Plate IX) is that with it the sponge does not become imbedded in the tissues of the cervix as when the sponge is directly applied. Dr. Em- met * describes the instrument and its uses in the following language : " Through a disk of hard rubber passes a brass tube, which is perforated by a number of small holes at the upper portion, and is open at each extremity. This tube is passed through the center of a sponge tent of suitable size. The tent is then covered by a thin India rubber cot or bag, and its mouth stretched over the edges of the disk. The free edge of the cot, which has been drawn over the disk, is then secured, com- pressed between the under side of the disk and the brass plate A B, on screwing up the latter sufficiently. The brass disk A B has attached to it on side at B a knob which can be grasped by a pair of forceps, the limbs of which are closed by sliding forward the canula E. When the knob B is held by the forceps, a ball-and-socket joint is formed, which will admit of any motion within the radius of a sphere. To the bulb at C is attached a piece of India, rubber tubing, a foot or more in length, through which water is introduced for swelling up the tent, and at the end of the tube is a stop-cock. To the other side of the stop-cock a Davidson syringe may be joined, or what I have found to answer better, a thin India rubber bag, such as are used for pessaries, with tube and stop-cock. The dilator is introduced by steadying the cervix with a tenaculum in one hand ; and by holding the forceps and tubing in the other the proper direction can be given to the instrument. When it has been introduced within the canal to the proper depth, a small amount of water is to be thrown in before removing the forceps. As the tube occupying the center of the sponge * Emmet's "Principles and Practice of Gynaecology," page 32. 152 EATON ON DISEASES OF WOMEN. is open at its extremity and its sides perforated, the water will make its exit at the upper portion, and dilatation will extend from above downward, so that the instrument can not slip out. Enough of the sponge is dilated in a few moments for the purpose of retention, so that the forceps may then be removed by sliding back the canula. I direct the patient to lie in bed on her back, and to place on the abdomen the air bag, which has been filled with water, from Avhich a sufficient supply to fully dilate the sponge is made to flow by occa- sionally compressing the bag with the hnnd. "I generally leave the dilator in place for some twelve hours, unless there should exist some special reason for more rapid dilatation. The instrument is easily withdrawn by placing the patient on her back, removing the bag, and turn- ing the stop-cock for the escape of water from the sponge. The forceps can be passed along the index finger into the vagina and attached to the instrument, when it can be with- drawn, guarding against displacing the uterus by holding the finger against the cervix. "The chief advantage of this dilator is that it greatly reduces the risk of blood poisoning, and if we could dispense with the unprotected sponge in the first instance this danger would be entirely obviated. Fortunately, when this does occur, it is seldom from the use of a, single tent; and, if the precaution be taken, which I always insist upon, to wash out the canal thoroughly whenever a, tent is removed, we will greatly lessen the risk. It is also a great advantage gained from the use of the dilator that the mucous membrane is not injured, and consequently we have no bleeding from the canal when it is removed. "The disadvantages are, that we can seldom dilate to the same extent as can be done by the tent alone. The resist- ance offered by the uterine wall will yield to the steady pressure of the sponge, but the elasticity of the India-rubber Plate IX. TIEMANN & CCVS ASPIRATOR. EMMET'S SPONGE DILATOR. INSTR UMENTS. 153 bag is persistent, and will, to some extent, counteract the force of the sponge. Consequently, we are obliged to use a cot much larger than the sponge, which will occupy an additional space, and, therefore, makes it necessary that the canal should be partially dilated before the dilator can be introduced. " On the other hand, this dilator has the advantage that the force can not be concentrated at any one point, but must be exerted throughout, as the sponge gradually dilates. I have used the instrument several times for rapid dilation, and it ansAvers the purpose, but, unless there should be a necessity for doing so, the more gradual process is to be recommended, as attended with less risk in surgical pro- cedures; but the contrary is true in obstetrical practice. For rapid dilatation, however, it has no advantage over any other instrument of the kind, as at first the water escapes outside of the sponge when rapidly thrown in, and becomes the dilating power, but, as soon as the sponge has had time to expand, it absorbs the water, and the pressure then becomes uniform." ASPIRATORS. Aspirators are now used very extensively. They enable us to evacuate effusions into the pleura, and even in the pericardium. In gynaecological practice they are used to diagnose the nature of an ovarian cyst, and differentiate it from the cyst of the broad ligament in some cases. With it we may sometimes evacuate a pelvic abscess. The wound made by the introduction of the aspirating needle is so small that little or no irritation in the tissues is left after its use. I copy the description of Dieulafoy's instrument, given by Dr. Jas. L. Little, of New York (see Plate X). Tie- maim & Co., of New York, make another very good instru- ment also (see Plate IX). I .have had some trouble in keeping the stopper in the jar of this instrument air-tight. 154 EATON ON DISEASES OF WOMEN. The Tiomann instrument is so simple that it needs no special description : " Dieulafoy's aspirator consists of a strong glass cylinder, about seven inches in height, two inches in diameter, and of a capacity of one hundred and forty-five grammes, equal to nearly four fluid ounces. In front, upon a nickel-plated German silver casing, which envelops the cylinder in part, is a graduated scale that reads off in grammes the amount of fluid contents — the gramme here being not a measure of weight, but of capacity (each gramme being equal to the space occupied by a cubic centimeter of water at a tempera- ture of 39.2° Fahr.). Above, the piston is raised by means of a rack and pinion motion, worked by the handle, and kept from slipping by the spring. At the bottom are two stop- cocks that may be opened or shut as needed. Upon these are fitted two strong, yet perfectly flexible, rubber tubes. Upon the one may be seen a perforated aspirator needle, while the other is dipping into a receiving bowl. In the tube which holds the needle is inserted a piece of glass tubing, near the needle extremity (not shown in the cut), that indicates whether the material to be evacuated is pass- ing through the tube. The other tube is to allow discharge of the cylinder's contents. " The capillary tubes, trocars, or aspirator needles are seen on Plate X. They are of various lengths, and vary greatly in their diameters, the smallest being one-third of a milli- meter (the size of the ordinary hyperdermic needle), while the largest is about one and one-half millimeters, in diameter. "It is well to have also two or three small canulas and trocars on hand, their handles detachable, so that when introduced, and the trocar withdrawn, they may be attached to the rubber tubing. "To use the instrument, attach to the two taps the two pieces of rubber tubing, and to the one tube attach the needle to be used. The other tube should be placed in a Plate X. DIEULAFOY'3 ASPIRATOR. VULSELLUM FORCEPS. - —-___-=-__ -j ^zt G.T JEM A NM &C0 " I EXPLORING TROCAR AND CASE. INS 7 'A' UMEN TS. 155 basin. Having every thing in readiness, close both stop- cocks, turn the handle, thus raising the piston to its fullest extent, and creating a vacuum. Next insert your aspirator needle with a gentle rotary motion into the cavity to be aspirated, turn the stop-cock, and the fluid will be seen to pass through the glass tubing and up into the instrument. When this is filled, close the stop-cock, and open the oppo- site one, pull out the spring, and push the piston down. The fluid is thus driven out through the tube into the bowl or bottle ready to receive it. If there be more fluid present turn both stop-cocks, and, again raising the piston, proceed in the same manner as before. " In using the instrument attention to the following prac- tical points is necessary : " 1st. Before using, assure yourself that the instrument is in perfect working order; that there is neither stoppage, leakage, or difficulty in manipulating, or stop-cocks hard to turn. "2d. The needles or trocars, which should be perfect, should be oiled before attempting their introduction. " 3d. Slow, steady, even pressure, with rotation, the needle being held between the thumb and index finger, will be found to accomplish the result with as little pain and injury to the tissues as is possible. The skin should be slightly nicked with a scalpel before inserting the needle. Local anaesthesia may be used if thought desirable. "4th. In removing the trocar, do so slowly, aspiration being continued meanwhile, to prevent the escape into the tissues of any fluid that may be in the trocar. Bear this in mind, especially in aspirating the peritonaeum. "5th. After using the instrument each time, carefully wash it out, and its attachments, by drawing carbolized or chlorinated water several times, with the cylinder, through the tube attached to taps, forcing the same out through tube at taps, after the manner of aspiration and discharge of fluid. 156 EATON ON DISEASES OF WOMEN. "6th. The piston may be kept in good condition by occasionally unscrewing the head of the cylinder, and pour- ing in about half an ounce of sweet oil. " 7th. Always keep wires through the needles when not in use/' Lentis' Modified Inhaler — (See Plate XI) — needs no explanation. It is convenient where we desire to use anaesthetics. Little's Antiseptic Spray Apparatus — Consists of a spirit lamp placed underneath a copper boiler, as seen in 'Plate XI. The antiseptic or disinfectant is placed in the glass jar at the side, and the steam generated in the boiler forces the liquid in the jar up through the glass tube inserted into it by means of the vacuum produced, and a fine spray is made by the steam coining out through the horizontal tube. ABDOMINAL SUPPORTERS. Appliances for holding up the abdominal viscera, from pressing down unduly upon the pelvic organs, are termed abdominal supporters. They have been so poorly adjusted, or have been so poorly made, in some instances, as to be designated by a contemporary as abominable supporters. And when improperly used, or constructed improperly, they are abominable. Must we condemn them in toto because they are capable of doing injury when improperly used? Under this ruling, I believe, every surgical, obstetrical, and gynaecological instrument might be condemned and called hard names. Fire or water may destroy life when improperly used; on the contrary, they may preserve it, when properly made use of. Shall we banish fire, water, surgical, obstetrical, and gynaecological instruments because, when improperly used, harm may result? Or shall we use them properly, and obtain the good results which follow their intelligent use ? The abdominal band, when applied to compress the~ ab- Plate XI. LENTE'S MODIFIED INHALER. LITTLE'S ANTISEPTIC SPRAY APPARATUS. ASHTON'S PERINEUM NEEDLE. /Z PEASLEE'S PERINEUM NEEDLES. NELATON'S TUMOR FORCEPS Plate XII. SILK ELASTIC ABDOMINAL SUPPORTER. THE OLD LONDON ABDOMINAL SUPPORTER. EATON'S IMPROVED LONDON ABDOMINAL SUPPORTER. INSTRUMENTS. 157 domen around the waist, must be injurious, by pressing the abdominal viscera down into or towards the pelvis. On the contrary, if applied to the lowest part of the abdomen tightly and made less tight above, it lifts and holds up the abdom- inal viscera, especially when the patient is erect. (In the reclining posture no abdominal support is ever required.) Twenty and more years of practical experience in the use of abdominal supporters gives me stronger faith in their beneficial effect, than in any previous time of my life; and I have always been an advocate of their proper use. Their range of application is in those cases where there is tender- ness, inflammation, or displacement of the pelvic organs, cystitis, metritis, ovaritis, versions, flexions, or prolapse of the uterus, all of which require that the weight of the intes- tines be kept from pressing down into the pelvis. This can, of course, be done by maintaining the horizontal position, but it is usually desirable that our patient take some exer- cise, which she can not do without injury in these com- plaints, unless some means are used to maintain the intes- tines in situ, or even lift them above their natural position slightly. I am not particular about any special make of supporter ; we only insist upon the principle being carried out. Some- times extemporized bands are made by patients themselves, or their friends, which support the abdomen quite well. Dim- can Bros., Chicago, have a very good supporter of this kind, which needs, however, to be improved by inserting strong, elastic straps. Ordinarily, however, among a well-to-do class, it is best to buy for them a band made by the regular instru- ment-maker. The band needs to be a little firm in front and back, to prevent wrinkling, and must be elastic in part that it may give somewhat, and not bind the hips, as the lower part of the band, to be of service, must come below the crest of the ilium. The supporter which we commonly use has two elastic 158 EATON ON DISEASES OE WOMEN. straps on the side, reaching from the front to the back piece, one of which I place below, and the other above the crest of the ilium. Leaving the upper one a little loose, I make the lower one quite tight, having the front stiffened part bent inwards, to fit the shape of the abdomen. In cases of small abdomens, we have to apply a pad underneath the band in front, so as to get a better upward pressure with the supporter. (See Plate XII.) This is a modification of the London supporter, which I have had made by the Messrs. Wocher, of this city. The London supporter (see Plate XII) is objectionable in that it is more difficult to obtain the tightness of the band at its lower part, where it is needed, the straps being too near together, and the lower one too far above the lower part of the front piece of the supporter. Sometimes, in case of pen- dulous abdomens, we have the entire band made of silk elas- tic to fit the shape of the lower abdomen, and buckled on so as to be tightest in its lowest part. (See Plate XII.) We could not get along without the use of some support for the abdominal viscera. Fitch's supporter made with springs of steel, which are placed over the crest of the ilium and rest against two pads at the back, and in front against a stiff piece well padded, is made too small, and the steel pieces are too stiff; conse- quently, it has gone into disuse. It might, however, be made a useful instrument by correcting the objectionable parts of it, which I have mentioned. The woman affected with uterine complaints is more uni- versally relieved by the use of a properly applied abdominal supporter than by any one means within our knowledge. The physician using abdominal supporters intelligently will receive more thanks and gratitude for them than for any other service he can render, for the reason that relief is so apparent. Objections. — Objections have been urged to their use that they do not fulfill the indications. I reply, then they were carelessly or ignorantly applied. Plate XIII. HALF CURVED SUTURE NEEDLES BOZEMAN'S TENACULUM. riEMA NN —CO. CALLENDER'S DRAINAGE CANULA. SELF-RETAINING CATHETER. FULL CURVED SUTURE NEEDLES. Plate XIV. IiVS TR UMENTS. 159 It has been objected to the use of abdominal supporters, that the patient becomes accustomed to them, and after awhile can not do without them. We reply, this has not been our experience. That they have usually to be worn Cor several months is true, as regards chronic cases, but is not true in recent cases requiring their use. UTERINE ELEVATORS. Various instruments have been devised to replace flexions and versions of the womb. Sims' elevator (see Plate XIV) is a very ver the puncture, and pin a bandage tightly about the abdo- men : maintain pressure. Tsz :z iez TrM-KLAsnc Tube. — It is recommended, B md Simpson, that a gum-clastic e e passed through the canula. when a rasidei J>le part of the fluid had been evacuated, the canula withdrawn, and that the injection be le through the tube. I object to this on the ground that the elastic tube must be smaller than the canula in order that it . i be inserted, nd, xrasequen ly, the puncture into the be ) rgei than the tube, and will allow the escape of the fluid or injection into the perit: - spec ially the puncture . de through the abdominal walls. In case _ vagina, there is not the same objec- tion, as it is :he most dependent portion of the sac ; but even here we get alon_ better with :be canula alone, as It is firmly _ sped by the tissues Through which it passes, and is retained more easily than a smaller tube could be. E.i:in: Injecttohs. — In case the cyst should refill, and — r :-el sure ::v.::: : - ::z: