'"< ,-\ <$+> J A tf V ^ ° * . ^ ^-C^i/ C c ,0o X «*' v '*X ^ L . B< V ' vO ■\ Co V 7 /, > %, Zwanck's pessary Zwanck's pessary of box- wood Coxeter's modification of Zwanck's pessary Roser's pessary Scanzoni's pessary Hoffman's pessary shaped like the pelvis Bourgeaud's pessary Grariel's pessary Sound with sharp points (Sims) Uterus fixed by the sound (Sims) Speculum and sound in position (Sims) Sims's operation of elytrorrhaphy, sutures in Emmet's operation of elytrorrhaphy . Normal position of uterus (Wieland and Dub place isay) PAGE 225 227 227 228 230 230 232 237 237 239 239 240 241 243 243 245 248 259 261 266 267 267 278 279 297 298 301 306 306 306 307 307 307 307 308 308 309 309 310 311 311 313 XX11 LIST OF ILLUSTRATIONS. FIG. 123. Position of the pregnant uterus 124. The degrees of anteversion 125. Gariel's air pessary in place (Wieland and Dubrisay 126. Operation for shortening anterior vaginal wall (Sim 127. Retroversion of the uterus 128. The degrees of retroversion 129. Sims's uterine repositor 130. Replacing a retroverted uterus (Sims) 131. Uterine repositor 132. Uterus bound down by false membrane (Picard) 133. Hodge's closed lever pessary . 134. Hodge's open lever pessary 135. Scattergood's pessary, with spiral springs in branche 136. Sims's block-tin pessary 137. Cutter's pessary 138. Meigs's ring pessary 139. Anteflexion (Wieland and Dubrisay) 140. Peaslee's stem»pessary 141. Detschy's stem pessary (Wieland and Dubrisay) 142. Creation of new uterine axis . 143. Sims's knife . . . 144. Posterior section of the cervix (Sims) 145. The uterus descending changes its axis 146. Scattergood's pessary in position (Peaslee) 147. Partial inversion of the uterus 148. Complete inversion (Horteloup) 149. Uterus inverted by a fibroid attached to fundus (McClintock) 150. Polypus .... 151. Inversion .... 152. Sessile fibroid .... 153. Partial inversion 154. Reducing an inverted uterus (Sims) . 155. Plug for making counter-pressure in inversion 156. Pelvic peritonitis, showing roof of pelvis 157. Subperitoneal hematocele (Simpson) . 158. Peritoneal hsematocele . 159. Submucous fibroid (Sims) 160. Subserous fibroids (Boivin and Duges) 161. Interstitial fibroid 162. Submucous fibroid 163. Aveling's polyptome 164. Nelaton's forceps (Wieland and Dubrisay) 165. The ecraseur, straight and curved 166. The arms of Sims's porte-chaine (Sims) 167. Sims's porte-chaine ready for encircling a tumor (Sim 168. Ecraseur with joints and elastic arms 169. Gfooch's canula armed with a ligature 170. A tumor encircled by Grooch's canula . LIST OF ILLUSTRATIONS. XX111 FIG. 171. 172. 173. 174. 175. 176. 177. 178. 179. 180. 181. 182. 183. 184. 185. 186. 187. 188. 189. 190. 191. 192. 193. 194. 195. 196. 197. 198. 199. 200. 201. 202. 203. 204. 205. 206. 207. 20S. 209. 210. 211. 212. 213. 214. 215. 216. 217. 218. The ecraseur at work .... Submucous fibroid (Wieland and Dubrisay) . A cellular polypus with long pedicle (Boivin and Duges) A cellular polypus attached within the cervix uteri Glandular polypi (Boivin and Duges) Fibrous polypus growing from fundus (Clarke) Fibrous polypus growing from lip of cervix (Sims) Cancer of the body of the uterus Scirrhus of anterior lip not ulcerated (Boivin and Duges) Cancer in ulcerative stage (Boivin and Duges) Cancer in extreme degree of ulceration (Boivin and Duges) Transverse section of a vegetating epithelioma (Virchow) Vegetating epithelioma (Simpson) Cystic degeneration of chorion (Boivin and Duges) Flexion productive of dysmenorrhoea . Sounds of hard rubber or metal for dilating the cervi: Priestly's dilator for the cervix Simpson's hysterotome Stohlman's hysterotome Cervical hysterotomy (Sims) . White's hysterotome .... Dysmenorrhceal membrane (Simpson) Recamier's curette .... Sims's curette, representing the angles at which it may be bent Syringe for dry cupping the cervix Galvanic pessary .... Vaginal leucorrhcea under the microscope (Smith) Cervical leucorrhcea under the microscope (Smith) Conoid cervix (Sims) .... Flexion a cause of sterility Version a cause of sterility Excess of tissue in the cervix (Sims) . Covering stump of cervix with mucous membrane (Sims) Uterine scissors, bent nearly at a right angle . Galvano-caustic apparatus Side view of the galvano-caustic apparatus Trocar for tapping in ovarian dropsy . Canula, with India-rubber tube attached >■ Scanzoni's trocar and canula ..... Maisonneuve's trocar and permanent canula (Wieland and Dubrisay) J- Trocar and canula for draining cysts through the abdomen Bourjeaud's elastic compressor (Wieland and Dubrisay) Ovariotomy, position of operator (Simpson) Spencer Wells's trocar and canula .... Spencer Wells's clamp ...... PAC4E 424 427 433 434 434 435 435 441 442 445 446 459 460 466 479 481 481 482 482 483 484 486 491 492 499 500 503 504 509 509 509 511 515 516 517 517 558 558 564 565 565 572 587 589 591 XXIV LIST OF ILLUSTRATIONS, 519. | 220. } Koeberle's constrictor FIG. 219. 220. 221. Storer's clamp shield ..... 222. Closure of the abdominal wound (Wieland and Dubrisay) 223. Tubal dropsy (Hooper) .... 224. Tubal dropsy (Boivin and Duges) 225. Tubal dropsy (Simpson) .... PAGE 593 594 597 604 621 622 THE DISEASES OF WOMEN CHAPTEE I. HISTORICAL SKETCH OF UTERINE PATHOLOGY. Nothing- adds more to the interest of the student who investi- gates the present condition of any department of science than a knowledge of what was done in reference to it, and what was known concerning it in previous ages. This alone would be suf- ficient to call for the present chapter in advance of others of a more practical character. Any attempt, however, at a full and complete review of this subject would be out of keeping with the plan of this work. That a knowledge of medicine as a science was possessed by the ancient Egyptians there can be no doubt, since Pliny informs us that in the time of the Ptolemies a medical school was estab- lished at Alexandria, and dissections of the human body com- manded. As to the extent of their acquaintance with it, however, we have no information, as the literature of that remarkable people has been entirely closed to us, until, within a few years past, the genius of Champollion has discovered a key for its comprehension. Thus far the deciphering of papyri and tablets has failed to enlighten us as to any knowledge which they possessed in Gyne- cology ; though we may reasonably hope for such a result in the future, as Herodotus 1 distinctly announces the fact of specialties existing among them. " Here," says he, u each physician applies himself to one disease only, and not more. All places abound in physicians ; some for the eyes, others for the head,, others for the 1 Book II. c. 84. 34 HISTORICAL SKETCH teeth, others for the parts about the belly, and others for internal diseases." From Hebraic literature, which is so abundantly at our com- mand, we learn almost as little upon our subject ; and from the time of Moses, about 1500 B. C, to that of Hippocrates, 400 B. C, all testimony of knowledge upon it is utterly wanting. And yet the learning which the latter evinces in reference to it was surely handed down to him from previous ages, for the Greeks were instructed by the Egyptians, as the Eomans subsequently were by the Greeks. With the writings of Hippocrates commences the literature of Gynecology. He devoted three volumes to it, in which he dis- cusses metritis, induration, menstrual disorders, displacements, &c. Aretaeus, Galen, Archigenes, and Celsus, who probably lived in the first and second* centuries, all treated of the subject ; the first describing accurately the vaginal touch, the varieties of leucor- rhoea, and ulceration of the womb ; while the second makes the first allusion on record to the speculum vaginae, as being a dis- tinct instrument from the speculum ani, and the third gives an excellent description of peri-uterine cellulitis. From this time, for centuries, there is abundant evidence that the study of the subject was pursued with vigor, but so many of the works of the authors of those periods exist only in fragments, and so many are strongly suspected of being fictitious, that we pass them over to stop at the faithful compilation of Aetius, 1 Avho flourished at Alexandria in the sixth century after Christ. His works, compiled in the great library at Alexandria, contain a digest of what was known and done by his predecessors and con- temporaries, and offer the fullest and most reliable evidence con- cerning the knowledge of those times. In quoting him, and his immediate successor, Paulus JEgineta, who was also a compiler, though a far less conscientious one, I must be understood as re- cording, not the views of these individuals, but those entertained by physicians who lived from the time of Hippocrates to the time of their writing, a period of about one thousand years. In his XYI. book Aetius treats of the diseases of women in such 1 I am indebted to the library of the N. Y. Hospital for an opportunity of fully consulting this and other rar« works which were accumulated by the late Dr. John Watson. OF UTERINE PATHOLOGY. 35 a manner as to leave no doubt as to his having had a thorough knowledge of many disorders and means of investigation and treatment, which being rediscovered thirteen hundred years after- wards, have, in many instances, been regarded by us as entirely new. Thus he speaks of the speculum, sponge-tents, peri-uterine cellulitis, medicated pessaries, vaginal injections, caustics for ulcers of the cervix, dilatation of the constricted cervix, a sound for replacing the uterus, &c. As I have already stated, Galen speaks of the speculum vaginae in the second century ; but Aetius still more clearly mentions it and gives rules for its introduction, which are copied almost ver- batim by Paulus without acknowledgment. The use of sponge tents he very fully describes, telling of their mode of preparation, and even advising that a thread should be passed through them, for removal, and that a succession of them should be employed till complete dilatation is accomplished. 1 The importance of injections, the douche, hip-baths, and application of caustics to ulcers of the cervix, he also dwells upon, and advises the dilatation of a con- stricted cervix by means of a tin tube. The variety of Vaginal injections in use among the Greeks was as great as that of to-day. As astringents, pomegranate rind, galls, plantain, rose oil, alum, sumach, &c, were employed, and as emollients, linseed, poppies, barley, &c, exactly as we use them now. Upon the use of medi- cated pessaries they relied to a great extent in the cure of ulcera- tions and inflammatory engorgements, employing wool covered with wax, or butter mixed with saffron, verdigris, litharge, &c. Octavius Horatianus even goes so far as to advise a mixture of arsenic, quicklime, and sandarach in very foul ulcers. In addi- tion to injections and pessaries, Aetius mentions the use of vapor, medicated or simple, conducted to the cervix by means of a reed passed up the vagina. The use of a uterine sound, passed into the uterus and employed as a repositor, is likewise alluded to by this author, in a passage where he advises that displacements of the uterus should be cor- rected specillo el digito. Paul of iEgina, who succeeded Aetius, alludes distinctly to the speculum as an instrument in general use before his time. "If, therefore," says he, "the ulceration be within reach, it is detected 1 Dr. H. G. Wright. Med.-Chir. Rev., No. lxxi. 36 HISTORICAL SKETCH by the dioptra ; but if deep-seated, by the discharges." And again : " The person using the speculum should measure with a probe the depth of the woman's vagina, lest, the tube of the speculum being too long, it should happen that the uterus be pressed upon." It is curious to see how, even in many minor matters, the ancients anticipated discoveries which our contemporaries have brought forward as entirely new. For example, the air-pessary, made so popular in France and other countries by Gariel, is described and recommended by the Greeks. Colombat 1 declares that "the ancient Greek physicians made use of pessaries like those just mentioned (air-pessaries), of the form and length of the male organ, which is the reason why they are called *p«w«aartora, or priapiform pessaries." Albucasis, in 1104, advised the use of an inflated pig's-bladder for the same purpose. The last-named author also describes herpes uterinus, and uterine haemorrhoids are alluded to by Paulus iEgineta 2 in this explicit manner : "Haemorrhoids form about the mouth and neck of the uterus, which- will be discovered by the speculum." And thus it is with so many other modern suggestions, that the student of ancient medical literature is most willing to admit the truth of the propo- sition, formulated by Aristotle over two thousand years ago, that "probably all art and all wisdom have often been already fully explored and again quite forgotten." The learning of the Greek School was appropriated by the Eoman, which was an offshoot from it, as the writings of Celsus, Aspasia, Moschion, and Antyllus abundantly testify. But the knowledge of the schools of Greece and Rome was destined to be scattered abroad. At the period of the subjugation of Egypt and the destruction of the celebrated library at Alexandria by the Saracens, A. D. 640, it passed as a trophy of war into the hands of the Moslem invaders. "In a few centuries the fanatics of Mohammed had altogether changed their appearance," says the learned Draper. 3 " When the Arabs conquered Egypt, their conduct was that of bigoted fanatics; it justified the accusation made by some against them, that they burned the Alexandrian library for the purpose of heating the baths. But scarcely were 1 Diseases of Females, Meigs' translation, p. 152. 2 Sydenham Society's edition, vol. i. p. 645. 3 Intellectual Development of Europe, p. 285. OF UTERINE PATHOLOGY. 87 they settled in their new dominion, when they exhibited an ex- traordinary change. At once they became lovers and zealous cultivators of learning." The physicians of Alexandria were greeted by them as instructors, and from the seed thus planted sprang up the Arabian School. With other information, of course, they gained that pertaining to Gynecology, but, the Ma- homedan laws forbidding the examination of women by one of the opposite sex, the study languished in their hands ; and although Rhazes, Avicenna, and their successors copied from Greek writers upon it, a want of zeal, due to want of personal observation and experience, allowed a retrograde movement to occur which left the subject enveloped in darkness for centuries afterwards. Al- bucasis, one of the last of this school, flourished at the end of the eleventh century, and after him, although from time to time writers of greater or less merit on diseases peculiar to women appeared, nothing worthy of special note occurs, except the occa- sional allusion to the speculum, which had evidently fallen almost entirely into disuse. Although these facts prove that the physicians who flourished from the foundation of the Greek School of Medicine, 400 years before Christ, to the dispersion of the Alexandrian School by the Saracens, 640 years after Christ, were well informed in Gyne- cology, and were familiar with means of investigation which were subsequently lost or ceased to be appreciated, it must by no means be supposed that their knowledge was of the same exact and scientific nature as that which has prevailed since the modern introduction of the speculum. They did not sufficiently separate inflammations of the pregnant and non-pregnant uterus, confounded affections of that organ with those of the pelvic areolar tissue, and made no distinctions between mucous and parenchymatous metritis and morbid states of the neck and body. Among their remedies were numerous articles which to-day we regard as inert or even injurious — as pigeon's dung, woman's milk, stag's marrow, &c. ; and Aetius and Paulus seem to have been as partial to the " grease of geese" as our Milesian popu- lation is at present. The learning of the Arabians was in time, as that of the rest of the world, gradually enshrouded by the ignorance and super- stition of the period termed the "Dark Ages." During that time many uf their writings, like those of the Greek and Roman 38 HISTORICAL SKETCH schools, were destroyed or lost ; but as society emerged from the darkness which overshadowed its intelligence, we see the thread at once taken up and followed, though languidly and without vigor, to the beginning of the nineteenth century. Toward the middle of the seventeenth century we find very special and full allusion made to the speculum and its uses by Ambrose Pare and Scultetus; the instrument being very well represented by diagrams, with descriptions attached. Ancient valvular specula. (Scultetus.) "Fig. 1," says the author, "is an instrument which they call ' speculum ani et vaginas uteri,' in that by its help ulcers of the rectum, vagina, and uterus may be seen, to be carefully observed according to their extent and kind." {Scultetus.) Aetius and Paulus evidently knew of a tubular speculum, since they say, "lest the tube of the speculum be too long," &c; but Scultetus figures a bi-valve and quadri-valve closely resembling those in our hands at present. It is worthy of mention, in this connection, that there is now preserved in the Museo Borbonico at Naples a bi-valve speculum which was removed from the ruins of Pompeii. It has already been stated that Aetius makes an obscure refer- ence to a sound for replacing the uterus. This is by no means the first notice of this useful instrument, for it is repeatedly men- tioned by Hippocrates, and Avicenna, the Arabian, likewise OF UTERINE PATHOLOGY. 89 alludes to it. Prof. Simpson 1 asserts, however, that it was used only for dilatation of the cervix, and not for exploration and measurement. In 1657 a probe, used as we now employ the uterine sound, and intended especially for uterine exploration, was actually described by Wierus, 2 and alluded to by Hilken, Cooke, and others. As we pass in review the chief works which appeared upon our subject in the eighteenth century, we find frequent mention of the speculum, which is spoken of as a matter of course in the treatment of uterine affections, and yet was evidently not so employed as to render it really a valuable aid in diagnosis or treatment. This constitutes one of the most curious episodes met with in the history of any discovery with which we are acquainted. A most simple and useful instrument was not only well known in ancient times and subsequently fell into disuse, but fell into disuse without having ever been really forgotten. It was described by successive writers up to the nineteenth century in language as distinct as words could make it, and yet not only did they who read, but they who wrote it, not comprehend its meaning or appreciate its significance. Like the Indians possessed of the diamond, all saw and yet none valued. How could Ambrose Pare, for example, writing in 1640, have indicated its use more clearly than when he tells us, in chapter xix., that ulcers of the womb may be recognized, "by the sight, or by put- ting in a speculum"? In a copy of his works in the library of Dr. W. A. Hammond the word speculum is italicized in this sen- tence. Scultetus, as we have seen, not only described but figured the instrument in 1683. In 1761, Astruc, 3 "Royal Prof, of Physic at Paris," in describ- ing occlusion of the vagina and obstruction to the menstrual flow, says : " There is nothing more required than to examine the vagina by introducing the finger into it, rubbed previously with oil or pomatum; but, if that be not sufficient, a speculum uteri may be used, or some other more simple instrument for dilatation, in order to be able, by means of the dilatation of the vagina, to judge by the sight of what the touch could not decide." 1 Obstetrical Works. 2 Dr. H. G. Wright, loc. cit. 3 Dis. of Women, Eng. ed., vol. i. p. 135. 40 HISTORICAL SKETCH In 1801, forty years after this, Recamier is supposed by many to have discovered the speculum. Nothing is farther from my mind than the wish to cast the slightest discredit upon the inte- grity of the labors of this great man, who was really the founder of the modern school of Gynecology ; but after the evidence which I have adduced, I feel fully justified in asserting that the instrument was not his discovery. Guided by the advice found in many works which his library must have contained — works with which to suppose him not to have been perfectly familiar, would be to cast a slur upon his medical research — he employed a speculum vaginae in 1801. Like his predecessors, he did not appreciate the great results which were to flow from it ; nor did he appear to have regarded himself as having invented it. It was not until 1818 that he introduced it to the profession, and gave it its place as a valuable addition to science. Can any one suppose that it could have required seventeen years of experi- mentation and study for a man with the talent of Recamier, to have applied this simple and useful instrument to purposes of utility ? Is it not more likely that the experience of seventeen years taught him the full value of the instrument? The credit which belongs to Recamier is not that of a discoverer, but that which is equally great, of having recognized the value of what was well known, but badly appreciated before his time. Even before this fortunate revival, as the eighteenth century approached its close, the glimmer of the new era which was about, to dawn could clearly be detected in the advanced views which were promulgated by Garangeot and Astruc in France, and Denman, John Clark, and Hamilton in England. The early part of the nineteenth century found the field occupied chiefly by Sir Charles Clarke and Dr. Gooch in England, and Recamier and Lisfranc in France. These were not the only eminent writers of that time, but they were unquestionably those who chiefly moulded professional opinion. Even at that period Gynecologists ranged themselves into two parties, which, so late as at our day, have scarcely coalesced. In England the feeling was strongly in favor of regarding the local disorder as the result and not the cause of concomitant constitu- tional derangement: while in France the uterine disease was viewed as the main element, and the general condition as .de- pendent upon and resulting from it. OF UTERINE PATHOLOGY. 41 The great advantages of the speculum secured its rapid adop- tion in France. More slowly it forced its way, in spite of many prejudices, into Great Britain, and before a great many years had passed, it was, throughout the civilized world, placed upon an enduring basis as one of the boons bestowed by medicine upon humanity. The way being opened for investigation by this instru- ment, new aids to diagnosis and treatment were rapidly advanced. In 1826 Guilbert read before the Academy of Medicine of Paris an essay proposing the application of leeches to the cervix. In 1828 Samuel Lair read before the same body a paper in which he counselled the use of the uterine sound. In 1832 M. Melier presented an essay, in which he offered two new suggestions in the treatment of uterine diseases — one, injections into the cavity of the cervix; the other, local applications in the vagina by dossils of lint saturated with astringents, narcotics, &c. His views are quoted extensively by French writers, and Nonat says that the author recognizes, "avec une franchise qui l'honore," that Boyle, Chaussier, Gruillou, and others, had a short time be- fore him used similar means. Yery curiously neither Melier nor his commentators mention that both these suggestions are made and fully elaborated by Astruc, in his excellent article upon " Ulcers of the Uterus." He describes these applications of medicated charpie very carefully, remarking that it is advisable to " tie a thread to every pledget, in order to draw it out again when it is proper to renew the dressing." And he not only advises injections of water, impregnated with different substances, into the cavity of the womb, but also the juices of plantain, houseleek, nightshade, &c. "For," says he, "as it is of conse- quence that these injections should enter into the uterus, where the ulcer has its seat, it is proper they should be made by a pro- fessor of midwifery, capable of introducing skilfully the end of the canula into the orifice of the uterus," &c. At this time arose the question as to cancer of the uterus, whether it was the local manifestation of a general blood state, or the result of an inflammatory engorgement long neglected ; a question which excited warm discussion, and brought forth the most opposite views. The ambition of Kecamier was not satisfied with exposing the cervix uteri to view. He had the boldness to explore the cavity of the body of the organ, almost establishing the use of the 42 HISTORICAL SKETCH sound, and even, by means of a species of scoop called a curette, ventured in certain cases to scrape oft* its investing mucous mem- brane. In addition he described, through one of his students, pelvic cellulitis, and gave the first intimation which modern observers have had of the possibility of pelvic hematocele. These discoveries on the part of the French physician mark an era in Gynecology ; one no less important was created by the appearance in the field of labor of Professor, now Sir James, Simpson, of Edinburgh. About the year 1843 he rapidly deve- loped and recommended to the profession several of the most important means of diagnosis now at our command. The utiliza- tion of the uterine sound, which Lair had never succeeded in introducing into general practice, and the dilatation of the canal of the cervix by sponge-tents, so that the body may be exam- ined, are both due* to his genius and enterprise. He likewise contributed from time to time original and valuable papers upon pelvic cellulitis, hematocele, uterine flexions, &c. His articles, indeed, first excited the study of uterine displacements in Great Britain, and to his efforts may be traced, in a great degree, the interest which has been of late years aroused in that country with reference to uterine pathology. Until this time the subject had attracted very little attention there, and advances which had been made in it were due almost entirely to French pathologists. It is true that the excellent work of Sir Charles Clarke existed ; but that warm and zealous interest which has since resulted in so much benefit to Gynecology, had not then been excited. But Prof. Simpson was not alone in this work. Dr. J. H. Bennet, of London, at that time a young physician, who had for some years served as interne in the hospitals of Paris, returned to his own country imbued with the views which Eecamier and Lisfranc had disseminated among a large circle of followers. In 1845 the first edition of his work on Inflammation of the Uterus appeared, and it is safe to assert that no work of modern times, written upon any subject connected with our profession, has exerted a more decided and profound influence. Taking up the subject with a vigor and energy which forced attention, if not conviction, he produced an undeniable impression upon the profession, not only in his own country, but in Germany, France, and America. However others may differ from him, no candid mind can deny him the obligation under which he has placed his brethren by OF UTERINE PATHOLOGY. 43 arousing their attention and directing their investigations into proper channels. The chief points insisted upon in his work are these : 1. That inflammation is the primum mobile in uterine affections, and that from it follow, as results, displacements, ulcerations, and affections of the appendages. 2. That menstrual troubles and leucorrhcea are merely symptoms of this morbid state. 3. That in the vast majority of cases, inflammatory action will be found to confine itself to the cervical canal, and not to have affected the cavity of the body. 4. The propriety of attack- ing the disease in its habitat by strong caustics. About this time a discussion sprang up between Dr. Bennet on one side, and Drs. Eobert Lee, West, and Tyler Smith on the other, with reference to the true character of ulceration of the neck ; Dr. Bennet supporting the view that the cervix is often affected by inflammatory ulceration, and his opponents denying it. The discussion, looked at calmly by posterity — nay, even at the present time — will be pronounced a polemic disputa- tion, which has not served to clear up the subject, nor to have accomplished any really good end. One further benefit which Dr. Bennet conferred in his work, was in placing upon a surer basis than it had yet occupied, the differentiation of inflammatory engorgement and induration from commencing cancer of the neck. It would be well, before proceeding farther, to state as suc- cinctly as possible the different pathological views which from this time, and even somewhat before it, were offered to the pro- fession, and more or less generally adopted. They may be thus enumerated : — 1st. That inflammation is the starting point of most of the affections of the uterus, and that a large number of evils follow this morbid state as results. 2d. That uterine disorder is dependent upon a constitutional derangement, and would }deld without other treatment than that directed to the removal of the general condition. 3d. The view of Dr. Bennet, which is similar to the first men- tioned, with this additional point, that metritis generally limits itself to the neck, and only exceptionally affects the body. 4th. The view of Dr. Tyler Smith, that leucorrhcea arising from glandular inflammation in the cervix is the cause of granu- lar degeneration of this part, and of subsequent engorgement. 44 HISTORICAL SKETCH 5th. The view that uterine disorders often, if not generally, commence in displacement, which is a primary and not a se- condary condition, and that to relieve the train of morbid symp- toms, this, its exciting cause, should be first removed. 6th. The view that uterine disorder is commonly the result of ovarian inflammation, which reacting on the womb is the prime mover, in many cases, of its morbid states. I have no intention of discussing here the merits of these the- ories, but will limit myself to a few words connected with the history of each. The theory mentioned first in this enumeration is the oldest on record, the writers of the Greek School, even, adopting it. Thus Paulus iEgineta heads his chapter on the subject, " Inflammation of the uterus and change of its position." One of the symptoms of such inflammation he considers to be retroversion of the uterus. In the beginning of the present century this was gene- rally accepted in France. Lisfranc and Eecamier adopted it, and it was transferred to, and advocated in, Great Britain by the writ- ings of Dr. Bennet. I do not believe that I state too much in asserting that the great majority of Gynecologists in this country accord in it ; though of course I admit that the statement is open to error, as every other statement of this kind is when not forti- fied by statistical proof. N"o one can devote himself to the practical study of uterine diseases without being impressed with the strong grounds which exist for the maintenance of the second of the theories mentioned. ~No grave uterine trouble affects the system for any length of time without reacting to a greater or less extent upon the general health. The nervous system becomes greatly disordered, the functions under its influence are badly performed, and derange- ment in hsematosis is the invariable result. As the local disease often approaches stealthily, and may exist for a length of time without exciting suspicion, what is more natural than that many should view it as one of the numerous results of the general de- preciation? These three facts, however, which will constantly repeat themselves, as often, I may say, as favorable cases offer for testing the question, will, I think, very generally lead to a distrust of the doctrine: 1st, the fact that uterine disease and constitutional derangement existing together, a cure can rarely be effected by general means alone ; 2d, that the uterine affection OF UTERINE PATHOLOGY. 45 being removed, the general state is at once improved ; and, 3d, that those general conditions which prostrate the vital forces to the last degree, as, for instance, tuberculosis, uraemia, scurvy, leucocythemia, &c, destroy life without ever showing, unless as an exception, the local disease as " a fragment of the constitu- tional malady." The third of the theories mentioned has been already suffi- ciently spoken of. Those parts of it which are peculiar to Dr. Bennet will be fully dealt with elsewhere. The theory of Dr. Tyler Smith 1 I lay before the reader in his own words: "It is my conviction, notwithstanding, that in the majority of cases in which morbid states of the os and cervix are present, cervical leucorrhoea, or, in other words, a morbidly aug- mented secretion from the mucous glands of the cervical canal, is the most essential part of the disorder, and that the diseased conditions of the lower segment of the uterus, which have been made so prominent, are often secondary affections resulting from the leucorrhceal malady." This theory was by no means a new one, when advanced as above mentioned, for Lisfranc 2 mentions it thus : " Observation proves that leucorrhoea can in the first place cause uterine engorgements, and that later it may be kept up by them ; it occasions them often." Lisfranc, however, says " often," while Dr. Smith says, " in the majority of cases." But even before Lisfranc it had attracted attention, for Paulus iEgineta 3 gives "defluxion" as one of the causes of " ulceration of the womb." That an acrid leucorrhceal discharge will create abrasion of the os, follicular vaginitis, ure- thritis, pudendal inflammation, and pruritus, no one will deny, for we see a similar irritation occurring on the upper lip in nasal catarrh in children, which sometimes spreads as an eruption over the whole face. The leucorrhoea regarded by Dr. Smith as the primary disease is only a symptom of cervical endometritis, which may cause inflammation in the deep tissues of the cervix, and result in enlargement and induration. The views of Dr. Smith were brought forth at a time when Dr. Bennet was pressing the theory of inflammation as the keystone of uterine pathology, and in combating the idea of parenchymatous inflammation, he merely 1 On Leucorrhoea. 2 Clin. Chirurg., vol. ii. p. 303. 3 Op. cit., p. 624. 46 HISTORICAL SKETCH recorded the fact that it is often preceded by, and results from the same process taking its rise in the mucous lining of the canal. Dr. Smith's position was maintained with all that ability and force which have rendered him so popular as an author amongst us in America, and the influence of his writings upon uterine patho- logy can be at present clearly traced in this country. In the year 1854 a discussion, which soon assumed extensive proportions and elicited great warmth, arose in the Academy of Medicine of Paris, with reference to the treatment of uterine displacements. M. Velpeau stood forth as champion of the view which is here expressed in his own words. " I declare, neverthe- less, that the majority of the women treated for other affections of the uterus have only displacements, and I affirm that eighteen times out of twenty, patients suffering from disease of the womb, or of some other part of this region, those for instance in whom they diagnose inflammation (engorgements), are affected by dis- placements." In this and subsequent discussions he was upheld by some of the first physicians of Paris, and by many the view then expressed is still adhered to. It has resulted in a vast num- ber of mechanical contrivances, called pessaries, to restore the organ to its place in the hope of thus striking the pathological series at its root. Intra-uterine, vaginal, and abdominal sup- porters have been employed, and attempts have been made to offer support even through the rectum. I was present during the discussion in Paris in 1854, and being engaged in the report of it for an American medical journal, 1 paid strict attention to its progress. Influenced by the arguments which it elicited, and by the teachings of Valleix, whom I daily followed at La Pitie, I was convinced of the truth of Velpeau's position. Experience, however, has led me to dissent from it. I have found most of my cases of displacement, which were attended by evil symptoms, to be accompanied by marked evi- dences of inflammation ; have found them usually susceptible of no permanent benefit from replacement; and have obtained relief from the symptoms for which I was called, chiefly by means which cured uterine inflammation. I have noticed that similar displacements almost invariably result from inflammation which commenced when the uterus was in its proper place; and have 1 The Charleston Medical Journal for 1854. OF UTERINE PATHOLOGY. 47 seen complete retroversion of the womb, where no inflammation existed, produce, after the patient had become accustomed to it, no symptom. These observations have led me to discard the belief in the mere dislocation as being commonly the cause, and induced me to regard it as generally a result, of inflammation. In making this statement I am not, however, disposed to deny the occasional morbid agency of uncomplicated displacement which may have resulted from inflammatory action, which has entirely passed away, or from force suddenly or gradually applied, or from loss of power in some of the uterine supports. A source of error which may arise in such cases as to the primary link in the chain of disease, exists in the fact that a displacement induced by the second or third of these causes will sometimes create con- gestion, inflammation, and ulceration of the uterus. The peculiar and very marked sympathy existing between the uterus and ovaries has given rise to the theory mentioned last in the enumeration. I meet very often, as I suppose every practi- tioner does, with cases of simple, uncomplicated uterine disease in which the patient has been treated for ovarian disorder, which is presumed to have been the cause of the uterine ailment. So often do I meet them, indeed, that I cannot but regard the belief in this view as very prevalent in America. Frequently it is used as a cloak for ignorance, the physician fixing upon it from his inability to elucidate the real pathological features of the case. At other times sensitiveness over the ovaries, with enlargement, is regarded by capable men as producing a series of evils, no special attention being paid to coexisting metritis, which is viewed merely as a complication. There can be no doubt that ovarian inflammation, which is clearly diagnosticable, gives rise to many of the symptoms of uterine disorders, but under these circum- stances a carefully made differential diagnosis will generally set- tle the point. Nor is it less certain that uterine diseases very frequently produce sympathetic trouble in the ovaries, resulting in great sensitiveness upon pressure, and sometimes enlargement. As, however, in this case no treatment directed to the ovaries will remove existing uterine disease, while curing the latter will gene- rally remove the ovarian affection, it appears to me that in the present state of our pathological knowledge we are forced to con- clude that if certain symptoms diagnostic of uterine or ovarian 48 HISTOKICAL SKETCH disease exist, and an examination shows a uterine lesion, with evi- dences of ovarian enlargement and sensitiveness, it is safe to decide that the latter state is the result of the former; but if no uterine disease is discoverable, and the ovarian symptoms alluded to exist, we are warranted in believing that ovarian disorder gives rise to them. Of late years rapid advances have been made in the surgical treatment of the diseases of women. Under the lead of Marion Sims, Spencer Wells, Baker Brown, Clay of Manchester, Emmet and Bozeman of New York, and the Atlees of Philadelphia, ope- rations for ovariotomy, the cure of ruptured perineum, vesico- vaginal fistulas, constriction, or tortuosity of the cervix, &c, have been perfected and are now in constant practice. France and Great Britain have laid the world under obligation by the advances made during the last half century in Gynecology. Germany has done little in comparison, though works which are pronounced of great merit, by those to whom this literature is open, have been produced by Siebold, Mende, Meissner, Kiwisch, Lumpe, and Oppolzer. The work of Scanzoni, translated by Dr. Gardner, of this city, is well known to all, and Dr. John Clay, of Birmingham, has rendered service by his able translation of the chapters of Kiwisch's work on the " Pathology and Treatment of the Diseases of Women," which relate to affections of the ovaries. It is a great source of pleasure to me before closing this sketch to be able to record the fact that America has not been wanting in her contribution towards the progress of this branch of medi- cine. It is to this country that is due the credit, not only of the first performance of ovariotomy in 1809, by Dr. Bphraim McDo- well, of Kentucky, but its subsequent development into a syste- matic operation by his compatriots. It was never even attempted in Great Britain until 1823. No successful case was ever per- formed in London until 1842, in Scotland only one successful case was reported up to 1862, and in Ireland, at that time, not one success was on record. 1 In the mean time it had taken deep root in America; even as early as 1830 Dr. McDowell having performed it thirteen times, with eight favorable results, and before 1862 Dr. Atlee had achieved that eminence, as an ope- rator, which he now enjoys. 1 Peaslee on Ovariotomy. OF UTERINE PATHOLOGY. 49 Systematic works upon Gynecology of great merit have been issued by Meigs, Hodge, Bedford, Sims, Byford, Elliot, and Emmet. It would be inappropriate for me to speak lengthily here in praise of these, but all who know them will admit the justice of the statement that each possesses a marked individual- ity, and that each has aided in the advancement of the science of which it treats. I have elsewhere called the results of the labors of Eecamier and Simpson eras in the progress of this department. I now venture so to style those of Marion Sims. In doing this I make no reference to the improvements inaugurated by him in the treat- ment of injuries to the genital organs; my allusion is to the great advantages which now flow and are to flow from the invention of his speculum, which exposes the uterus by a new principle, and opens the way to a more complete examination of that organ. Eecamier marked an era by improving our powers of diagnosis in exposing the cervix uteri; Simpson another, by opening to investigation the body of the uterus ; and Sims a third, by render- ing both investigations more simple, complete, and satisfactory. The ordinary specula in use before the discovery of Sims's simply separate the vaginal walls mechanically, and thus expose the ute- rus. Sims's instrument, on the other hand, elevates the posterior vaginal wall, which allows the entrance of air to distend the whole passage, the woman lying on her side in such a manner that the cavity can be probed with the most perfect ease, and applications made to the fundus. I am fully aware that many will differ from me in this opinion, but being entirely free from prejudice in favor of this instrument, or against the ordinary varieties, I maintain it fearlessly, feeling confident that time will prove it to be correct. No one who has not tested the two methods of examination is really entitled to an opinion upon the point, and I cannot doubt the conclusion of him w T ho has done so faithfully and intelli- gently. "Within the last twenty years a vigorous attempt has been made to open the field of Gynecology to female labor, and to place it and its sister branch, obstetrics, to as great an extent as possible, under the management of female practitioners. For this purpose female medical colleges have been established in Geneva. New York, Philadelphia, and other cities of America: and of late the English journals inform us of the foundation of one in 4 DO HISTORICAL SKETCH London. In France a proportion of the -work Las, for a long time, been allotted to the " Sages Femmes," or midwives. Many of those who foster the attempt appear to regard it as a novel one, and reiterate the assertion that woman has never been allowed a fair trial in this, her most appropriate sphere of action. This is a great error. K"ot only has the way been open to her as competitor with man, but at times it has been almost entirely relinquished to her keeping. If success has not attended her efforts, it has been due, not to want of opportunity, but of capacity or adaptation. Aetius makes mention of the writings and prac- tice of Aspasia, who was a doctress at Rome about the third century, and copies extensively from her upon ulceration and displacements of the womb. Paulus iEgineta is, for some of his chapters, indebted to Cleopatra, fragments of whose writings he has preserved to us. He evidently quotes her with respect and credits her with what he borrows. In the thirteenth century an Arabian woman, Trotula by name, published a treatise, in which she mentions that many Saracenic women practised the art of obstetrics at Salerno. In later times, during the eighteenth and nineteenth centuries, women were graduated as Doctors of Medi- cine in the Italian Universities, and as such enjoyed great con- sideration. In 1732, La Dottoressa Laara Bassi graduated at Bologna, and filled the chair of Xatural Philosophy for six years. In the last part of the eighteenth century, Madonna Manzolina lectured on anatomy at Bologna, while others of lesser note filled positions of minor importance. The women of Greece and Rome approached the task much better prepared to meet its requirements, both mentally and physically, than do those of our day; and surely no lack of opportunity could have been complained of by the successors of Agnodice. 1 Those of the Arabian civilization had not only opportunity, but the incentive of necessity, to urge them on to the acquirement of knowledge and skill ; for so great were the sensuality and libertinism of the Saracens, that the Mahommedan laws prohibited the attendance of males upon 1 The story of this physician is worthy of note. Contrary to the existing laws, she studied medicine, met with great success under the disguise of a man, was accused of corruption and brought to trial. Making her sex known to the judges, she was not only acquitted, but a law was passed allowing all free-born women to study medicine in future. OF UTERINE PATHOLOGY. 51 females; and thus the whole duty, except in extreme cases, devolved upon the midwives. No one of extended views can desire to see the doors of science shut to any who are sincere in their wish to engage in its pur- suits ; nevertheless, there is no resisting the evidence of history, that, in spite of opportunities and incentives, female practitioners have failed in times past, not only to advance, but even to main- tain the integrity of the art intrusted to their hands. The expe- rience of the future may belie that of the past ; but even its doing so will offer no good reason for despising the lesson which the past has left on record. I am so often consulted by recent graduates as to the works which they should make the basis of a library upon Gynecology, that I feel that I may render a service by the following list. Only such works are recorded as will prove of absolute service to the active practitioner who seeks knowledge chiefly upon practical points : — Nonat — Maladies de l'Uterus, 1 vol. Aran — " " 1 vol. Becquerel — " " 2 vols. Blatin et Nivet — Maladies des Femmes, 1 vol. West — Diseases of Women, 1 vol. Tilt — Uterine and Ovarian Inflammation, 1 vol. Bennet — On the Uterus, 1 vol. Simpson — Diseases of Women, 1 vol. Hewitt— " " 1 vol. Churchill — " "1 vol. Byford — Medical and Surgical Treatment of Women, 1 vol. Sims — Uterine Surgery, 1 vol. Baker Brown — Surgical Diseases of Women, 1 vol. Tilt — Uterine Therapeutics, 1 vol. Scanzoni — Diseases of Females, 1 vol. Meigs — Diseases Peculiar to Females, 1 vol. Bedford — Diseases of Women and Children, 1 vol. Colombat — On Females (annotated by Meigs), 1 vol. Ashwell — Diseases of Women, 1 vol. McClintock— •" " 1 vol. Courty— Maladies de l'Uterus et de ses Annexes, 1 vol. Hodge — Diseases Peculiar to Women, 1 vol. Klob — Pathological Anatomy of the Female Genital Organs. 1 vol. Spencer Wells — On Diseases of the Ovaries, 1 vol. Kiwisch— " " " 1 vol. Elliot— Obstetric Clinic, 1 vol. Wright — Diseases of Women, 1 vol. Emmet — On Vesico-Yagiual Fistulse, 1 vol. CHAP TEE IT. THE ETIOLOGY OF UTERINE DISEASES. In investigating the causes of uterine diseases which are active in this country, I would not be understood as drawing any com- parison between their frequency here and abroad, for in the ab- sence of statistical evidence such an attempt would necessarily be futile. It is easier, however, to write of habits which are under our immediate observation, than of those concerning which we merely read and hear, and for this reason I give myself the limits herein prescribed. My intention is not to review all the causes of ute- rine disorders, but to confine myself to the consideration of those which are avoidable, incurred merely from disregard of the laws of health, and which are generally rather predisposing than ex- citing. Others, which are accidental and exciting, will be men- tioned in connection with special diseases as they come under notice. If we compare the present state of women in refined society over the world with that of the working peasants of the same latitudes, or with the North American squaws or the powerful negresses of the Southern States, we can with difficulty believe that they all sprung from the same parent stem, and originally possessed the same physical capacities. Observation proves that women who are not exposed to depreciating influences can com- pete in strength and endurance with the men of their races, and in savage countries they are sometimes regarded as superior to them. In the lower orders of animals this equality is still more marked. The mare endures as much as the horse, and some of our most celebrated racers have represented the female sex. The lioness is fully as dangerous to the hunter as her more majestic consort, and the bitch proves as untiring in the chase as the most muscular dog in the pack. From all these facts we may logically argue, that the human female, if properly developed and placed beyond causes which militate against her physical well-being, would be in no great WANT OF AIR AND EXERCISE. 53 degree the inferior of the male. This position I now assume, and maintain that the customs of civilized life have depreciated her powers of endurance and capacity for resisting disease. My efforts will be directed to an endeavor to point out what these habits and influences are. Those which are most prominent and universal may thus be enumerated : — Want of fresh air and exercise. Excessive development of the nervous system. Improprieties of dress. Imprudence during menstruation. Imprudence after parturition. Prevention of conception and induction of abortion. Marriage with existing uterine disease. Want of air and exercise, in deteriorating the blood and enfee- bling the muscular and nervous systems, should be classed first among these predisposing causes. There can be no doubt that American women take much less exercise than those of Europe. Walking, riding, rowing, bowl- ing, &c, which are there so common, are here not much prac- tised. In our large cities will be found hundreds of ladies who do not walk a mile in a day for weeks together, and many more who have never engaged in any exercise which called forth the action of other muscles than those employed in the quietest loco- motion. This is partly due to the fact that, with us, recreations which require muscular efforts on the part of women are not fashionable; partly to a morbid desire to cultivate an appearance of delicacy in form and complexion ; and in great part to impro- prieties of dress, which render it dangerous for them to remain in the open air except in good weather. Instead of our girls being- encouraged to engage in out-door pursuits calculated to create muscular power, they are reared in the belief that such pastimes are hoydenish, unbecoming, and fit only for rough boj r s. Their hours of leisure are occupied by reading, music, drawing, or some similar light task, and an hour's walk every day is regarded as an accomplishment quite creditable to the performer. This pernicious system of training is observed most markedly in our large female seminaries or boarding schools, where every hour of the day is allotted by rule to its especial work. By this plan 54 ETIOLOGY OF UTERINE DISEASES. the mind is constantly kept in the thraldom of control, and chafes nnder the depressing influence of a never-ending surveillance. A set of romping school-girls could as profitably laugh by rule as really enjoy and improve by exercise under the eye of an instructress or professor of calisthenics. It is not the mere bodily exertion which is of benefit, but the total mental relaxation, the exhilaration and the abandon which accompany it. The prisoner working for eight hours on the tread-mill does not profit by it as the free and happy equestrian or oarsman does, by one-eighth the time of exercise. Excessive Development of the Nervous System,. — The necessity for a due proportion existing between the development and strength of the nervous and muscular systems has always been recognized, and has given rise* to the trite formula, " mens sana in corpore sano," as essential to health. Unfortunately the restless, ener- getic and ambitious spirit which actuates the people of the United States, has prompted a plan of education which by its severity creates a vast disproportion between these two systems, and its effects are more especially exerted upon the female sex, in which the tendency to such loss of balance is much more marked than in the male. Girls of tender age are required to apply their minds too constantly, to master studies which are too difficult, and to tax their intellects by efforts of thought and memory which are too prolonged and laborious. The results are, rapid development of brain and nervous system, precocious talent, refined and cultivated taste, and a fascinating vivacity on the one hand ; a morbid impressibility, great feebleness of muscular system, and marked tendency to disease in the generative organs, on the other. That this statement of the advantages which are gained and the price which is paid for them is perfectly true, no American practitioner will deny. But the mere existence of the fact is not the most melancholy feature of the case ; it is far more painful to see mothers listening to it, admitting its truth, and yet calmly and dispassionately choosing to make the trial, as we see them doing every day. Improprieties of Dress. — The dress adopted by the women of our times may be very graceful and becoming, it may possess the IMPROPRIETIES IN DRESS. 00 great advantages of developing the beauties of the figure and con- cealing its defects, but it certainly is conducive to the develop- ment of uterine diseases, and proves not merely a predisposing, but an exciting cause of them. For the proper performance of the function of respiration, an entire freedom of action should be given to the chest, and more especially is this needed at the base of the thorax, opposite the attachment of the important respira- tory muscle, the diaphragm. The habit of contracting the body at the waist by tight clothing confines this part as if by splints ; indeed, it accomplishes just what the surgeon does who bandages the chest for a fractured rib, with the intent of limiting thoracic, and substituting abdominal respiration. As the diaphragm, thus fettered, contracts, all lateral expansion being prevented, it presses the intestines upon the movable uterus, and forces this organ down upon the floor of the pelvis, or lays it across it. In addition to the force thus exerted, a number of pounds, say from five to ten, are bound around the contracted waist, and held up by the hips and the abdominal walls, which are rendered protuberant by the compression alluded to. The uterus is exposed to this downward pressure for fourteen hours out of every twenty-four ; at stated intervals being still further pressed upon by a distended stomach. In estimating the effects of direct pressure upon the position of the uterus, its extreme mobility must be constantly borne in mind. No more striking evidence of this can be cited than the fact, that in examining it by Sims's speculum, if the clothing is not loosened around the waist, the cervix is thrown so far back into the hollow of the sacrum as to make its engagement in the field of the instrument often very difficult, and that attention to this point in the arrangement of the patient will at once remove the difficulty. While the uterus is exposed by the speculum, it will be found to ascend with every expiratory effort, and descend with every inspiration ; and so distinct and constant are the rapid alterations of position thus induced, that in operations in the vaginal canal the surgeon can tell with great certainty how respiration is being affected by the anaesthetic employed. An organ so easily and decidedly influenced as to position by such slight causes must necessarily be affected by a constriction which, in autopsy, will sometimes be found to have left the impress of Ob ETIOLOGY OF UTERINE DISEASES. the ribs upon the liver, producing depressions corresponding to them. No one will charge me with drawing upon my imagination, even in the remotest degree, for the details of the following pic- ture, for a little reflection will assure all of its correctness. A lady who has habitually dressed as already described, prepares for a ball by increasing all the evil influences which result from pressure. Although she may be menstruating, she dances until a late hour of the night, or rather an early hour of the morning. She then eats a hearty supper, passes out into the inclement night air, and rides a long distance to her home. This is repeated frequently during each season, until advancing age or the occur- rence of disease puts an end to the process. A great deal of exposure is likewise entailed upon women by the uncovered sta Sounds of Valleix and Kiwisch. and dangers attending its employment are considerable, as may be judged of from the following quotations : — Becquerel 1 says: "But its employment is attended with such difficulty that it requires all the skill of an adroit and experienced practitioner, and we dread seeing it popularized among young physicians of little skill and experience." JSTooat 2 declares that " on account of the accidents which sounding may excite, it should only be resorted to with great caution and in those cases where its necessity is clearly shown." Scanzoni 3 candidly acknowledges that, "in the first place, the uterine sound is by no means so harmless as has been asserted," and then goes on to sum up the evils which may result from it. But I will not quote more; this suffices to show how the difficulties and dangers to which I have alluded are esteemed by some of the best authorities of our day. The facts which may be ascertained by the probe are these : — 1. The capacity of the uterus. 2. The existence of growths within it. 3. Deviations of the course of its canal. 4. Differentiation of these from uterine tumors. 5. The existence of endometritis. 6. The mobility of the uterus. The great importance of these facts with reference to diagnosis is evident, and one would suppose that an instrument revealing so much would be universally employed. Such, however, is not 1 Maladies de l'uterus. 3 Diseased of females, Am. ed. 2 Maladies de l'uterus. THE UTERINE SOUND AND PEOBE. 79 by any means the case. By adepts it is commonly resorted to, but in general practice will be found many, indeed a majority, who do not employ it from fear of its results, the difficulty of its introduction, and uncertainty as to its revelations. It is my opinion that no case of uterine disease should be regarded as fully investigated unless the cavity of the uterus be probed. Of course there are, in some cases, contra-indications to such a pro- cedure, but where none exists it should be considered as essential to a thorough examination. Dr. Sims has furnished us with a new instrument and method for probing this organ, which acts upon an essentially different principle from that formerly employed, and makes the investiga- tion so simple and void of danger that I strongly recommend its Fig. 18. Sounds of Simpson and Sims compared. (SiffiS.) adoption. In my own practice I use it in almost even case which I examine, and never have I done injury to a patient ex- 80 MEANS OF DIAGNOSIS. cept ill a few rare cases where miscarriage was produced, no sus- picion of pregnancy being entertained. Figure 18 represents the sounds of Simpson and Sims, for the purpose of contrasting them. The first is a strong, unyielding staff, composed of German silver, and as large as a No. 3 catheter. The second is not a sound, but a probe, only a little larger than the ordinary surgical probe, composed of pure silver or copper, and perfectly pliable. Dr. Sims has gradually decreased the size of the probe, so that that which is very commonly employed in New York, at pre sent, is no larger than represented in Fig. 19. Fig. 19. Sims's probe, smallest size. Mode of Probing the Uterus. — While the woman lies on her back, the examiner, by vaginal touch, carefully ascertains the position of the uterus, by passing his finger, first into the fornix vaginae over its posterior face, and then along the base of the bladder, over its anterior wall. This gives him a definite idea of the direction of the canal along which he is to pass his probe, and without it he should never essay the procedure. The specu- lum is then introduced, the patient preserving the dorsal decubitus if a short cylindrical instrument be employed, and being turned on the left side if Sims's or one of its varieties be used. The examiner then takes the probe, and with his fingers gives it the exact curve which he supposes the uterine canal to have, and gently passes it in. Should he fail, he withdraws the instrument, alters the curve slightly, and makes other attempts until he suc- ceeds, which will be very soon if he has used this method so often as to have given himself experience. Every effort at intro- duction is made cautiously as if the probe were passing into the larvnx instead of the womb, and no force whatever is exerted. Success is attained by properly curving the probe, and by that TENTS. 81 alone. Sometimes the inflection given to it must be the arc of a small circle ; at others a sharp angle ; sometimes the instrument is left perfectly straight ; in fact every variety of curve may be given it. In a certain set of rare cases, even a spiral twist is required. Thus employed, the uterine probe becomes a means of verify- ing a diagnosis which has been made by touch, and is certainly safe, easy of introduction, and painless. It may be used in all cases, except pregnancy, doing no injury even in metritis, so gentle is its entrance into the inflamed cavity. Having passed it, no one can dispute the fact that it performs the chief functions of the sound, proclaiming the course, length, and capacity of the uterine canal. Tents. — Before the time of Eecamier, the cavity of the uterus was a space entirely closed to investigation and local therapeutics, unless the os were greatly dilated by disease. He not only aspired to an accurate knowledge of its affections, but boldly ap- plied his remedies directly to the diseased surface ; and in cases of intra-uterine granulations, scraped off the diseased mucous coat with the curette. Even to him, however, the diagnosis of diseases within the cavity when the os was closed was an impossi- bility, and for the means of combating this difficulty we are again indebted to Dr. Simpson, who, in 1849, placed the use of sponge tents among the most important of our resources for diagnosis. The object for which they are employed is the dilatation of the cervical canal in order that the cavity of the body may be exa- mined by touch, or sight, and that treatment may be applied in cases of polypus, granulations, fibrous tumors, hydatids, removal of the products of conception, &c. A variety of substances have been recommended for the manu- facture of tents, only two of which have come into general use, compressed sponge and the laminaria digitata, or sea tangle. Mode of Preparing Sponge Tents. — The sponge employed should be of good quality, though not of the finest texture, which is not sufficiently unyielding to overcome the resistance of the cervix as it expands. It should be thoroughly cleansed by boiling in water rendered alkaline by bicarbonate of soda, and all adhering particles of earthy matter carefully removed. This being done, it should be cut into conical pieces, varying in bulk from that of 6 82 MEANS OF DIAGNOSIS. ' the little finger to that of an egg, and in length from two inches to three and a half. Small tents which are to be employed only for opening the cervical canal, need not be made longer than two inches, but those employed for complete dilatation in cases of polypus and fibrous tumors should measure three or even three and a half. As Dr. Noeggerath has advised, each piece should then be soaked in a weak solution of carbolic acid, which de- stroys to a great extent the fetid odor developing itself after the tent has been kept in the uterus for some hours. The sponges are then saturated with mucilage of gum acacia, and a sharp wire being passed through the centre of one piece, it is tightly wrap- ped with strong cord from the apex to the base. The wire is then removed and the tent left to dry. As soon as it is thoroughly dried the cord is removed, the asperities of the tent pared off with a sharp knife, and a piece of cord or tape tied to the extremity, if the practitioner desires, to facilitate its removal. Fig. 20. A sponge tent. In Europe they are prepared by machinery, and are far supe- rior to those made as above described. To prevent contact between the sponge, loaded as it is with organic elements, and the mucous lining of the uterus a variety of expedients has been resorted to, such as coating them with tallow, glue, wax, &c. A very ingenious plan for accomplishing this has been recently suggested by Prof. J. C. Nott, 1 of New York, who speaks highly of it from extensive experience. The tent prepared as above directed and made smooth by sand- paper is covered by goldbeater's skin, which is brushed over with a paste which is prepared after the following formula. Take of acetate of lead and sulphate of alum each jiij and dissolve in water. Take of gum Arabic 3v and dissolve in one pint of water. Mix in a dish a quarter of a pound of wheat flour with the gum 1 Richmond Med. Journ., July, 1867. TEXTS. 83 water cold, till pasty in consistence. Pat the dish on the fire and pour into it the mixture of alum and lead. Shake well, and take it off the fire when it shows signs of ebullition. Let the whole cool, and the paste is made ; if too thick, add to it some gum water till of proper consistence. The goldbeater's skin, cut of the length of the tent, is coated with this paste, and the tent rolled in it until it is enveloped five or six times. It is then dried, after which several rows of perforations are made from end to end of the tent, with a pocket knife, to admit fluids. They are now as smooth as cigars, very firm, and can be introduced very easily. In introduction and removal the skin protects the uterus perfectly. Preparation of Sea Tangle Tents. — In 1862 Dr. Sloan, of Ayr, Scotland, recommended the use of this substance for dilating the cervix uteri. The laminaria is an aquatic plant found upon various parts of the Atlantic coast of Europe and America. That found in the Bay of Fundy, I am informed by Messrs. Tie.- man & Co., is far superior to any other with which they have experimented. This plant, when saturated with moisture, swells to three times the bulk which it has when thoroughly dried. In its moist state a long piece of it is perforated at both extremi- ties, in order that it may be hung up and allowed to dry, a weight being attached to the lower end so as to stretch it and make it straight. When dry, this is cut into pieces from two to two and. a half inches long and made perfectly smooth and round by a knife, a piece of glass, or sandpaper. Tieman k Co. prepare them very beautifully by turning in a lathe. Dr. Greenhalgh, of London, has improved these tents by having them perforated from one extremity to the other, so as to make them tubular instead of solid. Thus prepared they will dilate much more rapidly and completely. One of Dr. Green- halgh's tents is represented in Fig. 21. Fig. 21. A sea tangle tent. The advantages of these tents over tho^e made of sponge con- 84 MEANS OF DIAGNOSIS. sist in their creating no fetor, and presenting no animal matter for absorption. Their disadvantages are their requiring a longer time for expansion, their being kept in the cervix with greater difficulty, and offering a harder substance to the walls of the cavity of the uterus. My own experience with them leads me to believe that from their decided inferiority to tents made of sponge, and to the fact that the latter are being rapidly freed from their disadvantages, sea tangle tents will in a few years dis- appear from practice. Mode of Introducing Tents. — If the uterus be low in the pelvis and its neck dilated, a tent may be held in the bite of any pair of uterine dressing-forceps and slipped in without the speculum, the woman lying ^on the back. In ordinary cases they should be introduced through the short cylindrical, or one of the varieties of Sims's speculum. The introduction is most easily accomplished with the last in all cases, and in some it can only be effected with it. The uterus being fixed and held by the tenaculum, Fig. 22, Fig. 22. Tenaculum for fixing the uterus. the tent grasped by a pair of mouse-tooth forceps, is directed in coincidence with the axis of the uterus, as ascertained by the probe, and gently pushed through the cervix, as represented in Fig. 23. Should its retention be doubtful, a mass of cotton is then packed against it so as to keep it in place, and the woman is directed to keep quiet upon her bed until it is removed. Its removal is accomplished, through the speculum, with the same forceps by which it was introduced, in from twelve to twenty-four hours. Dangers. — There is always danger in dilating the cervix by tents, though it is by no means so great as to make one hesitate in employing them. In a case which I saw in consultation with Dr. Edward Parsons I employed two tents in succession, and, in about twenty-four hours after removal of the second, tetanus developed itself, which proved fatal. In one case, in the practice of another physician, I have seen death result from peritonitis after their use ; and in three others have known peri-uterine cel- lulitis thus produced. THE ENDOSCOPE Fig 23. 85 Introduction of a tent (Sims.) The Endoscope. — This instrument consists merely of a long cylindrical tube of metal, through which, by a very strong light, we are able to see for a considerable distance down narrow canals. It has been employed for visual examination of the deepest por- tions of the urethra, and by means of reflecting mirrors even hollow viscera, as the bladder, have been explored. I have not experimented with it sufficiently to determine what can be accom- plished by it for the diagnosis of uterine disorders, but have satis- fied myself that as far as the os internum it may be used with slight advantage. I have employed a straight tube only, and hence have not been able to explore the body of the uterus, but varieties which are bent and supplied with mirrors have been used. If the cervix be dilated, the endoscope may be at once introduced after the part has been carefully cleansed of mucus. If it be closed, it will be necessary to dilate it with a tent, and to wash away all blood ooz- ing forth in consequence, with ice water, which will check further flow. Then the tube is carried up through the speculum to the requisite extent, and the light to be employed thrown through it. The endoscope will, probably, never prove of great value in this field. The Exploring Needle. — By means of a long, delicate needle. or very narrow tube, constituting a canula for a trocar the size of a small knitting-needle, the contents and characters of tumors in the pelvis may be ascertained. These instruments are not employed 86 MEANS OF DIAGNOSIS. in treating cysts, but are required only to remove sufficient fluid to annouoce the character of the contents of the tumor. Some- times a tumor, supposed to be solid and irremediable, is thus proved to be amenable to treatment by incision or the trocar. The Miceoscope. — The microscope will sometimes prove use- ful as an aid in diagnosis in determining the malignant nature of certain morbid growths, the character of products of inflamma- tion, the connection of intra-uterine growths with the results of conception, the purulent nature of uterine leucorrhcea, and, as Dr. Sims has pointed out, the deleterious effects of uterine discharges upon the zoosperm in the production of sterility. Auscultation and Percussion. — The important assistance of auscultation and percussion in mapping out the size of tumors, determining pregnancy, differentiating this from ovarian cysts, &c, is so evident as merely to require a passing mention. RECAPITULATION OF MEANS FOR EXPLORING THE VISCERA AND TISSUES OF THE PELVIS. 1st. Vagina and Cervix — Vaginal touch ; Sight, through the speculum. 2d. Outer Surface of Uterus — Vaginal and rectal touch, while the organ is brought within reach by hypogastric pressure or the tena- culum ; Conjoined manipulation-; Vesico-rectal exploration. 3d. Cavity of Cervix and Body — Tents, followed by introduction of finger ; The uterine probe; The endoscope. 4:th. The Ovaries, Broad Ligaments, Pelvic Peritoneum, and Pel- vic Areolar Tissue — Vaginal touch ; Eectal touch ; Conjoined manipulation ; Abdominal palpation ; Auscultation and percussion ; The exploring needle. CHAPTEE IV. DISEASES OF THE VULVA. Normal Anatomy. — The vulva is the elliptical opening which exists at the distal extremity of the vagina, and comprises the mons veneris, labia majora and minora, clitoris, meatus urinarius, vestibule, fossa navicularis, fourchette and hymen. Labia Majora. — From the mons veneris, which consists of adi- pose tissue covered by skin in which exist numerous hair bulbs, two folds of integument pass downwards to unite at the fourchette. These are called the labia majora. Externally they are covered by skin, which contains scattered hair bulbs, but on their inner surfaces their covering is mucous membrane, which is studded with sebaceous follicles, the secretion of which is unctuous and semi-solid. Within, the labia are filled with adipose tissue, a portion of which is inclosed in sacs of which one arises from each external abdominal ring and extends downwards towards the fourchette. The Clitoris. — Beneath the superior commissure of the labia juts forward a little erectile organ, which is analogous to the penis of the male, and receives the name of clitoris. It is covered by mucous membrane, consists of erectile tissue, and arises by two rami, one of which is attached to each ramus of the pubes. Like the male penis, this little organ is provided with a prepuce and frenum. Labia Minora. — These consist of two folds which, arising at the clitoris, pass downwards and disappear about halfway between the two commissures. Like the clitoris they are formed of erectile tissue covered over by mucous membrane, and an attentive exa- mination discovers upon their surfaces a large number of glands which secrete a sebaceous material. The Fossa Navicularis and Vestibule are merely spaces inter- vening; the first, between the perineum and vagina ; the second, 8S DISEASES OF THE VULVA. between the meatus and clitoris. They are both covered by mucous membrane, and the latter is studded with follicles. The Hymen is a thin veil consisting of a double fold of mucous membrane, which in part closes the ostium vaginas. When rup- tured its remains contract and form little tubercles on the walls of the vagina, which receive the name of carunculae myrtiformes. Passing over the clitoris, to which it is attached, and running downwards on each side of the vulva so as in part to cover the bulbi vestibuli/ will be seen a muscle, the sphincter vaginas. Some of its fibres pass down to the perineum to inosculate with the sphincter ani, with which it continues as a figure 8, but the greater portion decussate to the surrounding areolar tissue. Vulvitis. Definition. — Vulvitis is the name applied to inflammation of the mucous membrane lining the vulva. Affecting all of this structure, its surface covered by epithelium and the glands im- bedded in it, the inflammatory action sometimes extends through the submucous tissue into the proper structure of the parts underlying it, creating tumefaction, pain, and sometimes even suppuration. Varieties.- — Authorities differ with regard to the classification of its varieties. That which appears most appropriate is the following : — ■ Purulent vulvitis ; Follicular vulvitis; Gangrenous vulvitis. Purulent Vulvitis. This variety of the affection may be either of non-specific form, or a true gonorrhoea of the vulva. The former is in many respects analogous to ulcerative stomatitis, while the latter resembles very closely specific inflammation in other mucous membranes of the body. Causes. — It may result from Vaginitis ; Want of cleanliness; Injury; Eruptive disorders ; Onanism; Chemical irritants. PURULENT VULVITIS. 89 Symptoms. — The parts are red, swollen, hot and at first dry. Then a free flow of pus takes place which bathes the whole sur- face and stains the linen of a yellow hue. In addition to these signs of active inflammation, superficial ulcers will be found scattered over the parts affected, and in rare cases patches of diph- theritic membrane will be seen adhering to them. At times the meatus urinarius becomes affected, and painful micturition, with scalding and heat, is complained of. At others the most intense pruritus affects the vulva, and the patient, in endeavoring to ob- tain relief, may contract the habit of masturbation. Should the inflammation extend to the vagina, the symptoms of vaginitis will also show themselves, and by a similar extension to the bladder those of cystitis may develop. In severe cases febrile action, with thirst, heat of skin, and general discomfort, is pre- sent, but not usually. Course and Termination. — Even without treatment it is proba- ble that the affection would always be recovered from in time ; but it would run a lengthy and tedious course, and perhaps give rise to complications which would be productive of greater evil than the original disorder. When properly treated, it generally runs a rapid course and is readily cured. Treatment. — If inflammatory action is excessive, the patient should be kept in bed, upon low diet, and the bowels be freely acted upon by saline cathartics. Cooling and emollient applica- tions should be made constantly to the inflamed part, and clean- liness scrupulously observed. The patient should be directed to bathe the vulva freely with warm water three or four times daily, and to apply a warm poultice of powdered linseed, slippery elm, or grated potato. To the poultices may be added with ad- vantage acetate of lead and tincture or powder of opium. As soon as the acute action has subsided, the lead and opium wash should be kept in contact with the parts, by dossils of lint soaked in it, and placed between the labia. It is thus com- pounded: — R.— Tr. opii, §ij. Plumbi acetat. 5J« Aquae, Oj. — M. At a still later period the diseased surface should be painted over several times a day with equal parts of solution of persul- phate of iron and glycerine. Should the disorder not be entirely 90 DISEASES OF THE VULVA. eradicated by this treatment, the vulva may be painted over once in every forty-eight hours with a solution of nitrate of silver, ten grains to the ounce of water, and kept constantly powdered with lycopodium, bismuth, or starch, until recovery is complete. Follicular Vulvitis. Definition and Synonymes. — It has been already stated that in the mucous membrane lining the vulva, more especially in that covering the labia majora, labia minora, and vestibule, numerous follicles exist. Presenting themselves as solitary glands, they are classified under the three following heads — muciparous, sebace- ous, and piliferous. In ordinary purulent vulvitis, these, as com- ponent parts of the diseased membrane, are implicated in the morbid action. Sometimes, however, they alone are affected by disease, when the name of follicular vulvitis or vulvar folliculitis has been applied to the condition. Any or all the varieties of glands just mentioned may be diseased, and authors have given special names to the varieties, so that a list which would com- prise them all would be a long one. As examples may be men- tioned papillary, pruriginous, erythematous, sebaceous, granular vulvitis, &c. We may avoid tediousness of detail, and at the same time run no risk of being led into error, by classing all forms of inflamma- tion affecting the solitary glands of the vulva under the head of follicular vulvitis; provided that we bear in mind that all the varieties of glands may be simultaneously affected, or that one set alone may be diseased, the others remaining healthy. Causes. — This form of vulvitis may be induced by the follow- ing influences: — Pregnancy ; Neglect of cleanliness ; Vaginitis; Exanthemata ; Eruptions on the vulva. Symptoms. — These are burning, itching, and heat in the vulva, with increase of glandular secretion. At times the secretion is excessively offensive and irritating in character. The urethra frequently becomes inflamed at its vulvar extremity, and scalding in the passage of urine results. The vulva may become so sensi- FOLLICULAR VULVITIS. 91 tive to touch, that efforts at sexual intercourse excite vaginismus, which thus constitutes a symptom of the disease. Physical Signs. — Should the muciparous follicles be chiefly affected, the mucous membrane of the vulva is intensely red in spots or patches, which are slightly elevated. These are most commonly found on the edges of the lower vaginal rugae, the Follicular vulvitis. (Huguier.) nymphae, and the carunculae. They sometimes resemble the swollen villi upon the tongue, and bleed upon slight irritation. Should the disease have affected chiefly the sebaceous and pi- liferous glands, little red, rounded papillae will be found on the surfaces of the labia majora and minora, and the base of the pre- puce of the clitoris. After a while a drop of pus will appear in the apex of each, which is soon discharged, and the distended follicle shrivels. Beneath the labia minora a semi-fluid mass of offensive secretion will generally be found, which will, if not carefully removed, conceal the follicles underlying it. Course and Duration. — If this disorder occur during pregnancy, it may disappear at its conclusion. If not, and it be not appro- priately treated, it may continue for an unlimited time and estab- 92 DISEASES OF THE VULVA. lish urethritis, not only in the patient, but in her husband. This fact should be especially recollected, for a suspicion of want of chastity may be excited in the mind of the husband, and serious domestic difficulty result. . Treatment. — Follicular vulvitis should be treated upon the same principles as the purulent form, by repeated ablution, warm poultices, sedative washes, and astringents, especially the per- sulphate of iron and nitrate of silver. Dr. Oldham, who was one of the first to enlighten the profession in regard to this affection, placed great confidence in the following prescription: — ify. — Acidi hydrocyanici dil. 5'j- Plumbi diacetatis, ^j. Olei cacao, §ij. — M. Apply after washing the parts with cold water. Sometimes the affection lasts for many years, and cure can be effected only by dissecting off the whole of the mucous membrane lining the vulva. By this procedure I have recently cured a case of twenty years standing. Gangrenous Vulvitis. Definition and Synonymes. — This singular disease, which is in many of its attributes akin to the cancrum oris of children, has been synonymously described under the names of noma, carbuncle of the genitals, gangrene of the vulva, &c. It is fortunately a very rare affection, as it commonly proceeds to a fatal issue. Pathology. — A survey of the predisposing causes, none which are exciting being known, will convince the reader that this form of vulvitis, unlike the other affections of the genital organs which we have just considered, is dependent upon a depraved blood state, one somewhat similar to that which produces like results in the mouth and fauces in continued fevers, scarlatina, &c. Causes. — The constitutional states which are known to result in it are — Peculiar epidemics of puerperal fever ; An unknown epidemic influence ; Scarlatina, measles, and continued fever. The affection has sometimes been observed to take on an epi- demic character like similar disorders in the throat and mouth. Symptoms. — Velpeau 1 describes these in the following graphic manner: "A patch or vesicle of grayish, reddish, or blackish 1 Diet, de Med., vol. xxx. p. 991. INFLAMMATION OF THE VULVO- VAGINAL GLAND. 93 hue, which ulcerates and soon becomes depressed in the midst of swollen and indurated tissues which are of a red color, forms gene- rally the point of departure. From this moment the gangrene advances step by step ; mortification affects the parts ; an ichorous, fetid, nauseating fluid bathes the labia majora; separation of the gangrenous patches takes place slowly, and instead of limiting itself the process of destruction continues sometimes to extend until the death of the patient. The vital forces rapidly break down, and many children would die of this dreadful affection if art did not promptly interpose." A swollen, purplish, and oedematous state of the labia, accom- panied by grave constitutional signs, in a child exposed to any of the predisposing causes mentioned, would at once excite the suspicion of one at all familiar, even in theory only, with the existence of this malady. The only disease with which it would probably be confounded is diphtheria of the vulva, and this would* readily be differentiated by the patches of false membrane which would cover the mucous lining of the part. Treatment. — As soon as the nature of the disease is ascertained, both constitutional and local treatment should be promptly and energetically established. The patient should be placed in bed, in an apartment supplied by the purest air, and all depressing in- fluences should be removed from her. The most nutritious food and wine or other stimulants should be administered, and the forces sustained by quinine and muriated tr. of iron in large and repeated doses. If the local disorder be not rapidly arrested, death will undoubtedly ensue in spite of all general means, and no time should be lost in trying inefficient remedies. A powerful caustic is the only hope. The gangrenous spot should be destroyed by the actual cautery or muriatic or nitric acid, the patient being under the anaesthetic influence. After this, disinfectant poultices should be applied, and every effort at sustaining the vital forces continued, and should a fresh gangrenous spot appear, a new application of the caustic should be resorted to. Inflammation of the Vulvo -Vaginal Gland. Anatomy. — Just anterior to the hymen, or its remains the oa- runculse myrtiformes, will be found on each side a little opening, sufficiently large to admit a small probe or bristle. This opening- leads through a canal three-fifths of an inch long, which is the 9-i DISEASES OF THE VULVA. excretory duct of a conglomerate gland which has received the name of vulvo- vaginal gland. These glands are found, one on each side of the ostium vaginae, between the vagina and the ascending branch of the ischium, from which they are distant three-tenths of an inch, and lie in contact with the transverse artery of the perineum. The fact that they are separated from the vagina by an aponeurotic prolongation, lie between the superficial and middle layers of the ischio-pubic fascia, and have the unyielding ischium on one side, accounts for the complete confinement of pus forming in their tissue, and its not being discharged by the rectum or vagina. They were described by Buverney, Bartho- linus, Morgagni, and their immediate successors, but in time, very singularly, tHey were lost sight of. In 1841 M. Huguier, of Paris, redescribed them fully, and threw much light "upon their diseased conditions. , Sometimes, their mouths becoming occluded by adhesive in- flammation, their secretion is retained, and they undergo great enlargement and distension. At others their proper tissue be- comes inflamed, as we see that of the breast in mammitis, and abscess is the result. Causes. — The causes of inflammation of these glands are very much the same as those of vulvitis, of which, indeed, this affection is often a concomitant disorder. Symptoms. — There is heat about the vulva, pruritus, and pain upon touch. The mouth of the duct is red, and the finger pressed over the site of the gland discovers a hard, painful, and perhaps fluctuating tumor about the size of a large almond. Course and Duration. — The disease is one of no great moment, and its natural tendency is to recovery. Its usual duration is from two to three weeks, and the inflammatory process may terminate either by resolution or by suppuration. Should the latter occur, the pus may be discharged through the ducts of the gland, near them, or in the furrow between the labia minora and majora. Treatment. — An emollient poultice or cooling and anodyne lotion should be kept applied to the vulva, and rest should be prescribed until suppuration has occurred. Then, if pain be very severe, the accumulated pus may be evacuated, by means of a lancet, near the mouth of the gland or at any other point where fluctuation is most distinct. If pain be not severe, the evacuation of the pus may be left to nature. ERUPTIVE DISEASES OF THE VULVA. 95 "When frequent return of the morbid process makes it advisable to resort to an operation to give permanent relief, extirpation of the gland may be practised. An incision should be made at the point where one labium minus unites with the labium majus, through which the gland may be seized by forceps and dissected out with scissors. The transversus perinei artery will probably be severed, and should be ligated for fear of hemorrhage. Eruptive Diseases of the Vulva. The skin and mucous membrane making up the vulva may, like that of other parts of the body, be affected by eruptive dis- orders of various kinds. It is not my intention to enter with any minuteness into the consideration of these diseases, for which I refer the reader to any of the modern works upon dermatology, but merely to note the fact that they may occur at this part, and mention the leading characteristics of the most frequent of them. Any eruptive disorder which may elsewhere affect the skin or mucous membrane of the body may show itself at the vulva. The following list includes those which are most commonly met with and most frequently call for diagnosis and treatment : — Prurigo and lichen ; Eczema ; Acne ; Elephantiasis ; Erythema and erysipelas ; Syphilides. As is the case elsewhere with prurigo, that of the vulva pre- sents large, scattered papules, very irritating and generally hav- ing their apices bereft of cuticle. Lichen shows more numerous papules, and which rest upon a thickened and somewhat indurated cutaneous basis. In eczema the surface is red, heated, and covered by little vesi- cles, which, breaking, give forth a serous fluid. Acne consists in engorgement of the sebaceous follicles stud- ding the labial faces; not in inflammation, which would bring the case under the head of follicular vulvitis, but merely in engorge ment by their own retained secretion. Elephantiasis of the labia differs in nothing from that of other parts. 96 DISEASES OF THE VULVA. Er} x thema and erysipelas are simply accompanied by graver symptoms when they affect the genital organs than when they develop on the skin elsewhere. Syphilis in secondary and tertiary form may affect the labia, creating hypertrophy, ulceration, and all the evils which it excites in other parts. These disorders create the ordinary symptoms of vulvitis, and hence they are commonly confounded with it. Pruritus vulvas is one of their most constant signs, and the itching which it produces often first attracts attention to their presence. Treatment. — Little need be said here of treatment, for it should be guided by the rules which govern the management of the same cutaneous disorders in other parts of the body. The general health should be carefully attended to ; change of air advised ; and tonics and alteratives, such as iron and arsenic, prescribed in combination, the second, with the tinctures of cinchona, or gen- tian ; or, the first, with Colombo. Local treatment should consist in the maintenance of strict cleanliness by bathing the diseased parts freely in tepid water, and the pruritus, which invariably exists and excites scratching, should be relieved by lotions containing acetate of lead, opium, borax, or a small amount of creasote or carbolic acid. Phlegmonous Inflammation of the Labia Majora. The areolar and adipose tissues, which in great degree make up the bulk of the labia majora, are very frequently the seat of inflammation and abscess. The disease is excited by irritating vaginal secretions, vulvitis, direct injury, and the peculiar blood state which results in the development of furuncles and carbuncles. Symptoms. — In the first stage there is active congestion, which in the second produces hardness and tension from effusion of liquor sanguinis into the areolar tissue. The third stage consists in the breaking down of this mass by the process of suppuration and formation of abscess. The pus which is thus created is usually very offensive from propinquity to the rectum and vulva. Fig. 25 represents the disease. The diagnosis is usually very easy. Attention is directed to the part by heat, pain, throbbing, difficulty of locomotion, and exquisite sensitiveness upon pressure. Upon physical explora- RUPTURE OF THE BULBS OF THE VESTIBULE. 97 tion one labium is found very much Fi s- 25 - swollen, and quite hard and tender- Although this is usually the ease ? care must always be taken to dif- ferentiate it from labial hernia,, dis* placement of an ovary, pudendal hasmatocle, oedema labiorum, and vulvitis. As this point will engage our attention elsewhere, it requires no further mention here. Treatment. — The treatment should consist, in the first stage, of the ap- plication of cold and sedative lo- tions, low diet, saline cathartics, and perfect rest. One of the best local applications will be found to be the lead and opium wash. As the second stage advances the process of suppuration, which is now inevi- table, should be encouraged by poultices, and as soon as pus is distinctly discoverable it should be evacuated by puncture. Early opening is advisable, because the tissues obstinately resist natural evacuation, and the accumula- tion may pass upwards towards the abdominal ring through the dartoid sac. Phlegmonous inflammation of th< labia majora. (Boivin and Duges.) Rupture of the Bulbs of the Vestibule. Normal Anatomy. — If an incision be made by a scalpel through the skin and its subjacent adipose tissue, around the vulva, and all the tissues making up that part be dissected off, a reticulated plexus of large veins will be found beneath the labia called the pars intermedia and bulbi vestibuli. These extensive channels for blood have been represented by Kobelt, as shown in Fig. 26. Any influence which causes a rupture of these vessels must produce one of two effects; if there be a corresponding rupture of the skin, a free hemorrhage will occur ; if not, the blood pour- ing out into the areolar tissue, surrounding the wounded plexus, will soon form a coagulum, which will constitute a bloody tumor. 7 DISEASES OF THE VULVA Fig. 26. Plexus of veins of the vestibule. (Kobelt.) which has received the name of thrombus or pudendal hema- tocele. Pudenda I Hemorrhage. Especial attention has been called to this condition by Sir James Simpson, 1 who, in 1850, recorded from his own experience, and that of others, a number of instances in which from a very slight rupture of one labium fatal hemorrhage had taken place. He declares that criminal cases have repeatedly occurred in Scot- land, in which women, both pregnant and non-pregnant, had sud- denly died from pudendal hemorrhage, arising from rupture of the bulbs of the vestibule. Suspicion of injury at the hands of the husbands or neighbors, had been entertained in most or all of the instances referred to. Causes. — The great predisposing causes are pregnancy, varicose condition of the veins, and a large pelvic tumor. The exciting causes are: — Great muscular efforts; 2 Blows rupturing the labia; Incisions or punctures; Passage of the child's head through the pelvis ; Delivery by forceps. 1 Obstet. Works, vol. i. p. 277, Am. ed. 2 Prof. Simpson records a case due to straining at stool. PUDENDAL HEMATOCELE. 99 Symptoms. — The hemorrhage that announces the accident will lead to a physical exploration, which will at once reveal the nature of the lesion. Treatment. — The nature of the accident being once recognized, the control of the flow will not be difficult. If it be not effected by cold and astringents, such as ice, the persulphate of iron, or tannin, the actual cautery will probably check it without delay. Before resorting to this powerful means, however, a stick of nitrate of silver should be passed into the bleeding opening and held there until coagulation of the albuminous elements of the blood takes place. Then pressure, kept up by means of a bandage and com- press, will probably accomplish the end in view. Pudendal Hsematocele. Definition and Synonymes. — The term thrombus, derived from the Greek flpo^oo, " I coagulate," and which is used synonymously with hgematoma and sanguineous tumor, is that which is gene- rally applied to this condition. I have preferred the appellation of pudendal hsematocele, given to the disorder by Dr. A. H. McClintock, from its pointing out the similarity between it and pelvic hematocele, which resembles it in pathology. Pudendal haematocele is a tumor formed by a mass of clotted blood effused into the tissue of the labia, the wall of the vagina, or the areolar tissue immediately surrounding these parts. History. — As early as 1554, the disease was mentioned by Eueff, of Zurich, and in 1647 Veslingius is said by Dr. Merriman to have noticed it. It attracted the attention of Kronauer, of Basle, in 1734, and subsequently that of Levret, Boer, Andibert, and others. 1 But in time it passed somewhat out of notice, until the researches of Deneux, 2 in 1830, drew attention to it in more recent times. It is generally alluded to by authors only as one of the results of pregnancy aud parturition, though it is incon- testably proved that it may occur in the non-pregnant and even in the virgin state. Yelpeau records an instance in a girl of fourteen years, who had not yet arrived at puberty, and declares as the result of his experience, that "thrombus vulvae occurs almost as frequently in non-pregnant women as in those who arc 1 Velpeau, Diet, de Mc'd., vol. xxx. 2 Sur les Tumeurs sanguines de la Valve et du Vagiu. 100 DISEASES OF THE VULVA. in labor." He declares that he has, in the course of one year, observed six cases in the non-pregnant woman ; and in his whole experience he has met with twenty instances of the affection. Pathology. — The pathology of this condition is identical with that of pudendal hemorrhage, which has just received notice, for both are results of rupture of the bulbs of the vestibule. In that which we are now considering the effused blood, instead of pouring away, collects in the tissue of the labia, under the vagina, or even in the areolar tissue of the pelvis, and forms a coagulum. It bears to pudendal hemorrhage the same relation which a simple fracture bears to one of compound character. Eupture of a branch of the ischiatic or pudic arteries may, during labor, likewise produce a bloody tumor, 1 but this should not be treated of under the technical head of thrombus, for it would really constitute a case of false aneurism. Mode of Development. — When a large vessel has been injured, a tumor — perhaps the size of an orange — is suddenly discovered at the vulva. At other times the tumor is quite small, not larger than a hickory nut. The extent of the laceration likewise governs the rapidity with which the tumor forms after the injury has been inflicted. In some instances a slight flow slowly continues until compression from the clot checks it. Thrombus occurring in the non-pregnant state is generally less extensive than that in pregnancy, and is usually confined to the vulva. Causes. — The causes are identical with those of pudendal hemorrhage, namely: — Muscular efforts; Blows rupturing the labia; Incisions or punctures; Passage of child's head in labor; Delivery by forceps. Symptoms— -The symptoms are usually a sense of discomfort, with pain and throbbing, and if the effusion reaches the urethra, there is obstruction to urination. The patient or attendant will often first recognize the fact that something abnormal has occurred by the sense of touch, practised without a suspicion of the real difficulty. 1 Meigs' Treatise on Obstetrics, 5th ed., p. 94. PUDENDAL HEMATOCELE. 101 Differentiation. — Care must be observed not to confound the accident with — Abscess of the labia ; Pudendal hernia ; Inflammation of vulvo-vaginal glands; A mass of feces in the rectum ; (Edema labiorum. The mere announcement of the possibility of error in diagnosis is all that is necessary, for the physical characteristics, mode of development, and rational signs of these affections are so differ- ent from those of thrombus, that examination will always settle the point with certainty. Prognosis. — If the sanguineous collection be small, it will, especially in the non-pregnant state, generally disappear spon- taneously. If, however, it be large, and if the patient have recently been delivered, there are always two dangers to be appre- hended. The lesser of these is hemorrhage; the greater, puru- lent infection through the walls of the cyst left empty by evacua- tion of the clot, or the formation of an extensive abscess, which may produce the same result. Natural Course. — Should the tumor be left to itself, it may be absorbed in a few days and leave no trace ; or in five or six days it may burst and discharge ; or the clot may become encysted, and remain indefinitely in the tissues. Treatment. — Should the tumor be small, and not excite much pain, a cooling lotion of lead and opium should be applied, the patient kept quiet, and the evacuations of the bladder and rectum regulated, in the hope that absorption will take place. So soon as evidences of phlegmonous inflammation around the tumor appear, suppuration and discharge should be encouraged by poul- tices. When the tumor is large, and we feel sure, on this account, that it will not undergo absorption, it is advisable to evacuate the blood-clot by incision. This should be done by means of a bis- toury, upon the mucous face of the labium majus, the patient being placed under the influence of an anassthetic. After an in- cision has been made, one finger should be inserted, and the clot turned out of its nidus. If hemorrhage ensue, the cyst should bo thoroughly washed with solution of the persulphate of iron, and pressure exerted. Should this not check it, pledgets of lint soaked 102 DISEASES OF THE VULVA. in this astringent should be passed into the cyst, and, if necessary, counter-pressure exerted per vaginam by a tampon of cotton. Pudendal Hernia. Normal Anatomy. — By some anatomists it is stated that the round ligaments of the uterus end in the mons veneris ; but this view is not generally accepted. A more careful dissection traces them through the internal abdominal rings, along the inguinal canals, to the labia majora, where they are lost in the dartoid sacs, described by Broca as passing through these folds. The labia majora are unquestionably the analogues of the scrotum of the male, and the rou*nd ligaments correspond to the spermatic cords. Definition. — Down one of these canals, by the side of the round ligament, a loop of intestine, and sometimes a portion of the me- sentery, an ovary, or even the bladder, may pass, as inguinal hernia occurs in the male. The fact that this disease is by no means frequent, makes its recognition the more important, for were the practitioner not aware of the possibility of its occurrence, the intestine might be wounded, under the supposition that the labial enlargement was due to abscess, or distension of the vulvo-vaginal glands. Causes. — The displacement may be produced by violent mus- cular efforts, or blows, or falls, as in the male. Symptoms. — Strangulation of the intestine with its characteristic signs may occur, according to Sir Astley Cooper and Scarpa, 1 although it is very rare. The hernia may usually be overcome by taxis. In one case with which I have met, reduction was ex- tremely difficult, and could only be accomplished by prolonged effort. When the intestine becomes prolapsed, no strangulation existing, a sense of discomfort, upon bending the body or even upon walking, directs the patient's attention to the affected part, and leads her to apply to the physician. By him the nature of the case will at once be suspected, from the peculiar gaseous or airy feel yielded to the sense of touch. Certainty of diagnosis will be arrived at by absence of all signs of inflammation or oedema, impulse felt upon coughing, resonance upon percussion, and the possibility of diminishing the volume of the tumor by 1 Scanzoni. op. cit., p, 560. PRURITUS VULVAE. 103 taxis and position. There are no difficulties attending the differ- entiation of the disease. The danger is that the possibility of hernia at this point may be forgotten, and deductions drawn without considering it. Although the probability of error be not great, the appalling nature of the accident in which it would re- sult, warrants the relation of the following case, which is illustra- tive of its possibility. A patient called upon me with the follow- ing history: she had had an abscess just below the external abdo- minal ring, which, after poulticing, had been evacuated by her physician, about a month before the time of her visit to me. After this, she had felt well until a week before, when, after a muscular effort, the pain had returned with all the original signs of abscess, and these had continued, although she had painted the part steadily with tincture of iodine, as she had been directed to do in case of such an occurrence. Being in great haste at the moment, I examined the enlargement, while the patient was standing, and under a recent cicatrix, which was painted with iodine, I discovered what I supposed to be a reaccumulation of pus. As the patient came to me in the absence of her physician, merely for the evacuation of this, I placed her in the recumbent posture, and, bistoury in hand, proceeded to operate. But to my surprise, I discovered that change of posture diminished the size of the enlargement. This excited my suspicions, and I found that a recent hernia had occurred under the old cicatrix. Treatment. — The patient having been placed in the knee- elbow position, the tumor should be grasped, compressed, and pushed up the canal, down which it has descended, until it returns to the abdomen. Then a truss, so arranged as to press upon the exter- nal abdominal ring, should be adjusted, and worn with a perineal strap, to keep the compress of the instrument sufficiently low down to effectually close the point of exit. Should strangulation have occurred, and return of the prolapsed part by taxis prove impossible, the case will require the surgical operation for that condition, for a description of which the reader is referred to works on general surgery. Pruritus Vulvae. Definition. — This affection consists in irritability of the nerves supplying the vulva, which induces the most intense itching and 104 DISEASES OF THE VULVA. desire to scratch and rub the parts. Although not itself a disease, it is always so important, and often so obscure a symptom, that it requires special notice and investigation. Pathology. — It has just been stated that it consists in disorder of the nerves supplying the vulva. It matters not whether this be a true neurosis or one secondary to some other pathological state, the great element of pruritus vulvas is nervous irritability or hyperesthesia. That it is often excited by irritating discharges and eruptive disorders there can be no question. Whether it ever depends upon idiopathic nervous hyperesthesia, as some suppose, is doubtful. I have never met with an instance in which it appeared to do so. Mode of Development and Course. — In the beginning, the irrita- bility and tendency to scratch are sometimes very slight, so as to annoy the patient very little and give her but trifling uneasiness. Sometimes they exist only after exertion, in warm weather, upon exposure to artificial heat, or just before and after menstruation. The disorder is aggravated by the counter-irritation which it demands for its relief. The rubbing and scratching that are prac- tised cause an afflux of blood, render the skin tender and its nerves sensitive, and in time greatly augment the evil by pro- ducing a papular eruption. The disease, and the remedy which instinct suggests, react upon each other, the first requiring the second, and the second aggravating the first, until a most rebel- lious and deplorable condition is developed. It would be difficult to exaggerate the misery of some of these cases. The patient is bereft of sleep by night, and tormented constantly by day, so that society becomes distasteful to her, and she gives way to despon- dency and depression. It is generally intermittent, in some cases occurring by night, in others only at certain periods of the day. In two cases that I have met, the patients were free from all irri- tation except at night, when the disturbance and nervous anxiety became so intense as to prevent sleep, except when large doses of opium were given. Loss of sleep, the use of opium, and the nervous disturbance incident to the disease, often prostrate and exhaust the patient to an astonishing extent. Its duration has no limit, months and even years sometimes passing before relief is obtained. Causes. — Every practitioner dreads to take charge of an aggra- vated case of pruritus, for he knows how obstinate the malady PRURITUS VULVJ. 105 commonly proves. The only reasonable hope of controlling it must rest in viewing it strictly as a symptom, and striving to dis- cover and remove its cause. No fixed prescriptions, however much lauded for their efficacy, should be relied upon. The pri- mary disorder should be sought for and cured, in the hope of removing that one of its results which is most pressing in its de- mands for relief. Should the case have progressed for some time, it will often be found impossible to decide as to its cause, for the friction excited by it will frequently establish a cutaneous disorder, the connection of which with the pruritus, whether as cause or effect, will be doubtful. In all the instances of pruritus vulvae that I have been able to examine early enough to determine as to the etiology, I have found one of the following conditions to exist as the apparent cause of the hyperaesthetic condition of the nerves : — 1st. Contact of an irritating discharge— Leucorrhcea; Hydrorrhcea ; Discharge of cancer ; Dribbling of urine ; Diabetes. 2d. Local inflammation — ■ Vulvitis ; Urethritis. 3d. Local irritation — Eruption on the vulva ; Animal parasites ; Onanism. Of all these, leucorrhcea is the most frequent cause. This symp- tom of uterine disorder fortunately produces pruritus only as an exception to a rule. Under certain circumstances it appears to possess peculiarly irritating and excoriating qualities, which, even when the flow is very slight in amount, will excite the most in- tolerable itching. This feature is most commonly observed in the discharge attending pregnancy ; and in that of senile endome- tritis, which covers the vagina with bright red spots, and gives it a glazed look like serous membrane. In an exceedingly obsti- nate case, occurring in a woman of seventy years, the leucorrhcea! discharge was so small in amount that the patient was not aware 106 DISEASES OF THE VULVA. of its existence, nor did I appreciate its connection with the dis- order until I discovered accidentally that the only relief which could be obtained followed the application of a wad of cotton against the cervix uteri. In every case of pruritus the vagina should be carefully investigated for evidence of leucorrhoea, unless some other sufficient cause is apparent. In the same manner the other vaginal discharges mentioned may cause nervous irritability in the vulva. I have so often found diabetes accompanied by this symptom that I always examine the urine in obscure cases. This result is probably not connected with the constitutional effects of the dis- ease upon the nerves, but with some direct and local influence exerted by the disordered secretion. Local inflammation, by the discharge which it excites and the itching which attends it, is very evidently calculated to give rise to pruritus ; and yet cases thus established are not the most rebellious with which we meet. Any form of eruption upon or around the vulva may, and usually does, excite itching. Eczema, prurigo, lichen, and many others, may do so here as they do elsewhere, and the natural warmth of the part, formed as it is of folds of tissue and covered by hair which is thickly interspersed with sebaceous and piliferous glands, makes them the more likely to prove active in causing it. Animal parasites of two varieties may give rise to it, the pedi- culus pubis and the acarus scabiei. The first excites enough irritation to beget a lichenoid eruption, while the second produces scabies, or itch. One of these causes will generally be found to have given rise to pruritus vulvas, but it is only in originating the difficulty that it will prove active. Yery soon secondary influences, as eruptions, excoriations, ulcerations, and increased discharges the results of scratching, superadd themselves as auxiliary agents, and keep up the difficulty. Treatment. — It has been stated that the first effort of the prac- titioner should always be to discover the disease of which the pruritus is a symptom, and to endeavor to remove it by appro- priate means. Should leucorrhoea be the cause, the uterine or vaginal affection which gives rise to it should be treated. Should an eruptive disorder be found to be the source of the difficulty, the measures which would be advisable elsewhere, laxatives, PRURITUS VULVAE. 107 baths, change of air, tonics, and arsenic would be equally bene- ficial here. But this alone will not be sufficient. While eradication of the mischief is thus attempted, palliative means must be vigorously adopted for the sake of present relief. Should the case be re- garded, upon careful investigation, as due to contact of an irritat- ing fluid with the nerves of the vulva, perfect cleanliness should be secured by three, four, or, if necessary, a larger number of sitz baths daily. The vagina should, at the time of taking each bath, be syringed out with pure or medicated water, the irritated surface protected by unctuous substances, or inert powders, as bismuth, lycopodium or starch, from the injurious contact, and in case the discharge comes from the uterus, a wad of cotton should be placed daily against the cervix uteri to prevent its escape to the vulva. A very useful vaginal injection, and wash for the vulva, under these circumstances, is the following : — R. — Plumbi acetatis, ^ij. Acidi carbolici sol. 5J« Tr. opii, §iv. Aquae, Oiv. — M. This may relieve itching for the time, until removal of the cause of the symptom is accomplished. In case the pruritus is the result of a local inflammation, this should be treated as elsewhere recommended, by poultices of lin- seed, potato or slippery elm, to which have been added a proper amount of lead and opium ; or fomentations of lead and opium wash, or poppy-heads may be used in their stead. If vaginitis be present, great relief will often be obtained by painting the lining membrane of the canal over with a strong; solution of nitrate of silver, or by touching the whole surface lightly with the solid stick. Should an eruptive disorder be the exciting cause, it should, as already stated, be treated upon general principles. Meantime temporary relief may be obtained by painting the surface of the vulva over with a solution of nitrate of silver (3j to §j), the use of the ungt. creasoti, ungt. chloroformi, or ungt. atropise of the U. S. Dispensatory. Dr. Simpson advises an infusion of tobacco. Should eczema or lichen have produced inflammatory action in the skin and subcutaneous areolar tissue, poultices, &o., should 108 DISEASES OF THE VULVA. be employed, as if local inflammation was the cause of the affec- tion. While these palliative and curative means are being adopted, sleep should be secured by preparations of opium, or one of its substitutes, codeine, cannabis Indica, hyoscyamus, or chlorodyne. At the same time the general state of the patient should be im- proved by vegetable and mineral tonics, good food, and fresh air. In some cases more benefit will arise from the use of iron, the mineral acids, and sea-bathing, than from any other means. Coccyodynia. Definition and Frequency. — This affection consists in a peculiar condition of the coccyx, or the muscles attached to it, which renders their contraction, and the consequent movement of the bone, very painful. It is of frequent occurrence, numerous cases having been observed, since attention has been called to it, by practitioners who saw it previously without regarding it as a special disorder. History. — Coccyodynia was first described in 1844 by Dr. J. C. Nott, formerly of Mobile and now of this city. Under the name of neuralgia of the coccyx he described a case which so fully em- bodies the symptoms and treatment of the affection, that I cannot refrain from a free quotation of it. Extirpation of the Os Coccygis for Neuralgia. — Miss , aged about 25, had been very much deranged in general health and suffering from neuralgia for ten months, for which she was treated by an eminent physician in Charleston, and afterwards by Prof. Jones in New Orleans. She came under my care the latter part of June, 1843, at which time her condition was a deplorable one ; her general health was completely shattered and strength exhausted ; dyspepsia ; constant nervous headaches ; menstrua- tion regular though difficult ; excruciating pain at the point of the coccyx ; pains in the uterus, vagina, neck of the bladder, and back. The most prominent symptom was the excruciating pain at the "point of the coccyx, which became intolerable when she sat up, walked, or went to stool, or in short when motion or pressure was communi- cated to it in any way. This symptom was so peculiar, that I was led to suspect some organic lesion about the coccyx, and on ques- tioning her closely, she informed me that she had fallen about COCCYODYNIA. 109 four years ago and received a blow upon the coccyx, which gave her a good deal of pain at the time and for several weeks after- wards ; but these symptoms passed off, and did not return until about ten months before I saw her. This fact had been concealed from her former medical attendants. I then told her that her physicians had exhausted all the arti- cles of the materia medica which afforded any prospect of relief, and that she had better consent to an examination to ascertain whether the coccyx, either by disease or displacement, had not become a source of irritation to one or more of the nerves in its vicinity. She consented, and on examining the whole course of the spine, I found no tenderness of any consequence until my finger touched the point of the coccyx, when she screamed with pain. I then proposed the extirpation of this bone as the only chance of relief. She had suffered so long and so severely that she did not hesitate, and told me she was in my hands to do what I thought best, and would submit to anything I would advise. Accordingly, on the 2d of July, I made an incision down to the bone, and extending from the point upwards two inches ; I then disarticulated the bone at the second joint, divided the mus- cular and ligamentous attachments, and without much difficulty dissected out the two terminating bones. On examining the bones after the operation, I found the left one carious and hollowed out to a mere shell ; the nerves were exquisitely sensitive, and the operation, though short, was one of the most painful I ever per- formed. For several hours after the pains were extremely violent, coming on every ten or fifteen minutes, and accompanied by a sensation of bearing down like labor-pains. Morphine in large doses and other anodynes afforded no relief; the pains became gradually less frequent and less violent ; the wound soon healed, and at the end of a month the local disease disappeared and the general health was much improved. 1 About the year 1860, Profs. Simpson and Scanzoni had their attention attracted to it, and the appellation which I have em- ployed was applied to it by the former. Anatomy. — The coccyx serves as a point of attachment for the greater and lesser sacro-sciatic ligaments, the ischio-coccygei mus- cles, the sphincter ani, levatores ani, and some of the fibres of 1 N. 0. Med. Journ., May, 1S44. 110 DISEASES OF THE VULVA. the glutei muscles. These are thrown into activity by certain movements, as rising from the sitting into the standing posture, the act of defecation, &c, and in such acts the existence of the disorder which we are considering is revealed. Pathology. — The pain which characterizes it is probably due to a hyper-sensitive state of the fibrous tissues surrounding the coccyx, or that making up the tendinous expansions of the mus- cles. So long as the bone is uninfluenced by contraction of the muscles attached to it, no pain is experienced, but as soon as contraction produces motion it is excited. Causes. — It occurs most frequently in women who have borne children, but it is by no means confined to them. I have on two occasions met with it in young, unmarried ladies, and Herschel- man reports two cases in children from four to five years of age. The chief causes for it are the following : — Parturition ; Delivery by forceps ; Falls or blows upon the coccyx ; - Cold; Exercise on horseback. Symptoms. — The patient upon sitting down, rising to stand, mak- ing any effort, or passing feces through the rectum, experiences severe pain over the coccyx. In some cases this is so severe as to cause the greatest dread of sudden or violent movement. In others, the patient is unable to sit on account of the discomfort caused by pressure on the bone. The most trying process is that of rising from a low seat, and, to accomplish this, the sufferer will obtain all the aid that is practicable, by assistance with the hands, which will be placed as auxiliary supports upon the edges of the chair or stool upon which she rests. Differentiation. — The only conditions with which this may be confounded are painful haemorrhoids and fissure of the anus, and from both a careful examination by sight and touch will always readily distinguish it. Prognosis. — Coccyodynia often lasts for years, annoying and distressing the patient, but never to any degree depreciating her health or constitutional state. If left to nature, it may wear itself oat, but it is probable that it would generally remain for a long time, if not relieved by art. Treatment. — Counter-irritation, opiates by the mouth, rectum, COCCYODYNIA. Ill skin, and hypodermic injection have all been tried in vain in aggravated cases. In slight cases, blistering and the enclermic use of morphia may effect a cure, but should they not do so promptly, no great length of time should be consumed in efforts Fig. 27. Sketch of the anatomical relations of the coccyx, a. Great sacro-sciatic ligament, b. Small sacro-sciatic ligament, c. Surface from which the gluteus maximus muscle (//) has heen detached, d. Sphincter ani. e. Levator ani. f. Coccygeus muscle, g. Fascia in contact with the rectum, h. Glutaeus maximus of the left side. (Simpson.) of this kind. Eecourse should at once be had to one of two radical methods of cure — section of the diseased muscles, or amputation of the bone to which they are attached. The first, placed at our disposal by the ingenuity of Prof. Simpson, consists in severing the attachments of all the coccygeal muscles: the second in amputating the coccyx itself, after the plan of Dr. Nott, The first operation is performed subcutaneouslv by an ordinary tenotomy knife. This is passed under the skin at the lowest 112 DISEASES OF THE VULVA. point of the coccyx, turned flat, and carried up between the skin and cellular tissue until its point reaches the sacro-coccygeal junction. Then it is turned so that in withdrawing it an incision may be made which entirely frees the coccyx from muscular attachments. The knife is then introduced on the other side so as to repeat the section there. As is usually the case in subcuta- neous operations, no hemorrhage occurs unless some large vessel be injured. Complete convalescence is rapid. Should this fail, as it may do, an incision should be made over the coccyx, the bone laid bare by severance of its attachments, and the whole of it removed by a pair of strong bone forceps, or disarticulated by the knife as practised by Dr. Nott in the case already detailed. By one of these procedures cure can be con- fidently promised, and as neither is attended by danger, our re- sources in this affection may be regarded with great satisfaction. CHAPTER V. KUPTUKE OF THE PERINEUM. Definition. — The perineum, which consists of the union of the tendons of a number of strong and important muscles intervening between the verge of the anus and that of the vagina, may by certain traumatic agencies be torn or ruptured so as to weaken the normal support of the posterior wall of the vagina. Normal Anatomy. — The perineum extends from the edge of the anus to that of the vagina over a space of an inch or an inch and a half. It consists of skin, areolar tissue, and the tendinous expansions of several muscles, and is covered over internally by the posterior wall of the vagina, which ends at the fourchette. No muscular tissue exists at the raphe of the perineum, but this part is formed by the junction of the following muscles, which have there a point of attachment ; the sphincter ani attached pos- teriorly to the tip of the coccyx, the sphincter vaginae passing upwards over the clitoris and attached to its crura, and the trans- versus perinei attached on each side to the tuberosities of the ischia. An examination of a diagram representing this part will show that rupture of the perineum at the raphe will result in destruction of one of the fixed points, by drawing upon which the muscles there inserted act, and that the other point, remaining fixed, the lips of a wound existing there must be made to gape. Another fact connected with the anatomy of this part which must be borne in mind, is that it is the inferior support or buttress for the distal extremity of the posterior wall of the vagina. This wall runs to the end of the perineum, arching backwards towards the rectum. Should its support be destroyed, the vaginal wall may be affected unfavorably in two ways : first, the destruction of the perineal raphe weakens the sphincter vaginae, and thus the whole of the ostium vaginaa loses support; second, the distal extremity of the posterior wall being carried, by the rupture and subsequent cicatrization, farther back towards the coccyx, the 114 RUPTURE OF THE PERINEUM. previously existing arch is impaired, and prolapse is rendered probable. Figs. 28 and 29 will illustrate this view. Fig. 28. Fig. 29. Normal perineum ; posterior wall of vagina, Ruptured perineum ; posterior arching backwards, and ending at the fourchette. arch destroyed. It is evident that the greater the extent of the laceration the more serious will be the evils which will accrue from it. Results. — The following are the evil results which may follow this accident, directly or remotely : — Prolapsus vaginae with cystocele or rectocele ; Prolapsus uteri ; Incontinence of feces and intestinal gases ; Prolapsus recti ; Cervical metritis, the result of friction. These evils do not follow when the accident has involved the perineum to so limited an extent as not. to have sundered the union of the sphincters, or at least they are not likely to occur. Even when the two passages are laid into one, it is sometimes surprising to see how little the patient may suffer ; but generally, under these circumstances, her condition is truly deplorable. Pecal matters and gases pass without control, and the uterus, vagina, bladder and rectum tend so strongly to descend, that exercise, muscular efforts, or tenesmus, produce weariness, pelvic pain, and traction upon the broad ligaments. In some instances, so great is the disturbance of function that the unfortunate woman finds herself an object of disgust to her associates and even of loathing to her husband. Varieties. — All cases may be classed under four heads: — 1st. Superficial rupture of the fourchette and perineum, not involving the sphincters ; PROGNOSIS. 115 2d. Rupture to the sphincter ani ; 3d. Rupture through the sphincter ani ; 4th. Rupture through the sphincter ani and involving the recto- vaginal septum. Causes. — The usual causes of the accident are, Parturition ; Passage of a large tumor ; Use of forceps ; Manual delivery ; Craniotomy ; Injury by falls or blows. Minute details upon this subject and upon means which should be adopted for prevention, belong rather to a work upon obstet- rics. All that is necessary to state here is that parturition is the great exciting cause of it, and that it is never met with in nulli- parous women, except after removal of large tumors per vaginam. Prognosis. — In an incomplete case of slight character, in which neither the sphincter vaginas nor sphincter ani has been injured, no evil will probably result. Although the wound, occurring as it does immediately after labor, is extremely unlikely to heal by first intention, it may do so by the process of granulation without surgical interference other than binding the thighs together, and producing constipation by opium. The first and second varieties of the accident are very gener- ally trifling in their consequences, and frequently pass unnoticed by both patient and attendant. The third is an evil of much greater moment, and not at all likely to undergo spontaneous cure; while the fourth represents the most serious form of the condition. The greater the injury the less likely will be spontaneous re- covery, and the more probable the complications and results which have been mentioned. It may be affirmed, in a general way, that any laceration which does not entirety sever the sphincter ani may heal without surgical treatment, and that none which converts the two passages into one will do so. Even when the rupture has been complete it has been asserted thai spontaneous cure has taken place, but such reports need con- firmation. Peu 1 once affirmed that he had seen a woman thus 1 Velpeau, Traite de l'Art des Accouelienients, vol. ii. p. 639. 116 RUPTURE OF THE PERTNEUM. injured, and who passed her feces involuntarily, entirely recover. De La Motte declares that thirty years afterwards he met and examined Peu's patient in Normandy, and found that no recovery had occurred. Treatment at Time of Occurrence. — If the case be an incomplete one in which it is not deemed advisable at once to resort to suture, an effort should always be made to secure union of the lips of the wound by the following means. The wound being thoroughly cleansed of blood clots, which would prevent union, the thighs should be brought together and kept in contact by a bandage placed around them at the knees. The patient should then be placed upon the side so as to cause the lochial discharge to flow through the superior vaginal commissure, and prevent its pouring over the raw surface. Opium should be given to pro- duce constipation, the bladder be kept empty by use of the catheter, and, once or twice in every twenty-four hours, the patient should turn upon the back, in order that the vagina may be cau- tiously and gently sj^ringed out with tepid water. This plan should be pursued for ten or twelve days, in the hope that union may occur, though, unfortunately, in the great majority of instances, it will not be rewarded by success. Time for Operation. — Upon this point authorities differ widely; some urging immediate action, some advising delay until the effects of parturition have entirely passed away, while others compromise the matter by giving preference to the plan of wait- ing a few days only. To the first class belong Baker Brown, Demarquay, Scanzoni, Simon, and others of equal weight. Scan- zoni thus clearly points out the advantage of early interference : "The operation should be performed just after the delivery, be- cause it is more likely that the bleeding lips of the wound will then unite, and because, vivification of the edges not being neces- sary, the procedure is simpler and less dangerous." The worst cases of the accident with which we meet generally follow instru- mental or manual delivery, and when the discovery of its occur- rence is made the patient will usually be in a profound anaesthetic sleep. Every operator should be prepared, under such circum- stances, to attempt repair, for, if it succeeds, the patient will be saved much suffering, while failure will not in any wise depreciate her condition. I have in a number of instances resorted to im- mediate operation, and the result of my experience leads me TREATMENT. 117 always to adopt it, unless the sphincter ani and recto- vaginal wall be implicated in the laceration to such an extent as to make the operation a serious and lengthy one, or to insure the passage of lochial discharge between the lips of the wound. Among those who are opposed to immediate interference are Koux and Vel- peau; while Nelaton, Yerneuil, and Maisonneuve advise delay for a few days, when all hemorrhage will have ceased and the edges of the wound be covered by granulations. 1 Treatment of Cases which have cicatrized. — The operation which is now universally adopted in these cases, and which has received the name of perineorraphy, consists in vivification of the edges of the lips of the wound and their approximation by sutures. Although the accident for which this procedure is instituted was described by the ancients, no surgical means of cure were ever advised for it until the time of Ambrose Pare. He advised the suture, and was followed in its use by his pupil Gruillemeau. Subsequently it was employed by Delamotte, Saucerotte, Trainel, Noel, and others. Dieffenbach employed it successfully, adding to the operation oblique lateral incisions involving the skin and areolar tissue, for the purpose of relieving tension upon the parts brought together by suture. About the year 1832, Eoux, of Paris, obtained the most bril- liant results from the operation, and probably its elevation to the position of a reliable surgical procedure was due more to his achievements than to those of any other individual. He employed the quilled suture, and cured by it four out of the first five cases operated upon. Although such success was obtained in France at this period, we find English writers, as late as 1852 and 1853, 2 doubting the efficacy of sutures, and advising that assistance should be limited to aiding the efforts of nature. Of late years rapid advances have been made in the operation by Mr. Brown in England; Verneuil, Laugier, Demarquay, and others in France; Langenbeck in Germany ; and Sims, Emmet, Bozeman, and Agnew in the United States. The varieties of the operation now before the profession are too great to require enumeration. Operators differ chiefly in these respects : some cut the tissue of the perineum or the sphincter ani, 1 Wieland and Dubrisay, French Trans, of Churchill on Dis. of Women. 2 Baker Brown, Surgical Diseases of Women. 118 EUPTURE OF THE PERINEUM, and employ the quilled suture, while others make no " liberating incisions," as the French surgeons style them, and employ the interrupted suture. As a type of the first class I shall describe the operation of Mr. Brown, and of the second that of Dr. Sims, explaining the omission of other methods by the statement that one of these will always succeed in effecting a cure when per- formed with the requisite skill. Preparation of the Patient. — The general health being in proper condition, the bowels should be thoroughly evacuated a day or two before the operation by some mild cathartic, and the vagina thoroughly syringed out to remove secretions, and quiet local irritation. The patient, dressed for bed, should be placed upon a table before a window admitting a strong light, in the position for lithotomy, and put under the influence of an anaesthetic. Four assistants will be serviceable, although three would answer the purpose. One of these should administer the anaesthetic, one should hold the knees, and the third should attend to the duty of sponging blood from the wound. Baker Brown 1 s Operation. — The instruments required are a scalpel, a blunt-pointed, straight bistoury, a pair of long dissect- ing forceps, three large needles, several small ones, a tenaculum, pieces of gum-elastic catheter to act as quills, common hemp twine waxed, and sponges. All being in readiness, an assistant holds the sides of the fissure so as to secure tension, and the operator, by means of a bistoury, removes aH the cicatricial tissue, first from one edge, and then from the other. This should be done so as not only to vivify all the cicatricial surface, but also the super- ficial layer of tissue above the cicatrix. After this the external sphincter of the anus is divided, with the skin and areolar tissue lying over it. The muscle is cut on both sides, about a quarter of an inch in front of its attachment to the os coccygis, by two incisions, carried outwards and backwards, as represented in Fig. 30. For this purpose a blunt-pointed bistoury, guided by the finger, is carried up the rectum for an inch and a quarter, and by it an incision of an inch in length is made, extending outward from the anus, between the coccyx and tuberosity of the ischium. The thighs are then approximated and the sutures introduced. The left edge being grasped between the thumb and fore-finger of the left hand, a strong needle, armed with a double thread, is inserted an inch external to the pared surface, and passed down- TREATMENT. 119 wards and inwards so as to make its point come out at the bottom of the denuded surface. It is then passed through the opposite lip, and brought out through the skin, at the same distance from the edge of the wound. This suture is passed at the upper angle. Fig 30. Shows the denuded surfaces and the insertion of the quill suture before the parts fire brought together, and also the division of the sphincter on each side of the coccj'X. (Brown.) Another suture is then passed in the same manner at the mid- dle, which should go as deep as the septum, and even pass through it. A third suture is then passed at the lower angle. Two bits of gum-elastic catheter are now placed, one on each side, the first within the loops of the suture, the other at the opposite extremi- ties. The sutures are then tightened, the opposing lips adjusted and the sutures tied. From four to six silver sutures are then passed through the edges of the skin, and the operation is complete. Mr. Brown advises that before the patient is removed the index finger of the right hand be passed into the rectum, and that of the left into the vagina, in order to ascertain that apposition is com- plete. The parts are then sponged, and a cold water dressing 120 RUPTURE OF THE PERINEUM, applied and secured by a T bandage. The patient is kept in bed upon unstimulating but nutritious diet, the bowels constipated by opium, and the bladder frequently emptied by the catheter. The deep sutures should be removed in from three to six days, and Ficr. 31, the wound closed. (Brown.) on about the eighth day the superficial ones may be withdrawn. During convalescence the vagina should be syringed out with warm water, or with a weak solution of chloride of soda, if offensive discharge exist. Constipation should be kept up by the use of opium for two or three weeks, and when alvine dis- charges do occur they should be encouraged, and rendered easy by enemata. Should a perineo-vaginal or rectal fistula remain, Mr. Brown thinks highly of the actual cautery in its cure. Sims's Operation. — The operation performed by Dr. Sims differs from that just described in many respects, most notably in silver sutures being employed, and no section to afford relaxation being practised, either upon skin and areolar tissue, after Dieffenbach's TREATMENT. 121 plan, or upon the muscles of the part, after that of Horner, Cope- land, Cooper, and Baker Brown. The first operator who treated these cases by metallic sutures was Mettauer, of Virginia, who, in the Edinburgh Med. and Surg. Journal (vol. xix. p. 552), described several cases successfully treated by lead used as an interrupted suture. I avail myself of a description of Sims's operation given by Dr. Emmet, and published in the N. Y. Med. Journal of December, 1865:— "In the operation for closing a lacerated perineum, either par- tially or entirely through the sphincter ani, it is unnecessary to, divide the muscle, or to make incisions into the soft parts for the purpose of relieving tension. " As early as 1855 Dr. Sims, in the Woman's Hospital, simpli- fied this operation by bringing the scarified edges of the lacera- tion together by means of deep, interrupted silver sutures, and from this time the use of the quill suture, or a division of the sphincter ani, has been abandoned. Further experience demon- strated a necessity for the use of a short rectal tube for some ten or twelve days after the operation, that a free escape of flatus might be unobstructed. Where the laceration of the perineum has extended only to the sphincter, the rectal tube is not needed, and three interrupted sutures are generally sufficient ; if more ex- tensive, so as to involve the muscle, two in addition are required. The first suture passed should be the one nearest to the rectal mucous membrane, and should be made to follow the laceration entirely around, so as to bring together the sphincter. The second should also include the sphincter, and be passed in the recto- vagi- nal septum, just beyond the first one. The remaining sutures are introduced [as in the operation for a partial laceration of the peri- neum] through one labium about half an inch from the edge on one side, introduced from within outward into the other, and withdrawn at a point equally distant, so as to approximate per- fectly apposite surfaces. If the laceration has extended up the recto-vaginal septum for some distance beyond the sphincter ani, the edges should be brought together down to the sphincter by interrupted silver sutures, at a distance of about five sutures to the inch. On introducing the first suture to clear the perineum, care must be taken that it is passed between the first and second sutures uniting the septum, and the next one in turn between the 122 RUPTURE OF THE PERINEUM. second and third. Without this precaution an opening into the vagina will be produced just behind the sphincter, from the fact that, as one set of sutures is passed at a right angle to the other, on twisting those of the perineum tension would be exerted. This is a weak point, for if the tube is allowed to become obstructed, a small recto-vaginal opening will always result from the escape of flatus in this direction. I always scarify by means of scissors ; it can be done rapidly, and with less hemorrhage. The knees should be kept tied together for ten days after the operation, and the urine drawn with care, so that none is allowed to escape over the surfaces brought in apposition. " The sutures of the perineum are usually removed about the sixth day ; those within the vagina must remain for two weeks or longer, until the parts are strong enough to admit of the intro- duction of a speculum. The bowels are to be kept constipated for two weeks, at least, in all cases where the sphincter is lacerated. When the bowels are acted on by either a purgative or warm mucilaginous injection, the success of the operation will greatly depend on the dexterity of the nurse in properly supporting the parts." In his recent work upon Vesico-Vaginal Fistula, 1 Dr. Emmet declares that to avoid protrusion of the folded lips into the rectum he now employs a hollow, awl-shaped needle, with a handle. By this a larger amount of tissue can be taken into the grasp of the suture, and the operator is enabled to pass his wire thread simul- taneously through both lips, which secures more perfect adaptation. When the lower portion of the rectal wall is involved as well as the perineum, it must be closed before the latter. This may be done by an entirely separate operation, performed a fortnight be- fore the other, or the two openings may be closed at one time. The rectal opening should be closed by viviflcation of its edges, and approximation by silver sutures, placed a quarter of an inch apart. J Vesico-Vaginal Fistula. By Thomas Addis Emmet. Wm. Wood & Co., N. Y. CHAPTEE VI. VAGINISMUS. Definition. — This affection consists in a peculiar sensibility or hyperesthesia in the nerves of the vaginal mucous membrane at the site of the hymen, which upon irritation produces spasmodic contraction in the sphincter vaginae muscle. Frequency. — Yaginismus is of frequent occurrence, and will often be met with in practice. It has received little notice hereto- fore, not because it is rare, but because the attention of practi- tioners has not been specially directed to it. Dr. Sims declares that during twenty-four months he met with it seventeen times, and during the past two years I have seen six well marked cases. History} — The fact that such a condition occurs and becomes a morbid state of considerable importance was known to Dupuytren, Koiix, and Burns, 3 of Glasgow. They not only described it, but adopted an operative procedure which has since been revived, and is at present regarded as the most reliable method of cure. Their views did not apparently attract much attention, nor was their import really appreciated until, at a later period, they were insisted upon by Professors Simpson and Scanzoni. Between August, 1861, and October of the same year, it was described by Debout, Michon, and Huguier, and just afterwards by Marion Sims, who applied to it the appellation which I have adopted. By these authors incision, subcutaneous or through the mucous membrane, was recommended in imitation of earlier investigators, after less severe measures have failed in effecting a cure. Since the period last referred to, the affection has been allotted a space in the various systematic text-books which have appeared upon Gyne- cology. Anatomy and Pathology. — The mouth of the vagina is closed by 1 I am indebted to Dr. Parvin for some important corrections of statements made in first edition concerning this subject. 2 Bnl. Gen. de Therap. Med. et Cbir , 1861. 3 Simpson, Clin. Lect. Dis. of Women. 124 VAGINISMUS. a muscle of elliptical shape called the sphincter vaginas, which is analogous to the accelerator urinae in the male. 1 This muscle is attached by its upper extremity to the corpora cavernosa and body of the clitoris, some of its fibres passing over that organ so as to compress the vena dorsalis when it is in the state of erection. Passing downwards so as partially to cover the plexus retiformis, a portion of its descending fibres decussate to the surrounding tissues, and some of them go down to unite with those of the sphincter ani, with which it forms a figure 8. Certain morbid states produce so great a degree of irritability in the nerves supplying the vulva and lower part of the vagina, that upon contact with foreign bodies a spasm occurs in this mus- cle which constitutes the disease which now engages us. The attention of some has been chiefly fixed upon the nervous condi- tion, the pudic nerve being, according to them, the seat of the difficulty, while others have especially regarded the resulting muscular spasm. It is curious to perceive how, from different standpoints, both parties were led to the same surgical resource. Causes. — This affection bears to the vagina the same relation which blepharospasm does to the lids, or laryngismus to the larynx; and, like those affections, is not ordinarily a primary disorder, but one which results from some special local cause. It may arise from excessive nervous irritability affecting the whole system, as is often seen in hysterical women, or be produced by some local disorder of apparently insignificant character. Prof. Willard Parker 2 reports a case which was due to an irritable tubercle of the meatus not larger than a flaxseed, removal of which resulted in cure. In other words, it may be an idiopathic affection, or symptomatic only of some other disorder. The recognized causes of the disease are: — The hysterical diathesis ; Excoriations or fissures at the vulva ; Irritable tubercle of the meatus ; Chronic metritis or vaginitis ; Pustular or vesicular eruptions on the vulva ; Neuromata ; 3 Fissure of the anus. 4 1 Gray's Anatomy, p. 780. 2 Bui. N. Y. Acad. Med., vol. i. p. 439. 3 Simpson, Med. Times and Gaz., 1857, vol. i p. 336. 4 H. Dewees. TREATMENT. 125 Some of these produce it by direct irritation of the nerves of the vaginal mucous membrane; others, by creating a discharge which indirectly establishes the same condition. Symptoms and Physical Signs. — The patient will generally com- plain of excessive pain upon sexual intercourse, the mere attempt at which will throw her into a state of nervous trepidation and apprehension. This and sterility will probably be all that will have attracted her attention, though in some cases a marked tendenc}^ to spasm will have been noticed upon sudden changes of position, or washing the genital fissure. One or more of these symptoms will call for a physical exploration, when the following facts will be recognized. As soon as the finger is brought into contact with the site of the hymen, the patient will probably spring from her place, complain of agonizing pain, and evince great nervous disturbance. Should the examination be persisted in, introduction of the finger will be found almost impossible, and if it be forced into the canal, a violent contraction of the sphincter will be perceived. If, instead of the finger, a camel's hair brush or a feather be employed, severe pain and contraction will follow even this application to the surface. There is no other affection with which this can be confounded. All that it will be necessary to decide concerning it, will be whether it is an idiopathic or a symptomatic disorder. Course and Duration. — In its duration it is unlimited. Cases are recorded in which it lasted for twenty-five and thirty years, and unless relieved by art, it will probably, in its worst forms, become a permanent condition. In its less severe type, and more particularly when dependent upon some other diseased state, it may often be relieved by mild means, or pass away without treatment. Prognosis. — " From personal experience," remarks Dr. Sims, " I can confidently assert that I know of no disease capable of producing so much unhappiness to both parties to the marriage contract, and I am happy to state that I know of no serious trouble that can be so easily, so safely, and so certainly cured." Treatment. — Careful search should be made, before the adoption of treatment, for the cause of the affection. Should this be dis- covered, hope may be entertained that its removal will effect a cure. Should no cause be discovered, or its treatment not be followed by recovery, the general state of the patient should be 126 VAGINISMUS. altered and improved by exercise, change of air and scene, vege- table and mineral tonics, sea bathing and cheerful society. Ex- ercise on horseback has been especially advised, but rowing, bowling, walking, or any other which develops the system and improves the tone of the nervous organism, will probably answer as well. Local treatment calculated to soothe the excited vaginal nerves should then be resorted to. The free use of vaginal injections containing laudanum, creasote, or acetate of lead is sometimes productive of good. Dr. Peaslee speaks highly of an ointment composed of two grains of atropine to an ounce of lard. This alkaloid, or the extracts of opium, belladonna, hyoscyamus, or stramonium; may be incorporated in an ointment, and applied freely over the sensitive part. At the same time the glass tube, represented in Fig. 32, should be gently inserted into the vagina, Fig. 32. Sims's vaginal dilator. and kept there for as many hours a day as practicable. Its pre- sence will tend to benumb the nervous sensibility and produce a tolerance of foreign bodies. During this treatment the patient should live apart from her husband. Should success not attend these therapeutic measures, the pa- tient should be thoroughly anaesthetized and the ostium vaginae stretched to its utmost capacity in the hope that forced dilatation may accomplish for muscular spasm here what it so commonly does for such a condition in the sphincter ani. In a patient whom I saw with Dr. J. S. Thebaud, of this city, dilatation, effected by the thumbs, accomplished a permanent cure. Should these means fail, the operations of section of the sphinc- ter vaginae muscle, as recommended by Sims and others, or of the pudic nerve, as recommended by Burns and Simpson, offer them- selves as procedures promising cure. Situs's Operation. — The patient being put under the influence of ether, and placed on the back, upon a table, the remains of the TREATMENT. 127 hymen are entirely excised by & pair of curved scissors. The slight hemorrhage resulting from this will soon cease under the application of a compress wet with ice water, or of a solution of the persulphate of iron. The index and middle fingers of the left hand are then passed into the vagina, so as to put the fourchette on the stretch. By- means of a scalpel a deep incision is then made on the right of the mesial line, terminating at the raphe of the perineum. A similar incision is then made on the other side, the two being united at the raphe, and extended to the perineal integument and through its upper border. Each of these incisions will extend from about half an inch above the upper border of the sphincter to the perineal raphe, thus passing across the muscle, and mea- suring nearly two inches. They should pass over the sphincter muscles, but not entirely through it, Dr. Sims 1 especially declaring that this is unnecessary. After this, the vaginal dilator is placed in the canal, either im- mediately, or in about twenty-four hours, and worn for two hours in the morning, and three or four in the evening, according to the tolerance for it, which is manifested. Fig. 32 represents the glass vaginal dilator, which is three inches long, slightly conical, open at one end and closed at the other, and varying in size from an inch to an inch and a half in diameter. This instrument is kept in place by a T bandage, and should be worn for two or three weeks. Dr. Emmet has altered Dr. Sims's method of performing the section, which he makes complete, so far as concerns the fibres of the sphincter vaginae inosculating with the sphincter ani. Passing the index finger into the vagina, the patient lying in the lateral position, he elevates upon it the sphincter vaginae, which feels like a cord rolling upon it. Then, by means of a pair of scissors, he clips the muscle upon both sides of the peri- neal junction, and the operation is complete. Burns' Operation. — This operation is described by Simpson' 2 in the following manner: The pudic nerve "is often preter- naturally sensible, so as to cause great pain in coitu as well as at other times. It may be exposed by cutting through the skin • Trans. N. Y. Acad, of Med., pp. b'l and 62. 2 Dia. of Women. 128 VAGINISMUS. and fascia, at the side of the labium and perineum ; beginning on a line with the front of the vaginal orifice, and carrying the inci- sion back for two inches. The nerve being blended with cellular substance is not easily seen in such an operation ; but it may be divided by turning the blade of the knife and cutting through the vagina to its inner coat, but not injuring that. It may be more easily divided by cutting from the vagina. Slitting merely the orifice of the vagina will not do ; we must carry the incision fully half an inch up from the orifice, and also divide the mucous membrane freely in a lateral direction." Dr. Simpson has modified the operation of Burns by simply cut- ting the pudic nerve subcutaneous^ by a tenotomy knife. With regard to its efficiency I have no experience, but it is spoken of with confidence by those who have employed it. There is no reason why it should not accomplish what Sims's operation does, for in the latter the muscle is not cut, but the mucous membrane merely, so as to divide " the nerves of the part" as the author expresses it. The pudic nerve arises from the lower part of the sacral plexus, passes out of the pelvis through the great sacro- sciatic foramen, below the pyriformis muscle, and returns to it through the lesser. It then divides into the dorsal nerve of the clitoris and the perineal nerve. The act of parturition would be very likely to remove this con- dition entirely, but unfortunately one of the most constant of the results of vaginismus is sterility. This arises from the fact that sexual intercourse is so painful that it is imperfectly performed, or, as is more commonly the case, all efforts at overcoming the obstacle to it cease, and the woman lives absque marito. Should this state of things be found to exist, the patient may be thoroughly anesthetized, in the hope that complete connection, accomplished under these circumstances, may result in pregnancy. For a number of interesting cases of this character the reader is referred to Dr. Sims's work upon uterine surgery. CHAPTEE VII. VAGINITIS. Definition and Synonymes. — The mucous membrane lining the vagina is subject to inflammatory action, which receives the name of vaginitis. It is the same disease which by certain authors has been described under the titles of vaginal leucorrhoea, blennor- rhcea, and blennorrhagia. Normal Anatomy. — The vagina is a canal which extends from the vulva to the os uteri externum. Its general form has been aptly likened, by Dr. Savage, 1 to that which would be assumed by a flexible tube if shortened to nearly half its length by a cord passed from end to end through one of its sides. The ridge thus formed is called the anterior column of the vagina, and marks the vesico-vaginal septum. It is about two inches long, while that of the posterior wall, the posterior column, as it is called, is twice that length. The anterior column, or cord, which shortens the vagina, puckers its investing mucons membrane and throws it into folds or rugae, which run transversely towards the posterior column. This mucous membrane is studded with papillae, which are covered by pavement epithelium. The papillae of the vagina, which were first fully described by Dr. Franz Kilian, were regarded by him as sensitive in func- tion. He represents them as being threadlike and filiform, as shown in Fig. 33. Much discussion has occurred among anatomists as to the presence of muci- parous glands between the folds of the vaginal mucous brane, some asserting and others as positively denying Filiform papillae of the (Kilian.) me in - their On Female Pelvic Organs. 130 VAGINITIS. existence. The researches of Huschke, Jarjavay, Jamain, and other eminent investigators, enable us to accept their existence as an undoubted fact, though it is curious that Charles Eobin 1 and Sappey 2 have been unable to discover them. The vagina may then be said to be lined by a mucous membrane which is covered b}^ epithelium, and thrown into folds which are studded by projecting, filiform papillae, between which lie numerous muci- parous follicles. Varieties. — Vaginitis assumes three forms, which differ so widely in their pathology, etiology, and symptoms, as to require separate investigation. They are denominated as follows : — Simple vaginitis ; < Specific vaginitis ; K Granular vaginitis./ Simple Vaginitis. Definition. — This variety of vaginitis consists in inflammation of the mucous membrane of the vaginal canal from some cause disconnected with gonorrhoeal contagion. Varieties. — It may exist in the acute or chronic form, either of which types may appear originally or be the result one of the other. The acute form may be excited by some special cause and rapidly pass into the chronic ; or, originating as a low grade of inflammation, the disease may at any time take on the characters of virulence and acuity. Causes. — In the great majority of instances this affection, more particularly in its chronic form, depends upon a discharge from the uterus, to which it is secondary. It may, however, arise from any of the following exciting influences : — Exposure to cold and moisture ; Injury from pessaries or coition ; Disordered blood states, as in phthisis and the exanthemata ; Ketained and putrifying secretions ; Chemical agents ; Parturition. After matrimon}^ the acute form is not unfrequently excited, and in prostitutes, whose occupation involves an abuse of sexual intercourse, it is quite common. 1 Nysten's Dictionary. 2 Descriptive Anatomy. SIMPLE VAGINITIS, 131 A bit of sponge, or other substance which retains the natural secretions, left in the vagina until putrefaction occurs, will often induce the affection, and three of the most virulent cases that I have ever met were caused bj contact of a solution of chromic acid with the vaginal walls in making an application to the uterus. Symptoms. — Acute vaginitis manifests itself by the following symptoms : — A sense of heat and burning in the vagina ; Aching and weight at the perineum ; Frequent desire for micturition ; Profuse purulent leucorrhoea of offensive character; Violent pelvic pain and throbbing ; Excoriation of the parts around the vulva. In the chronic form the disease shows the same symptoms, though with much less severity. In very mild cases, only a slight itching or burning sensation is experienced, with discharge of leucorrhceal matter. Physical Signs. — When the inflammation is acute the labia are found swollen and tense, the mucous membrane of the vaginal canal red and covered with pus, and the animal heat very much increased. Introduction of the finger produces great pain, and often cannot be tolerated. For a period varying from fifteen to thirty hours after the inception of the disease, the natural secretion of the part is checked ; then there pours forth freely pus of acrid and offensive character, which, in a week or ten days, is replaced by muco-purulent material. This dis- charge is found to consist of liquor puris, large numbers of epithelial cells, pus, blood-globules, and an infusorial animalcule called the trichomonas vaginalis by M. Donne, who first described it. By some the last has been regarded as ciliated epithelium separated from the uterus, but it is probably an animalcule which exists in vaginal mucus of uuhealthy character. M. Donne at first regarded Epithelium in all stages of develop- ment, in simple vaginitis. 220 diame ters. (T. Smith.) 132 VAGINITIS. it as characteristic of specific vaginitis, but subsequently renounced the view. Prognosis. — In its acute form it usually runs its course in about two weeks. In the chronic form it lasts for an indefinite time, often subsiding into ordinary vaginal leucorrhoea, or rather into a state of which this is the only prominent symptom. Differentiation. — Simple vaginitis may be confounded with — Gonorrhoea ; Endometritis, Pelvic abscess ; Cervical ulceration. From the first* the differentiation is always difficult and fre- quently impossible. The means by which it may sometimes be accomplished will be mentioned in the article relating to Specific Vaginitis. From the three remaining affections it is readily dis- tinguishable by the speculum and vaginal touch. An error will be committed only when the practitioner is not alive to the possi- bility of its occurrence, and draws his conclusions from insufficient data. I have seen two cases of profuse and obstinate vaginal dis- charge regarded as the result of vaginitis, which were in reality produced by pelvic abscesses that emptied their contents into the upper part of the canal. An element in such cases calculated to mislead a superficial examiner is the fact that vaginitis does really exist to a limited extent as a result of the purulent flow from the abscess. This remark likewise holds true in reference to endometritis and ulceration. Complications. — Yaginitis sometimes produces violent urethri- tis, and less frequently results in endometritis, Fallopian salpin- gitis, and pelvic peritonitis. Specific Vaginitis, or Gonorrhoea. Definition and Synonymies. — This variety of the affection consists in inflammation of the vulva, vagina, and urethra, arising from a specific contagion which is transmitted by a yellow, purulent dis- charge. Pathology. — The purulent material which is the contagious element, after remaining for some time in contact with the vagi- nal walls, excites in their investing mucous membrane an active hyperemia which results in heat, swelling, pain, and an ichorous SPECIFIC VAGINITIS OR GONORRHOEA. 133 and abundant purulent secretion. This inflammation may be simulated by simple acute vaginitis, but its most characteristic features are usually excited by the contagious influence just alluded to. The disease may affect all the localities above men- tioned at the same time, but very often it is limited to the upper part of the vagina, to the vulva, or to the urethra. In some cases it is for a length of time concealed in the vaginal cul-de-sac, no other part of the vagina being affected. This fact explains, says Alphonse Guerin, 1 how women apparently healthy transmit gonorrhoea. Causes. — As there is but one cause for scarlet fever, for measles, and for variola, namely, absorption of a specific poison or conta- gious material, so is there but one cause for gonorrhoea. It is true that simple acute vaginitis may simulate gonorrhoea so closely that the most experienced observer will be foiled in diag- nosis, but this fact does not prove the diseases identical. The poison of gonorrhoea produces inflammatory results as a certain consequence ; the causes of acute vaginitis produce them as an accident which probably in a different state of the patient's sys- tem would not have occurred. 2 Symptoms. — The symptoms of this variety of vaginitis differ very little, indeed in many cases not at all, from those of the simple acute form. They may be thus enumerated : — Heat and burning in the vagina ; Aching and sense of weight at the perineum ; Frequent desire for micturition ; Scalding in the passage of urine ; Profuse purulent leucorrhoea of offensive character ; Violent pelvic pain and throbbing ; Excoriation of the parts around the vulva. Physical Signs. — The vulva, vagina, and urethra will be found swollen, tense, red, and hot. In the beginning they are unnatu- rally dry, but very soon a profuse secretion bathes them with a creamy pus, sometimes streaked with blood. Should the affection have exerted its influence chiefly upon the vulva, pruritus, exco- 1 Maladies des Organes Genitaux, p. 285. 2 This view is denied by many of the best authorities, who regard gonorrhoea as having nothing specific about its nature. At the same time that I have no wish to ignore the opinion with which mine conflicts, I have preferred to give my own impressions without discussing the matter. 184: VAGINITIS. nation, and an increase of sexual appetite will be observed. Should the urethra be chiefly or solely diseased, instances of which are recorded by Eicord and Cullerier, the most violent scalding upon the passage of urine will especially annoy the patient. Differentiation. — It will be seen, from what has been already stated, that the differentiation of this disease from simple acute vaginitis must be extremely difficult. In many cases it is impos- sible, for there are no signs which can be regarded as positively conclusive. The trichomonas vaginalis, once supposed by Donne to be pathognomonic of specific vaginitis, is now known to exist in the pus of that which is simple ; and urethritis, formerly viewed as diagnostic by many, is sometimes a complication of the simple form and is sometimes absent in the specific. The following are the symptoms which should lead us strongly to suspect the specific nature of a case : — Great virulence and acuity in development ; Development in a woman previously free from vaginal dis- charges ; Marked urethral complication ; Copious purulent discharge ; Transmission to the male from coition. Although it is true that in many cases these symptoms will render us certain in our conclusions, in many others they will exist in cases certainly of non-specific character. I have on two occasions seen them all attend cases of vaginitis, excited by acci- dental contact of chromic acid with the vaginal walls. Course, Duration, and Termination. — The duration of the disease will depend in great degree upon the character of the treatment adopted. Under proper management even a severe case may be cured in from two to three weeks, but if neglected, it may continue for months and perhaps years. The morbid action passing up into the uterus may exist as an endometritis long after the vagi- nal trouble has disappeared ; or it may pass into the bladder and excite cystitis; or down their narrow ducts into the vulvo- vaginal glands. Complications. — The complications of gonorrhoea in the female are numerous and important. The disorder sometimes becomes an exceedingly grave one, and, in some instances, destroys life. It may induce the following results : — GRANULAR VAGINITIS. 185 Bubo or vulvar abscess : Cystitis ; Inflammation of vulvo-vaginal glands ; Endometritis; Fallopian salpingitis ; Pelvic peritonitis. Mr. Salmon, 1 who first drew attention to inflammation of the vulvo-vaginal glands as a result of the disease which we are con- sidering, declares that it is quite common. The passage of the disordered action into the uterus, through the tubes, and into the peritoneum, is the most dangerous of all its consequences, and produces great risk to life, from the pelvic peritonitis which it excites. Granular Vaginitis. Definition and Synonymes. — This variety of vaginitis was first described by Eicord, under the name of Psorolytrie. In 1844, M. Deville, 2 a pupil of Eicord, described it fully, and it was sub- sequently treated of by Blatin, Gruerin, and others, under the names of papular, glandular, and granular vaginitis. Pathology. — By these writers it was regarded as an hypertro- phy of the muciparous follicles, lying imbedded between the rugas of the vagina. This hypertrophy it was thought was generally the result of pregnancy, though it was admitted that it might arise from simple or specific vaginitis. Many recent writers deny the existence of this variety of vaginitis, and view it only as an hypertrophy of vaginal papillae, the result of the forms of the affection already mentioned. Thus Dr. Bumstead, 3 in speaking of granulations found in the vagina as a result of vaginitis, says, "They have been erroneously regarded by Dr. Deville as peculiar to the vaginitis of pregnant women." Scanzoni 4 and West 5 both deny its existence, and upon the same ground, viz., the fact that Mandl and Kolliker have discovered very few mucous follicles in the vaginal mucous membrane. When, however, in opposition to the negative fact that these excellent observers, supported by Eobin and Sappey, have not discovered these glands, is arrayed 1 Bumstead on Venereal, p. 172. 2 Archiv. de Med., 4th series, t. v, 3 Op. cit. l Diseases of Females, Am. ed.. p. 529. 6 Diseases of Women, Eng. ed., p. 640. 136 VAGINITIS. the positive fact that Huschke, Jamain, Kichet, Becquerel, Guerin, and others have clone so, the grounds for denial must be admitted to be insufficient. Even if such evidence of the propriety of admitting this variety of vaginitis did not exist, clinical research would corroborate the truthfulness of the deductions of M. De- ville. The disease is characterized by hemispherical granula- tions, about as large as half a millet-seed, scattered thickly over the mucous membrane of the vagina and over the cervix uteri. Causes. — The glandular hypertrophy which gives to the disease its characteristic features and name, generally results directly from pregnancy, though it may be produced by either simple or specific vaginitis. Some women in successive pregnancies suffer from it. Symptoms. — It demonstrates its presence by the symptoms already recorded as characteristic of simple and specific vaginitis. With these, pruritus vulvas and a lichenous eruption about the pubes are apt to appear. As parturition comes on and puts an end to pregnancy it usually disappears, very often without any treatment whatever. Treatment of Vaginitis. — The treatment of the various forms of •this disease is so similar that it may be described under one head, modifications being suggested for those cases which have assumed a subacute or chronic aspect. If the case be one of acute charac- ter, the patient should be kept perfectly quiet in bed, and loco- motion and sexual intercourse strictly interdicted. Pain should be relieved by opiate or other anodyne suppositories placed in the rectum, and febrile action prevented or combated by mild, unstimulating diet and refrigerants. Every fifth or sixth hour the patient, placing under the buttocks a bed-pan upon which she lies, and between the thighs a bucket of warm water containing boiled starch, infusion of linseed, or infusion of poppies to render it soothing, should, by means of a syringe with continuous jet, or an irrigator, throw a steady stream against the cervix uteri for fifteen or twenty minutes, or even for a longer time. The methods most appropriate for syringing the vagina are fully described in chapter fifteen, and to it the reader is referred for details. After the severity of the attack has been subdued by these means, the acetate of lead or sulphate of zinc, with tr. of opium, may be added to the water in small amount, not more than a drachm of the mineral preparations being dissolved in a gallon TREATMENT. 137 of fluid. As soon as the signs of acute inflammation have dis- appeared, the sulphate of alum, persulphate of iron, tannin, or infusion of oak bark may be employed to render the fluid injected more decidedly astringent. At the same time laxatives should be administered, and ardor urinse relieved by the use of soda, potash, or other alkaline diuretics. Should inflammatory action run very high and much pain be experienced, benefit may be obtained by the application of leeches to the perineum, but this will rarely be found necessary. When the acute form shows a tendency to become subacute or chronic, the speculum of Sims should be cautiously introduced, the whole vaginal canal painted over with a solution of nitrate of silver, one drachm of the salt to one ounce of water, and a roll of cotton, saturated with glycerine, placed against the cervix. The cotton saturated with this or some anodyne substance may be renewed daily with advantage, but the painting with the caustic solution should not be frequently repeated. After free vaginal injection, suppositories composed of butter of cacao or gelatine and gum tragacanth, with persulphate of iron, alum, copper, zinc, or opium, may, by means of the suppository tube represented by Fig. 35, be placed at intervals in the upper part of Fig. 35. Hard rubber tube with piston, for placing medicated cotton or suppositories in the vagina. the vagina. The general state of the patient should be carefully watched, and if tonic or chalybeate treatment be indicated, it should at once be resorted to. CHAPTEE VIII. ATRESIA VAGINA. Definition and Synonymes. — The term atresia, derived from a, privative and *p tt w, "I perforate," signifies an imperforate condi- tion, and should in its strict import be limited to complete closure of an aperture or canal, but custom sanctions its application to any obliteration or occlusion which is so extensive as to remove the case from the class of strictures. The genital canal of the female may be imperforate at the vulva, in the vagina, or in the canal of the uterus itself. In the present essay it is proposed to treat only of those forms which affect the vagina and receive the appellation which serves as the caption of this chapter. History. — Hippocrates 1 refers to this condition as a result of labor ; Aristotle speaks of the accidental and congenital varieties ; Celsus devotes a chapter to it, and it claims attention, as we come down to subsequent times from Aetius, Avicenna, Lanfranc, Wierus, Euysch, Mauriceau, and Eoonhuysen. Heister and Boyer advauced our knowledge of it, and still more lately Amussat, in 1835, operated for its cure with greater boldness than his predecessors had ventured to do. Pathology. — As a result of injury from mechanical or chemical agencies, a vagina once fully developed may close from adhesion of its walls, its calibre may be diminished by absolute removal of its component structures in consequence of ulceration or sloughing, or the other parts of the female genital system may go on to full development while this is arrested in its growth and remains a fibrous cord rather than a distensible canal. Varieties. — It may be either congenital or accidental ; and it may likewise be partial or complete. In a case of stillicidium mensium, 2 presenting itself during the last winter at the clinique 1 Puesch De l'Atresie des Voies Grenitales de la Femme. Paris, 1864. 2 This term is employed by Aetius, Tetrab iv. p. 990. ATRESIA VAGINJE. 139 of the College of Physicians and Surgeons, I found the vagina apparently completely closed at its middle, yet permitting a slight flow of menstrual blood. Upon careful examination a small opening, admitting only a probe, was discovered, leading into a sac between the vaginal constriction and the neck of the uterus, which contained several ounces of thick, tenacious blood. If the atresia be congenital, the whole canal will probably be found obliterated ; but this is rare. Generally the inferior, mid- dle, or upper part is the seat of stricture. Causes. — The following causes may be enumerated as produc- tive of it : — Arrest of development ; Prolonged and difficult labor ; Chemical agents locally applied ; Mechanical agencies ; Sloughing, the result of impaired vitality ; Syphilitic or other extensive ulcerations. One case which has come under my observation resulted from syphilis, another from prolonged labor, and another from the acci- dental passage of a sharp bit of wood up the vagina. Among the causes of sloughing from impaired vital force should be especially mentioned the continued and eruptive fevers, typhus fever, scar- latina, variola, &c. ; and cholera as a cause of the accident is re- ferred to by M. Courty. 1 Dr. Trask, of Astoria, N. Y., has written an excellent article upon this subject, his conclusions being based upon thirty-six cases, of which fifteen were due to prolonged labor. Symptoms. — The disorder will demonstrate its existence only by incapacitating the vaginal canal for its important functions, copu- lation and transmission of menstrual blood. Should it occur in one too young or too old to require such functions from the vagina, no suspicion will be aroused as to its existence. The notice of the practitioner will generally be called to the patient by amenorrhcea or by an inability to perform the act of coition. Should the men- strual hemorrhage have taken place, a large amount of blood will generally be found confined above the constricted part of the canal, and violent uterine contractions will have demonstrated the efforts which the uterus has made to expel the accumulation. Besides these, no other rational signs will show themselves, but thev will 7 O •/ 1 Mai. de l'Uterus, p. 369. 140 ATKESIA VAGINJE. be sufficient to urge upon the attendant the necessity of a physical exploration. Physical Signs. — The patient being placed upon the back, and the vaginal touch attempted, entrance of the finger into and up the canal will be found to be impossible. A little investigation will prove that this is not due to vaginismus, imperforate hymen, or adhesion of the labia majora, and the rectal touch will usually show the vagina running up the pelvic cavity as a fibrous cord. Results. — From the mere obliteration of the vagina there is no immediate or direct derangement. But in certain cases where menstrual blood is poured out by the vessels of the uterine mucous membrane, and is accumulated at each monthly epoch in the portion of the canal above the stricture, or in the uterus, which has been dilated to receive it, rupture of this organ or of the Fal- lopian tubes may occur, reflux through these tubes into the peri- toneum may take place and pelvic hematocele be the conse- quence ; or the retention of the menstrual flow may produce all those nervous and cerebral symptoms so characteristic of such an occurrence. Prognosis. — The prognosis of these cases as regards the possi- bility of removal of the abnormal state, will depend upon the extent and completeness of the obliteration, and destruction of tissue. The smaller the amount of vaginal tissue found by rectal touch and examination by a sound in the bladder, to exist, and the more complete and extensive the adhesion of the vaginal walls, the more closely will the case resemble one of entire absence of the vagina. Differentiation. — Before any surgical interference is established for the relief of atresia, it should be differentiated from absence of the vagina. The latter very rarely, if ever, Scanzoni 1 says never, exists without simultaneous absence of the uterus and rudimentary development of some of the external organs of generation. If an obliterated vagina be present, it may be generally recognized as a hard, fibrous cord, by one finger in the rectum and a sound in the bladder. Sometimes a short cul-de-sac will be found at the vulvar extremity, and aD other at the uterine, which are united by a cord of fibrous character. Should deformity of the external genitals exist, the uterus not 1 Diseases of Females, Amer. ed., p. 478. TREATMENT. 141 be discoverable, and no signs of distress at menstrual epochs show themselves, it may be concluded that the case is one of absence of the vagina, and not of complete atresia. But, thanks to the boldness of Amussat, even absence of the vagina does not pre- clude the possibility of establishing an artificial route. The importance of the differentiation consists in the fact that the surgeon should in such a case be doubly cautious and circum- spect in his efforts, and guarded in his prognosis. Treatment. — The sudden evacuation of menstrual blood, which has been for a long time imprisoned in the uterus and vagina, is always a procedure attended by danger. Even where the ob- struction has been only an obturator hymen, such an operation has been followed by endometritis, peritonitis, and death. The danger is probably dependent upon the fact that the imprisoned fluid distends the uterus and Fallopian tubes, and renders them so sensitive that the admission of air produces a septic endometritis, which in its course and termination resembles closely the most common form of puerperal fever. Such accumulations should not be evacuated, therefore, without great caution, and it is always well for the operator to announce to the patient, or her friends, the fact that dangerous consequences may result. Menstrual blood thus retained may be removed through the vagina, bladder, or rectum, by three operations: — 1st. Puncture by a large trocar and canula; 2d. Puncture by a small trocar and use of tents ; 3d. Incision by knife or scissors. Should the occluding space be limited in extent, a full supply of tissue exist on both rectal and vesical aspects, and a volume of menstrual blood be imprisoned above, a trocar and canula may be plunged through the obturator tissue or the wall of the rec- tum and the fluid evacuated. In case it be thought best to effect the discharge more gradually, and if doubt be entertained as to the safety of passing a large instrument, which may require for its passage more tissue than the case presents, a small trocar or exploring needle may be employed, and the canal created by it dilated by systematic use of tents of sponge or sea tangle. In a case which I recently saw with Profs. I. E. Taylor, Hamilton, and Peaslee, this plan succeeded most perfectly in the hands of the first-named gentleman. Should incision bo deemed necessary, the patient, thoroughly anaesthetized, and having had the bladder 112 ATEESIA VAGINiE. and rectum emptied, should be placed upon the back upon a table, in the position adopted in operating for stone. By means of a scalpel or pair of curved scissors, conducted up to the point of obliteration upon one or two fingers, the tissue should then be very cautiously cut, and the finger introduced into the opening made in the mucous membrane. By this a little force should be employed in order to separate, if possible, the adhering surfaces, or tear up a new tract. Then, one finger being kept in the rec- tum, and a sound in the bladder, cautious and gradual dissection of the canal should be practised, great care being observed to avoid opening into the rectum posteriorly, the bladder anteriorly, and the peritoneum above. Dr. Emmet, whose experience in this class of cases has been extensive, declares that if the new tract be created by incisions by scissors and tearing of tissue by the fingers, subsequent contraction and atresia are much less likely to occur. According to his experience incisions made by the knife granulate and undergo cicatricial contraction with much greater rapidity. In 1832 Amussat advocated forcible pressure continued until the parts were softened and gave way, and when fluctua- tion was discovered, the use of a trocar or knife for evacuation of the fluid. Dr. Grraily Hewitt asserts that he rejected the use of the knife, and effected laceration of the tissues by tearing by the finger. Dupuytren followed a mixed method, performing the operation partly by cutting and partly by tearing the textures. Bernutz, 1 who believes that the admission of air into a uterus previously closed to its entrance, causes contraction, which forces imprisoned blood into the peritoneum, advises, for the avoidance of this accident the following plan. He proposes to operate in from eight to ten days after menstruation, when the calm which succeeds it is well established, and at the same time at a period distant from the next epoch. In place of a large incision, he pro- poses puncture by a very small trocar guarded by gold-beaters' skin. In this way gradual discharge is accomplished, and air excluded. He does not leave the trocar in place, but prefers sub- sequent puncture, if necessary. The fatal termination of four cases which he reports has led to the adoption of these precau- tions. After evacuation of all the retained blood, and diminution of the size of the distended uterus, he recommends the practice "to 1 Clin. Med. sur les Mai. des Femmes, vol. i. p. 303. TREATMENT. 143 make sure of the permanent freedom of the excreting channel "by as extensive incision of the obturator membrane as is practicable, and the employment of dilatation." However the operation be performed, there is always great dan- ger of relapse, and unless special means be adopted for maintain- ing the perviousness of the canal, it will invariably occur. To prevent such a result, a plug of glass, such as represented by Fig. 32, should be introduced into the vagina, secured by a T bandage, and worn for weeks. After this it should be kept in place at night for many months. Where the entire canal has been obliterated even these efforts may. fail and closure occur above, which grad- ually advances to the ostium vaginae. If no menstrual blood has been imprisoned above the stric- tured portion of the vagina, the canal should be kept scrupulously clean by injections of tepid water practised twice a day. If the uterus and tubes have been distended by retained fluid, the cavity of the former should, just after the operation, be carefully washed out with tepid water very slightly impregnated with carbolic acid or Labarraque's solution of soda. The patient should then be kept as quiet as possible in the recumbent posture, and under the full influence of opium. The period at which operation should be resorted to is a sub- ject of importance. Velpeau advocates operating in infancy, but Puesch, Boyer, and others regard the age of puberty and approach of menstruation as a more appropriate time. Should the meno- pause have arrived, no operation will be called for. It should not be forgotten that delay in interference is often very disastrous during the period of menstrual activity, for lives have, in numerous instances, been destroyed by rupture of the Fallopian tubes, and even of the uterus itself, as seen by Puesch. This observer drew his conclusions from 258 cases of atresia, in 18 of which rupture of the Fallopian tubes from distension by menstrual blood occurred. In one instance of atresia I saw an hematocele the size of an infant's head, result from regurgitation of blood through the tubes into the peritoneal cavity. It is highly probable that the mental emotion of the patient, and her struggles during the operation, may account for the entrance of blood into the peritoneum as noted by Bernutz. Hence, every effort should be made to avoid these, and care should be taken not to allow of pressure upon the uterus in examination, or in restraining the patient. CHAPTEE IX. PROLAPSUS VAGINA AXD VAGINAL HERNIA. Prolapsus Vaginae. Definition and Synonymes. — The mechanism by which the pelvic organs of the female are kept in their proper positions and rela- tions to each other offers, in its simplicity and perfectness, an excellent example of that adaptation of means to an end which is so often repeated in the animal economy. The uterus is so sus- tained that when necessity requires it, not only in pregnancy but under a number of other circumstances, it may rise or fall, or tilt backwards or forwards, while the rectum, bladder, and lowest layer of small intestines are kept in place and allowed to distend and empty themselves without material change of relation. The three organs which are mainly instrumental in this result are the vagina, the peritoneum, and the pelvic areolar tissue. The first of these performs an important part. By it the uterus and super-imposed layer of small intestines are to a great extent supported, the bladder is prevented from falling backwards when in a state of repletion, and the anterior wall of the rectum from undergoing displacement forwards. When the tone of the walls of the vagina is impaired and they pouch into its own canal so as to fall downwards towards the vulva, the condition is called prolapsus. As, however, loss of the support which the vagina previously gave usually results in descent of the uterus, small intestines, bladder, or anterior wall of the rectum, it is often included under the names of prolapsus uteri, cj^stocele, enterocele, or rectocele. As considerable diversity of opinion exists concerning the nature of prolapsus vaginas, it is necessary for us, before proceeding, to comprehend its definition with perfect clearness. By some it is maintained that hernia of neighboring viscera into the vagina should not be included under the head of prolapsus, which, as Colombat declares, is an " inver- sion of the internal lining membrane, caused by infiltration of PROLAPSUS VAGL^Jl. 145 the cellular texture that unites the mucous to the subjacent membranes." By others it is believed that true prolapse is im- possible without simultaneous displacement of one or more of the surrounding pelvic organs. All admit, of course, that in such an exuberant development or hypertrophy as that which occurs during pregnancy, a portion of the canal may be forced out of the vulva, but this is not what is ordinarily meant by the term prolapsus vaginas. Dr. Savage 1 expresses himself thus upon the point: "Prolapse of the vagina alone, or prolapse of the vaginal mucous membrane alone, are two affections which, anatomically considered, would seem impossible." The text-books, however, mention both. Noel mentions a case of this kind where the pro- lapse reached down to the knees! It is an important question whether there can be prolapse of the vagina without vagino- rectocele, vagino-cystocele, vaginal hernia of intestine forcing down the vaginal cul-de-sac, or uterine prolapse. When the vagina has lost its elasticity by excessive and frequent distension, the vaginal canal is often occupied by a collocation of its own folds, which may form a considerable projection at the vulva ; but this does not constitute true prolapse of the vagina. Upon the whole, it would be unsafe to look upon any vaginal prolapse as unconnected with one or other of the above-men- tioned affections, and it would be most unjustifiable to treat it as a prolapse of mere mucous membrane. The anterior or upper wall of the vagina is closely bound to the base of the bladder and front of the cervix uteri, and by means of the utero-sacral ligaments it is indirectly attached to the sacrum. This wall aids powerfully in support of the uterus, bladder, and small intestines. The posterior wall is not so firmly bound to the rectum, though the adhesion at the extremity of the utero-rectal pouch of peritoneum is quite strong. At the vulva the vagina is fixed by the deep perineal fascia and closed by the sphincter vaginae muscle. These anatomical arrangements account for the fact that prolapse of the vagina without simulta- neous displacement of one or more of its surrounding viscera is exceedingly rare, and that when it does occur as a distinct disease it is very generally found to affect only the posterior wall. Pathology. — Any influence which impairs the natural tonicity 1 Female Pelvic Organs. 10 146 PROLAPSUS VAGIKJ. and strength of the vaginal canal, renders it abnormally volumi- nous and lax, or destroys its lower buttress or support, will tend to induce the affection. As pregnancy and parturition combine most, and sometimes all, of these, they are generally found to be predisposing, and very frequently exciting circumstances. The development of the vagina, and increased weight of the uterus dependent upon the former, and the distension of the canal and stretching of the sphincter incident to the latter, all unite in bringing about prolapsus. The affection is very rare, except in those who have borne children, although it may occur. Sir Astley Cooper met with it in a girl, aged seventeen, who was admitted into Gruy's Hospital, for supposed prolapsus uteri, and Prof. Meigs 1 mentions that Dr. Mutter, of Philadelphia, saw it occur in a child six months old in consequence of a convulsion. Causes. — From what has just been said the following causes will naturally suggest themselves as those most likely to produce this displacement : — Violent efforts of the abdominal muscles ; Eepeated parturition ; Excessive weight at the uterine extremity of the vagina; Senile atrophy of vaginal walls ; Eupture of perineum ; Distension by pessaries, or tumors ; Long-continued vaginitis. It is evident that these causes act either by debilitating the power of the vaginal walls by mere mechanical distension, by specifically robbing them of their tonicity, or by removing the buttress against which the canal rests at the vulva. Varieties. — The displacement may be of two forms, sudden and gradual. The power of the canal may be overcome by a violent effort, a fit of coughing, uterine or abdominal contractions, or simi- lar acts, which, with great suddenness, force the contents of the abdomen down upon the pelvic viscera. This occurrence, which is very rare, is generally accompanied by sudden descent of the uterus, or follows parturition. The ordinary form of the affection is that in which by the slow and steady action of one or more of the causes enumerated, the resistance of the vagina is gradually overcome, and little by little a fold is forced downwards towards 1 Translation of Colombat. SYMPTOMS. 147 and through the vulva. The first variety is the result of a few minutes' effort ; the second, that of months, or even years of mor- bid action. Prolapse of one wall, partial prolapsus, as it has been styled, is often lost sight of in view of the hernia of the bladder, rectum, or small intestines, which accompanies it. Hence cys- tocele, rectocele, and enterocele may be regarded also as varie- ties, although, strictly speaking, they are complications .of the affection. Course, Duration, and Termination. — A sudden attack of pro- lapsus being overcome by proper means, and the patient kept quiet, may disappear, and not return ; but in that variety which occurs gradually there is no limit to the disease. Generally, the physician is not called until it has existed for a long time and become complete. Fortunately, it has no serious results, except the occurrence of the herniae just alluded to, and these prove only annoying, not dangerous to life. Prognosis. — The prognosis as to cure will depend upon the degree and duration of the malady. It is always, whatever be its extent, relievable by surgical means, but often proves incurable by those of medical character. Symptoms. — Should displacement of the vagina exist alone, that is without creating hernia of surrounding organs, the patient will complain of a sense of discomfort in the vagina, with a tendency to bearing down, as if to expel some foreign body ; a feeling of heat, fulness, and throbbing at the vulva ; a certain amount of pelvic uneasiness in walking, or making any muscular effort, and a general tendency to prostration, if the condition be one of aggra- vated character. Physical exploration will reveal the presence of a tumor between the labia, which touch will demonstrate to contain no liquid, and yet not to be solid in its nature. Some- times the mucous membrane covering it is excoriated, ulcerated, and purple in color ; at others it will be smooth, shining, tough, and covered by pavement epithelium. A simple vaginal prolapse of any extent is, as has been stated, quire rare. When it does occur it generally affects the posterior wall, but prolapse, accom- panied by hernia, is more commonly found to affect the anterior wall, cystocele existing. Should the case be complicated by vesi- cal or rectal prolapse, the symptoms just enumerated will present themselves, with the addition of others dependent upon disturb- ance of the functions of the part which forms the hernia. In one 148 PEOLAPSUS VAGINAE. case the concomitant symptoms will point towards the bladder ; in another, the rectum, and, in very rare instances, the small intestines. As the treatment of prolapsus vaginae is, with slight modifica- tions, the same for uncomplicated and complicated cases, it will be considered after the subject of vaginal hernias has been discussed. Vaginal Hernise. Cystocele. Cystocele, or yesico-vaginal hernia, consists of descent of the bladder towards the vulva, so as to impinge upon the vaginal canal. When the anterior wall of the vagina, which is closely adherent to the bladder, the base of which it sustains, ceases to afford the required resistance, the bladder descends and forms a small pouch in the vagina. This is at first very small, but gradu- ally it increases, until at last it forms a decided tumor, which hangs between the labia majora. The pouch thus created becomes filled with urine, which, in the ordinary act of micturition, cannot be evacuated, from its being contained in a species of diverticulum. This undergoes decomposition, free ammonia is formed, and cys- titis or vesical catarrh is established, which annoys the patient by pain, heat, vesical tenesmus, and scalding in urination. Should any doubt exist as to the character of the tumor felt in the vagina, a curved sound or catheter may be passed into it for the settle- ment of the question. It is an interesting question whether cystocele is ever the cause instead of the result of prolapse of the vagina. It is probable that it may be so in Yery rare cases, though such a connection between the two affections must be uncommon, since the former seldom occurs except in women who have borne children, and thus been exposed to influences which tend to diminish vaginal resistance. Scanzoni 1 is convinced that the vesical prolapse is sometimes primary, and due to irregular spasmodic contraction of the fibres of the body of the bladder while the neck remains firm. This forces the urine to the fundus, which dilates and undergoes displacement. 1 Op. cit., p. 497. RECTOCELE — ENTEROCELE. 149 Rectocele. Rectocele, or recto-vaginal hernia, occurs in a manner similar to that by which the bladder descends. The posterior wall of the vagina ceasing to give proper support to the anterior wall of the rectum, this forms a pouch which soon fills with fecal matters. The feces becoming hard, and, in consequence, irritating, create mucous inflammation and discharge, with tenesmus, obstinate constipation, and hemorrhoids. The tumor thus formed will sometimes equal in size a man's fist, and protruding over the peri- neum give some difficulty in diagnosis from its size and solidity. This difficulty will at once disappear upon rectal exploration and the use of an enema of ox gall and warm water. In one instance I saw a patient confined to bed for three or four months from one of these saccular accumulations of feces under the sup- position that cellulitis existed, which by effused lymph had com- pletely blocked up the pelvis. It may be supposed that such an error will rarely occur, yet the case which I have just mentioned occurred to a practitioner of great experience and ability. Enterocele. Enterocele, or entero-vaginal hernia, consists in descent of a portion of the small intestines into the pelvis, so as to encroach upon the vaginal canal. Such a descent usually occurs in this manner: a loop of intestine resting in Douglas's cul-de-sac stretches this serous prolongation, and, advancing between the rectum and vagina, pushes the posterior wall of the latter before it so as to form a tumor at the vulva. In a similar manner it is stated that the intestine may advance between the bladder and uterus and de- press the anterior vaginal wall, but this must be rare, as authors of extensive experience assert that they have never met with it. Enterocele is not an accident likely to produce evil results unless it occur during labor, when strangulation may take place. Even at this time such a complication is very rare, for the free passage afforded the displaced intestine back to the abdomen will almost always preclude this difficulty. Dr. Meigs' relates a case occurring during labor, in which the progress of the parturient 1 Notes to Colonibat, p. 211. 150 PROLAPSUS VAGINA. process was checked by a large mass of intestines until lie suc- ceeded in reducing the hernia. He says, with reason, that in such a case strangulation or contusion was to have been feared. One very momentous aspect in which these herniae must be viewed is in relation to puncture of vaginal tumors, occurring during labor, for ascertaining their contents. No such explora- tive means should be resorted to without careful differentiation of vaginal hernise of all descriptions, and especially of that of which we have last spoken. The peculiar sensation to the touch, of a tumor filled with air, a resonant sound upon percussion, the de- tection of peristaltic movements, and careful exclusion of all other forms of tumor which might appear under the circumstances, will serve to avoid error. When, however, it is borne in mind that vaginal tumors are very near the inflated intestines and that they often yield to the touch an airy sensation, it will be appreciated that great caution is necessary in arriving at a diagnosis. In a case which I have recently attended with Dr. Abram Dubois, of this city, a cyst the size of a walnut existed just below the neck of the uterus, and had many of the features of a knot of intestine. I was persuaded that it was a vaginal cyst, punctured and evacu- ated a mass of gelatinous matter which resulted in cure of the growth. Treatment of Prolapsus Vaginw and its Complications. — Should the accident have occurred suddenly, reduction should at once be accomplished, and the recurrence of the displacement prevented by appropriate means. The bladder and rectum being evacuated, the patient should be placed in the knee-elbow position, and, the fingers being well oiled, steady pressure should be exerted in coin- cidence with the axis of the inferior strait, until the prolapsed part is returned to its place. In the case of enterocele already referred to as treated by Prof. Meigs, the patient was placed upon the left side, and taxis being practised, the mass suddenly slipped above the superior strait, into which the next uterine contraction forced the child's head. To prevent a relapse the pelvis should be elevated, the patient kept perfectly quiet, tenesmus, if present, relieved by the use of opium, and the vagina constricted by astrin- gent injections. But sudden cases of vaginal prolapse and hernia are very rarely met with. It is usually those which have slowly and gradually established themselves that we are called upon to treat, and these TREATMENT. 151 are always obstinate and rebellious. The means at our command for overcoming such cases are the following : — ■ 1st. Local astringents and tonics; 2d. Supplementary support ; 3d. Surgical procedures. The first of these may be effectual in slight cases, but in those of graver character they will very generally prove insufficient. The tone and strength of the vagina may be temporarily restored by the use of injections of large amounts of cold water medicated w r ith tannin, alum, iron, or zinc, employed night and morning. The patient should be sent during the summer to a watering place, where sea-bathing and injections of sea- water into the vagina may be employed. A very excellent result will also sometimes follow the use of vaginal suppositories containing one of the astringents mentioned. Supplementary Support may be effected by an abdominal sup- porter, with perineal band, and by the use of a properly con- structed pessary, such, for example, as the double lever of Hodge, the ring of Meigs, or the stem of Cutter. Fig. 36. Abdominal supporters. (Brown.) In some instances the air pessary of Gariel will be found to be very useful, more especially where the bladder or rectum partici- pates in the prolapse. But this must necessarily be only palliative in its results, since while it relieves the immediate consequences of want of power in the canal, it increases the existing weakness by continued distension. 152 PROLAPSUS VAGINJS. Surgical Procedures. — Of these there are three which may prove effectual. If a ruptured periueum seem to produce the want of support, the operation of perineorrhaphy may be all that will be necessary. This is described on page 118. In a certain number of cases where the vaginal displacement has not resulted in pro- lapse of the uterus, and where from the advanced age of the patient patency of the vagina is no longer necessary, union of the labia majora for the lower three quarters of their extent may fulfil the indication. This operation, inaugurated by Yidal de Cassis and subsequently essayed by many others throughout Europe, con- sists in paring the edges of the labia majora, removing the labia minora, and uniting the vivified surfaces by silver sutures. I cannot lay the steps more clearly before the reader than by giving the account of a successful case by Dr. Schuppert, of N. 0. His operation was performed for complete closure of the vulva, and extended higher up than would be necessary in the case we are supposing. "The woman was placed on her knees, whilst her abdomen, chest, and head were supported by pillows. In paring the inner part of the labia majora, removing the nymphse to a level with the denuded surface of the labia majora, and vivifying a circular part of the entrance of the vagina to an extent of two centimetres, I had obtained a surface which, when agglutinated, would measure from four to five centimetres in depth. Entering now the long flexible needle from outside the lower vivified border of the right labium majus, in a horizontal line with the meatus urinarius, I thrust it in and back through the tissues, till its point came out in the centre of the posterior wall of the urethra, just above the meatus uriuarius. A silver wire was then introduced into the eyehole of the needle and the latter withdrawn, leaving the other end of the wire in the vagina. The needle, freed from the thread, was then inserted again in the left labium majus in a correspond- ing place with that of the right labium, thrust through the tissues, and brought out at the same point where the wire was hanging out of the urethral wall. This end of the wire was now carried through the eyehole of the needle. In withdrawing the latter, I had formed a loop which, when tightened, would include a depth of at least four centimetres. Three sutures were in this manner applied, each of them going through the posterior wall of the urethra. The other four sutures were placed at proper distances, TREATMENT. 153 reaching on each side above the denuded surface of the vagina. All the sutures were then secured outside the labia majora, over broad leaden clamps, by perforated shot." But if prolapsus uteri have occurred, or even a marked degree of vesical or rectal displacement, the operation of elytrorrhaphy, or diminishing the calibre of the vagina, is the only procedure upon which reliance can be placed. This operation will be fully described in connection with prolapsus uteri. CHAPTER X. FISTULA OF THE FEMALE GENITAL OKGANS. Definition. — As a result of certain traumatic and morbid pro- cesses, the continuity of the vaginal and uterine walls may be destroyed and communication established with adjacent viscera. To the tracts or passages thus opened, the name of fistulse has been given. Varieties. — These communications connect the vagina with some viscus in immediate proximity, for the natural outlet of which they act vicariously, or with some neighboring part, as the peri- toneum, the vulva, or the pelvic areolar tissue. Their varieties have received the following descriptive appellations : — ■ Urinary Fistulse. Yesico-vaginal fistula ; N Urethro-vaginal fistula ; ^ Vesico-utero- vaginal fistula | Yesico-uterine fistula.^ Fecal Fistulse. Recto- vaginal fistula ; Entero-vaginal fistula ; Recto-labial fistula. Simple Vaginal Fistulse. Peritoneo-vaginal fistula ; Perineo-vaginal fistula ; Blind vaginal fistula. Urinary Fistulse. Urinary fistulse may occur on any part of the anterior surface of the genital canal intervening between the vulva and fundus uteri. Fig. 37 displays the points at which they are usually ob- served. URINARY FISTULA, Fig. 37. 155 Varieties of vesical fistulge : 1. Urethrovaginal fistula ; 2. Vesico-vaginal fistula; 3. Vesico-utero-vaginal fistula ; 4. Vesico-uterine fistula. Vesico- Vaginal Fistula (2) is a communication between the bladder and vagina, either at the trigone or the bas-fond, which may involve only enough tissue to admit a small probe, or en- tirely destroy the vesico-vaginal wall. Such an opening may be oval, angular, elliptical or linear in shape, and its borders may be thick or thin, soft or indurated, rough or smooth, pale or vascular. Ureihro- Vaginal Fistula (1) resembles that just mentioned, ex- cept in the fact that the destruction of tissue which has produced it involves the wall of the urethra, and not that of the bladder. Vesico- Uterine Fistulee (4) are those in which there is a direct communication between the bladder and uterus above the point of vaginal attachment. The vagina is consequently not involved, and the urine passing into the uterus escapes at the os. Vesico- Utero- Vaginal Fistulse (3) are those in the production of which a lesion occurs in both uterus and vagina, as is Lmper- 156 FISTULA OF THE FEMALE GENITAL ORGANS. fectly shown by (3). At the vaginal junction there is a perfora- tion of the bladder, but this does not penetrate to the cavity of the uterus. A canal is created in its wall, and through this the urine escapes into the vagina. The last two forms of fistulse were first accurately described by Jobert, who made of the last, two varieties, superficial and deep. In the first a canal is channelled out on the vesical surface of the cervix uteri ; in the second, the cervix is to a greater or less extent destroyed by the process of sloughing, and through it the urine passes. In the first form the lesion is chiefly vesical and uterine, the vagina not being much injured ; in the other it affects three organs, the bladder, the uterus, and the vagina. All these forms of fistulas have thus been grouped into classes by Dr. Bozeman : — 1st Class. Those consisting in a communication between the urethra and vagina ; 2d Class. Those established at the expense of the trigonus vesicalis; 3d Class. Those situated in the bas-fond of the bladder ; 4th Class. Those involving the trigone and root of the urethra, the trigone and bas-fond, or all three of these parts together; 5th Class. Those implicating the cervix uteri. In some cases, however, multiple fistulas exist, and no special classification can be made. Causes. — Any influence which is capable of destroying the continuity of the vaginal walls, either by mechanical, chemical, or vital action, would of course give rise to this condition. Those which are found in actual practice to have proved most com- monly efficient, are the following : — 1st. Prolonged or very severe pressure ; 2d. Direct injury ; 3d. Ulceration or abscess. Pressure, which is more frequently a cause than any of the others mentioned, is generally produced by the child's head re- maining too long in the pelvis during labor. This is beyond all doubt the most prolific source of the accident, though it may also attend a rapid labor in which the vagina has been pressed against some point of the pelvis with great violence. Such pressure pro- duces sloughing of the part of the vagina receiving it, and at that UEINAEY FISTULA. 157 spot a deficiency of tissue in future exists, which constitutes a. fistula. The process of sloughing occurs from pressure of the foetal head, exactly as a bedsore takes place in one who lies for too long a time in the same position, the sequence being, dis- turbed and retarded circulation, impaired nutrition, and local death. Or a puerperal vaginitis may be established, which runs a violent course, and may end in sloughing at the end of several weeks. An involuntary flow of urine usually announces the existence of a fistula within three or four days after delivery, though when it is the result of injury inflicted by instruments employed in delivery, it may occur immediately. On the other hand, the separation of the slough, which will entail deficiency of tissue and its results, may not take place until much later, when perhaps all fears are allayed, and the case is regarded as progressing favorably. Jean Louis Petit records one case developing its symptoms after a month; Jobert one in which on the twenty-second day after de- livery the slough was found at the mouth of the vagina; Adler, of Iowa, one in which after twenty-nine days the slough was only partially separated; and Agnew, of Philadelphia, another, in which it occurred on the twenty-first day. Other agencies which may act in the same manner, but which have been rarely noticed, are pessaries, stones in the bladder, fecal accumulation, &c. Direct injury may produce the accident by contusing or lace- rating the vaginal walls, as may occur during delivery by the forceps or craniotomy. That these operations when carelessly or unskilfully performed may produce a fistula, no one will pretend to deny, but there can, with the evidence now recorded, be no doubt that they have often been credited with unfortunate results which were in reality due to tardiness in their employment. Yery often, where a labor has been allowed to be prolonged in the second stage until the vitality of certain points in the vagina has become irremediably impaired, and the process of sloughing been already inaugurated, delivery by forceps or craniotomy has boon regarded as producing fistula. Under such circumstances the real morbid agency, prolonged and violent pressure, is lost sight of, and the more palpable agents, the instruments employed, are viewed as the source of the accident. The truth with reference to this point should be well understood by eveiy practitioner, for 158 FISTULA OF THE FEMALE GENITAL OEGAKS. unless it be so, an incompetent person may shield himself from merited blame by casting censure upon a consulting physician by whose efforts the lives of both mother and child have been saved, or a skilful operator may suffer unjustly in a suit for mal-prac- tice. In a report upon this subject by Mr. I. Baker Brown 1 to the Obstetrical Society of London, in 1863, the following statements are made: " With regard to the causes of vesico-vaginal fistula, of the 58 cases admitted into the London Surgical Home, 47 were over 24 hours in labor, and 39 were as much as 36 hours or more; 7 were two days; 16 were three days; 3 were four days; 2 were five days ; 2 six days ; and 1 seven days. "In the whole number of cases instruments were used in 29, exactly one half, and in 4 only of these was the labor less than twenty-four hours, and with seven exceptions the patient had been thirty-six hours or more in labor before instruments were used. "Of the 58 cases, in 24 only the injury happened at the first labor ; in 7 at the second ; in 5 at the third ; in 4 at the fourth ; in 6 at the fifth ; in 2 at the sixth ; in 5 at the eighth ; in 1 at the ninth ; 1 at the thirteenth ; 1 at the fifteenth ; and 2 not men- tioned." " From the foregoing statistics it is evident that the cause of the lesion is protracted labor, and not the use of instruments or deformity of the pelvis." "As a necessary deduction from what has been stated, it follows that vesico-vaginal fistula would scarcely if ever occur, if a labor were not allowed to become protracted ; and this is a point for the careful consideration of practitioners in midwifery." The experience of Drs. Sims, 2 Emmet, and Bozeman 3 is confirmatory of that of Mr. Brown, and as the opportunities for observation enjoyed by these four practitioners have probably been as ex- tensive as those of any living authorities, their evidence may be regarded as conclusive. Ulceration or Abscess. — The vaginal walls may be eaten through by cancerous, syphilitic, or phagedenic ulcers, or a communication 1 Obstet. Trans. , vol. v. p. 23. 2 Gardner's Notes to Scanzoni, p. 503. 3 Agnew, Vesico- Vaginal Fistula. URINARY FISTULA. 159 may be established by an abscess opening into the vagina and into a neighboring viscus or part. In one case I found, in the autopsy of a woman who had died from a profuse diarrhoea, in which the feces had passed by the vagina, a communication created by abscess between the caput coli and that canal. Cancerous disease often destroys the vesico-vaginal septum, but as these fistulas are irremediable, and attend upon a rapidly fatal disorder, they attract little attention in themselves. Lastly, cer- tain diseases producing deficiency of nutrition, as, for example, the continued fevers, may cause sloughing of the vaginal walls or phagedenic ulceration. Symptoms. — The prominent symptoms and signs of urinary fis- tulae may be grouped under three heads : first, those furnished by a characteristic discharge; second, those arising from the irritant action of such discharge upon the part over which it flows ; and third, those afforded by physical examination. Sometimes the escape of urine is so excessive as to preclude the necessity of a discharge per vias naturales; at others the ex- cretion is partly evacuated by the natural and partly by the vica- rious outlet. This symptom shows at times eccentric variations. When the fistula is seated in the urethra the bladder may be dis- tended without loss, which may take place into the vagina during micturition. Sometimes while in the horizontal posture the escape will cease, the anterior vesical wall being pressed by the intestines against the bas-fond so as to close the opening, and in other cases, where the fistula is above the orifice of the ureters, the flow will take place while the patient lies, and cease when she stands. The passage of excrementitious material through a canal and over a tissue not intended by nature to tolerate it, produces inflam- matory action, pruritus, eruptions and excessive irritability. In urinary fistulae the vulva and thighs are usually red, excoriated, and covered by a vesicular eruption. The vagina is sometimes covered by urinary concretions, and from the patient's body emanates a highly offensive odor, which, to one accustomed to seeing the condition, is often sufficient for purposes of diagnosis. The general health of the patient is very likely in time to give way, and hysteria, chlorosis and graver disorders often show themselves. 160 FISTULA OF THE FEMALE GENITA.L ORGANS. Physical Signs. — If the fistulous orifice be a large one, even a* superficial examination by touch, the patient lying upon her back, will generally serve to reveal the nature and extent of the lesion. It is different, however, with very small fistulas, which will sometimes elude the most careful investigation. For their detection Sims's speculum should be employed, and in many cases it will be found advisable to place the woman in the knee-elbow position, instead of that on the side, before its introduction, and to have the buttocks and labia pulled apart by the hands of assist- ants. Even this method is not effectual in revealing the difficulty if the opening be very minute. Under these circumstances the bladder should b'e injected with water and its escape into the vagina carefully watched for. Sometimes, by this means, a ca- pillary opening just at the junction of the vagina and cervix will be detected. Kiwisch, Meyer, Veit, and others have used for this purpose water colored with substances which will impart a bright tinge to it. Infusions of cochineal, madder, or indigo may be thus employed. The opening being once detected, the probe and finger will readily reveal the course, extent, and terminus of the tract. Complications. — The complications which these fistulas deve- lop are vaginitis, vulvitis, stricture of urethra and vagina, and sometimes endo-metritis and peri-uterine inflammation. The most constant and important of these is the formation of bands, which contract the vagina, and which often require severance before operative procedure can be practised. Prognosis. — Previous to the year 1852 the prognosis of all cases in which the orifice acted as a vicarious outlet, for example, vesico-vaginal, recto-vaginal, and vesico-utero-vaginal fistulas, was eminently unfavorable, for they very rarely undergo spontaneous recovery, and the means of cure at our command up to that time were uncertain and full of discouragement. In 1860 Dr. Sims 1 stated, " Of 261 cases of vaginal fistula (vesical and rectal) 216 have been permanently cured by the silver wire suture; 36 are curable and 9 incurable. Every case is curable when the opera- tion is practicable, provided there is no constitutional vice to 1 Gardner's Notes to Scauzoni, p. 515. HISTORY. 161 interfere with the powers of union. Success is the rule, failure the exception." The enlarged experience of the profession has fully corrobo- rated these assertions, made seven years ago, and it may now be accepted as a true statement as to the prognosis of all fistulae of the female genital organs except cases of vesico uterine fistula, in which the point of rupture is out of reach of surgical interfer- ence. History. — The history of this subject dates back only to the sixteenth century, when attention was called to it and a plan of treatment proposed by Ambrose Pare. Before the discovery of the forceps the accident must have been one of very frequent occurrence, for then powerless labor was not under the control of the obstetrician, except by resort to a set of badly-constructed in- struments for craniotomy, which in themselves presented serious dangers of laceration. The symptoms which mark its existence are so palpable and distressing that it does not require a physician to diagnosticate it, and no case of any gravity could have escaped notice. And yet, curious to relate, there are few diseases to which woman is liable, which have received so little notice at the hands of the ancients. Even pelvic cellulitis and other affections which have but lately attracted attention from the physicians of our day are distinctly spoken of by the writers of the Greek school ; but this one, so annoying, so destructive of happiness, and so urgent in its demands for relief, has received scarcely any mention. It is true that Hippocrates makes some slight allusion to involuntary discharge of urine following difficult labors, but his remarks upon the condition are meagre and unimportant. I do not claim to have made a full examination of the writings of the Greeks and Eomans with reference to the subject, but base the statement which I have advanced chiefly upon the fact that the two great compilers of their period, Aetius and Paulus JEgi- neta, make no mention of it. The work of Aetius upon diseases of women (Tetrabiblos IV.) is made up of quotations from Sora- nus, Aspasia, Galen, Philumenus, Archigenes, Leoniclas, Rufus, Philagrius, Asclepiades, in fact of all worthy of note whose writ- ings were stored in the Alexandrian Library, which was the seat of his labors. By none of these is mention made of the affection. The works of Paul of iEgina, enriched as they have been by the 11 162 FISTULA OF THE FEMALE GENITAL OEGANS. copious notes of Dr. Adams, their translator, are equally silent ; and the researches of those who have examined the writings of the Arabians furnish no discovery of any description of it at their hands. At any rate, it is quite certain that no contributions to the treatment of the difficulty were made by the writers of the Greek, Roman, or Arabian schools. Beginning at the seventeenth century, I will allude only to those who have made some advance in treatment, and not en- deavor to record the names of all who have reported cures, or advised procedures which have not been of subsequent utility. Before proceeding with the historical sketch which ensues I would draw the attention of the reader to two interesting facts which it will demonstrate. It will be seen that for centuries steady, persevering, and systematic efforts have been made to render this revolting malady curable, and that, as has so often been the case in other great discoveries, the minds of several investi- gators pursued the same course until at last success was reached. After a discovery has been made it is always easy to point out the elements upon which it rests for its success, and even to follow the process of reasoning by which each in turn was supplied. There can be no question that the three elements necessary for successful treatment of the lesion which we are considering, were: — 1st. A means for exposing the fistula to view and manipula- tion ; 2d. A suture which would remain in place without causing inflammation ; 3cL A means of disposing of the urine during the process of cure. From the time that Pare suggested a plan of treatment, it will be noticed that surgeons brought these three means of cure to their aid. But they employed them separately, some using one of them, some another, and others still combining two. It was not, however, till the time of Gosset, in 1834, that the three were combined by the same operator. In 1570 Ambrose Pare proposed the closure of vesico-vaginal fistulas by a retinaculum. In 1660 Eoonhuysen, of Amsterdam, used a speculum, through which he pared the edges of fistulae, and united them by a needle. In 1720 Voelter, of Wurtemburg, advised a needle, needle-holder, suture by silk or hemp, and a HISTOEY. 163 catheter. In 1804 Desault used a vaginal plug and catheter in the bladder. In 1812 Naegele, of Wurtemberg, scarified the edges by scissors, used needles to approximate them, and em- ployed the interrupted suture. In 1817 Schreger, of Germany, placed the patient on the abdomen, scarified and used interrupted suture. In 1825 Lallemand, of France, applied nitrate of silver to the edges of the fistula, and approximated them by a " sonde erigne" passed through the bladder, and, of fifteen cases, cured four. In 1829 Eoux, of France, tried twisted suture with metallic bars and ordinary thread. In 1834 Gosset, of London, combined the knee-elbow position, levator perinei speculum, metallic sutures, and catheter permanently kept in the bladder. In 1836 Beaumont 1 employed the quilled or clamp suture. In 1837 Jobert de Lamballe resorted to autoplasty, transplanting a piece from the labia, buttocks, or thighs. In 1838 Wutzer, of Bonn, placed his patients on the abdomen, pared the edges of the fistula, and approximated them by insect needles and figure of 8 suture. To expose the fistula the perineum was held up by a hook and the labia drawn aside by assistants. In 1839 and 1840 Hay ward, of Boston, U. S., reported three cases cured by vivifying the edges and closing with silk suture. This surgeon introduced a notable improvement, and aided in the final success by vivifying not only the borders of the fistula but the neighboring vaginal surfaces. In 1844 Chelius 2 placed his patients in the knee-elbow position. In 1846 Metzler 3 , of Prague, employed the levator perinei specu- lum, perforated balls the size of shot, the knee-elbow position, gilded needles, and a permanent catheter. In 1847, Mettauer, of Virginia, employed the catheter and leaden sutures with such success that he was led to make the following statement: "I am decidedly of the opinion that every case of vesico-vaginal fistula can be cured, and my success justifies the opinion." In 1852, Jobert de Lamballe adopted his method styled "reunion autoplas- tique par glissement," which consisted in giving sufficient vaginal tissue for union, by cutting transversely through the vagina, ar its junction with the uterus, in a line with the fistula. In 1852, Marion Sims, 4 of the United States, combined the three essentials for success, the speculum, the suture, and the catheter, and placed the operation at the disposal of the profession. 1 Med. Gaz., Dec. 3d, 1836, p. 355. 2 Agnew, op. cit., p. 15. 3 Schuppert on Ves.-Vag. Fistula, p. 41. 4 Amer. Journ. Med. Sci., 1853, 164 FISTCJL-E OF THE FEMALE GENITAL ORGANS. The discoveries to which he laid special claim were these: — 1st. A method by which the vagina could be distended and explored ; 2d. A suture not liable to excite inflammation or ulceration ; 3d. A method of keeping the bladder empty during the process of cure. From a study of the literature of this subject it is made as evident as written testimony can make any history of the past, that not only did several investigators combine two of these elements of success in their operations, but that two, Gosset, in England, and twelve years afterwards Metzler, in Germany, absolutely combined all three. It is also made equally evident that they either failed to recognize the importance of what they had attained, or did not impress its value upon others, so that humanity could profit by it. Dr. Gosset's procedure is thus described in his own words in the first volume of the London Lancet, page 346. "Having placed the patient resting upon her knees and elbows upon a firm table of convenient height covered with a folded blanket, the external parts were separated as much as possible by a couple of assistants, so as to bring the fistula, which was imme- diately above the neck of the bladder, into view. I seized with a hook the upper part of the thickened edge of the bladder which surrounded the opening, and proceeded with a spear-shaped knife to remove an elliptical portion, which included the whole of the callous lip surrounding the fistula, the long angle of the ellipsis being transversely. This was readily effected; but, in conse- quence of the very contracted state of the parts, the next steps of the operation were with difficulty executed ; and I should not have succeeded in passing the sutures, had I not used needles very much curved, and a needle holder, which I could disengage at pleasure, the needles being withdrawn with a pair of dissecting forceps after the holder was removed. In this way three sutures were passed ; and afterwards, by twisting the wire, the incised edges were brought into contact and retained in complete apposi- tion until they had firmly united. One of the sutures was re- moved at the end of the ninth day, the second at the end of the twelfth day, and the third was allowed to remain until three weeks had elapsed. After the operation the patient was put to bed and 'desired to lie on her face, an elastic gum catheter, HISTORY. 165 having a bladder secured to its extremity for the reception of the urine, having been introduced and retained by means of tapes. She had not the slightest discharge of urine through the vagina after the operation, which completely succeeded in restoring the healthy functions of the part, The advantages of the gilt wire suture are these : it excites but little irritation, and does not appear to induce ulceration with the same rapidity as silk or any other material with which I am acquainted ; indeed, it produces scarcely any such effect, except when the parts brought together are much stretched. You can, therefore, keep the edges of a wound in close contact for an indefinite length of time, by which the chances of union are greatly increased. I have used it now in very many operations, as after extirpation of the breasts, tumors of various kinds, and for bringing the lips together after the removal of a cancerous growth, in all of which cases it an- swered extremely well." The method of Metzler was published in the Prague Viertel Jahresschrift for 1846, under the title of "Pathology and Treat- ment of Urinary and Vesico- Vaginal Fistulas, with a method of treatment easily executed and completely successful." I trans- cribe his article from the brochure of Dr. Schuppert already alluded to. "To perform the operation successfully, it is of much import- ance to have — 1st, a speculum, serving as a dilator of the vagina. Such an instrument consists of a grooved conical blade, five and a half inches long, three inches wide at the anterior part, one-half of an inch wide at the posterior. The end of the speculum is bent nnder at a right angle, and protected with wood for the handle. The instrument is best when made of silver, and polished to re- flect the light on the parts to be operated upon. 2d, an apparatus consisting of perforated clamps, gilded needles, and an instrument called 'Eosenkranzwerkzeng,' consisting of perforated balls of the size of large shot, by which the clamps are held in contact. After the patient is placed on her knees and elbows, the dilator is introduced into the vagina and given to an assistant, who in holding it presses it against the rectum. The edges of the fistula are then pared off, which may be accomplished with curved scis- sors. One line and a half from the mucous membrane of the vagina and half a line from the edge of the bladder have to be cut off; the needles are then applied, and the wound held in co- 166 FISTULA OF THE FEMALE GENITAL ORGANS. aptation by the clamps ; a female catheter is introduced into the bladder by the urethra, and the catheter fastened by a T bandage." From what has been said thus far it would appear that Dr. Sims was forestalled in all the details of the discovery by which he has rendered vaginal fistulae curable. To a certain extent this is unquestionably true, but only as regards the theory of the matter. Before his publications the unfortunate women whose lives were rendered miserable by fistulas through the vaginal wall were virtually almost as hopelessly affected as they were before G-osset and Metzler appeared in the field. Velpeau, 1 in 1839, thus speaks of cure of these fistulas : " To abrade the borders of an opening, when we do not know where to grasp them ; to shut it up by means of needles or thread, when we have no point apparently to secure them ; to act upon a mov- able partition placed between two cavities, hidden from our sight, and upon which we can scarcely find any purchase, seems to be calculated to have no other result than to cause unnecessary suf- fering to the patient." Yidal de Cassis 2 says : " I do not believe that there exists in the science of surgery a well authenticated complete cure of vesico-vaginal fistula." Malgaigne, 3 in 1854, says : " But the truly rational method, that which at present offers the greatest facility and efficacy, and the only one which should be applied in all cases of fistula of large size, is the suture by the procedure of Jobert." This was the real state of science with reference to this oppro- brium chirurgise when Marion Sims, by combining and utilizing the three essentials for success, gained it, and* rendered the ope- ration practicable for all surgeons. It must not be supposed that he availed himself of the results obtained by his predecessors. All that he attained was arrived at by hard and original labor. Indeed, no one can read his address upon " Silver Sutures in Surgery," delivered before the New York Academy of Medicine, in 1857, without being struck by his want of familiarity with the antecedent literature of the subject of his discourse. Since the first publication of Sims's method, numerous modifi- cations of it have been put into practice both in this country and Europe, and Dr. Sims himself has altered his plan of operating 1 Operative Surgery. 2 Pathologie Externe. 3 Manuel de Med. Operat. TREATMENT. 167 very much. The principle which he demonstrated is, however, the same, and the modifications of the operation all act in develop- ing it. Means for Obtaining a Natural Cure. — Within a few days after delivery the obstetrician is generally made aware of the existence of vesico-vaginal fistula by a steady and involuntary dripping of urine. As soon as this is evident a Sims's stationary catheter should be placed in the bladder, the vagina frequently syringed out with warm water to lessen inflammatory action, and the patient kept perfectly quiet in order that a repair of the injury may be accomplished by the efforts of nature. This is all that can be done at this time, for it is too early to resort to suture, and the lochial discharge would be interfered with by a tampon intended to aid in the cure. The operation by suture should not be undertaken before the immediate results of parturition have passed off and the fistula has assumed a permanent size and character. Treatment. The methods at our command for curing, or at least obviating the inconveniences due to fistulas of the female urinary apparatus, are — 1st. Cauterization ; 2d. Suture ; 3d. Elytroplasty ; 4th. Occlusion of the vagina or uterus. Cauterization. This once favorite method of treating all varieties of these fis- tulas has now almost entirely fallen unto disuse under the influence of improved methods by suture. Malgaigne probably gives this means its proper place when he declares that it should be em- ployed only in those cases where the fistula is scarcely perceptible. Even in such cases Sims's operation is far preferable, and cauteri- zation should be employed only where some special circumstance, such as want of skill or of the proper instruments, forces the operator to resort to it. The performance of it is very simple. Sims's speculum being passed so as to expose the fistulous spot, 163 FISTULA OF THE FEMALE GENITAL ORGANS. its borders should be thoroughly touched with a pointed stick of nitrate of silver or the actual cautery. This should not be re- peated before the slough created has separated, and an opportunity been allowed for granulation to fill up the opening. To check the flow of urine through the fistulous orifice and support the vaginal and vesical walls during the process of granu- lation, a small tampon of cotton, a Gariel's air pessary, or a glass vaginal plug, like that delineated at Fig. 32, should be kept in the vagina, and, to prevent distension of the bladder, a Sims's catheter should be permanently retained. Suture. Preparation of the Patient. — No operation in surgery more urgently demands a good constitutional condition, as an element of success than this. Should the patient's health not be good, and her blood-state be abnormal, a visit to the country, exercise, and fresh air, with vegetable and mineral tonics, will do a great deal towards avoidance of failure. At the same time the vagina should be regularly syringed with warm water to overcome local inflammation, and insure cleanliness. Should the disorder which caused the destruction of the vaginal wall have produced as a complication cicatricial bands in the canal, these should be cut, from time to time, and allowed to heal over a glass vaginal plug, and if contraction have taken place in the urethra, it should be overcome by bougies. Before the time of the operation the bowels should be thoroughly emptied by a cathartic, and on the day of its performance very little food should be taken, for fear that the long-continued use of an anaesthetic might produce vomit- ing, which would tear out the sutures. Sims's Operation. — This operation may be divided into three parts : — 1st. Paring the edges of the fistula ; 2d. Passing sutures through them ; 3d, Approximating them and securing the sutures. The patient being placed upon a table two and a half by four feet, which is covered by folded blankets, is brought under the influence of an anaesthetic, and placed in the following position. She is made to lie on the left side, with the thighs bent at about TREATMENT. 169 right angles with the pelvis, the right a little more flexed than the left. The left arm is placed behind her back, and the chest brought flat down upon the table so that the sternum may touch it. The assistant who is to hold the speculum, which is now introduced, does so with the right hand, while with the left she elevates the right side of the nates. The table should be so arranged that a bright and steady light may fall into the vagina, which being now fully distended, will be seen throughout its extent, except where it is obscured by the speculum. The operator having near him all the instruments, &o. which he will require, places his assistants thus : one holds the specu- lum, another administers the anaesthetic, and a third stands ready at his right hand to remove the blood accumulating in the vagina, by means of sponges, in the sponge-holders, Fig. 42, which are rapidly washed in a basin of water that stands by his side, to be used again. A fourth assistant, if attainable, may be well em- ployed in handing the instruments as they are required. All being ready, he now proceeds with the first step of the operation. Paring the Edges of the Fistula. — The edge of the fistula at the point which is deemed most difficult of access and manipulation, is caught by the tenaculum and held up. Then, with a pair of long-handled scissors, Fig. 38, or a knife, Fig. 39, a strip is cut, extending from the mucous membrane of the bladder to that of the vagina, care being taken not to wound the former. Fig. 38. Long-handled scissors. Fig. 39. Bistoury for paring edges of fistula. Another portion of the edge is then seized, and removed like the first. The wound thus left should be one bevelled from the vesical surface outwards, and great care should be observed to remove the entire border, for upon this success depends. It is of great moment that sufficient tissue should be removed. 170 FISTULA OF THE FEMALE GENITAL ORGANS Fig. 40. Fig. 41. o & Showing bevelling of edges, a, vesical border ; b, vaginal bor- der ; c c, incision. Paring the edges. (Wieland and Dubrisay.) Fig. 42. Sims's sponge-holder with handle nine inches long. (Sims.) and that the amount taken on the vaginal surface should be greater than that near the vesical. Prof. Simpson 1 makes this Diseases of Women. TREATMENT. 171 point very clear by the following language: "Enter the point of your knife into the vaginal mucous membrane at some distance from the fistula ; then transfix with your knife the edge of the fistula to the extent you intend to remove it, and, bringing it out at the vesical border, carry it right and left fairly round the open- ing, so as, if possible, to bring out a complete circle of tissue." The tissue, from the edge of the fistula to the point of vaginal section, should measure at least four lines, one-third of an inch, while above, it should just touch the vesical border, not wounding its mucous membrane. This is made evident by Fig. 41. Dur- ing this part of the operation the sponges, held in long-handled sponge-holders, will have to be freely resorted to, but the bleed- ing generally soon ceases, and the operator may proceed to the second step. Fig. 43. Passing the Sutures. — The sutures are passed by means of slightly curved needles held in a pair of strong forceps, Fig. 44, made for the purpose. In some cases the metallic thread, made of annealed silver, which is employed, may be passed at once, but usually silk threads are first passed, and then the silver sutures are attached and drawn through. Mr. Stohlman has recently adopted a very ingenious method for avoid- ing the necessity of threading the needle, and thus having a piece of silver wire folded over so as to interfere with its pas- sage through the tissues. He drills a hole for a short distance up the shank of the needle, the walls of which are made to act as a female screw. Into this the wire is passed by turning it ; the threads in the wall of the canal cut into the soft wire, and it is held firmly in place. Fig. 43 represents a needle of this kind with a roll of silver wire attached. The needle, held in the grasp of the needle- holder, should be passed at the angle of the wound which is most difficult of access, half an inch from the edge of the incision, and brought out at the vesical surface, but not involving its mucous lining. Fig. 45 represents the points of entrance and exit of the needle. The point of the needle having passed out, it is engaged by the Stohlmnn's! needle with wire attached. small, blunt hook, Fig. 51, until it can be seized and drawn 172 FISTULA OF THE FEMALE GENITAL ORGANS. through by the needle forceps, Fig. 47. Then it is plunged into the other lip and drawn out half an inch from the edge of the Fig. 44. point Course of the needle, a, vesical border ; b. vaginal border ; c, point of entrance of needle of exit of needle. Fig. 46. £& Passing the needle. (Wieland Fig. 47. Dubrisay.) Xeedle held in forceps Forceps for drawing needle. incision. The ends of the silk suture are now given into the charge of the assistant holding the speculum, and another is passed in the same way at the distance of one-sixth of an inch, from the first. In this way a sufficient number is passed to close the fistula, Fig. 48. During this procedure the edge of the fistula is to be fixed by the tenaculum, and should firm, opposing force be needed to make the needles pass, it may be given by that instrument. When the needle is seized by the forceps and pulled so as to make the thread follow it, some opposing force is needed, or the thread might cut through the tissues. This force is offered in the TEE ATM EXT. 173 species of fork represented in Fig. 50, which is put as a fulcrum under the thread at its point of exit, and made to sustain and draw it through. A bit of silver wire about twelve inches long is attached, by Fig. 48. Twisting the sutures. Fulcrum for supporting wire while it is twisted. Fork with blunt points to aid the passage of sutures. Hook for en- gaging needle. bending its extremity, to the first silk suture, and by the use of the fork just mentioned, the silk thread is drawn through so as to make the silver replace it. The silk is then cut off, the silver suture put aside, and the operator proceeds to replace each silk thread in the same way. This being accomplished, the instru- ments are now changed in order to effect the twisting of the sutures. The ends of the silver sutures being drawn together by the fingers, and the edges of the wound carefully approximated, each thread is slightly twisted so as to keep the whole in apposition. Then the ends of the first suture are seized in the bite of the forceps, Fig. 47, slipped into the fulcrum, Fig. 49, and torsion is made so as to close the wound completely at this point. In this way the sutures are, one after the other, twisted, care being- taken not to carry the torsion so far as to strangulate the tissues 174 FISTULA OF THE FEMALE GENITAL ORGANS. engaged in the constricting loop. Each suture is now clipped by a pair of scissors, about half an inch from the edge of the fistula, and by means of forceps pressed flat against the vaginal wall so as not to wound the opposite surface. The bladder should then be syringed out to remove all blood which may have accumulated there ; for if a large clot should be retained in this viscus, it may cause severe vesical tenesmus, and smaller ones may block up the mouth of the catheter, which is to be kept in place permanently, and call for its repeated removal. Fig. 52. 3 4 {Mtock; "MHdr 6 If I 2 Sutures twisted. (Wieland and Dubrisay.) The patient is now placed in bed by the assistants, an opiate is administered, and a Sims's sigmoid catheter is passed into the bladder and left there. The mouth of this instrument projects beyond the vulva, so that under it a small china dish may be placed, which will receive the urine as it passes through. The catheter should be examined every two or three hours to be certain of its perviousness, and to remove the urine which collects in the receptacle placed under it. Once in every twenty-four hours the vagina should be syringed Fig. 53. Sims's sigmoid catheter. out with tepid water, or with this and white castile soap, or any similar detergent ; but the bladder requires no further washing than that mentioned, except in cases of vesical tenesmus. The bowels should be kept constipated by opium. The diet should be governed by the same rules which guide us in the manage- ment of patients under other surgical operations. It should be nutritious and unstimulating:. TREATMENT. 175 In from eight to fourteen days the sutures should be re- moved. Dr. Sims declares that " it is unnecessary to allow the wires to remain longer than the eighth day ;" but others, calcu- lating upon the innocuousness of metallic substances in the tissues, have left them longer. In two of Dr. Schuppert's cases a leaking was detected when the bladder was injected on the sixth and Fig. 54. 'V Removal of the sutures. (Sims.) seventh days, which had disappeared entirely on the twelfth, when the sutures were removed and the cure was found complete. To accomplish the removal of the sutures, the twisted end of 176 FISTULA OF THE FEMALE GENITAL ORGANS. one of them should be seized by a pair of forceps and drawn upon gently until the edge of the loop emerges from the tissues in which it has been imbedded. Then the blade of a pair of scissors should be inserted into the loop and one side cut, after which a little traction w r ill remove the suture. An examination may then, with great caution, be instituted to ascertain whether success or failure has attended the operation. A visual examination will generally determine this. Should there be any doubt, the bladder may be filled very cautiously with tepid water to settle the question as to the entire closure of the fistula. Sometimes one operation fails to cure, although it diminishes the size of the fistula very much, and subsequent ope- rations must be resorted to. It may be necessary to repeat these very frequently before success is attained. The operation of Dr. Sims has been variously altered in all its steps, so that now the number of modifications is quite numerous — so numerous, indeed, that it would be out of the province of a work like this to mention them in detail. In his earlier opera- tions Dr. Sims employed the quilled suture, which he called the clamp suture, but a tendency on the part of the little metallic bars, which he used in place of quills to produce ulceration, in- duced him to resort to the interrupted suture. Four years after the publication of Sims's method Dr. Nathan Bozeman,' of Alabama, now of this city, proposed a method which he regarded as an improvement upon it, and which he syled the " button suture." It may not be out of place to state here that, judging from the written testimony bearing upon this subject, Dr. Bozeman acknowledged the priority of the claims of Dr. Sims, and accorded him the credit of developing the principle upon which the cure in these cases is effected. But finding the clamp, which had up to that time been employed by Dr. Sims, open to a number of objections, he proposed a modification which he sup- posed would obviate them. In announcing his method, he says : — " I do not wish to be understood as attempting to detract from the great credit due from the profession and the public to Dr. Sims for his untiring perseverance in bringing his method to its present high state of perfection. I consider that this gentleman is fully entitled to more than all the praise that has been bestowed 1 Louisville Review, January, 1856. TREATMENT. U7 upon him both in America and Europe. To the honor of his professional brethren in this country it may be stated that no one has been found who has not gladly accorded to him the high distinction that he at present occupies." Bozernari's Operation. — " The edges of the fistule having been pared, the wire sutures are to be lodged in their respective places in the usual way, by attaching them to the ends of silk ligatures previously carried by means of a needle through the septum from one side of the fistule to the other. But in connection with this step of the operation, there is some difference between Dr. Sims's procedure and my own. In the first place I do not usually take so firm a hold of the tissues, the space between the entrance of the needle and the edge of the fistule rarely if ever exceeding half an inch, and it matters not whether Fi g- *>•*». the parts be indurated or not, the wire is not likely to cut out very soon. Secondly, it is not neces- sary to observe the same scrupulous care in enter- ing and bringing out the sutures upon an exact line with each other; for, as will be hereafter under- stood, each one is in its action entirely independent of the others. Thirdly, instead of being obliged always to place the sutures parallel with each other, I have it in my power, if the peculiar nature of the case indicate, to insert them in any direction, and am thus enabled to bring within the sphere of suc- cessful treatment a large class of cases, which owing to the irregular shape of the fistule, and the scarcity of tissue not admitting of extensive paring, cannot be subjected to the clamp suture. " The next step in the operation is to draw the raw edges closely in contact by bringing the oppo- site ends of each wire together. This may be readily accomplished with an instrument which I have invented for the purpose, and call the suture adjuster. It consists simply of a steel rod, fixed in an ordinary handle, its distal extremity flattened, perforated, and raised upon one side into a kind of knob, as represented by Fig. 55. The opposite Boseman'ssu- ends of each suture are to be passed through the bure adjuster. 12 178 FISTULA OF THE FEMALE GENITAL ORGANS. aperture in the end of the adjuster from the convex toward the flat surface, and while the former are held firmly between the forefinger and thumb of the left hand, the latter is carefully slipped down upon the wires until it comes closely in contact with the tissues. In this way the edges of the fistule are gently forced together, and, for the time being, the stiffness of the wire Fig. 56. Fig. 57. Sutures adjusted. Button being passed. prevents their separation. Should it be found, however, that accurate coaptation does not take place, owing to the imperfect manner in which the edges have been pared, the sutures may be readily loosened, and the defect Fig- 58. remedied without the necessity of withdrawing the wires. The ap- pearance of the parts after all the sutures have been adjusted is faith- fully represented in Fig. 56. " A button of suitable shape and Passing the shot. size having been previously pro- vided, is now to be placed upon the wires (Fig. 57), its concave surface corresponding to the vesico-vaginal septum, and carried down in contact with the sep- tum. The wires being again held in the left hand, the button should be pressed gently against and adapted to the surface of the parts (Fig. 57). This may be accomplished by an instrument which I call the button adjuster, consisting of a stiff iron rod, bent at a right angle within half an inch of its distal extremity, and inserted into an ordinary wooden handle. " The shot are to be now passed down over the approximated ends of each suture to the convex surface of the button, and here TREATMENT. 179 each one is to be successively grasped with a pair of strong for- ceps, and held against the button, while contraction is made upon the corresponding suture, in order to bring the vaginal surface of the septum in close contact with the concave surface of the button, and insure close coaptation of the edges of the fistule. This having been accomplished, sufficient force is exerted upon the forceps to compress the shot and thus prevent its slipping. The operation is then concluded by clipping off the wires close to the shot." The advantages claimed by the inventor for this method are the following : — 1st. It exerts a controlling influence in bringing the edges into apposition, and preventing inversion and eversion. 2d. It gives steadiness and support to the edges of the fistula. 3d. It protects the lips of the wound from contact with the secretions. Dr. Bozeman operates with the patients in the knee-elbow position, and not on the side. This operation, like that of Dr. Sims, has been variously altered. Shields or splints of other forms have been substituted by Simp- son, Baker Brown, Agnew, Battey, and others ; but as no new principle or special advantage is developed by them, further mention would be superfluous. Dr. Startin and M. Matthieu, of Paris, have invented hollow needles, through which the silver threads can be passed without first passing those of silk. Needles, straight and curved, with long handles, are likewise employed by some. A very ingenious and simple needle, made by Messrs, Tiemann & Co., is represented by Fig. 59. By a sliding nut in the handle the metal suture is easily pushed through the hollow needle so as to facilitate its passage very materially. Fig. 59. Stohlmann's hollow needle. It will be remembered that the historical sketch given of this operation records the repeated use of pins, with figure of S sutures surrounding them, for closing fistulae, and that as late as 1848 180 FISTULA OF THE FEMALE GENITAL OEGANS Metzler, of Prague, employed them with good results. They are, however, not generally resorted to, and for that reason I, with the greater pleasure, describe the ingenious procedure of Dr. Mastin, of Mobile. Mastitis Operation. — The lips of the fistula being pared in the ordinary manner, Carlsbad suture pins are held in a needle-holder and passed through both lips. Then a long silver wire is passed as a noose over both ends, and twisted by a Startin's or Coghill's twister, the points of the pins are cut off and a sponge placed in the vagina to support the sutured part. This is daily removed and the vagina syringed out. In removing the pins the head of each is seized by a pair of forceps, the pin is withdrawn, and the wire drops into the vagina. One great advantage claimed for the Mastin's operation : a a a, wire threads surrounding b b b, pins in position. process by Dr. Mastin is this: if a leak be discovered, no new operation is necessary ; a tenotome is inserted, by twisting which ELYTROPLASTY. 181 the lips at the point of imperfect union are vivified, and an addi- tional pin is passed through so as to bring them into apposition. The plan certainly recommends itself for simplicity, and since it has uniformly succeeded in the hands of its inventor deserves trial. Figs. 60 and 61 show the steps of the operation very clearly. Fig. 61. Fig. 62. Wounds closed : c c c, threads twist- ed so as to close the fistula ; and d d d, pins cut short. Coghill's twister employed in the operation. Elytroplasty. — This operation was published to the profession by Jobert de Lamballe, 1 in 1834, and was subsequently altered and improved by Velpeau, Grerdy, and Leroy d'Etiolles. It con- sists in dissecting a flap from one buttock (Jobert), or the poste- rior wall of the vagina (Velpeau and Leroy), and fixing it by sutures into the orifice of the fistula, the borders of which have been previously pared. It resembles the operations of rhinoplasty performed upon the face, but is unfortunately even more difficult than they, and calls for such great manual dexterity as to preclude its frequent adoption. Yelpeau, by making two parallel, longi- tudinal incisions in the vagina, dissected up the intervening tis- sue and stitched it to the edges of the fistula. Leroy prolonged these incisions to the vulva, dissected up the intervening flap, and, rolling this upon itself, applied its under or bleeding surface against the fistula. Elytroplasty is still resorted to sometimes where great destruc- tion of tissue has taken place at the base of the bladder, but the difficulties and uncertainties attending it, together with the fact that more simple and efficient methods for dealing with this class of cases are at command, have rendered a resort to it very rare. 1 Bull, de l'Acad. de Med. de Pari?, t. ii. p. 145. 182 FISTULA OF THE FEMALE GENITAL ORGANS, Closure of the Vagina. This procedure is resorted to in despair of accomplishing the cure of the fistula, and in the hope of relieving the patient from the intolerable annoyance attendant upon an involuntary and con- stant discharge of urine. It is proposed only for those cases in which, from extensive destruction of tissue, no hope of closure by suture or elytroplasty can be entertained. By it the vagina and Fig. 63. Example of a case requiring obliteration of vagina ; a and c were united. (Sims.) bladder are rendered a common receptacle for urine and men- strual blood, the only advantage gained consisting in the fact that they may be retained and discharged at volition through the ure- thra which remains open. Closure of the vagina may be accom- plished by two operations, episiorrhaphy and obliteration of the canal. Neither of these, however, can be regarded as reliable or efficient methods, since they involve the necessity of the urine being retained in the vaginal canal, which is injured by its pre- sence. The first consists in paring the inner surfaces of the labia majora and uniting them by suture so as to cause their complete adhesion. The operation is exceedingly simple in its steps, but a very minute opening almost invariably remains just under the meatus through which a little urine exudes. This very nearly invalidates the success of the method, for even a slight escape renders the patient uncomfortable. The second consists in paring, not the labia, but the lower ex- URINARY FISTULA. Fiff. 64. 183 Obliteration of the vagina. (Wieland and Dubrisay.) tremity of the vaginal walls. Strips of mucous membrane being thus taken away, the bleeding surfaces are brought in contact by suture, and the bladder kept empty by a catheter until union has occurred. Dr. Bozeman, of this city, was the first to perform a modification of this method, which Simon, of Eostock, subse- quently adopting styled "cross obliteration." It consists in bringing the remains of the vesico- vaginal wall, which has been nearly destroyed by sloughing, into union with the posterior vaginal wall, so that the vaginal orifice is closed transversely. Urinary Fistulae Requiring Special Treatment. In the great majority of instances no other plan of treatment than the suture is ever thought of. There are, however, some 184 FISTULA OF THE FEMALE GENITAL ORGANS. cases of urinary fistulas in which the application of the suture is difficult, or even impossible. These will now engage our atten- tion. Fig. 65. The cervix is slit to ex- pose the fistula above, and sutures are passed. Vesico -uterine Fistulas. Jobert first pointed out the proper method for reaching these. His plan is not at pre- sent employed, but that now regarded as most reliable is only a modification of it. It consists in slitting up the anterior lip of the uterus until the fistula is reached, vivifying its edges and passing sutures directly through the cervix, as represented in Fig. 65, so as to approximate the walls of the cervix and the lips of the fistula. In case the fistulous orifice be so high as to be considered beyond reach, the only re- maining resource is to close the os uteri ex- ternum by suture, and allow menstruation to occur through the bladder. Vesico-ukro- vaginal Fistulas. For these the plans of Jobert and Bozeman of vivifying the anterior lip of the os, and thus making the uterine tissue subser- Fig. 66. Anterior lip of fistula united to anterior lip of cervix. URINAEY FISTULA. 185 vient to closure of the fistula, are peculiarly operation, represented at Fig. 66, is similar to that for ordi- nary vesico-vaginal fistula, the only difference being that one lip of the fistula is made of the vivified cervix uteri. In case the anterior lip of the ^uterine neck be so completely destroyed that it cannot furnish the requisite tissue for this pur- pose, the vagina may be united to the posterior lip so as to throw the cervix into the blad- der. Menstruation will after- wards occur into that viscus, and the blood thus accumulating be discharged with the urine. .pplicable. The Fig 67. Anterior lip of fistula united to posterior lip of cervix. (Wieland and Dubrisay.) Fistulse with Extensive Destruction of the Base of the Bladder. It has already been mentioned that elytroplasty and occlusion of the vagina offer resources in these cases, but neither of these operations is likely to produce good results as a general rule. To Dr. Bozeman we are indebted for a much more reliable pro- cedure, which consists in daily dragging the uterus down for weeks before the operation by means of a pair of forceps by which the neck is seized. By this means the uterus is made to approxi- mate the vulva. Then one lip of the cervix, being vivified, is brought into contact with the extremity of the remains of the vesico-vaginal septum and firmly united with it by suture. In addition to the varieties of urinary fistulas mentioned here, certain rare instances of union between the ureters and vagina or uterus have been recorded. A case of what is styled uretero-uterine fistula may be found detailed in the Dictionnaire de Medecine, vol. xxx., by the pen of M. Berard. It is not only interesting in itself, but as displaying the logical process of reasoning by which the diagnosis was made is worthy of special mention. Regarding it at first as a vesico-uterine fistula, from the fact that urine was 186 FISTULA OF THE FEMALE GENITAL ORGANS. discharged from the uterus, he arrived at a different diagnosis from these facts : — 1st. The urine flowed steadily from the cervix when the bladder was empty. 2d. The urine thus flowing was limpid, unlike that from the bladder. 3d. The patient being kept seated over a vessel for two hours, so as to preserve all the urine flowing per vaginam, a catheter was passed into the bladder and the amount removed exactly equalled that which had escaped vicariously. •±th. Injecting the bladder with fluid colored by indigo, the urine passing per vaginam remained limpid. oth. A sound being passed into the uterus and another into the bladder, their points could not be brought into contact. Uretero-uterine fistula is by no means common. Dr. Bozeman informs me that he has rarely seen it, and not one instance is mentioned by Dr. Emmet in his recent work upon Fistulse. An interesting instance of union between the ureter and vagina, uretero- vaginal fistula, is detailed by M. Eobert, 1 of Paris, as the condition remaining after an operation by Dr. Bozeman at the Hotel Dieu. The following is his description of the case : — " The vagina then being dilated by means of a speculum we explored this canal. The milk injected in the bladder neither escaped into the vagina nor by the urethra. After prolonging the examination, however, we saw now and then a drop of clear urine escape from the vesico-vaginal wall at the point precisely where Dr. Bozeman had encountered the right ureter, and which he endeavored to avoid with the suture. This examination, there- fore, demonstrates in a positive manner: 1st. That the vesico- vaginal perforation is obliterated, since the milk contained in the bladder does not escape into the vagina. 2d. That the urine which wets the vagina from time to time is turned directly into the canal by the ureter, which was implicated by the suture not- withstanding the efforts of the surgeon to prevent it. We would 1 Bozeman on Fistulse, N. 0. Med. and Surg. Journal, March and May, 1860. Dr. Bozeman clearly recognizes this form of fistula as a result of the ordinary operation for the vesico-vaginal variety, explains the method of its occurrence, and describes his " usual plan for overcoming this obstacle," when he has reason to fear its occurrence from cutting of the ureter. UKINAKY FISTULA. 187 remark that the dribbling of the urine from the right ureter into the vagina is limited to a few drops, because of the compression that the cicatrix exerts over the former, which is found to be con- siderably diminished in size. 3d. Lastly, and this is the main fact, that the opening in the vesico-vaginal wall being four centi- metres in diameter, has been completely obliterated by the simple suture without having recourse to incisions to permit locomotion of the tissues, and notwithstanding too the presence of the ureter between the edges of the fistule." CHAPTER XI. FECAL FISTULA. Definition. — These fistulse, which are much less frequently met with than the urinary, consist in communications established between the vagina or vulva and some part of the intestinal tract. Varieties. — They may be recto-vaginal, entero-vaginal, or recto- labial; the first being the most common, and the second the rarest of the varieties. Causes. — The causes which produce them are almost identical with those which result in urinary fistulae, viz : — Prolonged pressure ; Direct inj ury ; Ulceration or abscess. The first of these may produce them, as it does those occurring on the anterior vaginal wall, by creating an intense inflammation which results in sloughing, or the intensity of the pressure may be so great as rapidly to destroy the vitality of the part. Such pressure is most frequently the result of difficult parturition, but in rare cases it may arise from badly-fitting pessaries or scyba- lous masses in the rectum. Direct injury by instruments used in delivery, or others em- ployed for removal of impacted feces, may evidently produce them. Ulceration or Abscess. — These pathological conditions much more frequently produce this than the urinary form of fistula. For the recto-vaginal variety stricture of the rectum is a fruitful source, the stricture producing a retention of fecal matters which excites ulceration that may extend to the vaginal canal. An abscess between the vagina and rectum may cause a communica- tion between the two, or burrowing towards one labium may open there and connect this part by a tract with the rectum. In the same manner a purulent collection has been known to make a junction between the caput coli and vagina. Lastly, syphilitic PHYSICAL SIGNS. 189 and cancerous ulceration may open a channel between the intes- tinal and vaginal canals. Symptoms. — The most prominent, often the only symptom which will attract the patient's attention, will be a discharge of offensive gas or fecal matter by the vagina. The amount which escapes will of course be governed by the size of the fistula, but the annoyance dependent upon the accident will not be so, for even the smallest quantity will be sufficient to render the patient utterly wretched by the offensive odor to which it gives rise. Physical Signs. — The patient being placed upon the back, the touch should be practised upon all the surface of the vagina. If the fistula be one of any magnitude, this will at once discover it. If not, careful exploration by the speculum will almost always do so. Sims's speculum should be introduced under the symphysis so as to lift the anterior wall of the vagina while the lateral walls are held aside by spatulse. Should visual exploration not reveal Examination for fecal fistulas. (Wielnnd and Dubrisay.) the opening, the rectum may be filled with tepid water colored with cochineal or indigo, and its escape carefully watched for. Prognosis. — Fecal fistulas are more likely to be spontaneously recovered from than those of urinary character, from the fact that they give passage to gaseous and semifluid excretions, and not to 190 FECAL FISTULA. an irritating fluid which is constantly dribbling away and keeping the fistulous walls from uniting. But even these are rarely re- covered from unless surgical aid be brought to their relief. Treatment. — Eecto-vaginal and recto-labial fistulas may be treated by the following methods ; — Cauterization ; Suture ; Incision ; Ligature. Cauterization may be effected by one of the strong mineral acids, nitrate of silver or the actual cautery. If the fistula be direct, any one of these may be employed. If it be indirect, touching with a probe, the point of which has been covered by a coating of nitrate of silver by dipping it in that substance when in a state of fusion, will be the most appropriate plan. After cauterization the rectum should be kept perfectly quiet by opi- ates, and a glass plug should be worn in the vagina. In cases of recto-labial fistulse, Prof. Simpson speaks in high terms of the injection of strong tincture of iodine through the fistulous tract. Suture. — This is practised upon the same plan as that which is followed in vesico-vaginal fistulas, with these exceptions, that the patient is placed in the position adopted in operating for stone, and that the speculum is so inserted as to elevate the anterior instead of the posterior vaginal wall. After the operation, the rectum, which should have been thoroughly emptied by enema before it, should be kept perfectly quiet by opiates for ten or twelve days. When evacuations are first permitted laxatives should be employed in order to avoid tenesmus, which might de- stroy the union of the lips of the fistula. The cure by suture is not applicable to cases of recto-labial fistula, but only to recto- vaginal. Incision. — Should the opening be near the sphincter ani, the recto-vaginal wall together with the sphincter may be incised so as to unite the two canals from the fistula downwards. A pledget of lint is then placed in the wound, which will heal from its deep- est portion. Prof. I. E. Taylor, of this city, has recently reported 40 cases, of which 36 or 37 were cured by a method for which he credits Dr. Ehea Barton, of Philadelphia, and which he thus describes: "The treatment consists in full and complete division of the whole sphincter ani, laterally, either by the use of the specu- SIMPLE VAGINAL FISTULJE. 191 kim ani, or simply by the finger introduced, and dividing the sphincter from within outwards, which I much prefer. Th e sphinc- ter ani is divided on the side (the left being the most frequent), where the external orifice is found. If the fistula is double, then divide the sphincter ani on both sides laterally. In all the cases operated upon the sphincter ani has closed up well and remained perfectly natural. The fistula externally, either in the vagina or on the labia, is not touched, either by caustics or suture. The rule which guides the surgeon at the present day, as proposed by Brodie, Syme, Curling, and Quain, where the internal opening in fistula in ano is high up, is not to disturb or touch it, but let it alone. Experience has taught that the internal opening in the case of fistula in ano, though two to three inches high up, will close, after the sphincter ani only is divided through to the ex- ternal orifice, and so it is with recto-vaginal and labial fistulae of the nature I refer to." Ligature. — This method consists in the passage of a silk thread, by means of a bent probe, through the fistula, so as to embrace the recto- vaginal septum between the fistula and the perineum. A silver ligature being then attached to one of its ends, is drawn into place by it and tightened every day until it cuts its way out. Entero- Vaginal Fistulae. Entero- Vaginal Fistula, which consists in a fistulous tract be- tween part of the intestinal canal above the rectum, and the vagina, is rare, and when existing should be looked upon as an artificial anus, the closure of which would be attended by danger. If the opening is direct and there be no tract leading from one canal to the other, this would not be the case, but if a tract exists, the closure of its vaginal extremity would probably result in abscess excited by fecal matters passing out of the intestine. Simple Vaginal Fistulae. Definition. — Under this head is grouped those forms of fistulous connection with the vagina which do not act as vicarious outlets for any neighboring organ, as, for example, peritoneo-vaginal, perineo-vaginal, and blind fistuhe. Peritoneo-vaginal Fistula has been rarely met with. "When it 192 FECAL FTSTUL-E. does occur it is attended by danger of descent of the intestine into the vagina, and entrance of fluids and air into the peritoneal cavity. One reason for its rarity is probably the fact that no ex- crementitious substance passing through it, it very generally dis- appears without becoming chronic. Should it not do so, no annoyance would arise from its existence, and it would be suscep- tible of immediate cure by suture. Perineo -vaginal Fistula may result from partial closure of a rup- tured perineum leaving a small orifice near the sphincter ani, or from penetration of the presenting part of the foetus through the perineum. It would be readily cured by incision, ligature, cauteri- zation, or injection, after the plan just pointed out in connection with fecal fistulas. Blind vaginal Fistulse are those which lead to a purulent collec- tion in some part of the pelvis. They will be fully treated of when considering pelvic abscesses, and nothing need be said of them here further than to recapitulate the principles upon which their treatment rests : 1st, dilatation of the fistulous tract by tents or incision ; 2d, exerting an alterative action on the walls of the abscess by iodine, iron, nitrate of silver, water, &c. &c. CHAPTER XII. GENERAL REMARKS UPON INFLAMMATION OF THE UTERUS. Importance, — He who desires to become conversant with the diseases peculiar to women, to fully comprehend their pathology, and to be successful in their treatment, will do well to make the thorough understanding of inflammation of the non-pregnant uterus the basis of his education in this department of medicine. It is true that many diseased states of the pelvic viscera of the female are due to other causes, but it is not less true that the majo- rity either take their rise in this, or in their progress become com- plicated by it, so that it forces itself constantly upon the notice of the Gynecologist as the keystone of the arch upon which rest his knowledge and usefulness. These facts were, to a certain extent, recognized by the physicians of the Grecian and Roman schools, but, judging from those of their works which have reached us, their appreciation of them did not compare in thoroughness with that of our century. After the revival of let- ters, the importance of the pathological view which gave to me- tritis such prominence and moment was almost entirely lost sight of until the beginning of the nineteenth century, when Recamier and Lisfranc reinstated it. It has been already stated that to Dr. J. H. Bennet we owe its dissemination not only in his own country but throughout America. A great diversity of opinion exists as to the pathological importance and the frequency of chronic metritis. The most experienced and eminent men of the medical profession in our day .are at variance concerning these points, and discussions, into which great acrimony has been allowed to enter, have been and are now being indulged in. In reference to this subject I shall make no exception to the rule which I have laid down for myself in this work, to avoid as much as possible the con- sideration of unsettled and debatable questions, but I cannot avoid a few remarks upon it. A great deal of the existing diver- 13 194 REMARKS UPON INFLAMMATION OF THE UTERUS. sity appears to me to be due to a misunderstanding of what is meant by the term inflammation, a term employed with too much latitude and not limited by a sufficiently succinct and comprehen- sive definition. By many it was, and, I think, is supposed to signify an increase in the vital processes; an exaltation of func- tion; a rapidity and excess of life. To no such condition would I applv it in these pages. On the contrary, I adopt the view of those who look upon it as an arrest of function ; an interference with vital action ; a checking of physiological processes, which, if carried far enough, invariably results in abnormal development or local death. Inflammation of the uterus, as of every other organ or part, consists in congestion which results in change of secretion, an alteration of nutrition, and sometimes a development of exube- rant, homologous tissue. It matters not whether this action be acute or chronic in its course, the characteristics of its existence are always those just mentioned as pathological evidences, while pain, increase of animal heat, and swelling constitute its rational symptoms. Should mere blood stasis exist, unaccompanied by the circumstances mentioned, congestion is the name applied to the condition ; while, if excessive generation of homologous tissue occur without appreciable congestion, alteration of secretion, &c, the term hypertrophy conveys the idea of excessive development uncomplicated by inflammatory action. Unquestionably, the greatest advances which have been made of late years in the elucidation of the processes of inflammation have been effected by the German school. By the labors of Vir- chow, Eecklinhausen, Cohnheim, Schultze, and others, much light has lately been thrown upon it, and I now propose to lay some of their views before the reader. Virchow 1 has established a group of connective tissues which comprises the fibrous, the mucous, the adipose, the elastic, the cartilaginous, and the bony. The component parts of these are cells which vary in shape and contents, and intercellular substance which has been proved by Eecklinhausen to be perforated by little canals which convey nutritious juices. The walls of the bloodvessels, arteries, veins, and capillaries, as proved by Oed- mansson, have between their epithelial investments apertures or 1 See Xeftel's interesting rtsumt, N. Y. Med. Record, p. 223 et seq. PATHOLOGICAL ANATOMY. 195 stomata which, by vascular distension, become opened and allow of more easy escape of the contents of the vessels. An inter- ference in the functions of circulation, secretion, and nutrition occurs in these parts as a result of, and really may be said to constitute the first stage of, inflammation, which consists in con- gestion and distension of the canals just mentioned, and a stasis or arrest of the elements of the blood. Such an interference some- times results from local influences, hence the trite maxim of our forefathers, " ubi irritatio ibi fluxus ;" sometimes the nerves governing capillary circulation, nutrition, and secretion are disturbed by an influence reflected from some central cause; again, vascular derangement occurs without connection with the nervous system. " It is certainly true, as maintained by Virchow," says Brown-Sequard, 1 "that nutrition and secretion, normal and abnormal, can be carried on without the intervention of the nervous system ; but this does not at all prove that that system cannot interfere, for good or for evil, in nutrition and secretion in the various tissues and organs. For instance, there is no doubt whatever that an inflammation, followed or not by suppu- ration and ulceration, can take place without any intervention of the nervous system; but there is no doubt, also, that the same morbid processes, not only can be, but very frequently are, produced by a nervous agency." Whatever be the pathological condition resulting in impairment of capillary circulation and coincident disorder in nutrition and secretion, Cohnheim 2 has demonstrated, by vivisection, the follow- ing steps in inflammation. First, the arterioles begin to dilate and become tortuous, and soon the venules do likewise ; this is followed by retardation of the circulation and aggregation of the white corpuscles on the walls of the vessels. This retardation, dependent as it is on want of tone, almost paralysis, in the mus- cular coat of the vessels, distends these still more fully, opens their stomata, and through these ooze the plastic elements of the "blood, 3 an amorphous fibrinous matter, and also pass many of 1 Diagnosis and Treatment of Functional Nervous Affections, p. 21. 2 Revelations on Inflammation, &c, by M. Cohnheim, Loudon Lancet and Med. Times and Gazette. 3 The passage of fibrin from the vessels is denied by Virchow, who declares that all fibrin found outside the blood is "a local production." But this subject is one requiring too much space to admit of treatment here. 196 REMARKS UPON INFLAMMATION OF THE UTERUS. the white and a few of the red corpuscles of the blood. The white corpuscles soon pass out in great numbers and become pus cells. All this, even when the type of the action is acute, belongs to want or depreciation and not to increase or excess of vitality, When the process is of acute type, suppuration soon occurs, and disintegration of plastic effusion is at an early period followed by discharge ; or the semi-paralyzed vessels recover their tone, the stagnant circulation is restored to a healthy state, and the effused materials either become organized or are absorbed. But neither one of these terminations may occur. Instead of them the vessels may remain for an indefinite time varicose or distended, an abnormal supply of nutritive material may be fur- nished to the cellular and intercellular substances, and prolifera- tion or excessive growth of connective tissue be the result. Such a pathological process as that which I have just described is that which, in my opinion, constitutes the disease which we designate chronic metritis. The affection, although sometimes arising from mechanical conditions, which result in arrest of cir- culation, is more frequently due to some peripheric or central cause which produces a loss of power in the vaso-motor, incito- secretory, and incito-nutritive nerves. This, however, only accounts for the inception of the difficulty. Yery soon varicose vessels, distended intercellular ducts, and effused blood elements offer themselves as parts of the condition, and as complications which prevent return to a normal state. As will be stated elsewhere, acute parenchymatous inflam- mation of the uterus is an extremely rare affection, so rare indeed that some authors have denied its occurrence. So also have many refused to accord the name of chronic inflammation to that which I have described. Kiwisch treats of it as " infarctus ;" Klob as " Diffuse growth of connective tissue," while many others style it " congestion." I do not contend for a name. Every Gynecologist must very often have met with the condition which I have described and called chronic metritis. So long as each remembers the fact that the process presents nothing in its nature which is acute, and that antiphlogistic means are not necessarily called for in its management, no evil will result from our un- certainty as to nomenclature. Klob objects to the use of the term "infarctus," and also to that of "chronic inflammation," PARTS AFFECTED. 197 and looks upon the diffuse growth of connective tissue, with its consequent uterine enlargement, as the result of habitual hyper- emia. It is to this " habitual hyperemia," when accompanied as it usually is by altered secretion, derangement of function, pain and excessive development, that I prefer to apply the name of chronic metritis. Some of those who are most opposed to viewing this condition as chronic inflammation have invoked, as proof of its not being so, the fact that harsh treatment is employed, unlike that which is resorted to in inflammation elsewhere. No one denies an in- flammatory character to orchitis, yet at an early period of the disease firm pressure is employed in its subjugation. No one views granular lids as an affection free from inflammation, yet even solid lumps of sulphate of copper are rubbed over them. ISTo one asserts that the granulating surface of an old ulcer of the leg is not kept up by inflammation, yet we cauterize this, and exert great pressure upon it by compressed sponge, plates of tea lead, adhesive plaster and bandages. Even the first stage of a furuncle may be aborted by firm and constant pressure from a disk of compressed sponge and a well-adjusted bandage, yet all view this affection as the perfect type of a phlegmon. Parts Affected. — The parts of the uterus which may be affected by inflammation are, first, the mucous lining, and second, the parenchyma. The morbid action may limit itself to either one of these, though it rarely does so strictly, one usually, to a greater or less extent, complicating the other. But not only may the disease limit itself to one or other of these tissues ; it very gene- rally confines itself to one portion of the affected organ, the neck or the body being the part forming its habitat. A transverse section of the uterus passing through the os in- ternum divides the organ into two distinct parts, which are dis- similar not only in anatomical but in physiological and patholo- gical peculiarities. This makes a separate consideration of the diseases of the two parts, and an appropriate nomenclature neces- sary both for convenience and for facility of comprehension. If the mucous lining of the organ be diseased, the term endometritis has been applied to the condition, and if the parenchyma be the site of the morbid process, that of parenchymatous metritis, or simply metritis, designates it. But each of these forms must be divided into two others, according to the portion of the uterus 198 REMARKS UPON INFLAMMATION OF THE UTERUS. affected, and the varieties of metritis may be clearly expressed in the following manner : — Varieties of uterine inflammation. f General ; Endometritis •< Cervical ; ( Corporeal, r General ; Metritis -\ Cervical ; ( Corporeal. Some important facts connected, with the varieties of metritis may be thus stated in propositions : — ■ 1st. The cervix is much more frequently affected by inflamma- tion than the body* of the uterus. This was first insisted upon by Dr. Bennet, and its substantiation constitutes the marked feature of his work on the uterus. 2d. Metritis, whether cervical or corporeal, is generally the result of parturition or abortion. 3d. Cervical metritis, which is very common in matrons and multiparas, is rare in nulliparae, and extremely rare in virgins. 4th. The form of uterine inflammation most commonly met with in virgins and nulliparae is corporeal endometritis. This view, of the truth of which I have long felt satisfied, I regarded as original, until I met with it clearly and' fully stated in the ■works of Nonat and Aran. 5th. In their acute forms both the mucous and parenchymatous varieties are apt to invade the whole of the structure first affected, but in their chronic forms this is not so. The body or the neck may be alone affected for years ; in the one case the morbid pro- cess not coming down below the os internum, and in the other not ascending above it. Prognosis in Uterine Affections. — There is no organ of the body the inflammatory diseases of which offer greater difficulties in prognosis than those of the uterus. So much depends upon the habits of the patient, the injurious influences to which she is ex- posed, and the faithfulness with which she follows out the direc- tions of the physician, that often very little can be predicted, very little promised with any certainty. The error into which the incautious practitioner is most likely to fall is that of predicting a cure at too early a period, and fixing some definite time for its accomplishment. The patient may declare that she and her PROGNOSIS IN" UTERINE AFFECTIONS. 199 friends will be satisfied even if the limit be fixed not by months but by years, nevertheless she is desirous of knowing when she may confidently expect a cure. The answer to this question, not in the lesser interest of the practitioner, but in the greater one of the patient, must often be that no such time can possibly be de- termined upon. In some cases it becomes necessary to state further that not only is the time but the certainty of complete cure doubtful; that local treatment will cause pain, may result in danger, and may absolutely aggravate the existing symptoms. Another point which influences prognosis is this: in the man- agement of uterine diseases it is of primary importance that the practitioner should enlist the interest and co-operation of his patient. Should she be apathetic with regard to the result, or even having begun treatment with enthusiasm, become disaffected from any cause, his duties will probably prove irksome, annoy- ing, and fruitless. For this reason he should be cautious in urg- ing with too great earnestness the adoption of local treatment. In view of this and the additional fact that treatment may extend over months, and perhaps occupy years, before a cure is effected, the physician should avoid all resources which by their uncleanliness or disagreeableness may disgust a refined patient, or make her rather willing to bear her disease than the means adopted for its cure. If such means will be very likely to give relief, they should of course be employed; but if, as is the case with many of them, their efficacy is extremely doubtful, they should not be insisted upon. For example, if a lively, fastidious lady were called upon, for the relief of an endometritis which is not in itself very annoying, to forego society and spend most of her time in bed; to fill the vagina daily with a semi-solid mass of powdered linseed after the method of Melier ; to rub mercurial ointment over the hypogastrium, and have a weekly application of leeches around the anus, she would probably in time get tired of the treatment, and lapse into the very state of apathy to Avhich I have alluded. There is one class of cases in dealing with which I should especially recommend that perfect frankness be observed. It may be represented by a patient who has been persuaded by hus- band, mother, or friends, contrary to her wishes, to submit to treatment. She utterly repels the course to be adopted, is sure that it will do her no orood, is unwilling to fulfil the directions 200 REMARKS UPON INFLAMMATION OF THE UTERUS Fig. 69. left her for daily guidance, but yields, under the assurance of her advisers that the treatment will be free from discomfort, give no pain, and will surely cure her in a few weeks. The physician, for the sake both of his patient and himself, should avoid joining in this deception. Stating the facts fully to her, telling her of the danger which neglect will involve, and of her duty under the circumstances, he should appeal to her reason, and decline to take charge of her case until she really desires his services. There is a general rule which I have kept before me as a guide to prognosis, and which has so rarely failed me that I urge it upon the attention of the reader. If the disease affect that part of the uterus below a line running across it at the junc- tion of the neck and the body, it matters not how grave the affection, either of mu- cous or parenchymatous tissue, if it be not of malignant type, a prospect of cure may be held out. Should the morbid action exist above this line, even if it present no features of special gravity, the physician should be cautious in his promises of cure, and fix no limit as to time. It is true that recent cases, and sometimes even old ones, of corporeal endometritis and metritis may be cured ; but in those which are recent, cure is always very difficult, and in those which are chronic often impossible. Reasons for the Frequency of Failure in the Treatment of Uterine Diseases. — That some uterine affections of non-malignant type are incurable cannot be denied ; but even putting these out of con- sideration, the fact is notorious that the local treatment of these diseases is not as successful in its results as we could wish. I now propose an investigation into the causes of this want of success. It appears to me that the most apparent and most constant of them may thus be summed up : — Imperfect diagnosis; Erroneous prognosis ; Inefficient or inappropriate therapeutics ; Inattention to general management. A represents the dividing line between body and cervix. PROGNOSIS. 201 Imperfect Diagnosis. — It is not rare to meet with instances in which physicians have, for months, treated cases of uterine disease concerning the nature of which they not only did not have a correct theory, but had no theory at all. Under these circum- stances the most general practice is to pass, about once a week, a solid stick of nitrate of silver up to the os internum, not to cure cervical endometritis, for that has never been suspected, but to do the best one can in the way of treatment when he does not know the nature of the disease which he treats. I have no incli- nation to attribute this to any intentional laxity of morale, but rather to indecision and aversion to creating a disagreeable issue with the patient. It is, however, impossible to deny the fact that such a course will sometimes be pursued by those who in the case of a diseased eye, or inflamed knee-joint would not hesitate to con- fess, with the utmost frankness, their uncertainty and need of assistance. With uterine as with all other diseases the diagnosis must be properly made before treatment can prove curative. Erroneous Prognosis. — Even if the diagnosis and treatment be correct, an erroneous prognosis as to time of cure may so sap the confidence of the patient as to send her to other counsel. And now she may run the gauntlet of theories and therapeutics. Her first attendant having recognized corporeal metritis with result- ing displacement, the second may treat the displacement alone, as the origin of her symptoms. Passing into the hands of a third, she may be told that to check her profuse leucorrhcea would be to cure her disease, which the fourth might contradict, with the assertion that the uterine disorder was only a complication of ovaritis, which was the fountain of all her difficulties. Inefficient or Inappropriate Therapeutics may cause failure in cure even when a proper diagnosis and prognosis have been made. At times a too gentle course of local alteratives may be perse- vered in when disease of the parenchyma demands more vigorous caustics. At others it is necessary to carry the caustics up into the cavity of the body, and not of the neck alone ; and at others still, to perform a trifling surgical operation to remove a difficulty which, unless removed, may keep up the disease indefinitely. The best results in the management of these affections will not follow a direct resort to treatment of the most prominent existing disease, but will very often be obtained by removal of its cause, or the alleviation of its complications. Let me make my moan- 202 REMARKS UPON INFLAMMATION OF THE UTERUS. ing clear by some examples. The physician examines and finds metritis or endometritis to exist with its usual symptoms, leu- eorrhcea, pain, menstrual disorders, &c. This affection may be the result of an antecedent displacement. If it be so, replacing and retaining in position the displaced organ, should be the first step in treatment, as it was the first step in diseased action. Causa non sublata tollitur non effectus is as true as the converse proposi- tion. Again, a patient has menorrhagia and prolonged menstrua- tion with a long, contracted cervix uteri. Obstruction to the ready escape of menstrual blood often so alters the lining mem- brane of the body of the uterus as to create these disorders. If the physician treat the symptom, he will surely fail in curing it, while success will attend his efforts if he removes the obstruction which prevents the uterus from emptying itself. So also with the complications which are excited by uterine disorders. A patient is affected by cervical endometritis that in time produces cervical metritis, which by increasing uterine weight displaces the uterus. That organ lying upon the floor of the pelvis is injured by locomotion and coition, its lower segment is bathed in purulent leucorrhoea, and great pelvic pain annoys and harasses the patient. If the practitioner expect to cure her, let him at the same time that he treats the primary disease, the metritis, relieve a set of complications which, unless removed, will cause repeated relapses as often as he approaches the accomplish- ment of his end. One more example may be cited before concluding these remarks. A displacement of the uterus exists, and the practi- tioner knows that it has been due to one of two influences, either increase of uterine weight, or loss of uterine support. Which was primary he cannot determine, for at the time of his examination both exist. To effect a cure it would be the part of wisdom not to limit treatment to one, but simultaneously to treat both by giving artificial support/and diminishing uterine weight. "With- out being able to say which is the original disease and which the complication, he should endeavor to relieve both at the same time. Inattention to General Management and Hygiene. — The statement which we often meet with, that the majority of the cases of uterine disease require no local treatment whatever, is a fallacy, based upon strong prejudice against one of the most important modern improvements in medicine, or upon want of experience in such GENERAL MANAGEMENT AND HYGIENE. 203 cases. But too much stress cannot be laid upon the advantages to be derived from constitutional treatment and the general man- agement of these cases. We too often fail to insist upon rest, cessation of marital intercourse, quietude after applications to the uterus, and other points, a neglect of which may exert a powerful influence for evil, and frustrate the effects of all that is done by local means. Astruc begins his directions for treating uterine ulcers by ad- vising — " To charge the patient to abstain from all kinds of exercise and to keep constantly laid down on a long seat." " It is for the same reason fit, in the case of a married woman, that she should lie separately from her husband." " They should for the same reason guard against all the passions of the mind that may agitate it, as grief, uneasiness, and anger, &c." This advice, given over a century ago, is often neglected to-day, and too much reliance placed upon local means, and upon them alone. Every one who has had experience in the treatment of these disorders must have been struck with surprise at the wonder- ful improvement exerted "upon cases, which have long resisted local means, by a sea- voyage, a visit to a watering-place, a course of sea-bathing, or a few months passed in the country. Not only is this improvement manifest in the general state of the patient ; it shows itself locally, also, and in some cases complete recovery may be thus attained. The same fact is equally noticeable in old ulcers of the leg ; local means, the efficacy of which in such cases, no one doubts, having failed in producing good results, entire recovery is effected by means, such as those alluded to, which act upon the constitution. It should not be forgotten by the Gynecologist that chronic local inflammation is often caused by a general depreciation of the system. In some cases the lungs undergo chronic pneumonic consolidation, which often goes on to phthisis; in others, chronic corneitis or granular lids occur; while, in others still, cervical endometritis marks the altered constitutional condition. When such a result takes place, the two states continue to react one on the other. The depraved system increases the local disorder to which it has given rise, and the irritation, kept up by the latter, aggra- vates the degree of the former. This being true, it would evi- 204: REMARKS UPON INFLAMMATION OF THE UTERUS. dently be irrational to treat one of the two existing pathological conditions without having due regard to the other. Some cases of metritis, however, more especially those forms which affect the parenchyma, occur in women who are apparently in good health, and are usually the consequences of parturition or abortion. But cervical, and even corporeal endometritis, the latter of which may go on to granular degeneration, will generally be found to have engrafted themselves upon a depreciated system. The following case is illustrative of this view. Dr. Alfred !E. M. Purdy brought to my office, for examination, a patient who had two uteri and two distinct vaginas. As I proceeded to exa- mine, he stated that the right uterus was affected by granular ulceration. I discovered, however, that both were thus diseased. Dr. Purdy had not examined for some weeks, and, during this period, the general state which had produced disease in one uterus had effected the same change in the other. It may with justice be objected that both may have been produced by a local cause. None such could be discovered, the patient having been exposed to no local influences which had not existed for years previously. CHAPTER XIII ACUTE ENDOMETRITIS. Synonymes. — Acute uterine leucorrhoea, acute uterine catarrh, acute internal metritis. Frequency. — Acute inflammation of the lining membrane of the uterus is a condition which occurs quite frequently. Often run- ning a rapid course, however, and ending in recovery or chronic disease, it passes unrecognized in many cases. In this way I would explain many of the cases of suppressio mensium and con- gestive dysmenorrhea, which we so often find ending in chronic disease. And thus also would I account for the profuse and painful attacks of leucorrhoea occurring with exanthematous fevers, and lasting for a length of time after they have passed off. It is very generally stated that acute metritis is seldom met with except as a sequel of parturition, and I agree in the statement as applying to parenchymatous inflammation, but it is incorrect as regards endometritis, which often proves the source of sudden menstrual disorder and the cause of violent leucorrhoea. Varieties. — The morbid process may affect the lining membrane of the cervix or of the body alone, or it may attack the whole uterine mucous tract, its selection of site being governed by its cause. Thus, that form which immediately follows parturition or abor- tion or results from gonorrhoea, is likely either to affect the whole mucous tract or the cervical canal alone ; while that which is due to sudden checking of the menstrual flow is generally confined to the body. Causes. — The causes of acute endometritis are as follows : — Direct injuries ; Acute vaginitis ; Certain constitutional diseases ; Interference with the menstrual flow : Parturition ; Evacuation of retained menstrual blood. 206 ACUTE ENDOMETRITIS. Examples of direct injuries which may produce acute endo- metritis are the introduction of the uterine sound or the intra- uterine pessary, the employment of tents or the application of chemical irritants. Specific vaginitis or gonorrhoea will sometimes pass up into the cervix and body of the uterus, and out through the Fallopian tubes, creating pelvic peritonitis of most violent character. Even simple vaginitis, when of very severe form, may do so, though this is by no means common. The peculiar blood state, attending upon and forming an ele- ment of measles, scarlatina, variola, and roseola, and its influence on all the mucous linings of the body, will sometimes result in general endometritis, and the hasmic condition resulting from phthsis not rarely does so. Exposure to cold and moisture, great mental anxiety, or any other influence which suddenly checks the menstrual flow, very frequently produces this disease. At the moment of exposure what is termed suppressio mensium, or congestive dysmenor- rhoea, may take place, and from that time endometritis exists. When we consider that such a sudden check of menstruation will sometimes result in hematocele of fatal character, it is cer- tainly not to be wondered at that it may likewise produce the disease of which we are speaking. Parturition of normal type is a well known cause of general endometritis. In some cases it may, however, produce cervical disease alone, the body being unaffected. It is much more fre- quent after unnatural deliveries, or where the parturient act has been frequently repeated, or has occurred in one who previously suffered from chronic endometritis. It is a well known fact that when menstrual blood is retained for a long time in utero by an obstruction in the vagina or at its mouth, by an imperforate hymen, for example, the severance of the occluding medium and admission of air will often result in endometritis of dangerous and even fatal character. Such cases appear to resemble very closely the septic endometritis which occurs after parturition, and constitutes the first step towards puerperal fever. Symptoms. — The disease demonstrates its presence in the non- pregnant uterus without any very violent symptoms. Ordinarily the patient complains of pain, weight, and dragging COURSE, DURATION, AND TERMINATION". 207 in the pelvis; pain in the back, groins, and thighs; and vesical and rectal tenesmus. After three or four days there is usually a discharge of a viscid liquid which rapidly becomes creamy, puru- lent, and perhaps bloody; tympanites and sensitiveness upon pressure, and uterine tenesmus or " bearing-down pains." Physical Signs. — An examination by touch reveals the vagina hot and dry or covered by the discharge noted above. The os uteri is found gaping, the cervix swollen and very sensitive to pressure, the body slightly enlarged, and the whole organ lower than its normal position in the pelvis. Through the speculum the cervix is found to look swollen, oedematous, and red, and from the pouting os pours forth either a clear, albuminous looking fluid, muco-pus, or long tenacious shreds of cervical mucus. The probe, if used at all, should be employed with great caution. It will discover great sensitiveness throughout the uterine cavity, and the slightest touch upon the fundus will cause a few drops of blood to flow. Indeed, so great is the engorgement that the speculum will often cause blood to flow from the cervix. Differentiation; — The only diseases with which this would with any probability be confounded, are pelvic cellulitis, peritonitis, and acute vaginitis. Physical exploration would so easily settle the point that it requires no further consideration. Pathology. — In its first stage acute endometritis consists in an intense and active hyperemia of the mucous lining of the uterus, which is red, swollen, oedematous, and softened. Its surface is spotted, Scanzoni declares, from congestion of a capillary network around the mouths of the utricular follicles. When the second stage has set in, the cavity of the uterus is found to contain an excess of mucous or creamy looking pus which may be more or less mingled with blood. If the cervix be involved in this in- flammatory engorgement, the mucous membrane of the vaginal portion of the cervix participates markedly, as an examination by the speculum will prove. In the mucus just described the microscope reveals the presence of thousands of cells and sometimes entire casts of the utricular follicles. Gomjjlications. — The complications of the disease are urethritis, cystitis, vaginitis, salpingitis, and sometimes pelvic peritonitis. Course, Duration, and Termination. — Acute endometritis, when occurring in the non-pregnant state, may, without treatment even, go on to recovery, generally lasting from a month to six weeks, 208 ACUTE ENDOMETRITIS. and perhaps passing through its whole course without its exist- ence having; been ascertained. It sometimes ends in the chronic form of mucous inflammation or even in metritis, the superficial layers of the subjacent parenchyma becoming affected. Indeed, I doubt very much if any case of severe endometritis runs its course without being to a greater or less extent complicated by a slight degree of metritis. As already stated the disease may end in chronic endometritis or in recovery. It may, likewise, end in death ; inflammatory action spreading along the Fallopian tubes and causing salpingitis, which, by resulting in free purulent dis- charge into the peritoneum, may establish inflammation there. Prognosis. — In spite of all these possibilities the prognosis is always favorable if the patient take ordinary care of herself and yield to a judicious plan of treatment. Treatment. — The diagnosis having been clearly made, treatment should be at once established. Complete rest of mind and body should be regarded as essential points, the woman being kept quiet in bed. A few ounces of blood may be taken from the cervix or perineum by leeches, at intervals of three or four days, should there be severe pelvic pains, the patient be plethoric, or suppressio mensium be present ; and twice or three times every day a stream of water, at a temperature of 100° Fahr., should be thrown, by means of a syringe with continuous jet, against the cervix. The bowels should be regulated by saline cathartics, unless diarrhoea exist, and all beverages likely to irritate the bladder be avoided, as, for example, alcoholic stimulants and strong coffee and tea. Warm fomentations should be applied to the hypogastrium, and, should pain exist, anodynes should be administered by the rectum or vagina. Of the two channels I prefer the former, though in some cases great relief may be obtained from a suppository of opium or belladonna applied directly against or within the cervix. After the severity of the attack has been subdued and examination by the speculum becomes to a certain extent painless, the vaginal portion of the cervix and the whole cervical canal should, if this be the part of the organ chiefly affected, be painted over with a solution of nitrate of silver, about one scruple to the ounce of water, and this may be repeated twice a week with advantage. Under this plan of treatment the patient should be kept until recovery, or until we are admonished by time that the disease has passed into its chronic form and requires different remedies. CHAPTEE XIV. ACUTE METRITIS. Definition and Synonymes. — By this term is designated acute inflammation of the parenchyma of the womb, in contradistinction to that of its investing membrane. As already stated, neither disease ever occurs and runs its usual course without, at least to a limited extent, producing the other. In treating of them after the plan here adopted it is intended to convey the idea that, in certain cases, one or other structure is the main point of attack, and dis- ease of the adjoining tissue only a complication. Frequency.— -With reference to its frequency many conflicting statements will be found. This arises partly from the fact that some have written of the affection without making any distinction between the forms occurring in the puerperal and non-puerperal states, while others have confined their remarks, as is here done, to diseases of the latter condition ; partly from endometritis, active congestion from suppressio mensium, and pelvic cellulitis having been mistaken for metritis ; and in great part from the difficulty of gaining post-mortem evidence, the disease generally being recovered from. My own experience leads me to regard it as of extremely rare occurrence, since I have met with it but twice in a practice which has afforded abundant opportunities of seeing uterine disease. One of these cases resulted from slitting one wall of the cervix uteri up to the vaginal junction, and the other from the use of a badly fitting pessary. I have, however, seen numbers of cases which were regarded by others as of this character, and quite a number which I viewed as such until en- lightened by post-mortem or other evidence. Kokitansky de- clares that, " in acute inflammation of this organ, generally the lining membrane of the uterus is affected primarily, and that this is scarcely ever the case with the uterine tissue, as far as can be demonstrated by the pathological anatomist, with the exception 14 210 ACUTE METRITIS. of the reaction following traumatic influences, especially of the vaginal portion.*' In his recent work Klob 1 takes still stronger ground as to the existence of uncomplicated metritis, and asserts that never hav- ing met with an instance of the disease, * he is forced to describe it upon the authority of others. Some practitioners are prone to regard every case of inflam- matory action in the pelvis, accompanied by great tenderness over the uterus, as metritis. Such cases are much more frequently due to pelvic cellulitis or peritonitis, which are by no means rare affections, or to active congestion, caused by suppression of the menses or excessive coition. After parturition, either at term or premature, true metritis does occur not unfrequently, but this variety does not concern our present investigation. As regards that form which we are considering I feel convinced that if the experienced practitioner will put aside his preconceived views and interrogate the results of his observation, he will find, if he has had his attention aroused to the frequency of the diseases which simulate it, that he has met with this affection very rarely. Let it be borne in mind that as a complication of endometritis there is sufficient inflammation of the parenchyma to produce enlargement, pufnness, and sensitiveness, and that a differentia- tion of the affections, to be reliable, must be made with care. Varieties. — No varieties of acute metritis can be based upon the part of the organ attacked, for it is confined to no special portion, but affects the entire parenchyma from the cervix to the fundus. A distinction should, however, be made between the puerperal and non-puerperal forms, on account of their dissimi- larity in frequency, severity of symptoms, prognosis, and ter- minations. Causes. — The chief causes for the disease in the non-pregnant uterus are : — 1st. Mechanical injuries — from operations on the uterus, va- gina, or bladder; excessive or intemperate cohabitation about the menstrual epoch; the use of intra-uterine or vaginal pessaries; dilatation of the cervix by tents ; the careless use of the uterine sound, or attempts at removal of growths from the body of the uterus. 2d. Sudden suppression of the menstrual flow from any cause. 1 Op. cit.,p. 227. PHYSICAL SIGNS. 211 3d. Endometritis, whether its cause be vaginitis, specific or simple, or any other of those mentioned in the last chapter. 4th. Morbid growths in the parenchyma of the uterus, whether cancerous or fibroid. Symptoms. — It is generally stated that the disease announces its invasion by a chill. In the cases which I have seen this has not been the fact, and should an attack be thus ushered in, I should strongly suspect cellulitis or pelvic peritonitis. In the beginning, violent pelvic pain, accompanied by vesical, rectal, and uterine tenesmus, comes on, sometimes with nausea, vomiting, and diar- rhoea. The pain soon becomes agonizing, extends down the thighs, and is very much increased by the passage of feces through the rectum. Should the complication of endometritis be present in any marked degree, a glairy, tenacious and gummy flow will appear, which rapidly becomes purulent and creamy. Should it not exist, no vaginal discharge will take place, unless the disease occur during menstruation, when monorrhagia may show itself. All these symptoms will merely lead us to suspect the existence of metritis. The complete diagnosis will depend upon physical signs for its establishment. Physical Signs. — When pressure is made over the uterus great sensitiveness is found to exist. The finger introduced into the vagina discovers the organ lower than its normal position in the pelvis, the cervix enlarged and swollen, and the os dilated, and pressure upon the cervix gives great pain, as it does also when practised against the body in the fornix vaginae. This last symp- tom is still more clearly developed by rectal touch and conjoined manipulation, which generally detect the body of the uterus press- ing back upon the bowel. The passage of a speculum will gene- rally be attended by some pain, but it may, if necessary, be em- ployed. Should it be introduced, the cervix uteri will be seen to be swollen and the os gaping. The vagina will be hot and dry, unless bathed with purulent material discharged in consequence of endometritis. Differentiation. — The disease must be differentiated from peri- tonitis, cellulitis, endometritis and active congestion. From the first two it will be known by mobility of the uterus, which would be fixed if they existed; by sensitiveness being confined to the uterus, and not existing over the pelvis, and by enlarge- ment and tenderness of the os and cervix. If the case be one 212 ACUTE METRITIS. of endometritis, it will be known by the fact that the uterus will not be found markedly enlarged, nor so exquisitely sensitive upon pressure; the constitutional signs will not be so grave, and there will be the peculiar discharges marking this disease. From active congestion of violent character in its early stages, I know of no means of differentiation. The diagnosis must be determined by the subsequent progress of the case. Pathology. — The first stage of acute metritis is one of active congestion. The bloodvessels of the parenchyma become dis- tended, press upon the intervening nerves, and produce enlarge- ment of the uterus and pain. A blood stasis exists similar to that constituting the first stage of inflammation in other organs of the body. This is soon succeeded by the second stage, which consists in the exudation of organizable lymph, which being poured out into the interspaces of the muscular fibre rapidly becomes organ- ized, thickening the walls of the uterus and often indirectly pro- ducing displacement. The excessive amount of nutritive mate- rials furnished to the tissues results in a proliferation or abnormal growth of their component parts. It is very rare for suppura- tion to occur and abscesses to form subsequent to this as a third stage, though in a few exceptional cases such a result has taken place. Cases of this character are recorded by Depaul, Scanzoni, Eeinmann, and Bird. Complications. — It may be complicated by inflammation of any of the tissues most proximate to it. Peri-uterine cellulitis, peri- tonitis, endometritis, cystitis, or rectitis, sometimes occurs. Course, Duration, and Termination. — Its course is not lengthy, recovery or a passage of the affection into the chronic form being generally arrived at in a fortnight or three weeks. It may end in one of three ways : by resolution, formation of abscess, or pass- age into chronic metritis. The occurrence of the last termination is denied by Klob. Treatment. — As soon as the disease has been recognized the patient should be placed upon her back in bed and not allowed to leave it or to sit up upon any pretext, not even for evacuation of the bladder or rectum. Perfect rest should be insisted upon as an important element in the curative process. Warm poultices of flaxseed or corn meal should be laid over the hypogastrium, or, instead of these, towels wrung out of hot water and covered by oil-silk may be used. Should these be inconvenient on account TREATMENT. 213 of weight, the artificial poultice called spongio-piline, which con- sists of a thick layer of wool and sponge woven together and covered by a thin layer of India rubber, may be made to replace them. A speculum should then be passed with great care, the os uteri plugged by a morsel of cotton, and a sufficient number of leeches applied to the cervix to abstract the amount of blood deemed advisable in the special case, or instead of this leeches should be applied to the perineum. Pain should be relieved by opiates administered either by the mouth or rectum, or a supposi- tory of three grains of opium or one grain of extract of bella- donna may be deposited just within the cervix uteri. Under this treatment, combined with restriction to mild un- stimulating diet, the disorder will generally subside very rapidly, but great care should be exercised with reference to allowing the patient to resume her usual avocations, for carelessness in this respect may result in her becoming a sufferer from chronic metri- tis. For the purpose of preventing this, sexual intercourse, severe exercise, exposure during menstruation, &c, should be carefully avoided for some time after the apparent termination of the exist- ing affection. The practitioner should daily watch for the spread of inflam- matory action to the pelvic areolar tissue. Should it be detected, a blister should at once be applied over the hypogastrium, pre- ceded, if it be thought advisable, by a few leeches. It may be objected to this plan that a blister should not be applied during the existence of acute inflammation. I have never seen one used under these circumstances aggravate the symptoms and fre- quently noticed an amelioration from its employment. CHAPTEE XV. CHRONIC CERVICAL ENDOMETRITIS. When inflammation of acute character affects the uterus it has a marked tendency to invade the entire organ, and to involve both cervix and body, but with chronic inflammation this is not the case. Being of a lower grade of intensity, it more strictly confines itself to one tissue, either mucous or parenchymatous, and limits itself to the body or cervix. Such limitation is neither universal nor absolute, sometimes adjoining parts being more or less implicated and at others the entire organ being simultaneously and equally involved. Although it might be more in accordance with literary pro- priety and taste to describe, first, inflammation of the mucous membrane of the body and cervix, and then that of the paren- chyma, it will prove more useful for the student whose familiarity with the subject is not great, to speak first of the diseases affect- ing the lower segment of the organ, and subsequently, of those of the upper. Beginning, then, with inflammation of the mucous membrane, and subsequently taking up that of the parenchyma, we will study the morbid states of that portion of the uterus existing between the os externum and os internum, and having accomplished this, we will proceed to investigate those of the body of the organ. Definition. — By the term chronic cervical endometritis is meant chronic inflammation of the mucous membrane, extending from the os internum through the os externum and over the vaginal portion of the cervix uteri, as represented by the dotted lines in Fig. 70. Between inflammation affecting the vaginal surface of the cervix and that occurring within the canal there are many points of dif- ference ; so marked are they, indeed, that M. Nonat has been in- duced to make two varieties of the affection. The disease may NORMAL ANATOMY. 215 be, and commonly is, confined to one of these parts. When it occurs on the vaginal face of the cervix, friction and other influ- ences often produce granular or cystic degeneration; and parenchymatous inflam- mation is more likely to occur from the same causes. In spite of this I deem it best to define the disease as I have done above, relying for completeness of descrip- tion upon a subsequent chapter devoted to what is commonly termed ulceration of the os uteri. Frequency. — Of all diseases of the geni- tal system of the female this is without doubt the most frequent, and although not in itself a malady of dangerous character may prove the starting point for some of the most serious and rebellious of uterine disorders. Exposed as the cervix uteri is to injury during coition, laceration from parturition and irritation from walking, riding and lifting,, it is not surprising that its complicated investment should frequently become the seat of disease. Synonyrnes. — Tt has been described under the names of cervical catarrh, cervical leucorrhoea, and endo-cervicitis. Normal Anatomy of the Cervical Mucous Membrane. — The cavity of the cervix uteri is a fusiform canal, measuring about one inch and a quarter, beginning at the os internum above and ending at the os externum below. Dr. H. Bennet lays great stress upon the fact that the division of the uterus into two cavities, accomplished by the os internum, is very complete. He objects to the diagram of Dr. Quain, given in Fig. 71, and offers the representation in Fig. 72 as more correct. The internal os in the virgin uterus is represented by Dr. Bennet's diagram, while that of Dr. Quain more faithfully repre- sents that of the multiparous organ. The fact pointed out by Dr. Bennet attracted the attention of the ancients. 1 " Many of the ancient authorities describe the uterus as consisting: of two cavi- The dots represent the site of chronic cervical endome- tritis. Tbeopliilus, Com. on Hippocrates, Aph. ii. p. 469, Ed. Dietz. 216 CHRONIC CERVICAL ENDOMETRITIS. ties separated from one another by a membrane." On the ante- rior and posterior walls of the cervix are ridges, from which fold^ *ig- i 1. Fig. 72. Dr. Quain's representation of the cavities of body and cervix. (Quain.) Dr. Bennet's representation of nterine and cervical cavities. (Bennet) are given off which are arranged with regularity, and run obliquely upwards and outwards, to end in other indistinct lines on the sides of the canal. (Fig. 73.) This arrangement of mucous mem- brane has received the name of arbor vitse. Between these folds numerous mucous glands are seen, which are called the glands of Xaboth. Dr. Tyler Smith 1 estimates that a well developed virgin cervix probably contains at least ten thousand of these follicles. The mucous membrane forming these folds or rugae is covered over by cylindrical and ciliated epithelium and studded by villi, which are found in considerable numbers upon the larger rugae and other parts of the mucous membrane. (Fig. 74.) On Leucorrhoea, Am. ed., p. 3S. PATHOLOGY. Fig. 73. 217 One of the four longitudinal columns of rugae from the virgin cervix. Nine diameters. (T. Smith.) The natural secretion of the cervical canal has been shown by M. Donne to be alkaline, unlike that of the vagina, which is acid. Fig. 74. Villi of canal of the cervix uteri, covered by cylindrical epithelium and containing looped bloodvessels. One hundred diameters. (T.Smith.) Pathology. — Cervical endometritis consists in inflammation of all this structure and consequent alteration of its condition. The 218 CHRONIC CERVICAL ENDOMETRITIS. glands of Naboth are especially involved in the morbid action, the disease chiefly consisting in glandular inflammation. The glairy mucus which is secreted in large amount as one of its symptoms is the characteristic discharge of these structures. Looked at with a strong glass in post-mortem examinations, they are seen enlarged and elevated, and, according to Aran, 1 their mouths may be seen very much dilated. But the affection does not confine itself to these follicles for a long time. Yery soon the villi or papillae, especially those on the vaginal face of the cervix become diseased. At first there is a loss of the normal supply of epithelium which produces a slight and very superficial abrasion. This becomes in time more distinct and marked, from destruction of the villi themselves over spaces of greater or less extent. If this process of destruction should go on and affect the deeper tissue, a true ulcer would be formed, and no one would ever have denied the name of ulceration to the existing condition, but it does not thus progress. In time an hypertrophy occurs in the villi, which increase in size, project like so many hairs from the surface, and give to the os and cervix an appearance w r hich has caused the term granular degeneration to be applied to it. This state affects the vaginal portion of the cervix chiefly, but may extend up the canal. On the vaginal portion of the cervix are sometimes found muci- parous follicles similar to those existing in the cervical canal. These often enlarge, fill with honey-like fluid, and, bursting, give rise to follicular ulceration. Another pathological state, which is occasionally met with as a complication of cervical endometritis, is an eversion of the os and lower portion of the canal to such an extent as to keep up inflammation there by the friction of the membrane, thus exposed, against the floor of the pelvis. Some very obstinate cases are due to this condition. The diseased mucous membrane pours forth with great activity large amounts of thick tenacious mucus, which is loaded with epithelium and sometimes tinged with blood. Causes. — It may result from any influence which does mechani- cal injury to the os and cervix — as displacement of the uterus so that locomotion or muscular effort may force it against the pelvic i Mai. de l'Uterus, p. 423. SYMPTOMS. 219 walls, excessive coition, the use of pessaries, the parturient pro- cess, and efforts at preventing conception or producing abortion ; anything specifically exciting inflammation — as exposure to cold and moisture particularly during menstruation, or simple or specific vaginitis ; constriction of the canal, resulting in the forma- tion of clots in the menstrual blood which at intervals during menstruation are forced out by contractions of the uterus ; the existence of small polypi in the cervix; fissures or slits in the lower portion of the canal. Many other causes might be enume- rated, but these are the most common. Symptoms. — Cervical endometritis may exist for a length of time without presenting any symptoms of sufficient gravity to warn the patient of its presence. Even a leucorrhoea, which is somewhat abundant, often fails to attract her attention. The answer to a question as to its existence will often be a negative one in cases in which the practitioner will, by the speculum, dis- cover a considerable amount in the vagina. In the great majority of cases the disease will soon announce its existence by some or all of the following signs. The first symptom which will attract attention will probably be dragging sensations about the pelvis. These will soon be followed by pain in the back and loins, which will be very much increased by exercise or muscular effort. Then a more or less profuse leucorrhoea will be noticed, the discharge as it issues from the vulva resembling boiled starch or thick gum-water and often irritating the vulva and vagina to such an extent as to produce inflammation in them. Menstrual disorders will now show themselves. The discharge will be either too scanty or too profuse, too frequent or too infrequent, and to a certain extent painful, although decided dysmenorrhea from diseases strictly confined to the cervical mucous membrane is not common. Usually before the disease has existed for a long period the constitution of the patient will show signs of becoming implicated. She will become nervous, irascible, moody, and often hysterical. Her appetite will diminish and digestion grow feeble, so that im- poverished blood will soon be observed as a result of impaired nutrition. With some or all of these signs of the existing disorder the patient may continue for a length of time without suffering from others of more annoying or graver character. Complica- tions may, however, rapidly develop themselves; cystitis, cervical 220 CHRONIC CERVICAL ENDOMETRITIS. metritis, and corporeal endometritis coming on and proving ex ceedingly troublesome. At times pain during sexual intercourse constitutes a prominent sign of cervical disease, but it belongs rather to cervical metritis than to endometritis, the former hav- ing added itself as a complication to the latter and thus produced the symptom. Sometimes nausea, and even vomiting, present themselves as symptoms, and these, together with the digestive disorder before mentioned, produce so great a deterioration in the nutrition of the patient as to result in emaciation, excessive paleness, and loss of muscular power and capacity for endurance. Although these symptoms are enough to make us confident of the existence of uterine disorder, they by no means furnish reli- able grounds for a positive diagnosis. This can be arrived at only by physical exploration. Physical Signs. — The patient being placed upon her back, and the finger of the examiner introduced into the vagina, the os uteri will probably be found in its usual position in the pelvis, for the weight of the uterus is not increased, the parenchyma not being involved. The os may be somewhat enlarged and its lips slightly puffed, or it may be roughened on account of granular degenera- tion of its papillary structure. Sometimes, however, severe cer- vical endometritis may exist without any enlargement of the os, or any trace of abrasion or granular degeneration. If the finger be now placed under the cervix and that part raised by it, pain will be complained of, though not to any great extent. This will be most marked near the os internum. No other affirmative sign can be elicited by this means, and the speculum should then be used. By this the os will be found to be in the condition recog- nized by touch, and from it will be seen to exude a long string of tough, tenacious mucus which will closely resemble the white of egg. If entangled by a small mass of cotton attached to the end of a whalebone rod, it will be found so viscid and resisting that it cannot be drawn from the canal. It will resist even a stream of water thrown with some force upon it, and very often is re- moved only after several efforts by this or other means. The cervix will usually be found not to be enlarged. Its tissue may present a swollen, puffed appearance, or be intensely red as if in a state of ulceration, which will upon close inspection be found to be due to removal of its investing epithelium and the occur- rence of a granular degeneration. Should this condition exist, it DIFFERENTIATION. 221 will afford relief to the mind of the inexperienced Gynecologist, for the diagnosis of the case will be clear. But another state of things may be discovered which will leave him in doubt. Upon removing the plug of obstructing mucus he may discover no evi- dence of disease. The os is no larger than it should be, its tissue is not reddened, no ulceration exists, in fact nothing is found ex- plaining the backache, nervousness, emaciation, and profuse leu- corrhcea which led him to advise and urge the examination. The case is simply one of cervical endometritis which affects the inner and upper parts of the canal without involving the os and lower extremity, or the disease is corporeal and not cervical. Differentiation. — We will suppose the diagnosis of cervical endo- metritis to be made ; there are several questions to be decided before it should be considered complete. First, it must be settled whether the morbid state is confined to the cervix or extends into the body. Second, whether if confined to the cervix it is limited to the mucous lining of that canal or extends to the parenchyma. If the symptoms are no more severe than those already mentioned, more especially the constitutional signs, it may at least be re- garded as probable that the membrane of the body of the organ is free from disease. If the patient be a virgin, it is much more likely to be corporeal than cervical disease ; while if she have borne children, it is much more likely to be cervical than corporeal. More reliable information than this may be obtained from the use of the uterine probe, which should now be employed. The exami- nation by touch has taught us the position of the uterus ; now, bending the probe so as to give it a curve proper for entrance into its cavity we pass it gently in. If the disease be confined to the cervix, the instrument will meet with slight obstruction at the os internum, which will be dilated in case the affection has advanced beyond it, a fact which has been specially insisted upon by Dr. Henry Bennet. Passing the probe into the cavity of the body, it should be carried up to the fundus, which should be gently struck by it. Then it should be made to impinge with a slight degree of force upon the sides of the cavity. If the body be affected, this will give pain which may last, as a patient once expressed it, "like a toothache," for half an hour, and the removal of the instrument will very likely be followed by a flow of mucus and probably by one or two drops of blood. Should the disease be cervical, no pain will result from the ex- 222 CHRONIC CERVICAL ENDOMETRITIS. ploration, and the removal of the probe will be followed by the escape neither of mucus nor blood, unless improper force be applied. Course, Duration, and Termination. — Cervical endometritis is not a self-limiting disease, and consequently its duration will depend upon circumstances which control its progress. It may unques- tionably disappear without medical aid. Any alterative in- fluence which exerts a complete change in the economy, as, for instance, parturition, entire alteration of the habits of life, or some change equally decided, sometimes results in a cure. But it is certainly safe to say that, unchecked, it might pass, slowly, perhaps, but still steadily, into disease of the parenchyma, which would probably draw in its train hypertrophy, displacement, and all the long list of ailments which make the lives of women suffering from uterine disease so burdensome. Prognosis. — The prognosis of the disease is always favorable if proper treatment be adopted ; but great caution should be observed as to fixing the time at which recovery will take place. Even in the mildest case which has lasted for some time, from four to six months will probably elapse before perfect cure can be accom- plished, and even after this a relapse will be very likely to occur unless preventive measures be adopted and strictly adhered to, The prognosis will of course depend for its correctness upon that of the diagnosis, for if parenchymatous complication exist, or the morbid action have affected the lining membrane of the body, an equally favorable prediction cannot be made. Treatment. — The disease consisting in endometritis and not me- tritis, the efforts of the practitioner must be directed to producing an alterative influence upon a mucous membrane which is in a condition of chronic inflammation, and the prevention of all influ- ences which may cause it to spread to the muscular structure beneath. These ends will be best accomplished by the following means : — General regimen; Emollient applications; Alterative applications. General Regimen. — " The first care of the practitioner," says Sir Charles Clarke, " should be to remove, if possible, the causes of the disease. * * * Women who live in a moist atmosphere, who keep bad hours, who spend much of their time in bed, or TREATMENT. 223 who inhabit hot rooms (being generally weak women, and having a relaxed vagina), will be apt to be affected by the complaint." All such unfavorable circumstances should be modified. If any depressing influence, such as lactation, any habitual discharge, or any cause for mental anxiety be discovered, it should be carefully removed and the patient, unless absolutely plethoric, be put upon the use of vegetable tonics, the mineral acids and preparations of iron. The functions of the alimentary canal should be constantly supervised. ' The diet should be mild, unstimulating, and nutri- tious. But no system of starvation should be entered upon, for the tendency of the disease is to the production of spansemia, and this we should combat. All spices, and aromatic and stimulating condiments should be avoided. Every day, unless some special contra-indication exist, the patient should take fresh air and ex- ercise, by carriage or on foot for a time, which should be limited by the circumstances of the particular case. If she should be unable to do this from any cause, she should be thoroughly pro- tected and the pure air, even in winter, be allowed to circulate freely in her chamber, all the doors and windows of which should be opened, for two or three hours daily. This plan, which is sug- gested by Prof. Byford, of Chicago, I have found a most excellent one. The bowels should be kept regular by saline cathartics, and the skin in proper state by occasional baths. Care must be ob- served not to depreciate the strength by catharsis, and to prevent this a ferruginous tonic may be advantageously combined with the saline, as in the following mixtures: — R. — Magnesiae sulphatis, ^ij. Ferri sulphatis, gr. xvj. Acidi sulphurici dil. gj. Aquae, Oj. — M. One ounce (two tablespoonfuls) in a tumbler of iced water every morning upon rising. R. — Sodae et potass, tart. 5 i j . Vini ferri amari (U. S. D.), i=ij. Acidi tartarici, 3 i i j . Aquae, o x ii- — ^« One ounce in a tumbler of iced water every morning upon rising. Should one draught not be sufficient, two, or even three may be taken daily, for the result will prove tonic and reparative as well as cathartic. If much disturbance of the nervous system should exist, the 224 CHRONIC CERVICAL ENDOMETRITIS. bromide of potassium in closes of from fifteen to twenty grains, three times a day, will be found Yerj useful. The appetite and digestion are so often impaired that special attention will generally have to be directed to alleviation of that collection of symptoms, which are grouped under the head of dyspepsia. The stomach sympathizing with the nterus does not perform its functions with vigor ; the gastric juices appear to be wanting or inefficient, and fermentation of the food often takes the place of digestion. Under these circumstances I can recom- mend from lengthy experience with it the following digestive tonic : — I£. — One rennet washed and chopped, Sherry wine, Oj. Macerate for twelve days, then decant, filter, and add — Dilute nitro-muriatic acid, 5U« Tinct. mix vomica, gij Subnitrate of bismuth, 5ij« One tablespoonful in a quarter of a tumbler of water before each meal. This prescription combines the tonic properties of nux vomica and the peculiar alterative influences of bismuth, with a fluid which resembles the gastric juice. In many cases of habitual indigestion I have obtained from it the best results. Emollient Applications. — The cervix should be irrigated every night and morning, by warm water thrown against it by one of the plans recommended elsewhere. To the water may be added glyce- rine, boiled starch, infusion of linseed, slippery elm, or tincture of opium. The irrigation should be so planned as to last for twenty or thirty minutes without fatiguing the patient or proving a source of annoyance to her. The method for doing this is so fully described elsewhere that it need not be repeated here. Alterative Applications. — The local treatment by means of appli- cations made through the speculum will, with great advantage, be preceded by dilatation of the whole cervix by means of a tent of sponge or sea tangle. This not only exposes the canal to appli- cations, but opens the way for escape of fluids, and by pressure exerts an alterative influence on the diseased membrane. Should granular degeneration exist, it will be peculiarly applicable. The tent being removed the canal should be cleansed of blood and mucus, which may be done by a small pledget of cotton wrapped around a staff of whalebone, hickory, or bamboo, eight inches long, as thick as a pipe-stem, and tapering toward its extremity. ALTERATIVE APPLICATIONS. 225 Should the first pledget become saturated, it can readily be slipped from the staff and another wrapped in its place, or several staves may be prepared and kept ready for use. A little practice will be necessary to enable one to arrange the cotton upon the staff in a proper manner. When the plug of mucus is very tenacious and will not allow of removal in this way, a very small bit of Fig. 75. Rod eight or nine inches long, wrapped with cotton. sponge, not larger than a large pea, may be fixed in a sponge- holder or a pair of long forceps and passed up to the os internum. The sponge should be thrown away afterwards, for the repetition of its use might convey disease from one patient to another. A supply of such small pieces of sponge should be kept at hand in order that a new one may be used for each patient. Another method of cleansing the cervix and cervical canal, and one which I commonly employ, consists in the use of a syringe with a nozzle four or five inches long, which may be worked by one. hand. The thumb retracting the piston, while two fingers hold the body of this instrument, it is filled with Fig. 76. Syringe for cleansing the cervix and vagina. water, which is thrown with violence against the os and cervix, the tip of the nozzle being in direct contact with the part to be cleansed. The fluid thus ejected collects in the speculum if a cylindrical instrument be used, in the vagina if Sims's speculum or one of its varieties be employed. It is again taken up and projected against the cervix, and this is repeated until the part is sufficiently cleansed. I am thus particular in speaking of the process of cleansing the cervix, because I believe that treatment is often impaired in its efficacy by a neglect of it. The caustic used being neutralized by a thick envelope of coagulable mucus, is prevented from exerting a decidedly alterative influence upon the diseased part. Care must be taken not to throw the fluid into 15 226 CHRONIC CERVICAL ENDOMETRITIS. the body of the uterus, but even should this occur after dilatation, it will at once escape. The cervix can then be clearly seen and applications made. It is a fact, universally admitted in every department of thera- peutics, that certain substances of greater or less strength as escharotics have the property, when applied to inflamed mucous surfaces, of so modifying the morbid action existing in them as to diminish its intensity and in time to check its progress. It is upon this principle that chronic inflammation of the fauces, ure- thra, bladder, and many other mucous surfaces are treated. Those substances which have been found by experience to answer the best purpose in inflammation of the mucous lining of the cervix are the following : nitrate of silver, iodine, chromic acid, carbolic acid, sulphate of copper, solution of persulphate of iron, tannin, and acetate of lead. After the tent has been removed and the cervix cleansed, a brush composed of camel's hair, or, as is better, of delicate bristles, is dipped in a solution of one of the substances mentioned. If copper, zinc, or lead be employed, the solution may be made saturated, and if tannin be used, it may be dissolved in glycerine in large amounts. The whole cavity of the cervix is painted over thoroughly with the solution, from the os inter- num to the vaginal mucous membrane. After this application a bit of cotton, with a piece of stout thread attached, should be dipped in glycerine and applied against the cervix. This protects the vagina from contact with the drug, and, as Dr. Sims has shown, acts as a local hydragogue, depleting the part to which it is applied. This may be repeated once a week, the application being pre- ceded each time, by the tent, which should never be allowed to remain longer than twenty -four hours. It is difficult to give any rule with reference to a choice of these alterative applications. All that can be said is that it is indicated by the same rules which govern a selection when em- ployed elsewhere in the economy. In choosing the caustic the practitioner should bear in mind that one great objection to those of severe character is the liability of their closing the cervix by causing cicatricial contraction. For this reason I would never, unless to destroy a malignant growth, or cause contractions in an inverted cervical canal, introduce within the os externum, or apply nearer than three or four lines from its edge, the actual ALTERATIVE APPLICATIONS. 227 cautery or the acid nitrate of mercury. In the use of even the solid nitrate of silver, one should be cautious and limit its appli- cation to cases in which the canal is dilated. Chromic acid, which was, I think, introduced into uterine practice by Dr. Marion Sims, possesses the great advantage of not contracting the neck. At least I should say that I have never seen, nor heard of, a case in which it did so. The fluid preparation in general use is a saturated solution, though it may be used of any strength desired. The plan just described involves keeping the patient in bed only for twenty-four hours out of every week, while the tent is in place, and certainly shortens the course of the affection very much. Another means of making applications to the whole cervical canal, either after or without dilatation by tents, is the following : the uterine probe being passed up to the os internum and with- drawn, its curve shows the direction to be followed by the instru- ment by which the application is to be made. This consists of a flat silver probe, measuring with its handle about eight or ten inches. It is decidedly the best instrument for the purpose in view with which I am acquainted, and was introduced into prac- tice by Dr. Emmet of this city. It resembles very closely the uterine probe, the only difference being that it is flat and has no terminal bulb. Fig. 77, constructed after a plan adopted by Dr. Sims, represents a slight modification of this instrument. Two Fig. 77. Silver probe with slide. Fig. 78. ftlliiillllnhl htluiinilHii,,il'Wi,iil/lhliii,!,)r>,,,ill!.)/))l,llli>l))lli>W>))ihHir Same instrument with cotton wrapped around it and thread attached. inches of the extremit} r of this are wrapped with a very thin film of cotton, the arrangement of which, although it appears quite simple requires a little practice, and the probe is bent to the curve of the uterine probe which has been passed to the os 228 CHRONIC CERVICAL ENDOMETRITIS. internum. It is now dipped in a solution of chromic acid, nitrate of silver, or saturated tincture of iodine and passed up to the os internum, where it is kept for one or two minutes and then with- drawn. A stream of water should then be projected on the cer- vix to remove any surplus which may have escaped and the appli- cation should be repeated. This repetition is advisable because the first application sometimes only coagulates and removes tenacious mucus which remained in the upper part of the canal, and a second is required to really cauterize the surface. This instru- ment may be likewise employed so as to leave a long thin roll of cotton in the canal. The flat rod, being wrapped with this substance, is dipped in a solution of alterative or astringent char- acter. It is then carried up to the os internum, the cotton is slipped off by the slide and remains in the cervical canal. By the thread attached it may be removed in twelve hours. Instead of dipping the cotton in a solution it may be prepared in the following manner and applied dry. An ounce of the sulphate of copper, zinc, or iron may be dissolved in a pint of water. In this a mass of cotton is, "soaked, then dried in the sun, and it is ready for use. Or the cotton may be saturated with iodine and glycerine, as recommended by Dr. Greenhalgh, and employed in the same manner. Another convenient method for reaching the upper parts of the canal is by the use of a very delicate probe of hard rubber about eight inches long, the invention of Prof. C. A. Budd, of New York. Fig. 79. Budd's elastic probe. This instrument is wrapped with cotton as is Dr. Emmet's, and so delicate is it that when introduced straight into the cervical canal, it passes along its curve and goes directly to the fundus. Hold- ing it over the flame of a lamp for a few seconds will cause it to become pliable as a willow twig, when it may be bent as desired, and when it becomes cool it keeps the curve given it until heated again. These two probes leave nothing to be desired in making fluid applications. In applying solid caustics to the walls of the canal a different ALTERATIVE APPLICATIONS. 229 method should be pursued. Should the case appear to require a solid caustic, the nitrate of silver may, with great advantage, be employed, though the means generally adopted for applying this substance are inefficient. If a straight stick of lunar caustic be fixed in a quill or held in the grasp of a pair of forceps and passed into the os, by no possibility can the procedure accomplish what is desired. It may cauterize, and will probably do so with objec- tionable thoroughness, a quarter or half an inch of the lower por- tion of the canal, but how can it be expected to go upwards for an inch and a quarter and come in contact with the whole surface inflamed, a surface remarkable for its inequalities and convolu- tions. Sir Benjamin Brodie many years ago, according to Dr. Barnes, of London, advised fusing nitrate of silver and allowing it to cool upon the tip of a probe for cauterizing sinuous tracts, and Chassaignac, of Paris, applied the same substance to the cavity of the womb by coating platinum wires with it. "Within the last four years Dr. F. D. Lente, of Cold Spring, N. Y., has experimented extensively in reference to this subject, and the result of his investigations has been to furnish the profession with the best and most reliable of all the means at our command for applying solid lunar caustic to the mucous lining of the uterus. Other methods which have been suggested aud employed are these : the use of Lallemand's porte caustique ; leaving a pellet of nitrate of silver in the uterine cavity to dissolve ; carrying up a small piece held in a delicate wire casing, &c; but none of these compare with Dr. Lente's, which is thus practised. A probe, shaped like the ordinary uterine probe, is warmed and then dipped in a little platinum cup that contains nitrate of silver which has been fused over a spirit lamp. Eemoving the probe after dipping it, and waving it for a few seconds, a film of the nitrate will be found to have covered it. It may then be again dipped, and the process repeated until a sufficiently large pellet is made to cover the tip of the instrument. Figs. 80 and 81 represent the probe and cup. It is used thus: the cervical canal having been cleansed of mucus, and its direction learned by the ordinary probe, Lente's probe is passed up and rubbed against every part of its investing membrane, and dipped as carefully as possible into its convolu- tions before removal. After all such applications, a stream of water should be projected against the cervix and a pledget of 230 CHRONIC CERVICAL ENDOMETRITIS. cotton, which, has been freely saturated with glycerine, with a bit of thread attached, should be placed against it. By means Fig. 80. !?T^--^: ggQgj^^ < Lente's silver caustic probe. of the thread this may be removed by the patient in twelve hours. It is a question of some importance to decide how often Fig. 81. Lente's cup for fusing nitrate of silver. these caustic applications should be repeated. As a general rule I should say once a week, except in the case of a thorough appli- cation of chromic acid or the solid nitrate, when twice that time should be allowed to elapse. These cause decided sloughs to oc- cur, after the removal of which it is better to dress the surfaces left uncovered, by equal parts of glycerine and solution of the persulphate of iron, or by tincture of iodine, or weak solutions of the nitrate of silver left in the canal upon rolls of cotton. Another excellent plan of treating this affection is by the use of medicated tents of sponge. For the past two years I have employed it very generally, and now prefer it to any other mode of treatment. Tents of this character may be prepared in two ways. The sponge may be wound upon a large wire which will leave a capacious canal. This may be filled, after the tent is dried, with a long suppository of cocoa butter containing nitrate of silver, iron, or any other mineral in admixture. As the tent expands it is permeated by the elements contained in the supposi- tory, which thus come in contact with the walls of the uterus. Another method is this : sponge cut into proper shape is saturated for a length of time in solutions of zinc, copper, iron, iodine, carbolic acid, or lead. They are then squeezed, dried, soaked in a solution of gum acacia, and made into tents. They possess not ALTERATIVE APPLICATIONS. 281 only the alterative powers attached to the pressure which they exert, but bring into direct contact with the diseased surface alteratives of most reliable character. The influence of this means is unquestionably good ; it produces no more pain than the use of the non-medicated tent, and all offensive odor is pre- vented in the sponge. The idea of dilating a uterine neck affected by endometritis by means of sponge is apt to strike one who has never essayed the method as being attended by considerable danger. I can say with positiveness that it is not so. The tent not passing into the body of the uterus does not excite that part of the organ, and in no case in which I have employed one in the cervix have I been led to regret having done so. Instead of medicated sponge, a caustic or an alterative may be incorporated with butter of cocoa, gum tragacanth, or some simi- lar substance, made into suppositories two inches in length, and left in the cervical canal. Into these cervical suppositories may be introduced zinc, copper, iron, lead, or bismuth, with opium, conium, or hyoscyamus. They do not compare in efficiency with medicated tents, and it is difficult to keep them from becoming dislodged. To keep in mind the plans recommended for applying caustics and alteratives to the cervical canal the following resume will prove useful : — 1st. Dilatation by tents; 2d. Application of fluids by small brushes; 3d. " " by flat probe; 4th. " " by rolls of cotton ; 5th. " of solids by Lente's probe ; 6th. " " by medicated tents ; 7th. " " by suppositories. CHAPTEE XVI CHRONIC CERVICAL METRITIS. Fig. 82. Definition. — This affection consists in inflammation of the parenchyma of the cervix uteri, whether occurring alone or as a complication of cervical endometritis. It has been described under the names of engorgement, hyper- trophy, inflammatory hypertrophy, and chronic cervicitis. Causes. — The causes may be thus enu- merated : — Parturition or abortion ; Injuries; Excessive sexual indulgence ; Pessaries ; Displacements ; Cervical endometritis. It generally originates from parturition or abortion, and hence is exceedingly rare in the nulliparous woman, though it may arise from injury, the result of operations ; sexual intercourse ; badly fitting pessaries ; or friction from displacement of the uterus. I have seen it occur in a number of cases as a consequence of cervical endometritis, inflammatory action passing from the mucous membrane to the subjacent parenchyma. It must not be supposed that it is to be looked for as an early or constant result of the last named disease, which often continues for a long time without inducing it, but in exceptional instances it is unquestion- ably thus established. Symptoms. — The disease shows itself by pain in the back and loins, pressure on the bladder or rectum, painful and excessive menstruation, difficulty of locomotion, nervous disorder, pain The dots represent the site of cervical metritis. PHYSICAL SIGNS — PATHOLOGY. 233 during sexual intercourse, dyspepsia, headache, and a general sense of lassitude and debility. If no disease of the mucous lining exist, there will be no leucorrhcea ; but as this is usually present it is very commonly a prominent symptom, and should granular degeneration exist, the leucorrhceal discharge will often be tinged with blood. Physical Signs. — Vaginal touch will generally discover that the uterus has descended in the pelvis so that its cervix will rest upon the floor of it. The cervix will be found 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 at once 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 an exquisite degree of sensitiveness. Under these circumstances the position of the uterus will generally be found to be abnormal. The cervix will in some cases have moved for- wards and the body backwards, or the opposite change of place may have occurred. Course and Termination. — It is astonishing to what an extent enlargement of the cervix as a result of parenchymatous inflam- mation will go. Sometimes this part will equal in size a very small orange, and, filling the vagina, will compress the rectum quite forcibly, so as in a great degree to close its canal. Left to itself the disease has no limit, but sometimes passes away leaving the cervix enlarged and very soft and flabby, or very hard and nodulated. At other times an atrophy of the diseased tissue occurs, and the cervix becomes small, hard, and indurated. Pathology. — According to the formerly accepted view, the fol- lowing changes were supposed to occur. In the first stage the cervical parenchyma was regarded as gorged with blood, a state of active congestion existing. This was supposed soon to pass into the second 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 admitted to occur rarely here, or in the parenchyma of the body, but in time all inflammatory action ceasing, the cervix remained large and indurated without sensitiveness, or the effused lymph might be absorbed, and great diminution in size occur with induration. 234 CHRONIC CERVICAL METRITIS. Recently, Scanzoni, Klob, and other pathologists, have as- cribed the hypertrophic enlargement attending the disease to congestion and a proliferation of the connective tissue of the part. This produces engorgement, sensitiveness, increase of weight, and induration. It is highly probable that the second of these theories offers the true explanation of the results of disease in this part, and that the former was adopted more in consequence of analogical reasoning than of pathological investigation. It is probably for this reason that pregnancy is found to be so prolific a source of the affection, that condition furnishing the tendency to rapid growth of connective tissue, which constitutes its chief element. As I have elsewhere mentioned, Klob looks upon this state as an habitual hyperemia with coincident hypergenesis of the con- nective tissue. This theory accounts for the exceedingly slow progress of the affection, and for the diversity of opinion which has existed as to its true pathological nature. A long continued, persistent hyperemia resulting in excessive growth of connective tissue differs from mere congestion on the one hand and hyper- trophy on the other. To this middle ground I have thought it proper to apply the term metritis. Differentiation. — The only point to settle before the diagnosis can be considered complete, will be whether the cervix alone is affected, or whether its enlargement is only a part of a general uterine development from disease. To determine this question, two means are at command ; first, the examiner introducing one or two fingers under the body of the uterus, and depressing 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 is increased in size, the evidence is in favor of the disease having extended to the parenchyma of the body. Should its size be normal, this is probably not the case. The walls of the uterus should then be struck by the probe to test the existence of pain. Should pain last for some time after the removal of the probe, it is probable that the paren- chyma of the body is affected; should it not exist at all, the evidence is against that supposition. Prognosis. — In this affection, as in all others of the uterus, the COMPLICATIONS — TREATMENT — REST. 235 prognosis will depend in a great degree upon the patient. If she be unwilling to sacrifice her inclinations and pleasures, but half fulfil the directions of the attending physician, and clandestinely expose herself to prejudicial influences, the treatment will ac- complish 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, though the reduction of a large cervix may require a great deal of time, many months being often necessary to accomplish it completely. Complications. — Cervical metritis may give rise to many and serious complications, as, for example, displacements, cystitis, rectitis, and cellulitis, which may greatly annoy and discourage the patient. It likewise interferes decidedly with the functions of the uterus and menorrhagia, dysmenorrhcea, and sterility are its frequent accompaniments. Treatment. — In the treatment of the disease under consideration the same principles should guide us as in similar inflammations elsewhere, the special means at command being : — Eest; General regimen; Depletion ; Emollient and sedative applications ; Alterative applications ; Counter-irritation. Rest. — The patient should be instructed to take much less ex- ercise than usual, to lie upon her bed or lounge for several hours during the day, and to remain in bed during menstrual periods. It will rarely be necessary or advisable to confine her to her bed continuously, for many women become restive under the confine- ment, and suffer both in mind and body, the sanguineous and nervous systems being impaired by want of fresh air. If the parenchyma be much affected so that the cervix is painful upon pressure, absolute rest upon the back should be insisted upon, but my impression is that deprivation of fresh air and exercise ordinarily does more harm than is compensated for by the advan- tages arising from quietude. Should she not remain in bed, in order to prevent friction of the inflamed part against the floor of the pelvis, she should be especially guarded against lifting weights and climbing ascents, and the clothing should be worn very 236 CHRONIC CERVICAL METRITIS. loose around the waist and supported by suspenders or skirt sup- porters upon the shoulders. The application of an elastic ring pessary, or Prof. Hodge's double lever, will often accomplish much good by supporting the uterus and keeping it from falling upon the floor of the pelvis. Sexual intercourse during the existence of this disease must necessarily be productive of evil, and should be interdicted. There is only one method, as a general rule, bv which this can be accomplished, and that is by the separation of husband and wife. If this be impracticable, an injunction of ex- cessive caution should be substituted for total abstinence, which will be almost certainly disobeyed. By these means we do all in our power to place the inflamed part at rest as we would a frac- tured bone or inflamed testicle. General Regimen. — The strength should be sustained by mild, though thoroughly nutritious food, and everything of an exciting nature should be avoided. The bowels should be kept in natural condition, and the state of the sanguineous and nervous systems maintained by fresh, pure air, and moderate exercise. As this subject has been fully dealt with in the last chapter, the reader is referred to that in order to avoid repetition. Depletion. — General bloodletting is now almost universally abandoned in the treatment of chronic diseases of the female genital system, although M. iSTonat, a most excellent modern au- thority, and some others, still advise it in corporeal metritis. So marked is the tendency to spanaemia in all uterine affections that I cannot but regard the practice as highly pernicious. The three methods by which local depletion of the cervix can be best prac- tised are leeching, scarification, and cupping. In such a case as that which we are considering three or four large leeches, or a sufficient number of small ones, to take from three to five ounces of blood, may be applied in the following manner. A cylindri- cal speculum, of sufficient size to contain the entire vaginal por- tion of the cervix, being passed and the part thoroughly cleansed, a small pledget of cotton, to which a thread has been attached for removal, should be placed within the os, so as to prevent the entrance of the leeches to the cavity above. A few slight punc- tures, sufficient to cause a flow of blood, should then be made in the cervix and all the leeches to be applied thrown in, and the speculum filled at its extremity by a dossil of cotton pushed towards the bleeding surface. The speculum should be watched DEPLETION. 237 until they cease sucking, for if left for a very short time, even with the mouth of the instrument filled with cotton, they will escape. After their removal all clots of blood should be removed by a rod with cotton attached, the speculum withdrawn, a large sponge squeezed out of warm water placed over the vulva, and the patient directed to remain perfectly quiet. Should there be great pain upon pressing the cervix, or should the leech-bites give ex- cessive pain, as they sometimes do, they should in future be applied by preference to the perineum. Should scarification be employed, a very sharp and narrow bistoury or tenotomy knife should be introduced within the os, and drawn outward towards the vaginal edges of the cervix so as to sever all the superficial vessels over which it passes. I am in the habit of employing, in preference to the latter, acupuncture, which may be performed by an ordinary three-sided surgical needle held in the grasp of a pair of forceps, or, still better, by a little spear, the invention of Dr. Buttles, of this city. Fig. 83. Buttles's spear-pointed scarificator. This little instrument, when plunged about one-sixteenth of an inch into the cervix and given a rapid half turn before removal, causes a very free flow of blood should congestion exist. If a sufficient flow does not occur from three or four of its punctures, this can be caused by dry cupping the cervix by a very simple instrument, made of hard rubber, which is introduced through the speculum, the medium size of the cylindrical variety being large enough to admit it. Being passed up to the cervix, the piston is retracted, and so perfect is the working of these instruments when constructed of hard rubber, that a complete vacuum is pro- Fig. 84. G. TIEMANHiCth, Hard rubber cylinder for dry cupping the cervix uteri. duced. By using this for a few minutes, and then puncturing, with Buttles's spear, from two to four ounces of blood may readily 238 CHROMIC CERVICAL METRITIS. be drawn. The exhauster should not be used after puncturing but before it. All that will then be necessary will be to pass a sponge, attached to one of Sims's sponge-holders, over the punc- tured surface so as to prevent clotting in the mouths of the bleed- ing vessels. Dr. John Byrne, of Brooklyn, has recently drawn especial attention to still another method, which in some cases answers an excellent purpose. It consists in passing a long, deli- cate blade, such as that, for instance, of Emmet's or Sims's knife, up to the os internum and cutting through the mucous membrane, its bloodvessels and the superficial layer of muscular tissue as it is withdrawn through the os externum. Local depletion by one of these methods may be practised with great advantage once or twice a month, the patient for some hours after its adoption being kept perfectly quiet in bed, and directed to employ another anti- phlogistic means, the application of emollient and sedative sub- stances to the inflamed part. Emollient and Sedative Applications. — If any parenchymatous tissue of the body be inflamed, the application of emollient and sedative substances in the form of simple and anodyne poultices, of bags of anodyne herbs, as hops or poppies, and of wet com- presses, as employed in hydropathy, is, and has been from the earliest times, universally recognized as beneficial. It is upon the same principle that they are applied through the vagina to the cervix uteri by means of pledgets of cotton or lint introduced through the speculum, and by vaginal injections or suppositories. Other means, which are occasionally though much less generally emplo}^ed, are, the introduction into the vaginal canal of little bags filled with emollient substances, sponges impregnated with simple or anodyne fluids, the vapors of anaesthetic medicines, and the vapor of water ; which was recommended even as early as the Ara- bian school of medicine, Albucasis advising its introduction by a reed passed up the vagina. We are indebted to the recent work of Scanzoni on Diseases of Females for the explanation of the best method of using this important adjuvant in the treatment of uterine affections by injections. Vaginal Injections. — To be efficient they should be copious and long continued. There are four methods of employing them which I should recommend. Placing in a tub from one to two gallons of water, at as high a temperature as proves comfortable to the patient, she may sit over it upon a board placed across it, VAGINAL INJECTIONS, 239 Fig. 85. Davidson's syringe. Fig. 86. or upon a stool placed in it, and inject the water by means of a syringe. The most convenient syringes for the purpose are the Essex and Davidson's. Both of these are provided with a stem about five inches long, which being introduced into the vagina and carried up so as to touch the cervix, throws, when the ball of the instrument is compressed by the disengaged hand of the patient, a steady stream against it. By this means a stream of warm water is made to pour over the cervix for from twenty to thirty minutes, according to the amount of fatigue which the use of the instrument causes the patient. Another method is this : an ordinary tub or bucket, near the bottom of which a stop-cock has been inserted connecting with an India rubber or gutta-percha tube about five or six feet long with a metallic stem like that of the Davidson syringe at the end, is placed upon an eleva- tion, as, for example, a chair placed upon a table, or a shelf made for the purpose. The vaginal stem being inserted, the cock is turned by the patient, and for half an hour a stream of water freely bathes the inflamed part, passing out of the vagina, pours into a tub over which the patient is sitting. This avoids all fatigue, and produces a much more prolonged application. Fig. 87 represents a very inge- nious plan of irrigation practised by Scanzoni : b is a cup of lead, c a tube of gutta-percha, e a nozzle by which suction is practised so as to fill the tube, d is a nozzle for the vagina. After being once filled, the water pours as through a siphon. If the tube is rolled and dipped below the surface of the fluid, it is filled with- out the action of suction, and the siphon flow is equally well established. Lastly, the patient may take a warm hip- bath, or entire bath, night and morning, and use the vaginal injection while in the bath. This method possesses the additional advantages to be de- Tub for vaginal irrigation. 240 . CHRONIC CERVICAL METRITIS. rived from general and hip-baths in the treatment of these cases, while the horizontal posture favors very much the flow of the Fig. 87. Scanzoni's irrigator. injected fluid to the uterus and roof of the pelvis. Indeed, all of the methods may be rendered more efficient by being employed while the patient is lying in bed with the bedpan under the buttocks to receive the escaping fluid. Warm water is the best, as it is the simplest, most attainable, and cleanest of all the emollients which can be used for this pur- pose. But it may easily be medicated by addition of laudanum, half an ounce to the gallon, infusions of linseed, poppies, hops, slippery elm, hyoscyamus, conium, and farina ; or by the addition of glycerine, one ounce to the gallon, lime-water or tar-water, both of which last are often very soothing to vaginitis that may exist as a complication. Vaginal Suppositories may be made very useful if employed after and not instead of the injections just described, which are certainly of much greater efficacy. The best menstruum with which they can be compounded is cocoa butter, or, as recom- mended by Dr. Tilt in his Uterine Therapeutics, a mixture of starch, almond meal, and glycerine, the whole being coated with ALTEKATIVES. 241 suet or butter of cocoa. One grain of the acetate or sulphate of morphia, one-thirtieth to one-tenth of a grain of sulphate of atropia, one grain of belladonna, or three of opium having been incorpo- rated with these may be placed against the os and allowed to re- main all night, being washed away in the morning by an injection. The instrument which I employ for introducing these is one of hard rubber, represented by Fig. 88. Should there be pain, a sedative Fig. 88. Vaginal suppository tube. suppository may be employed every night after the vaginal in- jection, but should there be no special indication for it, it is better not to annoy the patient with a multiplicity of applications. Alteratives. — These may be directly applied by means of a brush, by suppositories placed against the cervix, or by vaginal injections. Churchill's tincture of iodine, solution of persulphate of iron, or strong solutions of sulphate of copper or chloride of zinc may be painted over the vaginal face of the cervix and carried up to the os internum. This is not done for their action upon the mucous lining of the canal, which we suppose not to be inflamed, but for the effect which they may exert on the subjacent parenchyma. The same drugs may be employed by injection and suppository. Before leaving this part of our subject it may not be out of place to remind the reader that vaginal injections and supposi- tories should not be employed under these circumstances empiri- cally, but with some definite object. They may prove useful when medicated with appropriate drugs in the following ways : — 1st. They may act as calmants, emollients, and detergents, quieting nervous irritation and soothing pain. For these pur- poses warm water, or any of the emollient or narcotic substances already mentioned, may be used. 2d. They may exert a direct alterative influence on a tissue affected by granular degeneration or erosion, by coming into im- mediate contact with it. For this end zinc, lead, iron, alum, bis- muth, tannin, &c, will prove useful. 16 242 CHRONIC CERVICAL METRITIS. 3d. They may so affect the nerves governing the nutrition of the part as to check excessive supply of nutrient elements to the connective tissue, and cause an atrophy of that which has under- gone exuberant development or cause absorption of lymph effused into the cervical parenchyma. To accomplish this we may em- ploy the iodide of potassium, chloride of sodium, sea water, water at a very high temperature, bromine, or iodine. 4th. They may be employed to give tone to the pelvic tissues, which have been relaxed by diseased action that has passed away. For this purpose the astringents and cold water will prove most useful. In the treatment of cervical inflammation these means may be brought to our aid to accomplish any of the objects which have been mentioned, and our choice should be governed by the special indication. The ends for which the means thus far mentioned have been employed were these: to cause diminution in the calibre of dilated vessels ; to check excessive nutrition and secretion ; and to quiet resulting neuralgia. In spite of all these remedial resources inflammatory engorge- ment will often still continue to affect the parenchyma, and it will become evident that other and more decided means must be re- sorted to. As in treating chronic parenchymatous inflammation elsewhere, we naturally turn most hopefully to counter-irritants. These are not employed for mucous inflammation, should it exist in conjunction with that variety which now engages us, but they benefit this indirectly ; for it, even although originally the cause of the parenchymatous disease, is kept up by the latter, which reacts upon it and causes its prolongation. Counter Irritation. — One of the best methods for practising counter-irritation upon the cervix uteri is by blistering, a means for which we are indebted, I believe, to Aran, of Paris. To blister the cervix, a large cylindrical speculum should be used which will take the whole part into its field. The cervix having been cleansed and dried by a soft sponge or dossil of cotton, a camel's-hair brush is dipped into vesicating collodion, which con- sists of ordinary collodion, commonly known as liquid cuticle in this country, containing in suspension cantharides, and painted over the whole vaginal cervix, no effort being made to avoid the os. There are two preparations of vesicating collodion, one made COUNTER-IRRITATION". 243 by ether, the other by acetic acid. The second is the more power- ful and the less likely to affect the vagina. In a few seconds after it is painted on the cervix, it forms a hard, insoluble cover- ing, npon which two or three other coats may be at once applied. The whole is then exposed to the air by keeping the speculum in place for a few minutes, a stream of cold water projected upon it, to prevent any escape into the vagina, and the process is finished. In from eight to twelve hours the epithelial covering of the cervix is entirely removed by this, and a free flow of serum takes place as from a blister elsewhere applied. After this the patient should be kept perfectly quiet for several days, cleansing the vagina by warm injections, and as soon as the discharge shows a tendency to cessation the blistering should be repeated. The only objec- tions to this method of counter-irritation are the liability to vaginitis and cystitis from escape of the blistering fluid into the vagina and mouth, of the urethra, which can readily be avoided, and the pain which is experienced in some cases while vesication is taking place. Another and still better method of destroying ^ Fig. 89. C, TIEMAVN-CO. — < 1 Fig. 90. =« Fig. 91. Cauteri zing irons. the epithelial covering of the cervix and producing serous dis- charge, is the application to that surface of metal warmed for fifteen seconds in an ordinary spirit lamp. For this purpose the steel rods, Figs. 89, 90, and 91, used in applying the actual cau- tery, may be employed. One of these should be held over a spirit lamp for from ten to twentv se- T ,. n ^ * rig. 92. conds, and then held against the cervix for several seconds, a few lines always intervening between the instrument and the os. Upon removing it a pearly white surface will be seen, which is created by death of the mucous mem- brane at this spot. The iron should again be warmed and applied to another spot, one such point being created on i • i r> , n . . . . Cervix blistered by the warm each side of the cervix, makmff m all • • *i * vw v x.v, iiiciiviii^ in aii iron in three spots. 244 CHRONIC CERVICAL METRITIS. three or four, as represented in the illustration. To this method there is no objection. It produces no pain, never affects the surrounding parts, and the destruction of the tissue is so super- ficial that no induration from cicatricial tissue results. Of all the means of counter-irritation for removiug chronic parenchymatous inflammation and causing diminution in the size of this part bj stimulating absorption, this is the most efficient and least objec- tionable as to consequences. Vesication may be easily produced by still another method, which is both effectual and simple. By means of a solid stick of nitrate of silver, which is rubbed gently over the whole vaginal portion of the cervix, its epithelial covering is destroyed, soon sloughs off, and leaves a granulating surface which may be dressed with any of the alterative substances mentioned above. But sometimes so obstinate is the engorgement of the cervix, that other and more powerful means are required, and these pre- sent themselves in the actual cautery and caustic potash. Both methods have many objectionable features, both are liable to result in great induration of tissue, and a contraction of the cervi- cal canal after the slough which they create has passed away ; yet there are cases of a rebellious character, fortunately very excep- tional ones, in which they may prove of service. The classifica- tion of these strong caustics among counter-irritants and not alteratives, may be objected to by many, and yet I can see no difference between their action on the uterus and that of issues elsewhere applied. They are unquestionably " escharotics," "alteratives," and "vitality modifiers," as has been stated, but do not blisters and setons act in the same manner ? A part, for example the cervix uteri, is in a state of chronic inflammation ; its bloodvessels are dilated, its connective tissue is excessively developed, and its vaso-motor nerves are in a morbid state, as if paralyzed, which prevents their proper functions being performed as regards circulation. A powerful counter-irritant destroys tissue to a greater or less extent, and produces a peculiar influence upon the vitality of the part, which results in a stimulation of absorp- tion and the awakening of the nerve power governing nutri- tion. Method of Applying Potassa cum Calce. — This preparation, con- sisting of two parts of lime to one of caustic potash, or two of the latter to one of the former, as Dr. Bennet uses it, is so far MODE OF APPLYING THE ACTUAL CAUTERY. 245 preferable to pure caustic potash that I shall speak of it to the exclusion of the more powerful escharotic. It was formerly used as Vienna paste, until M. Filhos prepared it in the form of a stick, at the same time rendering it much more powerful by combining two parts of quicklime with one of the caustic potash, instead of from thirty to fifty, as was done in the paste. A large cylindrical speculum having been introduced, and the cervix cleansed and completely dried, a dossil of cotton soaked in vinegar and squeezed almost dry should be forced by means of the long- shanked speculum forceps into the os. A large supply, similarly soaked and squeezed, should then be pressed around the neck between it and the rim of the instrument. As acetic acid neu- tralizes caustic potash, this will protect all the tissues which we wish to avoid injuring. A stick of caustic should now be taken in the grasp of a caustic holder and applied to the cervix. It should remain in contact with one point for from five to ten Fig. 93. Sims's caustic holder. seconds, then be removed and brought in contact with an adjoin- ing part until all the desired surface is cauterized. A stream of fluid, consisting of equal parts of vinegar and water, should then be repeatedly thrown against the cervix by the speculum syringe, a piece of cotton with a string attached and saturated thoroughly with the same be laid against it and the speculum removed. After this the patient should be kept per- fectly quiet, and pain relieved promptly by full doses of opium, by mouth or rectum; for this operation is sometimes followed by metritis, pelvic cellulitis, or peritonitis, and I have in one case known tetanus occur with a fatal issue. There is not great danger of these results ; but it is not the less true that they may occur, and it is the duty of the practitioner to be forewarned against the possibility. The application of this escharotic should always be regarded and treated as an operation, and the patient should distinctly understand that it is no trivial affair, to be lightly dealt with. Mode of Applying the Actual Cautery. — Yery little preparation is necessary for the use of this caustic. The iron being brought 246 CHRONIC CERVICAL METRITIS. to a white heat by placing it in a fire, or still better in the flame of a Enssian spirit lamp, which the operator may always have at hand and which gives the powerful aid of a blowpipe, by its in- genious mechanism, is passed up through a cylindrical speculum composed of metal, horn, ivory, or wood, the last being the best, and pressed for a few seconds against the cervix at some distance from the os. As soon as the tissue touched is destroyed, the cautery is brought in contact with another point until the desired amount of action is produced. A stream of water is then thrown against the cervix, a piece of cotton saturated with glycerine is introduced, the speculum withdrawn, and the patient directed to preserve the recumbent posture and cleanse the vagina by warm injections. The few cases to which these powerful caustics are applicable are great hypertrophy of the cervix, more especially hypertrophy with softening and puffing of the tissues, or of this and the body of the uterus, which have resisted all milder means ; malignant growths and obstinate ulcerations. They should never be intro- duced into the cervix for fear of causing contraction of its canal, and because other means will answer as well without the cor- responding danger. Bennet, Tilt, 1 and many other excellent au- thorities, however, advise that they should be passed up the cervical canal, and Amussat even goes so far as to counsel the cauterization of the cavity of the body of the uterus, with potassa cum calce in cases where hemorrhage from corporeal endometritis has proved rebellious to ordinary means. The primary action of all these counter-irritants, both super- ficial and profound, is not the only one of which we should avail ourselves. The denuded surfaces, as after blistering elsewhere, should be acted upon by light applications of lunar caustic, tinc- ture of iodine, chromic acid, or any similar substances which may be chosen. This brings us to the end of what may be regarded as the most important subject in a work on diseases of women — the treatment of inflammation of the neck of the uterus. Before closing it let me beg the reader to note that my constant effort has been to draw a strict analogy between the treatment of inflammation here and in all other parts of the body, and to make a marked distinction 1 Tilt, Uterine Therapeutics, Am. ed., 1855, p. 92. TREATMENT OF CERVICAL METRITIS. 247 between inflammatory action affecting the two structures, mucous and parenchymatous. I have described inflammation of each separately, because by this plan greater accuracy of detail is attainable, but in practice they frequently exist together, and the practitioner will usually be called upon to combine the two methods of treatment which have been advised. Resume of Treatment of Cervical Metritis. 1st. Best to the extent indicated in each particular case; avoid- ance of sexual intercourse and muscular efforts ; removal of weight from fundus. 2c?. General regimen, mild cathartics, baths, plain but nutritious food, avoidance of stimulants and spices, exposure to pure, fresh air without fatigue. 3d. Depletion by leeches, cups, or scarification. 4:th. Emollient and sedative applications by vaginal injections, medicated and simple, or by suppositories. 5th. Alteratives. — Applications of iodine, iron, nitrate of silver, etc. 6th. Counter-irritation by blisters, warm iron, and in certain very rare cases, by the actual cautery and potassa fusa. Fig. 94. CHAPTEE XVII. CHRONIC CORPOREAL ENDOMETRITIS. Like the cervix, the body of the uterus is liable to two distinct varieties of chronic inflammation, that affecting the mucous mem- brane which lines its cavity, and that of the parenchyma or tissue which makes up its walls. The first receives the name of cor- poreal endometritis, in contra-distinction to cervical endometritis ; the second that of corporeal metritis, which distinguishes it from the cervical form of the same disease. Synonymies. — This disease has been described under the names of endometritis, uterine catarrh, uterine leucorrhoea, and internal metritis. The precise seat of the affection is pointed out by the dots in Fig. 94. Frequency. — Few points in uterine pa- thology have created more discussion of late years than this. Some excellent authorities, following the lead of Dr. Henry Bennet, regard it as of rare occur- rence, while a large majority consider it quite common. "Internal metritis," 1 says Aran, "is more frequent, nevertheless, in spite of all that has been said to the con- trary, in the cavity of the body than in the cavity of the neck of the womb ;" and this opinion is concurred in by Dr. West and others. To show how unsettled this point is in the present state of pathology, let me contrast with this statement that of Prof. Byford, 2 of Chi- cago, whose excellent work on Medical and Surgical Treatment of Women has recently appeared : " Inflammation limited to the The dots show the site of cor poreal endometritis. i Mai. de l'Uterus, p. 40J 2 Op. cit., p. 182. NORMAL ANATOMY. 249 cavity of the body of the uterus is not common, but I am quite sure that I have met with at least two instances." While Dr. Byford's experience furnishes him but two instances, Dr. Tilt gives the statistics of fifty cases of which he has kept notes. The more industriously the student of Gynecology interrogates the literature of this subject, the more unsettled are his conclu- sions likely to be, and unfortunately his own investigations, how- ever carefully conducted, will often fail to enlighten him in the individual cases with which he meets, for the differential diag- nosis between cervical and corporeal endometritis is often very difficult. My own opinions upon this important point I shall state freely, unbiassed by those of authors for whom I entertain the highest respect, but whose conclusions conflict with what I have carefully observed at the bedside. The most frequent locality of uterine inflammation is that portion of the uterus below a line running across it through the os internum. That portion of the organ above this line, however, is much more commonly affected by inflammatory disease than is stated by Dr. Bennet. During the past eighteen months I have met, in private practice alone, nine well marked and unquestionable cases, and with several more in which I could not satisfy myself as to the exact limit of the disease. The lining membrane of body and cervix may be simultaneously affected, but this is the exception and not the rule; generally we find one or other portion of the organ the seat of disease. In making this last assertion I am fully aware of its importance, and of the fact that it will be dis- sented from by a great many. But feeling convinced, as I do, that upon its non-recognition depends a certain amount of the obscurity attending the differentiation of metritis of the neck and body, I wish to fix the attention of the reader upon it. Normal Anatomy. — If the mucous membrane of the uterus be examined by a lens, it will be seen to be studded with minute openings somewhat similar to the mouths of the glands of Lieber- kiihn in the intestines. These are the mouths of long, curling follicles which project by their closed extremities downwards to- wards the parenchyma of the organ. They are lined by delicate epithelium, and are supposed to secrete mucus in the non-preg- nant state. During pregnancy they become excessively active, and undergo great hypertrophy. Pathology. — Corporeal endometritis is, like the same affection 250 CHRONIC CORPOREAL ENDOMETRITIS. in the cervix, a glandular disease. The utricular follicles are the seat of the disorder, and it is to the exaggeration of their secretory functions that is due the uterine leucorrhcea, which constitutes one of its prominent symptoms. Causes. — These may be enumerated as follows : — Exposure during menstruation ; Sudden checking of the menstrual flow ; Obstruction to escape of menstrual blood ; Abortion and parturition ; Inflammation of the cervix ; Acute corporeal metritis or endometritis ; Sexual intercourse ; Injury from sounds, intra-uterine pessaries, and injuries re- sulting from attempts to produce abortion ; Certain hsemic conditions, as those accompanying phthisis and exanthematous diseases ; Tumors in the uterine cavity or walls. It is quite clear how either of the first two causes, in checking hemorrhage from the congested mucous lining of the uterine body, may at once induce the first stage of this disease. They generally result in the acute variety, which may rapidly pass off, but which sometimes ends in the chronic form. Obstruction to escape of menstrual blood is a very fruitful source of the affection. The menstrual blood, if it pour at once into the vagina, remains fluid from admixture of an acid mucus secreted by the lining membrane of that canal ; but if it be im- prisoned in the uterine cavity, where only an alkaline mucus exists, it very soon becomes clotted. These clots are, of course, too large to pass through a cervix of normal dimensions, much more so to escape from one unnaturally constricted. Their pre- sence in the uterine cavity, together with that of blood which they imprison, in time excites contraction, by which they are expelled. But this repeated dilatation and contraction cannot last long without exciting inflammation in the mucous lining either of the body, the cervix, or of both. Such an obstruction may have as its cause a small polypus, which acts as a ball valve at the os internum, congenital or acquired narrowness of the cervical canal, uterine flexion, or swelling of the cervical lining from congestion. The parturient process is a very frequent source of the disease, PATHOLOGY. 251 especially where the unripe placenta is prematurely separated from its uterine connection. Where, as in a prolonged labor, the early evacuation of the liquor amnii leaves the irregular outline of the body of the child pressing against the uterine investment for many hours, such a sequel is not astonishing. Of cervical inflammation Dr. Bennet 1 thus expresses himself: " It" (*. e., corporeal endometritis) " appears, however, to be gene- rally met with in practice as the result of the lengthened exist- ence of inflammatory disease of the cervix and its cavities. The inflammation gradually progresses along the cavity of the cervix until it reaches the os internum, and passes into the uterus." I have already stated my dissent from this view, although, at the same time, I admit that it sometimes holds true. Acute metritis may, instead of subsiding entirely, very natu- rally run into this disease. The effect of sexual intercourse as a causative influence is fre- quently observed soon after marriage, the first connubial ap- proaches exciting uterine congestion with greater or less intensity. Dr. Tilt 2 remarks, with reference to it: " It is useless to disguise the fact, connection has a downright poisonous influence on the generative organs of some women." I cannot believe that the Almighty has ordained a function as essential to the perpetuation of our species which has a downright poisonous influence on the generative organs of a healthy woman. And yet, to a certain extent, the statement is correct, for upon a woman who has en- feebled her system by habits of indolence and luxury, pressed her uterus entirely out of its normal place, and perhaps goes to the nuptial bed with some lurking uterine disorder, the result of imprudence at menstrual epochs, sexual intercourse has indeed such an influence. The taking of food into the stomach exerts no poisonous influence on the digestive system, but the taking of food by a dyspeptic who has abused and injured that organ, does so. Injuries from sounds, &c, act so evidently in exciting inflam- mation as to need only mention. Certain conditions of the blood sometimes produce acute cor- poreal endometritis, which, as already stated, may pass into that form under consideration. As a complication of the exanthema- 1 Op. cit., p. 75. 2 Op. cit., p. 234. 252 CHRONIC CORPOREAL ENDOMETRITIS. tons diseases endometritis is well known, and its occurrence with phthisis has been noted by Dr. Gardner in the American edition of Scanzoni. Every practitioner must have noticed it in connec- tion with that affection. Tumors in the cavity or walls of the uterus very generally produce this disease in consequence of the congestion of the mucous membrane which they cause. Symptoms. — The symptomatology of corporeal endometritis constitutes one of the most unsatisfactory and obscure subjects in the entire field of Gynecology. At times its symptoms are so slight and at others so masked and obscure that the disease often runs a lengthy course without exciting the suspicions of either physician or patient. Its effects upon the constitution also differ most unaccountably in different cases. Sometimes the disease will continue for ten, fifteen, or twenty years, producing profuse leucorrhcea, menstrual disorders, and nervous derangement, and yet result in no annoyance so grave as to cause the patient to seek medical aid. At others it passes rapidly into disease of the superficial parenchyma, which induces displacement and causes great pain on locomotion, sexual intercourse, and the passage of feces through the rectum ; or results in an ichorous discharge, which creates the most annoying symptoms of vaginitis, cystitis, or pruritus vulvae. The chief symptoms which usually present themselves in a case of uncomplicated mucous metritis of the uterine body are — Leucorrhcea ; Menstrual disorders ; Pain in the back, groins, and hypogastrium ; Nervous disorders ; Tympanites ; Symptoms of pregnancy ; Sterility. Profuse leucorrhcea of glairy character is one of the chief signs of the affection. This, when very tenacious and thick, is the pro- duct of the Nabothian glands, but the lining membrane of the uterus likewise secretes a similar fluid, differing from it chiefly in possessing the qualities mentioned, in a very much less marked degree. But uterine leucorrhcea differs from cervical in other particulars ; it is often more or less mixed with blood so as to have a rust-colored appearance, especially for a fortnight after SYMPTOMS. 253 menstruation. This, Dr. Bennet 1 looks upon as being "as char- acteristic of internal metritis as the rust-colored expectoration is of pneumonia." I have never seen it in endometritis unless the parenchyma were somewhat involved. At times the discharge is milky, and at others, and these are the most rebellious cases, perfectly purulent. There is a variety of corporeal endometritis which occurs in old women who have loug since ceased to men- struate in which a watery or creamy pus is secreted. These cases are often accompanied by the most wearing and harassing pruri- tus vulvae, and always, according to my experience, prove sus- ceptible only of palliation, cure being beyond medical means at present known. Menstrual disorders are rarely absent. The discharge is some- times too profuse, even lasting throughout the month and consti- tuting metrorrhagia, or it is very scanty, and shows a marked tendency to cessation. Where the parenchyma is entirely unaffected, menorrhagia may occur without pain, but this is not common, for that tissue is fre- quently involved and dysmenorrhoea coexists. Sometimes in these cases, an exfoliation of the entire lining membrane of the cavity of the uterine body occurs at the menstrual periods. This has received the name of the dysmenorrhceal membrane, and may generally be regarded as one of the signs of chronic corporeal endometritis. Pain in the back, groins, and hypogastrium is rarely absent, and at times a burning sensation over the symphysis pubis proves a source of great discomfort. Nervous symptoms in greater or less severity generally show themselves before the disease has lasted long. The patient com- plains of neuralgic headache, especially over the crown, hysterical symptoms, with sadness, tendency to weep, and a feeling of intense isolation and incapacity for any mental effort. Meteorism is a very common symptom, the connection of which with inflammation of the uterine mucous membrane is not, at first glance, clear. It is probably due to disorder of the nervous influ- ences governing peristalsis and giving tone to the intestinal mus- cular tissue, which proceeds to such an extent as to result in accu- mulation of gases in the canal. In the same way it may induce 1 Op. cit.,p. 76. 254 CHRONIC CORPOREAL ENDOMETRITIS. constipation, which is often one of its most obstinate accompani- ments. Symptoms of pregnancy often exist in connection with the dis- ease, and sometimes mislead the physician. Nausea and vomiting are by no means invariably present, but are valuable as positive signs. They appear to result from this disease as they do from occupation of the uterine cavity by the product of conception. Sometimes, in addition to these, there are darkening of the areolae of the breasts, and enlargement and sensitiveness of the mammary glands. When to these are added abdominal enlarge- ment, from tympanites and irregularity of menstruation, it will be perceived how easily an error might be made. Sterility is so commonly a result of endometritis that it should be considered as one of its signs. Yery often it has been the only symptom that has led to an investigation of the state of the uterus which has determined the existence of the disease. The affection does not, however, preclude the possibility of conception; it only diminishes the probability. Physical Signs. — The physical signs are neither numerous nor reliable, and those of real value only will be mentioned. The uterine probe passed into the cavity will often show the length of the uterus to be greater than it would be in health. The mucous lining being gently struck by the probe, pain will be at once complained of, and a few drops of blood with mucus will follow its withdrawal from the cavity. Upon conjoined manipu- lation, two fingers being placed in the fornix vaginae, or one behind the uterus in the rectum, and the fingers of the other hand made to depress the anterior wall of the abdomen, sensitive- ness will be found in the body of the organ. The recognition of the absence of cervical disease, while at the same time there are profuse uterine leucorrhoea and the other symptoms recorded, will lead us strongly to suspect it. Lastly, dilatation of the os internum, with or without that of the external os, may be taken as a corroborative sign. Course, Duration, and Termination. — It is very doubtful whether this affection, like that of the cervix, is susceptible of spontaneous cure, or eradication by constitutional means alone. It may be palliated by alterative and tonic influences, diminished in severity and relieved of complications by constitutional means, but I have never seen a case thus cured. If not cured, the tend- PATHOLOGY — PROGNOSIS. 255 ency of the mucous inflammation is to excite parenchymatous disease and thus to induce uterine displacements with their attend- ant evils. The duration of the disease is unlimited, twenty and thirty years often elapsing without its removal. It is astonishing to see how long the affection will remain confined, in some cases, entirely to the mucous membrane and not affect the parenchyma to any appreciable degree, but that it does affect it in excep- tional cases, even in the virgin, I feel satisfied is true. Pathology. — I have had three opportunities for examining post- mortem into the pathology of this disease, uncomplicated by parenchymatous or other attendant disorder. Two of these cases were presented to the Obstetrical Society of this city. In these instances the condition described by Scanzoni was most evident. The uterine cavity was found considerably enlarged, its walls diminished in thickness, and in one instance they were pronounced by Dr. J. B. Eeynolds, after microscopical examination, to be in a state of fatty degeneration. The uterine neck was in every case found healthy both as to parenchymatous and mucous structure, and the enlarged body displaced by anterior or posterior flexure. The mucous lining of the body was in two cases quite smooth and to a great extent deprived of epithelium, while in the third it was roughened, and presented points where the enlarged blood- vessels created a number of reddish spots. But enlargement of the uterine cavity is not always present ; it marks chronic cases, and will not be recognized in those of recent origin. It is highly probable, too, that in cases of recent origin the pathological ap- pearances which have been here described would not be found to exist, but in place of them a thickened, congested, and florid appearance would present itself. Prognosis. — The prognosis of chronic inflammation of the ute- rine body is always grave with reference to cure. Even if the case is not of very serious character, and has lasted only a short time, the possibility of rapid recovery is doubtful, while, if it has con- tinued for a number of years it will often prove incurable. Scan- zoni 1 says, with a candor which does him honor : "As for ourselves we do not remember a single case where we have been able to cure an abundant uterine leucorrhcea of several years' standing." In most cases a certain amount of amelioration may be effected 1 Scanzoni, Diseases of Females, Am. ed., p. 202. 256 CHRONIC CORPOREAL ENDOMETRITIS. even when they are of long standing ; in a certain number treated early, cure may unquestionably be accomplished ; while in a great many nothing whatever, either in the way of cure or of relief, can be obtained, and the patient, after passing from physician to phy- sician, settles down into a careful mode of life, resolved to cease treatment and bear as best she may an evil which she has learned to regard as incurable. The symptoms of a hopeful and desperate case of corporeal endometritis may be thus contrasted: — ■ Prognosis is Favorable when The case is of recent standing ; The discharge is mucus or blood ; Dysmenorrhoeal shreds are not cast off; Patient naturally of strong constitution ; Parenchyma is not affected ; No displacement exists ; Dimensions of cavity are not increased ; Discharge does not produce vaginitis ; Nervous system is not involved ; Patient near menopause. Prognosis is Unfavorable when The case is of long standing; The discharge is purulent ; Dysmenorrhoeal shreds are cast off ; Patient naturally of feeble constitution : Parenchyma is affected ; Displacement exists ; Dimensions of cavity are increased ; Discharge produces vaginitis ; Nervous system is involved ; Patient not near menopause. Complications. — The complications of the disease are cystitis, vaginitis, rectitis, ovaritis, corporeal metritis, cellulitis, and pelvic peritonitis. Treatment. — Special attention should be given to sustaining and improving the general health of the patient, which will always show a marked tendency to depreciation. Good diet, fresh air, systematic exercise, and avoidance of all circumstances calculated to depress the spirits or harass the mind should be recommended. If practicable, change of air and scene should be brought to our aid, and the patient sent occasionally to some suitable watering- place or country resort. The healthy condition of the nervous and sanguineous systems will be fostered by these measures, and should medicinal tonics be required, iron, the mineral acids, quinine, the bromide of potassium, or nux vomica may be admi- nistered. All condiments, as spices, and aromatics, should be avoided, and the patient should be guarded against habits of indo- lence and luxury which tend to exhaust the nervous strength. The uterus should be placed at rest by removal of pressure upon the fundus by clothing, cessation of marital intercourse, and avoidance of violent and intemperate exercise. The part affected being removed from the vagina on the one APPLICATION OF ALTERATIVES. 257 hand, and the pelvic and abdominal walls on the other, little advantage results from the emollient applications and depletory means which prove so useful where the cervix is diseased. Our chief hope of affording relief must rest upon the general means just mentioned, and upon the direct application to the diseased surface of alterative remedies. Medicated Tents. — I know of no plan which promises better results than the use of sponge tents, medicated as advised on page 230 when they can be borne. These are passed completely up to the fundus uteri and allowed to remain for twenty four hours, when, by a thread attached to them, the patient may remove them without difficulty. Tents medicated with iron, iodine, zinc, potassium, or copper, may be employed once a week with great advantage. Not only does the medicinal substance come fully in contact with the uterine walls, but the pressure exerted by the expanding sponge likewise proves beneficial. Application of Alteratives. — Eecamier was the first who had the boldness to cauterize the cavity of the uterus, which he did by means of nitrate of silver in an ordinary porte-caustique. The practice thus introduced was continued and spread abroad by Eobert, Eichet, Trousseau, Maisonneuve, and others, and to-day is esteemed one of our most reliable methods for combating this rebellious affection. There are four methods by which it may be practised : 1st, by the use of solutions painted over the surface ; 2d, by ointments left to melt in utero ; 3d, by injections of fluids into the cavity of the body ; 4th, by solid caustics. In commenc- ing treatment the practitioner should see that the cervical canal is well opened in order to admit the free escape of fluids from the cavity above, and the application of substances through it from below. This perviousness, should it not exist, should be secured by the use of tents before the local treatment is proceeded with. If the uterus be found sensitive to vaginal and rectal touch the patient should remain in bed for some days before the first application is made, the bowels be kept active by mild saline pur- gatives, and warm baths or hip-baths with copious vaginal injec- tions employed. If the operator use the ordinary long, cylindrical speculum, he will in the majority of cases fail to accomplish the end in view, reaching the fundus uteri, for through such an instrument, it is always difficult and dangerous to penetrate so high into the cavity. If, however, he use the Sims speculum, 17 258 CHRONIC CORPOREAL ENDOMETRITIS. or one of its modifications, or the short, telescopic, cylindrical instrument, he will succeed without effort or delay. The instru- ment being introduced and the cervix cleansed by the speculum syringe, the operator very gently passes to the fundus Sims's uterine probe and learns the exact course of the canal. Then, placing the flat dressing probe by the side of this, he gives it the exact curve he has ascertained to be that of the uterine canal, and wrapping it with a thin film of cotton passes it to the fundus. This removes a good deal of mucus from the cavity which would otherwise have neutralized the caustic introduced. Eemoving the cotton from the probe he wraps another piece around it, or, as is better, uses another probe already wrapped, and, dipping this into the fluid caustic which he has determined to use, he passes it directly to the fundus and keeps it still for from thirty seconds to a minute. This should not be repeated, for the astringent action of the caustic makes repetition difficult, and if properly done the first time it will be unnecessary. After this the patient should go to bed and remain perfectly quiet, for three or four days if a strong caustic have been used, for one or two days if a rnild one has been employed. The caustics which may be thus employed are : — Solution of chromic acid ^j to §j water ; Solution of nitrate of silver J}j or 5ss to §j water ; Churchill's tincture of iodine §ss to §j glycerine ; Saturated solution of sulphate of zinc ; Saturated solution of sulphate of copper ; U. S. D. solution persulphate or perchloride of iron ; Solution of chloride of zinc 5j to §j water ; U. S. D. muriate tincture of iron 5ij to §j water. It is evident that by the admixture of water, or glycerine, which is better, these may be weakened to any extent desired. Should the saturated solution of strong caustics, like chromic acid, be employed, let the practitioner be sure that there is no excitement about the uterus at the time the application is made, that not one superfluous drop is left upon the cotton, and that the patient remain perfectly quiet after the application. No one, unless familiar with the practice, should resort, at first, to strong caustics, but make use of one of the milder ones until he acquires the re- quisite skill. This method of employing fluid caustics is that in- troduced into the Woman's Hospital in this city, by Drs. Sims and Emmet, and surpasses any other with which I am familiar. SOLID CAUSTIC TO CAVITY OF UTERUS. 259 Use of Ointments. — The use of ointments is proceeded with in much the same manner, except that a different instrument is, of course, necessary for their introduction. That which answers the purpose best is the invention of Dr. F. D. Lente. It consists of a syringe with a silver tube attached as represented in Fig. 95. The ointment to be employed is put into the syringe by a spatula, Fig. 95. Lente's ointment syringe. and the tube being introduced into the uterine cavity the piston is pushed forward and the ointment is forced out. The following are the ointments which are generally thus employed, though any others — as lead, bismuth, calomel, iodine, &c. — might be sub- stituted: — fy. — Argenti nitratis, gij ; Belladonnae ext., £j ; Ungt. spermaceti, £)ij. — M. fy, — Plumbi acet., gij ; Morph. sulphat., gr. iv ; Butyr. cacao, §ss ; 01. olivaa, q. s. — M. The Application of Solid Caustic to the Cavity of the Uterus. — The only caustic which should ever be thus employed is the nitrate of silver, for although one author has advised a similar use of potassa cum calce, no one of whom I have heard has followed his counsel. The use even of lunar caustic gives such great pain and causes such grave constitutional symptoms that it never can become a popular therapeutical resource. It is, however, of great value in obstinate cases, and should always be held in reserve. Sometimes the se- verest uterine colic is produced by it, with nausea, vomiting, and great prostration. So violent have these symptoms been in some cases that I have been forced to use the hypodermic syringe freely for their relief, and now often employ it before resorting to the method. By Lente's probe the cauterization is accomplished in an easy and effectual manner not attainable by any other method. The nitrate being fused in the little instrument of platinum, repre- 260 CHRONIC CORPOREAL ENDOMETRITIS. sented on page 230, and the tip of the probe coated, the direction of the uterine cavity having been previously ascertained by Sims's probe, it is properly curved and passed in. By it every part of the uterine mucous membrane is thoroughly touched, the probe being kept within the cavity until its envelope has melted off. This application should always be treated as an operation. The patient should be warned of the pain which she will be likely to suffer and the practitioner remain with her or visit her within an hour after the application has been made, prepared to give relief by the hypodermic syringe. Injections into the Uterine Cavity. — There can be no question of the fact that by this means endometritis may be cured, nor of the additional fact that it may be used a great many times without injurious results. But it is ordinarily attended by great danger, and no one, not even he who has the largest experience, can tell when a fatal issue may ensue from it. The fluid thrown into the uterus is liable to pass through the Fallopian tubes into the peri- toneal cavity and produce the most alarming collapse, or perito- nitis and death. The literature of the subject contains a number of cases in which death has thus resulted. It has been found, however, that if the cervical canal be dilated by tents so as to allow of the escape of fluids from the cavity of the body, these dangers disappear to a great degree, and by anticipating the in- jections by such, means we may cautiously avail ourselves of them. The substances which may be thus used are persulphate of iron, tincture of iodine, weak solutions of nitrate of silver, sulphate of zinc, sulphate of copper, &c. The method for em- ploying uterine injections is very simple. A long-necked syringe, charged with the substance to be used, should be passed into the cervix through the os internum and the fluid very slowly and gently expelled ; or a small syringe may be fitted by its nozzle into a gum-elastic catheter, the extremity of which is passed into the uterine cavity and the fluid slowly discharged. The use of the curette in the treatment of corporeal endome- tritis is generally mentioned in works upon this subject, but the curette is not really used for this disease. It is emploj^ed to remove one of its results which produces metrorrhagia, for the checking of which it is most commonly resorted to. I allude to papillary hypertrophy of the uterine mucous membrane. CHAPTER XVIII. CHRONIC CORPOREAL METRITIS. Fi«. 96. Definition and Synonymes. — This term is applied to inflamma- tion of the parenchymatous structure making up the walls of the uterine body. It has been described under the names of metritis, parenchymatous metritis, inflam- matory engorgement and hypertrophy of the uterus. Frequency. — This part of the uterus, as already stated, is not so frequently affected by inflammation as the corresponding tis- sue of the cervix. Still it is hy no means unfrequently diseased. A large number of cases of incurable uterine disorders oc- curring as a remote result of parturition is really of this nature, and the displace- ments, rebellious leucorrhoea, and other concomitant evils which characterize them are merely symptoms of the parenchyma- tous affection. An important fact con- nected with this state is one to which atten- tion has been drawn by Dr. E. R. Peaslee. It is that where inflammatory hypertrophy of the areolar tissue exists as the chief element of metritis, tempo- rary or transient attacks of active congestion frequently occur and excite acute symptoms from time to time. These pass away, leaving the basis of the affection in its original state, soon to return with all the symptoms of relapse. And thus a series of short but severe exacerbations go on developing themselves in the ordinary course of an attack of the disorder. Causes. — Parturition or abortion ; Sub-involution ; Cervical metritis; Displacements; Corporeal endometritis. The dots show the site of corporeal metritis. 262 CHRONIC COEPOEEAL METRITIS. In the vast majority of cases the disease results from some dis- order occurring subsequent to pregnancy. The puerperal state may be said to be the great predisposing cause of this condition, which is met with very rarely under other circumstances. It may be that upon the exuberant state of the uterine areolar tissue produced by pregnancy, a low grade of metritis has been en- grafted, or that an arrest in the physiological absorption of the uterus has occurred. In either case the affection which we arc considering is likely to be the result. It is sometimes, though not often, the result of inflammation of the mucous lining, and hence anything which directly excites endometritis may possibly produce it indirectly. Cervical metritis may likewise pass up- wards and affect by contiguity of structure the parencyhma of the body. Corporeal metritis when found existing with uterine displacement is usually the cause of the latter condition, but it may in certain rare cases result from a displacement which, inter- fering with circulation in the uterus and causing a congestion of its structures, may produce a low grade of chronic inflammation and hypertrophy of the areolar tissue. Although all these influences must be admitted as occasionally productive of metritis, the fre- quency of parturition as the great moving cause must be fully appreciated. Symptoms. — The symptoms generally resemble very closely those of corporeal endometritis. The following are especially indicative of the parenchymatous affection. A dull, heavy, dragging pain through the pelvis, much in- creased by locomotion ; Pain on defecation and coition ; Pain of severe character beginning several days before men- struation, and lasting during that process ; Pain in the mammas, before and during menstruation; Darkening of the areolae of the breasts ; Nausea and vomiting ; Great nervous disturbance ; Pressure on the rectum with tenesmus and haemorrhoids ; Pressure on the bladder with vesical tenesmus. I would not convey the impression that these symptoms are distinct from those of corporeal endometritis, and that none of them occur with it. As already stated, the symptoms of the two affections are interwoven so frequently, and to such a degree, DIFFERENTIATION. 263 that they cannot be completely separated. Where, however, the mucous affection has lasted long, and the parenchyma becomes diseased, the symptoms just detailed superadd themselves to those before existing. Physical Signs. — 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 walls, the body of the uterus will, unless the woman be very fat, be distinctly felt, should the organ be anteflexed. Should it not be detected, let the two fin- gers in the vagina be now carried behind the cervix into the fornix vaginae, and the effort repeated; if the uterus be retro flexed or retroverted, 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 sensitiveness. This may likewise be accomplished to a certain extent by rectal touch. The uterine probe should then be introduced, the cavity measured, and the sensitiveness of the walls carefully ascertained. Course, Duration, and Termination. — Unlike inflammation in other parenchymatous structures, inflammation in that of the uterus does not tend to suppuration. Usually the organ becomes enlarged and displaced, and remains in this condition until the menopause ; or absorption of the exuberant tissue takes place, and it returns to its natural size or becomes atrophied. Pathology. — Most pathologists agree in the assertion that the affection consists in congestion of the parenchyma, which is fol- lowed by an effusion of liquor sanguinis into its tissue. Du- parcque 1 maintains that the muscular fibres are separated by a flbro-albuminous material, which may be forced out by pressure or scratching, and that it is this material which, subsequently contracting, strangulates the vessels that it surrounds, and pro- duces atrophy. Scanzoni 2 declares that there is an "hypertrophy of the cellular tissue," which results from organization of the material effused ; and this view is adopted by Klob and others of the German school. Differentiation. — The diseases with which it may be confounded are: — 1 Mai. de la Matrice, p. 244. 2 Op. cit., p. 181. 264 CHRONIC CORPOREAL METRITIS. Corporeal endometritis ; Cervical metritis ; Pregnancy ; Neoplasms ; Perimetritis. From all a most careful differentiation should be made; for if in error, the practitioner would not only surely fail in giving relief, but might do great injury. For example, an examina- tion by the probe might produce abortion, or so aggravate peri- uterine inflammation as to cause serious and alarming conse- quences. The introduction of the probe or sound should, for this reason, be practised with great caution, and only when good rea- son exists for supposing pregnancy and perimetritis absent. For distinguishing this disease from cervical metritis the fol- lowing will be the means upon which we must rely. We will suppose that we are dealing with a complicated case in which both tissues, mucous and parenchymatous, are affected, and not with one of those in which the parenchyma alone is diseased. Corporeal Metritis and Endometritis. I Cervical Metritis and Endometritis. Glairy, purulent, and bloody leucor- rhoea; Tympanites, often marked ; Uterine tenesmus ; Nausea and vomiting ; Glairy and very tenacious leueorrhcea, perhaps streaked with blood ; None ; None ; Not common ; Dysmenorrhoea severe, days before flow ; j Not severe ; Nervous symptoms grave, despondency ; Not so grave, no sleeplessness nor great and sleeplessness present ; despondency ; None ; Not so ; Not so ; Not so ; Does not; Tendency to exfoliation of mucous lining; Mammae painful at epochs ; Areolae darkened; Size of cavity often increased; Probe gives pain and a few drops of blood ; Conjoined manipulation shows sensitive- Does not. ness of body. Between pregnancy and commencing corporeal metritis, which is very apt to become aggravated under the influences of matri- mony, there is a chance of error in diagnosis ; for in both there are enlargement of the breasts, darkening of the areolae, enlarge- ment of the uterus, derangement of the nervous system, and nausea and vomiting. In the one, however, menstruation does not cease, there is no kiesteine in the urine, there is great sensi- tiveness of the body of the uterus, and an abundant leueorrhcea. PROGNOSIS — TREATMENT. 265 Dr. Tilt lias drawn especial attention to this important fact : "When most of the symptoms of early pregnancy are present/' says he, " without menstruation being suspended, in compara- tively young women, internal metritis may be suspected." Neoplasms or fibrous growths in the uterine walls will some- times, from the peculiar symmetry of their development, com- pletely mislead us, giving uterine enlargement, leucorrhoea of bloody character, &c. &c. I have now in my possession a uterus in the anterior wall of which a fibrous tumor, equal in size to a goose's egg, gives upon superficial examination all the appear- ances of engorgement of uterine tissue with anteflexion and endometritis. The only way in which a diagnosis could be made under such circumstances would be by the proper use of the uterine sound, and carefully studying the individual case by means of this and conjoined manipulation. Perimetritis, unless accompanied by endometritis, is unattended by leucorrhoea, and by it the uterus is rendered immovable. The uterine probe, if employed in such a case, should be used with great caution, and would show no sensitiveness of the uterine walls and no increase in the dimensions of the cavity of the uterus. Prognosis. — The prognosis is unfavorable with regard to cure, though highly favorable with reference to danger to life. Should the patient be approaching the menopause, hope may be held out that after the functions of the uterus cease, atrophy may occur and relief be obtained. But one cannot be sure even of this, for the monthly discharge may give place to metrorrhagia, or all the symp- toms of metritis may continue in spite of the menstrual cessation. Treatment. — No one, in the present state of uterine pathology and therapeutics, can write very positively upon this subject for it really constitutes one of the opprobria of Gynecology. The rules laid down for the treatment of parenchymatous disease be- low the os internum will disappoint us here. We cannot from the same means expect the same favorable results/ The thera- peutic resources which were recommended for cervical inflamma- tion were these : — Rest; General regimen; Depletion ; Emollients ; Alteratives ; Counter-irritants. 266 CHRONIC CORPOREAL METRITIS. Unfortunately in corporeal inflammation they often all fail to accomplish a good result. Nevertheless, since some cases are relieved by them, and a smaller number cured, it is our duty to essay them cautiously — so cautiously as to feel assured that if we accomplish no good, at least we shall do no evil. Rest. — It is not only useless but injurious, in a disease which will probably last for many months and perhaps years, to confine a patient to bed, for her general health will almost surely suffer if such a course be persisted in. She should be required to lie down for the greater part of the day while treatment is being in- stituted, and to remain quiet during menstruation, and for some days after applications have been made to the diseased part, but every day she should go, unless deterred by some s such 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 posi- tion, consequently all pressure should be removed from its fundus by the use of skirt supporters and a well-fitting abdominal band- age. Fig. 97 represents a very excellent skirt supporter, which has been patented by Mr. Bach- eller. Abdominal bandages are very unpopular with many prac- titioners, who believe that they absolutely do harm. I believe otherwise, and regard them as great adjuvants, not in keeping up the uterus, but in supporting the super-imposed viscera which, pressed downwards by tight clothing, and badly supported on account of the relaxation of the abdominal walls, fall directly upon the fundus. There are a great variety of abdominal sup- porters. I have no favorite, for one will accomplish the end in a woman of a certain figure which would be inappropriate for another. Some very simple and efficient supporters, which will answer the purpose in all but emaciated patients, are presented in the accompanying diagrams: — Bacheller's skirt supporter. GENERAL REGIMEN. 267 Fig. 98. Fie. 99. Abdominal supporter of jean or silk. Abdominal supporter in which the pad covers the hypogastriuin. Two additional patterns are depicted in Chapter IX., upon prolapse of the vagina. That one should be selected which abso- lutely accomplishes the end in view, namely, sustaining the vis- cera and supplementing the weakened muscles of the abdomen. In addition to these means of procuring rest for the uterus, the patient should, as far as possible, lead a life of celibacy. After displacement has occurred, and even before it has done so, great benefit may often be obtained from support rendered by means of a light and well -fitting pessary, the elastic ring of Tie- mann k Co., the accommodating lever of Scattergood, or the sup- porter of Cutter, for example. In some cases the benefit derived from these instruments will be the chief, perhaps the only relief which we can bestow, and even where we cannot cure the disease we may by their use render life much more agreeable by the alle- viation of discomfort. General Regimen. — The diet should be plain and unstimulating, but at the same time nutritious, and in every way calculated to maintain the normal state of the blood. Should spanasmia exist, ferruginous tonics, alone or combined with vegetable tonics, should be administered. The bowels should be kept in a per- fectly healthy state, and the skin active. Specific remedies have been, and are still, employed by some practitioners for stimulating absorption of redundant tissue. Foremost amongst these are the iodide or bromide of potassium, iodine and preparations of mercury. Their efficacy is doubtful, although many excellent practitioners rely upon them with confidence. No other general means compares in results with a change of 268 CHRONIC CORPOREAL METRITIS. abode and corresponding change of air, habits, and associations. A removal, for example, to the sea-side, where bathing can be enjoyed, a sea voyage, or a residence at an agreeable watering- place, may accomplish much good. Mental depression predis- poses to and aggravates this disease most markedly. Aran goes so far as to say that he has almost invariably found it present as inducing the disease. However this be, cheerful and congenial company certainly proves one of the best nervous tonics in a therapeutic point of view, and should always be sought for. A stay in a well-regulated hydropathic establishment, where the patient can have pure air, plain and nutritious food, and agreea- ble society, together with the strict attention to the general rules of hygiene which characterizes those institutions, will often pro- duce the best effects. Depletion, upon theoretical grounds, should be followed by most excellent results in corporeal uterine inflammation, and yet it is not so. So decided is my experience upon this point that I cannot but believe that that of others must be similar to it. As Nonat has pointed out, in cervical inflammation local depletion is productive of good results, for which we look in vain in cor- poreal disease. I have yet to meet with a case of corporeal metritis uncomplicated, be it understood, with, cervical disease, which has been materially benefited by the most methodical and sj 7 stematic local abstraction of blood, unless amenorrhoea was a symptom. In case this be so, a copious abstraction by leeches, during the menstrual epoch, will sometimes give relief. At times the leeches then applied will give great pain by their bites, under which, circumstances they should at the next period be applied to the perineum. The pain from the bite of leeches applied to the cervix, is sometimes so severe as to lead to the apprehension that one has escaped into the cavity; hence it is important that they should be counted before being placed in the speculum, and on their removal from it. Emollients, which, applied externally, are so useful in acute metritis, and by the vagina so beneficial in chronic cervical in- flammation, accomplish very little here. For purposes of clean- liness and relief of pelvic pains, copious vaginal injections should be employed; sedative suppositories may also be brought into re- quisition for the latter of these purposes, and either entire or hip ALTERATIVES. 269 baths be prescribed ; but further than this I do not believe that we can go with advantage. Alteratives. — Alterative remedies of a general character, as the iodide or bromide of potassium, should always be given a full trial, care being observed not to persist in their employment so long as to impair the tone of the stomach. Sometimes the fol- lowing prescription appears to be of benefit : — ■ R;. — Tr. cinchonse comp. §v ; Hydrarg. bicliloridi, gr. j. — M. A dessertspoonful in a claret glassful of water, three times a day. Should the affection have engrafted itself upon sub-involution, and metrorrhagia or menorrhagia exist together with enlarge- ment of the uterine cavity, ergot, in moderate doses, may be administered for several months, in the hope of stimulating con- traction and absorption. Of the effects of all these drugs I am forced to speak very guardedly, for my experience does not enable me to express decided confidence in their efficacy. European writers speak in high terms of the alterative influence of the various watering places and baths of the Continent, as those of Marienbad, Schwalbach, Briicknau, and Kissingen in Germany, and of Saint Sauveur, Bareges, &c, in Switzerland. None of these equal in reputation the waters of Kreuznach in Germany, the curative property of which is supposed to depend upon the bromide of magnesium which they contain. It is very probable that the hygienic and social influences which surround these places and render them attractive, are to be credited with all the good that they do. Aran, after admitting that the water of Yichy may exert some influence, thus pointedly expresses himself with reference to the others: "Whatever be their composition, in whatever countries they may be found, I know of no work in which we can find the approximation to a demonstration in their favor." In a very limited number of cases the cavity of the uterus will be found so tolerant of applications, and even of the presence of foreign substances, that alteratives of local character may be em- ployed with safety, but in the majority of cases such means are attended by danger, and are impracticable. The practitioner must, after careful experimentation, determine as to whether thev should be resorted to or not, and they should never be used with- 270 CHRONIC CORPOREAL METRITIS. out the fact that they are capable of setting up a train of danger- ous symptoms, being kept constantly before the mind. When the case is one admitting their use, local alteratives unquestionably accomplish good in this disease. They may be employed in two methods ; the os may be fully dilated by tents once every fort- night, and the entire uterine cavity painted over with pure tinc- ture of iodine or a strong solution of the iodide of potassium; or the drug employed may be brought into contact with the walls of the uterus by means of medicated tents. Sponges cut into proper shape for tents, having been soaked for a week or more in a strong solution of the bromide or iodide of potassium, or in the tincture of iodine, are moistened in a solution of gum acacia and wrapped in the ordinary way. One of these is passed to the fundus of the uterus at intervals of from ten to fourteen days, and allowed to remain -in position, should it not create disturbance, for twenty-four hours. By this means not only do we avail our- selves of the alterative influence of the drug, which is kept for hours in contact with the absorbing surface of the uterus, but we also obtain that which is due to pressure by the expanding tent. Counter -irritation. — Counter-irritation by means of blisters, issues, setous, &c, has long been practised on the abdominal walls for this affection, and is now regarded with much confi- dence by many Gynecologists. In some cases it is at once pro- ductive of great benefit, while in others it produces none whatever. The difference of action depends upon the existence or non-exist- ence of peri-uterine inflammation. Should peri-uterine cellulitis or peritonitis exist as a complication of metritis, the beneficial effects of counter-irritation will usually be marked, while if they be absent, the remedy will be fruitless. In employing this means, the practitioner should bear in mind that it is appropriate in the treatment of a complication, and not of the original affection. There is only one method by which in pure corporeal metritis counter-irritation can be employed with advantage. It is this : Sims's speculum being introduced, and the uterus fixed by a tenaculum fastened in the cervix, the whole external surface of the neck, together with the surrounding vagina, is painted freely with Churchill's strong tincture of iodine. This may be repeated once a week for a length of time, care being observed not to allow a surplus of the fluid to pour over and inflame the vulva. This COUXTER-IRRITATION. 271 method of application, which I learned from Prof. Fordyce Barker, is beneficial in a certain class of cases — those in which dragging of the uterus upon the utero-sacral ligaments gives pain in the hollow of the sacrum. It is probably by relieving inflammation in these structures, and not in the uterus itself, that it proves useful. CHAPTER XIX. ULCERATION OF THE OS AND CERVIX UTERI. This subject has given rise to a vast deal of discussion arid acrimonious dispute among Gynecologists, of late years ; some declaring that it is one of the most frequent of uterine disorders, while others have asserted, with equal positiveness, that it is of extreme rarity. Some have met with it in practice as a lesion of daily occurrence, while others of most extensive experience have never seen it, except of specific character. It must be evident that this discrepancy could not have existed in the facts with which the observers dealt, and equally probable that it must have been technical, a mere difference of statement due to disagreement with regard to nomenclature. Those who denied to a peculiar granular degeneration of the part, the name of " ulcer," found ulceration to exist very rarely, while those who thus denned such a degeneration, reported it as of very common occurrence. Even now, there is much difference of opinion as to the propriety of applying the term ulceration to this state ; many still looking upon it only as one of the elements of cervical endometritis, as Dr. Robert Lee did originally. That it is so, appears to me cer- tain; but it assumes such peculiar forms, and becomes of itself so absorbing a subject in a therapeutic point of view, that it appears necessary to treat of it apart. It certainly does not present the features which are generally considered characteristic of the pro- cess of ulceration elsewhere, yet as the term fulfils the purpose for which it is employed better than any other, and is too generally accepted and sanctioned to admit of alteration, I shall make use of it without further discussion. Varieties of Cervical Ulceration. The vaginal surface of the cervix uteri is subject to ulcerations of various types which, according to their character, exert a THE GRANULAR ULCER. 273 greater or less influence upon the health of the patient. They may depend upon inflammation originating in the mucous or parenchymatous tissues of the part, may be created by ichorous discharges, the result of inflammation of the cavities of the neck or body, or be due to some peculiar depravity of the blood, creating a vice of nutrition. All the common and generally admitted forms of cervical ulceration may be classed under the following heads : — 1st. The granular ulcer ; 2d. The follicular ulcer ; 3d. The true inflammatory ulcer; 4th. The syphilitic ulcer ; 5th. The corroding ulcer ; 6th. 'The cancerous ulcer. The Granular Ulcer. This variety of ulcer, which has been described under the names of erosion of the cervix,, granular degeneration, and abrasion, consists, as its name implies, in the development of a surface of granular character on the smooth face of the cervix and just within the os. Frequency. — Of all the varieties of cervical ulceration this is by far the most frequent. Yery often it exists for a length of time without any suspicion of its presence arising in the mind of patient or physician, and sometimes without causing symptoms which prove in any great degree annoying. At others, grave constitutional signs may be traced to it and entirely removed by its cure. Causes. — The great pathological feature, essential for this form of ulceration, is inflammation of the lining membrane of the cervi- cal canal, or of that covering the vaginal face of the cervix. This maybe associated with parenchymatous inflammation, but whether the last exist or not, a certain amount of mucous inflammation must be present for it to occur. Whatever, then, excites cervical metritis or endometritis may prove indirectly a cause of granular ulceration, but certain influences which exert a deleterious effect directly upon the cervico-vaginal covering and the os, will prove more directly causative. 18 274. ULCERATION OF THE OS AND CEEVIX UTERI. Examples of such influences are — Uterine displacements, causing friction against the cervix ; Abuse of sexual intercourse ; Yaginal or uterine leucorrhoea ; The use of pessaries ; Injuries to the os in parturition. Symptoms. — Should the disease exist, with but slight implica- tion of the subjacent uterine tissue, very few symptoms may be present. Indeed, profuse leucorrhoea is sometimes the only one of which the patient will complain. The fact that other and graver symptoms generally show themselves, is a corroboration of the statement, that inflammation of the parenchyma and mucous membrane are important elements in such cases ; for where we meet with true inflammatory ulceration occurring in procidentia and unattended by uterine inflammation or congestion, it is re- markable how little disturbance is excited by it. Ordinarily, these are the symptoms which will be noticed in a case of gravity : — Profuse bloody and purulent leucorrhoea ; Pain and hemorrhage after intercourse ; Menorrhagia or metrorrhagia ; Pain on locomotion ; Fixed pain in back and loins ; Tendency to spanaemia ; Nervous disorders and perhaps hysteria. Physical Signs. — Vaginal touch alone will often serve as a diagnostic means, for by it the cervix is felt to be covered by a velvety or granular surface, which, to the practised finger, is at once recognizable. But the speculum offers the fullest corrobo- ration or corrects any error committed by this means. By it, the cervix, more especially near the os, is seen to be covered by a mass of pus, which being removed lays bare an intensely red, granular, hemorrhagic looking space of greater or less extent, closely resembling the inner surface of the eyelids when affected by granular degeneration. The diseased surface does not appear depressed below, but is sometimes even elevated above the sur- rounding mucous membrane. Course and Duration. — There is no proof existing that this dis- ease is ever recovered from without surgical interference, although as to this being impossible I am by no means positive. The de- generated surface may go on for an unlimited time pouring out PATHOLOGY. 275 pus, and thus greatly impoverish, the blood and cause the gravest constitutional results; or the same unfortunate end may be reached earlier by spread of the morbid action up the canal as far as the os internum. Pathology. — The granular ulcer is produced by one of three pathological changes in the tissues of the part ; removal of epithe- lium and erosion of villi ; removal of epithelium and hypertro- phy of villi ; or eversion of the cervical mucous membrane. In the first instance, the ulcer is superficial and not hemorrhagic. The epithelial covering is first removed, producing what is called an abrasion, and the villi themselves are destroyed. In the second, after removal of the epithelium, the papillae or villi increase in size and length, and project forwards like granulations, the larger ones so compressing the smaller as to cause their death by atro- phy. Each of these papillae contains a looped capillary vessel which, becoming enlarged by its hypertrophy, and being entirely unprotected by epithelium, naturally tends to bleed. Sometimes the circulation in the supplying vessels is so much impeded that they become varicose. These two facts have caused the names of bleeding ulcer and varicose ulcer to be applied to the respective states. At times still another change occurs in this form of ulcer, giving rise to another name. Its surface becomes coated with false membrane, when the ulcer is termed diphtheritic. Eversion of the cervix is by no means a rare cause of granular ulcer. As a result of inflammatory engorgement, or in conse- quence of slitting the walls of this canal by surgical procedure, or the act of parturition, its lining membrane prolapses as the mucous membrane of the lids does in ectropion, and if not dis- eased at the time of displacement, very soon becomes so. At times the hypertrophy, which, under these circumstances, may take place in the crested folds of the everted cervical membrane, produces so great a degree of convolution and projection as to have caused the appellations of fungous ulcer or cocks-comb granulation to be applied to it, according to Dr. Arthur Farre,* though Scanzoni 2 regards this as merely an exaggeration of the villous hypertrophy recently mentioned. 1 Supplement Cyc. Anat. and Phys., p. 695. 2 Diseases of Females, Am. e7 out distending it and thus allow it to regain its former tone and power. Fig. 111. Coxeter's modification of Zwanck's pessary. Fig. 112. Roser's pessary. Fig. 113. Fig. 114. scanzom s pessary. Hoffman's pessary shaped like the pelvis. Elytrorrliaphy. — The idea of constricting the vagina so as to diminish its capacity and at the same time offer a column of cica- tricial material for the support of the uterus, long ago suggested itself to the minds of practitioners for the relief of prolapsus uteri. In 1823 M. Romain Grerardin made the suggestion before 308 PROLAPSUS OF THE UTERUS. the Medical Society of Metz, but the operation does not appear to have been essayed. In 1831 Dr. Marshall Hall, of England, Fig. 115. Fig. 116. Bourgeaud's pessary: a is a caoutchouc bag filled -with air. Gariel's pessary. again proposed it, with modifications, and some years afterwards it was performed by Dr. Heming, the translator of Boivin and Duges, on the Diseases of the Uterus, with complete success. Subsequent to this period it was performed, with various modi- fications, by Dieffenbach, Fricke, Scanzoni, Yelpeau, Eoux, Stolz, and others; the operation always consisting in "the removal of a band of vaginal mucous membrane and union of the two lips of the wound in such a manner as to diminish the calibre of the vagina. * * Dieffenbach refers to a great number of women who were completely cured by the procedure. * * * Fricke out of four cases cured three." 1 Judging from these quotations, it appears that the operation has been known and practised for a long time on the continent of Europe, especially in Germany. In England it has not been resorted to, if we may judge from the statement of Dr. Sims, 2 that after a discussion upon an essay pre- sented by himself to the London Obstetrical Society, Mr. Spencer Wells called his attention to the operation of Mr. Heming, already referred to, with the assertion that " at least one case had been successfully operated upon." 1 Wieland and Dubrisay, op. cit., p. 533. 2 Uterine Surgery, p. 312, Am. ed. ELYTRORRHAPHY. 309 Before the invention of Sims's speculum and method of vaginal exploration, this operation was practicable only by drawing the Fig. 117. Sound with sharp points. (Sims.) uterus down to the ostium vaginas, and in all probability the reason for its limited adoption was the difficulty attending its Fig. 118. Uterus fixed by sound. (Sims.) performance. I shall now proceed to describe Sims's method, 310 PROLAPSUS OF THE UTERUS. which differs very essentially from that adopted by his prede- cessors. Sims's Operation of Elytrorrhapliy. — The patient being put under the influence of an anaesthetic, is laid upon a table — upon the left side as for an ordinary speculum examination — and Sims's largest speculum introduced. The curved sound, with forked tenaculum points, represented in Fig. 117, is fixed in the cervix uteri and made to cause a fold in the anterior vaginal wall, as shown in Fig. 118. The parts being steadied by this instrument, the operator, by means of two tenacula, folds over the opposite walls of the vagina so as to decide where union is to be effected. Having settled this point, the mucous membrane is hooked up by a tenaculum several lines above the meatus and cut by curved scissors. The tenaculum lifting the shred thus cut, and when necessary being again attached to the mucous membrane, the incision is carried upwards so as to cut out a strip extending to one side of the Fisr. 119. Speculum and sound in position. (Sims ) cervix. Then another furrow is cut in the same manner on the other side, as represented in Fig. 120. Sutures of silk are then inserted after the plan emploved in vaginal fistuhe, and by them silver sutures are drawn into position. The passage of sutures should be commenced at the apex of the triangle and continued upwards, the sutures being placed as represented in Fig. 120. Dr. Emmet finding that the pouch, left anterior to the ute- rine neck by this procedure, was sometimes entered by the cervix, improved the operation by closing it as represented in Fig. 121- ELYTRORRHAPHY 311 The sound being removed and the cervix pulled down by a small tenaculum, the transverse line of denudation, shown in the diagram as uniting the two arms of the 'V, is accomplished. The only further difference between this and the other method con- sists in quilting the sutures. This is not properly shown by the diagram. The after-treatment consists in perfect quietude in the horizontal posture, the use of opium, fre- quent removal of urine by a ca- theter, and the production of constipation. The lower sutures may be removed in ten days, Fig. 121 Fig. 120. Siins's operation of elytrorrhaphy, sutures in place. Emmet's operation of elytrorrhaphy. and the upper in a fortnight. The patient should be kept in the recumbent posture for two or three weeks, and cautioned against immoderate muscular effort for some time afterwards. CHAPTEE XXII. VERSIONS OF THE UTERUS. Anteversion. Definition and Frequency. — This disorder of position consists in an anterior inclination of the uterus, so that the fundus approxi- mates the symphysis pubis and the cervix retreats into the hollow of the sacrum. Although not so frequent as its kindred condi- tion, anteflexion, it is by no means of rare occurrence. At times it presents itself as an annoying complication of chronic metritis or fibroid growths, while at others it is produced without any alteration existing in the uterine parenchyma. Dr. Churchill 1 opens his chapter upon this subject with these words: "It maybe thought somewhat out of place to treat of some of .these displacements here, as they are so intimately con- nected with pregnancy and parturition ; but as they do occur independently, it appears to me preferable to travel so far out of the way in order to complete the subject, rather than give a partial view, or omit it altogether.'' My own experience leads me to an entirely different conclusion from that here recorded by the emi- nent Irish obstetrician. I meet with versions very commonly in the non-pregnant state. At this time I have under treatment three cases of anteversion, one of which is due to corporeal metri- tis and endometritis, one to a small neoplasm, and a third, which produces very little disturbance, exists without assignable cause. M. Groupil, in 115 examinations of nulliparous women, met with version or flexion 1-i times: and in 114 examinations of multi- parse he found it in 36 instances. The normal position of the uterus is one of slight anteversion, the axis of the body corresponding with that of the superior strait, 1 Diseases of Women, Am. ed. ANTEVERSION. 313 which is a line running from the umbilicus, or a little above it, to the coccyx. The degree of this forward inclination may be so increased by slight causes as to constitute a morbid state. As to the line which Fig. 122. Normal position of uterus. (Wieland and Dubrisay.) separates what is normal from what is abnormal, it is impossible to lay down any exact rule ; experience must be our guide. In general terms, we may say that when the long axis of the uterus is found lying across the pelvis, the fundus near the symphysis pubis, and the neck in the hollow of the sacrum, anteversion exists. Causes. — The causes of anteversion may be thus presented at a glance. Influences increasing the weight of the uterus. Inflammation ; Subinvolution ; Neoplasms ; Pregnancy. Influences forcing the fundus directly forwards. Violent efforts ; Abdominal effusions ; Abdominal tumors ; Tight clothing. 314 ANTEVERSION OF THE UTERUS, Influences dragging the fundus directly forwards. False membranes ; Shortness of the round ligaments. A certain number of cases will be found due to metritis, a number by no means inconsiderable to fibrous tumors, some of the most irremediable cases to false membranes, while a few will exist without other apparent cause than direct pressure from some power which forces down the abdominal viscera upon the fundus. The last cause is much aided by laxity of the abdominal walls, which robs the viscera of support. In early pregnancy anteversion always exists, the increase of uterine weight due to that condition causing the uterus to fall forwards as represented in Fig. 123. Fig. 123. Position of the pregnant uterus. Symptoms.— In a certain number of cases anteversion will be found to exist without creating any disturbance either constitu- tional or local. When symptoms do exist with it, they are gene- rally the result of the disease which produces it. At times, how- ever, by pressure of the os against the posterior vaginal wall, it induces dysmenorrhea and sterility, and by pressure of the fundus against the bladder, and the cervix against the rectum, these vis- cera are irritated and interfered with in their functions. The bladder more especially suffers, sometimes a state bordering VARIETIES — DIAGNOSIS. 315 upon cystitis being engendered. Pressure upon the rectum more rarely produces tenesmus and a painful, irritable state. Course, Duration, and Termination. — Yery little need be said on these points, for they depend upon the peculiarities of the affections which have caused the displacement. If the cause be removed, whether it be metritis, fibrous tumors, direct pressure, or traction, the effect will disappear ; but until this be done no hope of permanent restitution can be indulged. Varieties. — Anteversion may be complete or partial. While there are three degrees of retroversion and of prolapse, there are but two of this displacement, for the axis of the uterine body is naturally inclined so much forwards as to prevent us from includ- ing slight increase of inclination under the head of disease. The following diagram, Fig. 124, will show the varieties referred to ; an inclination of 45° representing the first degree, or partial anteversion, and that of 90° the second degree, or complete ante- version. I have never met with the second degree, although it unquestionably occurs. Ficr. 124. The degrees of anteversion. Diagnosis. — When in a case of this displacement the vaginal touch is practised, the patient lying on the back, the index finger passed into the fornix vaginas discovers that the cervix is absent. 316 AXTEVERSIOX OF THE UTERUS. A rapid investigation will prove that it is not to be found in the pubic or lateral regions of the pelvis, and deep exploration with two fingers will discover it high up in the hollow of the sacrum. The finger being then passed towards the pubes will come in con- tact with a hard ridge, which will run towards the symphysis. Conjoined manipulation will prove this to be the body of the uterus, and complete the diagnosis. Should further evidence be required, the uterine probe, very much curved, may be passed into the cavity, though this is rarely necessary and always diffi- cult. Differentiation. — Capuron 1 tells us that Levret mistook the first case he saw for stone in the bladder, operated for this, and sacri- ficed the life of the patient. In spite of such a grave mistake at the hands of so great an authority, it may be stated that there is no diseased condition with which this should be confounded. The disease inducing the displacement may not be recognized, or some serious error may be made as to its nature, but that does not concern the present subject. The recognition of the mere fact of the anteversion is never difficult, if proper diagnostic means are brought to its elucidation. Prognosis. — The prognosis as to any serious injury which will arise from the displacement is decidedly good, but that as to cure is by no means so. It is generally very difficult to remove the cause, and even should this be accomplished, the uterus is so prone to retain the abnormal position in which it has been long kept, that great difficulty attends its restoration and retention. One of the reasons for this is the fact that the uterine ligaments readily alter their proportion under certain influences. Thus during pregnancy they are all elongated : in posterior displace- ments the utero-sacral ligaments are stretched ; and in anterior inclination the utero-vesical ligaments are similarly affected. As the antithesis of this fact, prolonged absence of function causes contraction in these structures; thus in anteversion, as Dr. Sims has pointed out, the utero-sacral ligaments are generally short- ened, and there can be no doubt that the round ligaments are similarly altered. Treatment. — The first point which the practitioner should settle before commencing treatment, is whether the displacement is the main source of existing morbid phenomena, or whether these are 1 Mai. des Femmes, p. 202. MEANS FOR REDUCTION. 817 due to some disease which underlies that condition. If he be led to regard the disorder of position as the disease, its rectification by artificial support must constitute the chief object of his atten- tion. But if he view it merely as a result of metritis, fibrous tumor, or pelvic peritonitis, his only hope of relieving it must rest in the cure of the special disorder which is its source. It should not be concluded, however, that treatment by artificial support must be confined to cases of pure, uncomplicated displace- ment, for it is very often required where this is the result of other disease. We are called upon to alleviate one of the most annoying symptoms of disease here, as we are in so many other instances. Pessaries are frequentty applied to the uterus as splints are to the fractured femur, not as a means of cure, but as adjuvants in treatment by which rest and freedom from pain can be procured while the healing process advances. Means for Reduction. — In the restoration of an anteverted uterus to its place, difficulty will rarely be experienced, for unlike re- troversion, the displacement does not often become complete. Even when it does so, reduction may be thus accomplished. The bladder having been emptied by the catheter, the patient should be placed upon her back on a hard bed or table, and all tight clothing removed from the abdomen. Her shoulders should be unsupported, and her buttocks very much elevated by pillows. The operator having oiled two fingers should then pass them into the vagina, and press their tips against the body of the uterus, which will have forced the walls of the bladder down before it. The fingers of the right hand being thus employed, the left should be laid upon the abdomen, so as to push up the abdominal viscera and uterus when reduction is attempted. The patient is now directed to fill the lungs with air, and then to expel it gently by a prolonged expiratory act. As this expiration is being finished, the operator presses up the body of the uterus by the fingers in the" vagina, and the abdominal viscera and fundus by the hand on the abdomen. He will very generally at once succeed in replac- ing the organ. Should he not do so, he should repeat the pro- cess as above described, until the end is attained. Of course where the dislocation is partial, restoration may be much more easily effected ; but in this case it accomplishes nothing — for no sooner does the force applied cease, than the organ again falls out of place. In such a case the fundus is lifted by bi-manual mani- 318 ANTEVERSION OF THE UTERUS. puliation, then the hand on the abdomen keeping it up, the finger in the vagina is placed behind the cervix, and this part is pulled forwards towards the symphysis. Some practitioners rely for cure upon the daily restoration of an anteverted or retroverted uterus — but hopes thus based will prove delusive. Where the version is complete and sudden, a return to the normal position may be final ; but never have I, in a single instance, seen it so result where the displacement was incomplete and gradual. Means for Retaining the Uterus in Position. — For this purpose we have the five following means : — The dorsal decubitus ; Prolonged retention of urine ; Eemoval of pressure from the abdomen ; The abdominal supporter ; Pessaries ; Elytrorrhaphy. The dorsal decubitus in cases occurring suddenly, as for ex- ample during pregnancy or after labor, is of great value, but in chronic cases it cannot be relied on, for the patient should not be confined to bed. Even in these, however, when practised for two or three hours at mid-day, it gives great relief. Prolonged retention of urine was first recommended by Piorry. It is a means of no great value, but is certainly worthy of trial. Removal of Abdominal Pressure, by prohibition of tight clothing, of heavy skirts supported by the hips, and of all constricting bands which cause a substitution of abdominal for thoracic respi- ration, is too often neglected in these cases. It is a means of great value, and often gives more relief than any other at our command. The Abdominal Supporter. — In proportion to the disadvantages resulting from corseting the upper segment of the trunk, are the advantages to be derived, in these cases, from thus acting upon the lower. "When the abdominal walls are lax and yield- ing, and do not properly sustain the viscera, they fall upon the fundus uteri, and tend to produce and keep up anterior obli- quity. No one can deny that by a well-fitting abdominal supporter, tone is given to the lax walls, and that the intestines, not the uterus, are sustained. I have already stated that many are prejudiced PESSAKIES, 319 against this means, and decry it as absolutely injurious; but I see it too plainly and certainly productive of good results in daily practice to admit of any doubt in my mind concerning it. Dr. J. 0. Nott offers a very plausible explanation of the fact that in some women benefit follows their use, while in others, absolute injury results from their employment. If the patient be emaci- ated, says he, and the abdominal walls retracted or even flattened, the supporter will depress and not sustain the uterus. On the other hand, if the woman be corpulent, the greatest support will be yielded by its application. Pessaries. — These instruments usually accomplish much less for anterior than for posterior displacements. In some cases, how- ever, great relief can be obtained by them, and a trial should always be made. Sometimes benefit results from merely lifting up the displaced organ by a ring or double lever pessary, but I have obtained better results from an instrument which acts directly upon the prolapsed fundus. This pessary for anteversion I have been in the habit of con- structing out of the ordi- nary block tin ring of Sims, lg * or by bending forwards, under heat, the hard rubber stem of Cutter, so that while one portion of the stem runs from the coccyx along the sacrum, its upper extremity passes forwards and sustains the fundus. In some cases the air pes- sar}^ of Gariel, combined with the abdominal sup- porter, answers a good pur- pose. Although no single resource will surely effect a good result, two or more of those mentioned, employed in combination, will often be successful. Elytrorrlm'pliy. — Should they fail, we may resort to an operation recommended by Dr. Sims as having been successful in his hands, which consists in shortening the anterior wall of the vagina. This operation applied to the purpose indicated, has as Gariel's air pessary in place. Dubrisay.) (Wieland and 320 RETROVERSION OF THE UTERUS yet been very little tried, but it is worthy of attention from the facts that it commends itself to the reason, and comes to us indorsed by excellent authority. It is thus described by Dr. Sims : two surfaces a half inch wide and running nearly across the ante- rior wall of the vagina, the one in juxtaposition with the cervix, and the other an inch and a half or more ante- rior to it, are to be denuded of mucous membrane. They are then brought into apposition by silver sutures, the patient put to bed, and the stationary catheter introduced. At the end of a fortnight the sutures may be removed, when the wall operated upon will be found shortened, so as to draw the cervix towards the symphysis. It is represented by Fig. 126. Operation for shortening anterior vaginal wall. (Sims.) Retroversion. Definition and Frequency. — Retroversion consists in a posterior inclination of the uterus, so that the fundus approaches the sacrum Fig. 127. Retroversion of the uterus. RETROVERSION. 321 and the cervix advances towards the symphysis pubis. As an idiopathic primary lesion, it is of extreme rarity, but it is fre- quently symptomatic of inflammatory disease or other states which increase the weight of the uterus. Causes. — These may be classified under four heads : — Influences increasing uterine weight. Neoplasms; Subinvolution ; Metritis ; Pregnancy ; Eesults of parturition. Influences dragging the uterus out of place. Adhesions from pelvic peritonitis or peri-uterine cel- lulitis. Influences forcibly displacing the titer lis by direct pressure. Severe succussion by blows or falls ; Muscular efforts; Distended bladder ; Tumors ; Management after parturition. Influences weakening uterine supports. Pregnancy; Tumors ; Relaxation of vagina ; Rupture of perineum. As might be presumed from the natural anterior obliquity of the uterus, anteversion not unfrequently occurs as an idiopathic lesion, resulting from pressure of superincumbent viscera forced down upon the fundus by tight clothing or muscular efforts. Of retroversion this is seldom true. It generally depends upon some pathological state in the uterus or its appendages. The third class of causes mentioned as retroverting the organ by direct pressure, may act through violent succussion and induce sudden displacement with symptoms of most urgent character. Pro- longed pressure from a distended bladder or from a tumor anterior to or above the uterus, may likewise induce gradual displace- ment. Anteversion is most commonly encountered in unmarried women, while retroversion occurs generally in those who have borne children. A little reflection will explain how the manage- ment of parturient women, by British and American practitioners 21 322 RETROVERSION OF THE UTERUS. at least, favors the occurrence of the accident. In the first place, it must be remembered that pregnancy combines in itself two of the influences which are productive of this condition, increased weight and relaxed support. It is no exaggeration to assert that the usual plan of management after parturition supplies one of the others which are mentioned above. The woman lying almost constantly upon her back, the heavy fundus naturally tends to fall backwards into the hollow of the sacrum. Many nurses insist upon this position and often for days refuse the patient the privilege of lying upon the side. But this is not all, many a nurse's reputation among ladies rests upon her capacity for "pre- serving the figure" by tight bandaging. A powerful woman will often expend her whole force in making the bandage as tight as possible to accomplish this purpose. No one who has watched the process can doubt its influence in displacing the uterus by direct pressure. There is no practice connected with the lying-in room, to which so much of almost superstition attaches as to the use of the obstetric bandage for preservation of the figure and prevention of hemorrhage. Varieties of Retroversion. — It may exist in slight degree, the uterine axis inclining so as to make with that of the superior strait an angle of 45° ; or it may incline to 90°, thus lying across the pelvis; or the cervix may be thrown up and the fundus descend so as to form an angle of 135°. These varieties are known as the first, second, and third degrees of retroversion. Symptoms. — Although retroversion is often itself a symptom, it creates disturbances which without its existence would not have shown themselves. For this reason it is difficult to deter- mine what elements of the case are due to it, and what depend upon the disorder producing it. It may exist without adding anything to the catalogue of symptoms, as proved by the fact that its removal accomplishes nothing in the way of relief; but very often it creates tenesmus of bladder and rectum, together with a low grade of inflammation in the lining membrane of these viscera; fixed, gnawing pain in the back; discomfort in loco- motion ; and pain in defecation. But these are not sufficient for diagnosis, and often do not excite suspicion of its existence. It is generally discovered by vaginal touch. These remarks do not apply to sudden retroversion, the result of succussion, in which variety the symptoms are marked and severe. The patient PHYSICAL SIGNS. 323 falls to the ground and is unable to rise, experiences the severest pelvic pain, suffers from suppression of urine and feces, and is Fig. 128. The degrees of retroversion. often in such agony that the face is bathed with perspiration and the pulse becomes weak and fluttering. Physical Signs. — The finger being introduced into the vagina discovers an absence of the cervix from its usual place, and upon further investigation finds it near the symphysis pubis. Upon passing the finger backwards to the sacrum it meets a resisting ridge which ends in a hard, round mass, resting upon the rectum. The size, rotundity, and distinctness of this will depend upon the degree of the displacement. In the first degree the resisting line but no tumor will be felt ; in the second, a slightly rounded mass ; and in the third, the fundus with its characteristic form will be perceived. Should doubt remain as to the nature of the mass thus felt, the rectal touch, uterine probe, and conjoined manipu- lation will remove it. Differentiation. — This affection may be confounded with fibrous tumor on the posterior uterine wall, and the results of pelvic peritonitis or cellulitis. A little attention to the direction of the uterine axis as demonstrated by the position of the cervix, the 324 RETROVERSION OF THE UTERUS, Fig. 129. use of conjoined manipulation, and the passage of the uterine probe will usually settle the question at once. Prognosis. — This will depend to a great degree upon the disease of which the displacement is a symptom. Generally this will be metritis of parenchymatous variety, the prog- nosis of which is by no means favorable. As a general rule, we may say that retroversion is an obstinate and most persistent complica- tion of uterine diseases, and that its relief can never be positively promised, unless it be the result of succussion, pregnancy, or some other temporary influence. Results. — This displacement may produce the following disorders : — Dysmenorrhoea ; Sterility ; Cystitis ; Eectitis. Treatment. — The first indication is to restore the uterus to its place, the second to prevent its again becoming displaced. Means for Reduction. — The bladder and rec- tum having been evacuated, and the clothing loosened, the patient is made to kneel upon a hard surface, and to place the sternum as closely as possible in contact with the plane which supports her. The practitioner then oils two fingers and carries them into the vagina **and against the fundus. He then directs the patient to fill the chest with air, and expel it completely. As she does so he forcibly ele- vates the fundus and restores it to its place. Should this plan fail, the buttocks should be still more elevated by placing cushions under the knees and the attempt repeated. If it cannot be restored in this way, Sims's repositor is an excellent instrument for the pur- pose, and should be employed. This instru- ment, which is represented by Fig. 129, consists of a short metal sound A terminating in a ball C. The ball is Alms's uterine repositor. MEANS FOE REDUCTION. 325 clasped by a straight shaft, moves upon a pivot running through its centre, and is perforated by seven holes. Through the shaft runs a rod which is projected by a concealed spring, that is governed by the finger passed through the ring B. The ball can be made to revolve so that the sound describes a half circle, by withdrawing the stop-rod which runs through the shaft and depressing the instrument. Fig. 130 represents the instrument introduced, and reposition being accomplished by retracting the stop-rod and depressing the ball. Fist. 130. Replacing a retroverted uterus. (Sims.) Another very efficient instrument for this purpose is the re- positor of Prof. G. T. Elliot. This consists of a jointed rod acted upon by a screw at one end and covered over with elastic webbing, similar to that employed in the manufacture of cathe- ters. By means of the screw the desired curve is given the in- strument to enable it to pass into the uterus, then by reversing the action the displaced organ is lifted to its normal position. In the majority of instances reposition is perfectly practicable by conjoined manipulation or rectal taxis, or by means of two sponge-holders, or the repositor represented in Fig. 131, which consists of a steel rod ending in a hard rubber bulb which passes into Douglas' cul-de-sac. Good results will often attend carrying a sponge staff up the rectum and another up the vagina, so as to make pressure upon the displaced fundus, after the plan adopted by Dr. Bond, of Phila- 326 RETROVERSION OF THE UTERUS clelphia, in his ingenious repositor, which is represented in Prof. Meigs's work on Midwifery. In replacing a uterus in this or any other malposition, the operator should never forget that inflam- matory action may have caused an effusion of lymph around it Fig. 131. Uterine repositor. which resists its removal, and that if these adhesions be violently ruptured, cellulitis or peritonitis may result. Fig. 132 shows a uterus thus bound down. Fis. 132. The uterus is here represented in a state of retroversion and bound down by false membranous attachments. (Picard.) Means for Retention. — Having restored the organ to its normal place, the question which should next suggest itself is not how to retain it there, but whether such retention is advisable, practi- cable, and void of danger ; whether the patient is suffering from MEANS FOR RETENTION. 827 symptoms especially referable to the displacement, or this is merely a sign of existing disease, upon which it exerts no influ- ence. If it be regarded as a symptom which is doing no evil of itself, the disease of which it is a result should be treated in the hope that this symptom will vanish with the disappearance of its other concomitants. Thus, if metritis exist, it should be cured ; if a polypus, it should be removed, &c. But if the primary disorder have disappeared and this one of its results remain, or if the original disease be still present, and the displacement be regarded as aggravating it, and adding to the discomfort of the patient, an effort should be made to overcome it by local means. Our resources for accomplishing this are the following : — ■ Abdominal decubitus ; Attention to keeping the bladder empty ; The abdominal. supporter ; Pessaries ; Perineorrhaphy. As I have alluded to the action of most of these methods in speaking of the treatment of anteversion, I shall not repeat my remarks here. With reference to pessaries and perineorrhaphy Fig. 133. Fig. 134. Hodge's closed lever pessary. Hodge's open lever pessary. a few words will be necessary. In speaking of the use of pessa- ries in anteversion, I stated that they accomplished very little. In retroversion, they are more efficient, and often afford decided relief. The instruments which will be found most useful are the closed or open lever pessaries of Prof. Hodge, the block-tin pes- sary of Sims, the ring of Prof. Meigs, the spring-lever pessary of Scattergood, and the pelvic pessary of Hoffman. An excellent instrument for sustaining the retroverted uterus 828 RETROVERSION OF THE UTERUS Fig. 135. Scattergood's pessary, with spiral springs in branches. is that of Dr. Cutter, of Massachusetts. (Fig. 137.) The inferior extremity of this pessary arches backwards over the coccyx and attaches to an elastic cord which passes upwards over the sacrum to a girdle around the waist. It is a painless and efficient method of giving support, and will gain a high reputation on account of these qualities, not only in displacement backwards, but, with a little alteration, for those in an anterior direction. The class of cases to which it is especially applicable, is that in which the Fig. 136. Fig. 137. Sims's block-tin pessary. Cutter's pessary. displacement is due to enfeeblement of the posterior vaginal walls from rupture of the perineum or other cause. When employed for posterior displacements the upper extremity of the instrument simply lies in Douglas's cul-de-sac, the cervix of course not enter- ing the fenestra. For anterior displacements the instrument must be heated in boiling water, and its upper end bent so as to bring the superior extremity against the anterior uterine wall, and allow the cervix to fall into the fenestra. MEANS FOR RETENTION. 829 Messrs. Tiemann & Co. have recently modified and improved Meigs's ring pessary by making it of a very delicate ring of whale- bone covered by India rubber. It is so elastic 1 -TIT 1 • F1 g- 138 ' as to assume any shape required by the pelvis, and answers an excellent purpose in patients who are so sensitive as not to be able to bear a less pliable support. Sometimes one of the stem pessaries, repre- sented on page 336, may be made to answer a good purpose. When no pessary can be tole- Mei g 8 .^7 e8Bary . rated, a roll of cotton or bit of sponge saturated in glycerine, or, as is better, in a solution of sulphate of copper or zinc, may be packed in the space behind the cervix so as to be made to sustain the fundus. It was success by this plan in a very aggravated case which led Dr. Hoffman to devise the instrument represented on a preceding page. Whatever instrument be em- ployed it should pass into the recto-uterine space, and sustain the displaced fundus without creating pain or discomfort. Should any such inconvenience be produced, it should be at once re- moved, for the most violent cellulitis may result. While a pes- sary is kept in the vagina, cleanliness should be secured by daily vaginal injections, and at intervals not exceeding two or three months it should be removed, examined, and reintroduced. Pessa- ries will sometimes produce severe ulceration, and pass from the vagina completely through the septum into the rectum or blad- der. Some years ago a case entered the service of Prof. L. A. Sayre, of the Bellevue Medical College, presenting very obscure symptoms of uterine disease. Examination proving that some foreign substance existed in utero, Prof. Sayre dilated the cervi- cal canal and extracted a globe pessary which had migrated from the vagina, into the uterus and been retained there for a length of time. If the posterior vaginal wall need support, which it has lost from rupture of the perineum, the operation of perineorrhaphy may be of great service. CHAPTER XXIII. FLEXIONS OF THE UTERUS. The uterus may be flexed upon itself anteriorly, posteriorly, or laterally, giving rise to the disorders known as — ■ Anteflexion ; Retroflexion ; Latero-flexion. Anteflexion. Definition and Frequency. — This, which is one of the most fre- quent of all uterine displacements, consists in a bending of the Fig. 139. Anteflexion. (Wieland and Dubrisay.) organ so that the fundus or cervix approximates the middle of the anterior wall of the uterus. ANTEFLEXION. 331 Before puberty it is so frequent as to have been considered by Boulard, Verneuil, Follin, and others, as physiological. Whether it be so or not, this at least is proved, that before that time it does not constitute, nor depend upon, a morbid state. At that period of life it is probably due to the want of tone and power which characterizes undeveloped uterine tissue, for even when anteflexion does not exist, the organ is generally otherwise dis- placed. Thus, M. Soudry, 1 in 71 post-mortem examinations of infants, found the uterus anteflexed 41 times, anteverted 11 times, retroverted 15 times, retroflexed twice, and retroverted with anteflexion twice. We may conclude from the evidence at pre- sent upon record : — 1st. That anteflexion is the rule during early childhood; 2d. That it is quite frequent in nulliparous women ; 3d. That in multiparas it is, in proportion to other displace- ments, infrequent. Varieties. — There are three degrees of anteflexion : first, where the uterus is simply curved upon itself, "antecourbure," as Aran styles it; second, where a decided flexion exists; and third, where the cervical and corporeal portions of the organ are in close prox- imity. The following peculiarities are noted in different cases: — Sometimes the body is flexed upon the cervix ; Sometimes the cervix is flexed upon the body; Sometimes both are flexed forwards; Sometimes the body is anteflexed and the cervix bent backwards. Pathology. — To a certain extent anteflexion of the uterus is prevented by the support yielded by the broad ligaments, which, passing from each side of that organ to the pelvic walls, sustain the weight of the fundus. The influence of ^these structures has, however, been greatly exaggerated with reference both to this accident and to retroflexion. That they are decidedly efficient in keeping the uterus upright and preventing versions, no one can for a moment doubt, but an examination of the pelvic organs of the cadaver will, I think, convince the examiner that their power does not extend to a material prevention of reduplication of the uterus upon itself. This is chiefly accomplished by the inherent strength and resistance of the proper tissue of the organ. Suppose a uterus to be composed of gutta-percha instead of 1 Aran, op. cit., p. 9S1. 332 ANTEFLEXION OF THE UTERUS. muscle ; the material forming the walls of the neck will support the fundus when the pear-shaped bag is held by the stem or narrow part. To carry the simile further, so long as the proper tissue of the stem or neck remains normally strong, flexion will be impossible unless its resistance be overcome by direct physical force exerted by pressure or traction. But if some influence be brought to bear locally, so as to soften the part sustaining the fundus, it is evident that as the gutta-percha wall grows weak, there may be a flexion of the fundus from its own weight. It will be said that these views represent the uterus . as supported by the vagina only, and leave out of consideration the broad liga- ments which sustain the fundus. If these ligaments were tightly drawn cords, I could admit their action, but as they are merely lax folds which are not made tense by the bending of the uterus upon itself, I do not do so. Causes. — As with the substance comprising such a bag, so is it with the tissue of the uterus. Its duty is to support the fundus, and for the performance of this it is abundantly competent, unless its function be impaired by one of the following influences : — ■ Influences weakening uterine support. Inflammatory softening of the neck ; Pregnancy ; Fatty degeneration ; An undeveloped state of the uterine parenchyma. Influences increasing the weight of the fundus. Inflammatory enlargement of the body ; Pregnancy ; Fibrous tumors. Influences pushing the fundus or cervix forwards. Abdominal tumors ; Ascites ; Fecal accumulation ; Tight clothing ; Muscular efforts ; Influences exerting traction forwards. False membranes from pelvic peritonitis or peri- uterine cellulitis ; Shortness of round ligaments. Of the first class of causes, inflammation affecting the paren- chyma of the neck and impairing its strength is, according to my SYMPTOMS — DIAGNOSIS. 833 experience, one of the most frequent, though Virchow denies its occurrence, as he likewise does the agency of fatty degeneration, observed by Scanzoni, at the point of flexure. The influence of parturition, abortion, and pregnancy has been admitted by all authorities. An undeveloped state of the parenchyma of the uterus is a fruitful source of anteflexion. This in part explains its frequency in infants, virgins, and nulliparae, and the fact that it is often cured by pregnancy and parturition. Dr. Noeggerath, whose attention has been especially directed to this point, dissents from the view here adopted, and believes that shortness of the round ligaments accounts for the frequency of anteflexion in the virgin, and the stretching of these by parturition explains its greater rarity after the occurrence of that process. The varie- ties coming under the head of the second set of causes are all universally admitted, as are also those belonging to the third. Fecal impaction may sometimes produce flexion of the body, and frequently causes the cervix to bend sharply forwards. The fourth set of causes is beyond question, in autopsies the uterus being often found thus bound in a state of flexion. Symptoms. — Anteflexion, pure and simple, that is, uncompli- cated by other disease, is not accompanied by symptoms, unless it so obstruct the uterine canal as to prevent ingress and egress of fluids. Unless such obstruction exist, the symptoms attending it will be due to metritis or endometritis, and not to the mere displacement. Diagnosis. — As the finger passes into the vagina and touches the cervix, nothing abnormal will be discovered. But as it sweeps along the anterior wall of the uterus, about the os inter- num a protuberance will be met with which presses upon the bladder. The finger which has thus far explored being kept in contact with this mass, the disengaged hand should then be laid upon the abdomen and made to depress the anterior abdominal wall so as to approximate the finger in the vagina. By this means the shape, size, and sensitiveness of the body may be ascertained. The diagnostician is, however, still in doubt whether the enlargement may not be one due to fibrous tumor or cellulitis. This point he settles by placing the patient on the side, introduc- ing Sims's speculum and gently probing the uterus to the fundus. Giving to the probe the curve which by the vaginal touch he has been informed is that of the uterus, he carefully passes it in. 334 ANTEFLEXION OF THE UTERUS. Should it not proceed without obstruction, he withdraws it, alters the curve, and tries again. Having introduced it, he learns the course of the uterine canal, its length, and the sensitiveness of its walls. Should the probe have entered the mass felt in the vagina, that mass is the uterine body. Should it go in the normal axis or backwards, it is not the uterine body but some growth in contact with it. Prognosis. — Whatever be the cause, the prognosis of this dis- placement is very unfavorable, with reference to cure. Fortu- nately, if its evil results can be prevented or removed, the flexure need create no anxiety — for in itself it is not of great importance. Treatment. — The indications for treatment are very simple : to restore and retain the flexed part, or, failing in this, to remove any obstruction created by the flexion, while the mal-position is allowed to continue. The fulfilment of the first alone is unim- portant, as the part restored to position falls out of it, as soon as the restoring power is removed. It must be borne in mind that flexions are unlike versions in respect to rapidity of pro- duction. Yersions may occur suddenly from some violent dis- turbing influence, under which circumstances they are susceptible of immediate relief. We have no proof that flexions are ever thus induced, unless occurring in advanced pregnancy. They are the consequences of influences long kept up, and can never be overcome with any reasonable hope that they will not imme- diately recur. Means for Preventing a Recurrence. — And now arises the im- portant question, are there any means at our command by which anteflexion can be counteracted ? Its answer is this : direct and immediate prevention is beyond attainment by any safe means at our command, but, indirectly, we may by perseverance accom- plish it. Should the practitioner discover, for example, that metritis is the source of the evil, it should be treated ; if it result from pregnancy, the dorsal decubitus should be observed until the causative influence has passed away; and if it arise from arrest of development of the parenchyma, growth should be stimulated by sponge tents, the galvanic pessary, &c. If tight clothing or abdominal effusion appear to have produced the flexion, the remedy is self-evident, as it is, likewise, if the neck have been sharply bent forward by fecal impaction. MEANS FOR PREVENTING A RECURRENCE. 835 The propriety of this course is a a plain and valid deduction, but in practice it unfortunately often fails in effecting a cure. The disorder which has been productive of the lesion may be removed, and yet the result remain. Under these circumstances, or where flexion exists so as to produce dysmenorrhcea and sterility, without the coexistence of any other morbid state, what are we to do for its relief? It is evident that but two courses are open to us, to maintain the displaced part, or to leave it in its abnormal position, and prevent as far as possible its resulting evils. In speaking of the treatment of versions, a variety of means for their relief were enumerated. Not one of these proves effi- cacious in anteflexion. Abdominal and vaginal supports are useless, unless it be in relieving a certain amount of version which complicates the flexion. They avail nothing in obviating the flexion itself. Recognizing our poverty of resources in cases of version, M. Velpeau, 1 between thirty and forty years ago, con- ceived the very plausible idea of restoring the uterine axis to its normal direction, by introducing a stem to the fundus, and retaining it there. After experiment he abandoned it, and sub- sequently Amussat followed in his steps, both in essaying and casting it aside. In 1848, Prof. Simpson again brought it into notice in versions and flexions, and met with a warm ally in M. Valleix, of Paris. The instrument known as the intra-uterine, or stem pessary, unquestionably counteracts directly and imme- diately both versions and flexions. But it has been found to cause metritis and death in a number of instances, and in conse- quence it has been almost entirely abandoned. In this city, I am led to believe that it is very rarely employed, from the facts that I never hear it mentioned as a resource, and that at a recent discussion upon displacements in the Obstetrical Society, it was never once alluded to. In an essay read before the New York State Medical Society, last year, Dr. Peaslee advocated its use, and stated that in his hands it has produced good results. It is beyond question that in exceptional cases, and in such cautious hands as those of the writer last alluded to, the stem pessary may be productive of good, but a faithful trial of the instrument for twenty years by capable practitioners in different 1 Discussion in Acad, de Med., reported in Charleston Med. Journ., 1S53. 336 ANTEFLEXION OF THE UTERUS. parts of the world, "has not returned a verdict in its favor. It is difficult to explain the encomiums once showered upon it by its advocates, and the remarkable cures reported from the use of an instrument now viewed with disfavor by the great majority of practitioners. Konat seems to have solved the paradox in declar- ing that, carried away by enthusiasm, "ils se sont laisses aller trop facilement sur le terrain glissant des illusions." Yet who will hesitate to indorse the sentiment expressed by Malgaigne, in the discussion upon the subject in the Academy of Medicine in Paris, in 1852, that, "a treatment which Amussat, Velpeau, Simpson, Huguier, and Yalleix had tried, cannot, should not, be considered as repugnant to common sense. " iDtra-uterine pessaries should be used with the greatest cau- tion; the uterus should be prepared for tolerance of the foreign substance by trials of one, two, or three hours for a week before Fig. 141. Peaslee's stem pessary. Detschy's stem pessary. (Wieland and Dubrisay.) the introduction of one, and afterwards the patient should be care- fully watched in order that the instrument may be removed on the first symptom of metritis. Even the most ardent advocates of stem pessaries will admit the necessity for these precautions, and even their bitterest opponents must allow that with them as a safeguard, in certain cases they should be resorted to. To cast OBVIATING THE CONSEQUENCES OF FLEXION. 337 them entirely aside when such high authority recommends them, would be irrational and unjustifiable. Figs. 140 and 141 represent the intra-uterine pessaries most commonly employed. Means of Obviating the Consequences of Flexion. — The reader should bear in mind these facts : — 1st. That flexion as an independent condition is often incurable ; but that, in compensation, uncomplicated flexion is often not pro- ductive of symptoms, and calls for no treatment ; 2d. That when complicated by morbid states, flexion may be much relieved by their removal ; 3d. That when flexion occasions evil symptoms, mechanically, we may frequently remove these by surgical interference. If a piece of stiff tubing be bent, the calibre of its canal will be obliterated at the point of flexure in proportion to the acute- ness of the angle created. In the same manner is the uterine canal affected by the lesion under consideration. The obstruction created in this way prevents the free escape of menstrual blood, which distends the cavity of the uterus and forms clots within it, and these at each menstrual period are expelled by uterine tenes- mus. In consequence of this, inflammation of the mucous lining of the uterus arises, that in time may produce parenchymatous disease, which favors further displacement by the increase of uterine weight attending it. The effort required for expelling clotted menstrual blood constitutes painful menstruation, and the same obstruction which retards egress of fluids interferes with in- gress and prevents conception. Thus it is that we so often meet with the following conditions complicating flexions, sometimes as its causes, but at others as its results : — Endometritis; Metritis ; Version ; Dysmenorrhoea ; Sterility. Having been forced to accept the displacement as an irreme- diable evil, we now endeavor to strike at the source of the patho- logical series which results from it by overcoming obstruction at the point of flexure ; in other words, by substituting a straight for a crooked canal. This can be accomplished by cutting through one wall of the cervix. 22 338 ANTEFLEXION OF THE UTERUS. If the posterior wall, in a case of anteflexion, be cut towards the vaginal junction so that a probe will pass into the uterus in the direction of the line a d, the obstruction resulting from the existence of an angle will be removed, and thus fluids may have free entrance and exit. The mechanical principle of the pro- cedure is explained by Fig. 142. Fi think elsewhere, unless the cervix be previously dilated by tents. But many other sources from which fluid may enter the peritoneum exist ; as, for example, rupture of an ovarian cyst, discharge of tubal dropsy, or of a pelvic abscess, intra- peritoneal hemorrhage, regurgitation of obstructed menstrual blood, &c. Traumatic agencies, as blows, falls, injury during labor, punc- tures, &c, may result in partial, as they do in general inflamma- tion of the peritoneum. Imprudence during Menstruation. — During a period in which a physiological function involves rupture of the peritoneum and produces hemorrhage, which must pass to the uterus by a narrow tube not permanently in immediate contact with the ovary, any degree of exposure must evidently tend to inflammation in the ruptured part. Of M. Bernutz's 99 cases, 20 were thus produced. Tubercles deposited in the part, either on the peritoneum, or in the tissue of the tubes or uterus, may, as they do elsewhere, result in secondary inflammation, and cancerous or cancroid degenera- tion would be still more likely to produce the same result. Varieties. — This affection may assume either an acute or chronic form, though when it constitutes the principal disease it gene- rally, in the beginning, presents the features of the former. When it occurs as a complication of cellulitis, tuberculosis, or uterine disease, it assumes from the beginning the chronic type. VARIETIES — SYMPTOMS. 385 Very often those cases which are destined to assume the chronic form present themselves thus ; the patient states, that on one or several occasions, after miscarriage, or during menstruation, per- haps, she has had severe cramping pain in the lower bowel, which she supposed to be due to some intestinal disorder, but the effects of which have never entirely passed off. This she believes to be the case from the fact that ever since the primary attack she has suffered from pain in locomotion, dysmenorrhoea, leucorrhoea, and perhaps menorrhagia. In spite of these symptoms, she attends to her usual avocations and fulfils all her functions as a wife. The history pointing to disease of the pelvic viscera, an examination is instituted which discovers the existence of the affection we are considering. Symptoms. — The acute form shows itself by — Pain and tenderness ; Fever ; Nausea and vomiting ; Anxious facies ; Mental disturbance. When a severe acute attack sets in it may cause either a chill, or a sensation of coldness so slight that the patient will not recall its occurrence unless her attention be especially directed to it ; or pain and fever may show themselves without this symptom. Pain is at times only moderate, but at others most severe. It may occur in paroxysms, which create the greatest agony and prostrate the patient by their severity. I have seen it amount to agony equal to that arising from the passage of a biliary cal- culus, causing the patient to roll in bed, seize the bedclothes in the teeth, and cry aloud most piteously. As a rule it is not so violent as this. Pain may show itself quite early in the disease, or may be preceded for several days by pelvic uneasiness and weight. Tenderness over the whole hypogastrium accompanies it to such a degree, that even the weight of the bedclothes is intolerable, and the patient, to relieve it, lies upon the back with the legs flexed in order to relax the abdominal muscles. The pulse shows in slight cases very little, and in severe cases a considerable amount of febrile action. It is small and wiry, and increases to 110 or 120 to the minute. 25 386 PELVIC PERITONITIS. Nausea and vomiting are common symptoms, though they do not generally exist to such a degree as to prove very annoying. The facies is peculiarly anxious, and is sometimes rendered very striking by the appearance of dark circles around the eyes. I have generally noticed in acute cases that the mind is markedly disturbed, as if the patient instinctively dreaded some serious disease, and even in chronic cases there is a decided tendency to slight mental alienation. It may justly be observed that these are the symptoms which mark general peritonitis. This is true ; it is merely the slighter degree of severity and the localization of pain and tenderness, which will point to the partial nature of the affection. With reference to general peritonitis, it may be stated that, on the one hand, it, of all diseases, may declare itself by the most numerous and characteristic symptoms, or, on the other, run its fearful course with the greatest obscurity, so as to mislead the most careful diagnostician, even up to its latest stages. If this be true as to the general disorder, how much more must it be so as to the local. Thus it is that we find the subacute and chronic forms passing off without recognition, and the fact that they have existed is known only by the discovery of firm adhesions over the whole pelvic roof in post-mortem examinations. In these varieties, there is less pain and tenderness and less tendency to nausea and febrile action than in the acute. Sometimes, indeed, there is merely a sense of local discomfort, increasing to pain at menstrual periods, accompanied by fever towards evening, by difficulty in locomotion, and by a general sense of feebleness and malaise. Physical Signs. — Should an examination be made during the first stage, nothing will be ascertained but the existence of sensi- tiveness upon pressure in the vaginal cul-de-sac and upon lifting the uterus. Tenderness will likewise be demonstrated by pres- sure on the hypogastrium. None of that doughy, ©edematous, puffy feel which accompanies cellulitis will be discovered by vaginal touch. Should the disease ran its course as one of those very insignificant attacks, which produce no grave symptoms and are scarcely recognizable, no other physical signs will pre- sent themselves at this or any other period. Should it be one of graver character, a sense of resistance merely, or a tumefaction like an ill-defined tumor, may be felt in the recto-vaginal space PHYSICAL SIGNS. 387 or at the side of the uterus. Or if very little lymph and much sero-pus have been the result of the inflammatory action, a sense of fluctuation may be detected very early. The uterus is always more or less interfered with in its mobility, and in severe cases it is absolutely immovable. This explains how Lisfranc and Boivin applied to it the name of " fixity" or " immobility" of the uterus. I have stated that a tumor is commonly felt posterior to, or at one side of the uterus. This tumor, which is formed by aggluti- nation of the pelvic and abdominal viscera, is extremely sensitive to touch. If the disease go on to formation of pus, the sense of tume- faction may disappear as this discharges itself, but if the effused lymph become thoroughly organized, it remains hard and resist- ing for a length of time. This accumulation almost invariably displaces the uterus, sometimes by pressing it in an inverse direc- tion, sometimes by drawing it towards itself as the lymph contracts. In a case which I saw a year ago with Prof. George T. Elliot, we were much puzzled for a short time before its fatal issue, by the existence in the fornix vaginae of a pouch, apparently filled with fluid, all the surrounding parts being unattached and no sense of tumefaction or resistance being discoverable. The patient died suddenly from general peritonitis, and upon post-mortem examina- tion, conducted by Prof. J. W. S. Grouley, we found, first, a small piece of fetid placenta in utero, the result of a recent abortion ; second, an abscess of the right ovary, which had created general peritonitis by emptying itself into the peritoneum ; and third, pel- vic peritonitis, which had evidently existed for more than a week. It had created a purulent collection in Douglas's cul-de-sac, which was limited to this space by false membranes, that formed for it a complete roof. This accumulation, it was, which gave the sensa- tion above described. In another case, sent to me by Prof. J. C. Hutchinson, of Brook- lyn, the uterus was found firmly bound to the sacrum by a hard, resisting mass, which was very sensitive. There was considerable corporeal endometritis, and I incautiously applied to the uterine cavity tincture of iodine, and as a result the most violent pelvic peritonitis developed itself, which almost became general. In ten days after its inception, a soft, fluctuating pouch formed in the fornix vaginae, which became so painful that I tapped it with an 333 PELVIC PERITONITIS. exploring needle and drew off about an ounce of clear serum, much to the patient's relief. Course, Duration, and Termination. — In no disease can these be more variable and uncertain than in that under consideration. A great similarity exists between its phases and those of pleuritis. As in that affection we have shades of difference, varying from the ordinary " stitch in the side," which results from inflammation of a portion of the pleura not larger perhaps than a silver half dollar, to empyema and tubercular pleuritis, which may continue till death by pulmonary consumption or pneumothorax closes the scene, so may we have in pelvic peritonitis like variations. It may run its course unobserved, leaving evidence of its existence only in adhesions found post-mortem. It may pass though its first two stages in three or four weeks, leaving the uterus perma- nently displaced by the continuance of the third. It may reap- pear with a certain amount of acuteness at menstrual periods, causing them to be very painful. It may, if due to tubercular deposit, continue so as to exhaust the patient slowly. It may produce a purulent collection, which, by emptying itself into the peritoneum through the adhesions thrown around it, may create general peritonitis, or this last may result from the spread of morbid action from the pelvic to the general serous membrane. Differentiation. — The diseases with which this is most likely to be confounded are — Peri-uterine cellulitis ; Pelvic hematocele ; Fibrous tumors. Peri- uterine Cellulitis. Differentiation between these two affec- tions is in severe cases simple enough, but in milder forms it is not so. Difficulty will occur when cellulitis affects, and is confined to, the tissue most immediate to the uterus, but this we know to be very rare. Our suspicions will often be turned into the proper channel by the cause of the attack. Cellulitis will very rarely occur except after parturition, abortion', or an operation on the pelvic viscera. Peritonitis will usually result from exposure during menstruation, disease of the ovaries, or collection of fluid in the peritoneum. Should the attack occur as a result of gonor- rhoea, it is probably due to serous and not cellular inflammation, a fact which the anatomical relations wouid lead us a priori to anticipate, and which is fully substantiated by statistics. West DIFFERENTIATION 389 and Aran credit gonorrhoea with the causation of cellulitis in from one to two cases in a hundred, and Bernutz declares it active in twenty-eight out of a hundred of peritonitis. Other signs by which we may arrive at a decision may thus be tabulated : — PERI-UTERINE CELLULITIS. 1. Tumor easily reached, generally felt in one broad ligament, and may be felt above pelvic brim ; 2. Marked tendency to suppuration ; 3. Abdominal tenderness chiefly over one iliac fossa ; 4. Tumefaction generally noticed late- rally in the pelvis ; 5. No constitutional signs of peritoni- tis present ; 6. Tendency to monthly relapses not marked ; 7. Retraction of thigh not rare ; 8. Pain severe and steady ; 9. Facies not much altered ; 10. Nausea and vomiting not exces- sive ; 11. Does not necessarily displace ute- rus ; 12. Not accompanied by tympanites ; 13. Uterus fixed to limited extent. PELVIC PERITONITIS. 1. Tumor very high, only in vaginal cul-de-sac, does not extend above supe- rior strait ; 2. Suppuration rare ; 3. Abdominal tenderness excessive above brim of pelvis ; 4. Generally noticed near or upon the median line ; 5. Constitutional signs of peritonitis present ; 6. Tendency to relapse every month very marked ; 7. Retraction of thigh never occurs ; 8. Pain excessive and often paroxys- mal ; 9. Facies very anxious ; 10. Nausea and vomiting often exces- sive ; 11. Always displaces uterus ; 12. Always accompanied by tympa nites ; 13. Uterus immovable on all sides. Pelvic Hsematocele. From this it may be distinguished by the great suddenness of appearance of haematocele, absence of signs of inflammation, presence of those of hemorrhage, and by the much greater dimensions of the tumor, which unlike that of peritonitis is at first rather soft and gradually becomes hard. The occur- rence of bloody flow will likewise point to hsematocele. Two facts in this connection must not be lost sight of: one, the rarity of hsematocele and frequency of pelvic peritonitis ; the other, that the former will sometimes excite the latter and thus that both may exist together. Fibrous Tumors. These will generally be known by their pro- ducing no pain, presenting no sensitiveness on pressure, no sense of oedema, no signs of inflammation nor rapidity of development. They are likewise movable and cause no fixation of the uterus. 390 PELVIC PERITONITIS. Importance of Differentiating Peritonitis from Cellulitis. — The importance of differentiating this disease from cellulitis rests in part upon the fact that it admits of less local interference. Some- times the passage of a uterine sound, an application to the cavity, or even the use of a cold vaginal injection which by accident has entered the uterus, have been known to destroy life by causing peritonitis which has extended to the whole cavity. It is like- wise important in reference to prognosis as to the course of the affection and its remote results. Lastly, it should not be forgotten that progress in the comprehension of the diseases of all organs must be preceded by a careful and systematic separation of them, one from the other. As the study of acute cardiac affections under the common name of carditis could never have accom- plished what that of each of its varieties has done, so could not investigation of these affections, undivided into their proper classes. Prognosis. — If the case follow parturition or abortion, the prog- nosis will be rendered graver by that fact. Otherwise it will be governed in great degree by the general symptoms. Should these show great intensity of inflammation, and constitutional disturb- ance be evidenced by excessive nausea and vomiting, quick pulse, anxious facies, &c. ; in other words, should the symptoms point to the probable spread of the disease over the whole serous sac, the ordinary prognosis of peritonitis may be made. In cases of chronic type, occurring in the non-puerperal state, it is decidedly favorable, unless the disease exist in a scrofulous or tuberculous patient, or show a tendency to severe monthly relapses. Another fact, which will increase the gravity of prognosis, is the existence of purulent effusion in place of lymph and serum as the result of the inflammatory action. Results. — The common results of the disease, which remain long after it has passed away, or perhaps permanently, are de- struction of the ovaries by abscess or atrophy ; obliteration or dropsy of the tubes of Fallopius ; and fixation of the womb in malposition, by organization of false membranes. As conse- quences of these lesions follow, very naturally, amenorrhcea, dysmenorrhoea, and sterility. Treatment. — Should the medical attendant be called in the first stages, leeches, if they can be tolerated, should be applied over the-hypogastrium, and a poultice, as warm as can be borne, should TREATMENT. 391 follow them immediately. The patient should be brought fully under the influence of opium by mouth, rectum, or the hypo- dermic syringe, and perfect rest should be enjoined. No cathartic medicine should be given, as it interferes with quietude, and very often it is well to keep the bladder empty by the sigmoid catheter. Milk, beef-tea, and other plain, nutritious and unstimulating food should be prescribed. In the second and third stages, where lymph has been the chief and perhaps the only product of inflammation, we must rely upon counter-irritants, and I know of none to be compared with the blister. One made of Spanish flies, four by six inches in dimen- sions, should be applied over the hypogastrium and its abrasion dressed with savine ointment. As soon as it heals entirely, another should be applied directly over the newly-formed skin, and this may be repeated every ten or fourteen days with great advantage. I have known patients who dreaded them in the beginning beg for them after experiencing the relief which they gave. Should the patient be rendered so nervous by this remedy that it cannot be employed, or should any other reason prevent its use, nitric acid issues may be applied over the iliac regions and kept open by issue peas or occasional cauterization with solid nitrate of silver. The blister is to pelvic peritonitis what it is to pleuritis, the most rapid and efficient of remedial agencies. Another very excellent method for producing counter-irritation is by tincture of iodine painted over the hypogastrium once in twenty-four hours for weeks. Treatment of Chronic Cases. — The affection having passed into the chronic stage, or originated with all the appearances of chronic disease, a different course of management becomes advisable. The patient should not be so strictly confined to bed nor dieted. She has entered upon an invalid course which may last for months or for years, and in making a strenuous effort to cure her local dis- order we may sap her general health and do her irretrievable injury. On the other hand, she should not attend to her house- hold cares, nor take exercise to any great degree; but remaining in bed or on a lounge most of the time, go out in the fresh air for an hour or two daily. Her diet should be of the most nutritious character, stimulants should be allowed in moderation, and the impoverished blood resulting from a combination of circumstances 392 PELVIC PERITONITIS. prejudicial to hsematosis, combated by change of air and the use of vegetable and mineral tonics, especially iron. One of the most important questions in the management of chronic cases is that of the amount of exercise to be allowed, and the strictness of confinement to be practised. No absolute rule can be laid down in reference to these points, for each case will call for special guidance, based upon careful experiment. In general terms it may be stated that when motion does not produce pain or discomfort,- the patient should ride in an easy carriage for two or three hours daily. In those cases which are still more free from local trouble, she may walk with moderation ; while in others which present elements of acuteness, no motion whatever shouJd be allowed. Sometimes the patient will even bear removal from home to the sea-side or some watering-place during the summer. If this be so, a locality should be chosen that is accessible by other means than railroad travel, which is peculiarly prejudicial. One great and ever recurring difficulty in this connection arises from the great tendency of patients, allowed to take exercise, to commit indiscretions by overtaxing themselves. This becomes so great at times, as to make it advisable to confine to bed one who would be benefited by moderate exercise, in order to avoid danger from her imprudence. The fact should never be lost sight of that the pelvic peritoneum forms a part, a sheath, as it were, of the sus- pensory ligaments of the uterus. The fibrous structure of the round, broad, sacral, and vesical ligaments is covered by it, so that dragging of the uterus upon them puts the peritoneum upon the stretch and strongly tends to excite renewed action there. Of all influences which act in a directly prejudicial manner upon these cases, sexual intercourse is the most decided, and its absolute interdiction should be made one of the first rules laid down for their management. Should acute exacerbations occur in chronic cases, the use of local depletion would be indicated, but as a plan to be strictly pursued with reference to cure it is highly objectionable on ac- count of the spanaemia which it induces. If it be deemed advisable to keep up the use of the iodide or bromide of potassium, the results of which are, however, doubtful, they may, with advantage, be combined with iron and vegetable tonics as in the following prescriptions : — METHODS OF EVACUATION. 393 fy. — Potassii iodidi, %v. Ferri iodidi syr., §iv. Tr. calutnbse, ^iv. — M. A dessertspoonful (^ij) in water three times a day. I£. — Potassii bromidi, 5 V - Vini ferri dulcis, §iv. Tr. calumbse, §iv. — M. A dessertspoonful in water three times a day. Should collections of pus or serum he evacuated? The important bearings of this question are manifest, but unfortunately no defi- nite answer can be given to it. In evacuating these collections the peritoneal cavity is not exposed to entrance of air, for a false membranous roof covers the collection, but there is always danger in perforating the delicate and easily inflamed serous sac. I have elsewhere reported a case in which I drew off one or two ounces of serum under these circumstances to the great relief of the patient, who rapidly improved and did well. It is the only case in which I have ventured to invade the peritoneum under these circumstances, though I have repeatedly evacuated pelvic ab- scesses resulting from cellulitis. The safest rule for practice will be this : if in spite of the sero-purulent collection the patient be doing well and do not suffer from the local trouble, it should be left to empty itself spontaneously. If, on the other hand, the patient suffer from the collection and be not progressing favorably, it should be evacuated. Methods of Evacuation. — Evacuation may be accomplished hy a small trocar and canula, or by a guarded bistoury or tenotomy knife. After evacuation the sac should not be injected, for fear of exciting peritonitis, although such a course has been advised. CHAPTER XXVII. PELVIC ABSCESS. Definition. — Upon this point little need be said, as any purulent collection originating in, and not simply passing through, the pelvis, comes under this head, regardless of its cause. Pathology. — There are three sources of pelvic abscess: 1st, breaking down of tuberculous material deposited in any of the tissues of the pelvis ; 2d, suppurative action taking place in the walls of a cavity formed by an hematocele or ovarian cyst ; 3d, inflammatory suppuration in the areolar tissue, the ovaries, or tubes, the pelvic peritoneum, or the parenchyma of the uterus itself. Of all these sources the third is decidedly the most fre- quently met with, and is most generally the result of cellulitis, occurring after parturition or in the non-puerperal state. Under the latter circumstances cellular inflammation may be primary, or secondary to irritation from some foreign body, as the debris of an extra-uterine foetus, a hard substance in the vermiform appendix, or a fibrous tumor of the uterus. Causes. — Any influence which induces cellulitis, or either of the other two pathological conditions mentioned, may prove im- mediately causative of abscess. As remote causes may be men- tioned the tuberculous, scrofulous, and syphilitic diatheses; great depression of the vital energies from any cause, as impure air, like that of a hospital; the puerperal state, and pyaemia. Symptoms. — These will not differ essentially from those of ab- scess elsewhere. When pus is forming, violent chills, followed by fever, with profuse sweating, are likely to occur. Then a feeling of prostration with throbbing pain in the pelvis, pressure upon the rectum and bladder, and sometimes interference with urination, present themselves. Pain down the thigh, which may be mistaken for sciatica, will also at times be noticed. Physical Sig?is. — By abdominal palpation, combined with rectal DIFFERENTIATION. 395 or vaginal touch, a fluctuating tumor will be felt, presenting the ordinary physical signs of purulent collections elsewhere. Course, Duration, and Termination. — Pelvic abscesses may evacuate themselves through any part of the floor of the pelvis, through its roof into the peritoneum, through any one of its walls by means of foramina, through any of the pelvic viscera, or by several of these channels at the same time. They may open by free outlet or by a long sinuous tract, which renders prognosis as to cure extremely grave. The most favorable points for evacua- tion are through the vagina and rectum. Next to these comes, in point of favorable prognosis, evacuation through the abdominal walls. "Nonat declares that when the collection "opens simulta- neously into the intestine and bladder, death is almost inevitable." In the " Charleston Medical Journal," for 1853, 1 published a fatal case of this character with autopsy. Sometimes, when left to themselves, these abscesses will go on to recovery without delay, opening into and discharging themselves through some of the parts mentioned and gradually contracting and disappearing. If deprived of the assistance of art, they may burrow deeply into the tissues, open by long fistulous tracts into some organ, as the large intestine or sigmoid flexure, or discharge into the perito- neum. Sometimes, even when the opening at first is large, it contracts so as to allow only an imperfect discharge of the contents of the sac. Then hectic fever arises, and the patient either leads a miser- able existence for years from the constant fetid flow, or is worn out by exhaustion or septicaemia. At other times these collec- tions of pus will remain imprisoned for a long period, without any attempt at escape. Differentiation. — The morbid states with which it may be con- founded are these : — Pelvic hematocele ; Extra-uterine pregnancy ; Displaced ovarian cyst ; Hydrometra ; Tubal dropsy. The first of these being a hemorrhage, gives certain symptoms characteristic of that accident, as prostration, coldness of the sur- face, great suddenness of appearance, &c. ; and absence of chill, 396 PELVIC ABSCESS. heat, fever, and other signs which are likely to accompany ab- scess. With the second, the signs of pregnancy exist, and as early as the fourth month 'foetal movements may be detected, while the perfect health of the patient with absence of menstruation will excite suspicion as to the character of the affection. Around abscesses, even of tubercular character, there is always a wall of lymph thrown up which would not be present in a dis- placed ovarian cyst. All the rational signs of suppuration would likewise be absent in the latter. He who confounds the distended body of the womb with abscess would surely be very culpable, for the spherical shape of the body and the light obtainable from the uterine probe should be guides by which to avoid error. Tubal dropsy is generally the result of inflammatory action affecting the Fallopian tubes and closing both uterine and ovarian extremities, at the same time that it causes a secretion, which distends the intermediate canal. The fluctuating tumor thus re- sulting being produced by inflammation and being often attached, in consequence, to the surrounding parts, would offer difficulties in diagnosis which might well prove insurmountable. If an error were made, however, no evil would result from it. Prognosis. — The prognosis will depend upon the following cir- cumstances: it will be favorable if the abscess be superficial, point upon a mucous tract, open low down in the pelvis by free exit, and give forth pus which has no offensive odor. Should it be deep seated, open by a long tract, give forth fetid pus, open high up and by two points of exit, as, for example, the bladder and bowel, or abdominal wall and bowel, the prognosis is deci- dedly unfavorable, unless the case can be so altered by surgical interference as to change its character. Treatment. — Nothing can be done in these cases by specific medication, by which I mean that directed especially to relief of the existing morbid condition. All of our efforts should be directed to supporting the vital forces, which are always much prostrated by the process of suppuration. The patient should take the most nutritious diet, as much animal food as she can digest, eggs, milk, fresh vegetables, and malt liquors. Whiskey or brandy should be allowed her, and the blood state should be improved as much as possible by vegetable and mineral tonics. TREATMENT. 397 Those most especially suited to the condition are preparations of cinchona, and of iron, as, for instance, the following pill : — I£. — Quinife sulphat., Bij. Ferri sulphat., £)j. Acid, sulph. arom., gtt. x. Mucilage acacise, q. s. — M. et ft. pil. No. xx. S. — One to be taken three times a day before meals. ,But it is to surgery that we must look most confidently for aid, and in this connection arises the important question as to the propriety of opening such abscesses, the best point for evacuation, and the time for interference. Is it best to open them f — Should an abscess in the pelvis show a rapid tendency to point and discharge through a favorable chan- nel, at the same time that no distressing or dangerous symptoms show themselves, it would be the part of wisdom to await the action of nature, for all must admit that there are few localities in the body into which it is more hazardous to cut than this. Even under these circumstances, however, there is danger in delay. Sir James Simpson relates a case which he saw with Dr. Ziegler one day when the abscess pointed decidedly towards the vagina and rectum very low down. Feeling sure that it must soon discharge, they left it till the next day, but before that time, to their surprise, it had burst into the peritoneum. This danger, as evidenced by statistics, is not great, and as experience goes to prove that the knife is often employed too early, rather than too late, I should strongly recommend the delay of surgical inter- ference as long as possible. If it be delayed, the tissues inter- vening between the pus and the point of introduction of the instrument become broken down, and thus a tract or sinus is avoided ; if two or three abscesses exist near each other, we give time for them to coalesce ; and the mass of lymph poured out is liquefied by the suppurative process. Should the knife be re- sorted to too soon, all these advantages will be lost. Let us suppose a different case, that the patient is suffering grave constitutional signs from the abscess. The answer to the question of the propriety of interference resolves itself into this; if the pus can be certainly, easily and safely reached, it should be evacuated. Should the abscess be deeply seated, on the other hand, so as to make the operation difficult and uncertain, it would 398 PELVIC ABSCESS. expose the patient to hazards greater than those attendant upon delay. The best Point for Evacuation. — To whatever surface the point of the abscess is nearest, that will, as a general rule, be the best for its evacuation. If there be a choice, the locations at which it will most likely point should be chosen in this order ; 1st, the vagina ; 2d, the rectum ; 3d, the abdominal walls. The Proper Time for Evacuation. — If possible, the operation should be delayed until all the lymph effused has been softened down, until all the abscesses have coalesced, and until the accu- mulated pus has broken down the mass of tissue between itself and the channel of evacuation. Methods of Operating. — The propriety of opening the abscess having been determined upon, the operator, if he intend reaching it through the vagina or rectum, should carefully investigate, by touch, as to the presence upon their walls of large bloodvessels, the opening of which might prove a source of serious hemorrhage. The patient being placed on the left side and Sims's speculum introduced, if the abscess be superficial, a trocar and canula may be plunged into it. If it be deeply seated, a bistoury may be employed, not to plunge in, but to cut line by line through the overlying tissues until it is reached. An ansesthetic should always be administered, as perfect quietude is essential to safety. If the opening made be large enough to admit the finger, it should be passed in and by it any tract leading into an adjoining abscess should be enlarged, and any sloughing tissue met, re- moved. After this, should there be any fear of closure of the canal just opened, its walls may be touched by nitrate of silver, or painted with solution of persulphate of iron, or a sponge tent, or piece of gum-elastic catheter may be left in it. If it be thought best to select the abdominal surface as the point of evacuation, all danger of escape of pus into the perito- neum should be avoided by following the suggestion of Recamier with reference to hepatic cysts, namely, causing adhesion of the layers of the serous membrane by a nitric acid issue over the point of selection. The trocar may be plunged through the centre of the issue without the danger just mentioned. Should the operator open any large vessel in the vaginal walls, hemorrhage may be checked by applications of persulphate of MEANS FOE CAUSING CLOSURE OF THE SAC. 399 iron, the vaginal tampon, or, should these not prove effectual, the actual cautery. Means for Causing Closure of the Sac. — Sometimes, after the evacuation of these abscesses, their sacs will not close, but, re- maining open for months and even years, go on pouring out large quantities of pus. The causes of their not closing are these — the existence of sinuses, which will not allow their complete evacuation ; a pecu- liar condition of their walls from the existence of a membrane, called by Delpech, pyogenic, which tends to prolong suppuration ; or the passage into the sac of air or feces from the intestines, or urine from the bladder. Of these the first is decidedly the most frequent, and should be met by dilatation of the tract leading to the abscess, by tents of sponge or laminaria, or enlargement by the knife. Should the abscess have a short and free outlet, the sac should be injected two or three times a week with tincture of iodine, at first in solution, afterwards pure ; or by solution of persulphate of iron, weakened by admixture with twice its bulk of water. In case of entrance of feces, air, or urine into the diseased part, a counter-opening should be made which will allow their free escape, and the part kept as clean as possible by injection of tepid water. Then the fecal or urinary fistula allowing the vicarious discharge should be cured by appropriate means. CHAPTER XXVIII. PELVIC HEMATOCELE. Definition and Synonymes.--TJn.deT this and the synonymous titles of retro-uterine hematocele, peri-uterine hsematoma, and bloody tumor of the pelvis, has been described an accumulation of blood in the pelvic cavity either above or below the peritoneum. History. — -Although an attempt has been made to prove that the ancients were cognizant of this affection, the proof of such a fact is not satisfactory. The earliest allusion made to it is contained in the works of Ruysch, of Amsterdam, who wrote in 1737. After this, little attention was paid to it until the time of Recamier, although mention of it was made by Frank, Deneux, and some others. In 1831 Recamier, under the impression that he was opening an abscess, cut into a tumor behind the uterus and gave exit to a large amount of black, grumous blood, and about ten years after- wards Bourdon, one of his pupils, published another case occur- ring in his practice. A tabular view of the names of those who have been chiefly instrumental in elucidating the subject and systematizing our knowledge upon it is here presented: — Recamier, 1831, " Lancette Francaise ;" Velpeau, 1843, " Recherches sur les Cavites Closes ;" Bernutz, 1848, " Archives de Medecine ;" Vigues, 1850, " Des Tumeurs Sanguines de l'Excav. Pelvienne;" Nelaton, 1851, " Gazette des Hopitaux ;" Nonat, 1851, " Theses de Cestan, Grallardo, et Prost ; Huguier, 1851, Lecture before Surgical Society of Paris ; Gallard, 1855, " Union Medicale ;" Voisin, 1858, " De l'Hematocele Retro-Uterine." I have not endeavored to record the names of all who have made valuable contributions in France, for had I done so, the list would have been a long one. Those only are referred to who have been foremost in advancing our knowledge. PATHOLOGY. 401 It will thus be seen that we are indebted to France for the early literature of pelvic hematocele. Germany has contributed little towards it. In Great Britain, Dr. Tilt was the first to pub- lish upon it, and in America, Prof. Gunning S. Bedford reported the first case which I can find recorded. More recently, we are indebted to Dr. Byrne, of Brooklyn, for a faithful report of several cases. Prior to the year 1851, although it had attracted some attention, it was not well understood even in France, for, in 1850, we find Malgaigne cutting into an hematocele under the impression that he was enucleating a fibrous tumor, and losing his patient from hemorrhage. Pathology. — The definition of hematocele has no relation what- ever to the cause of the hemorrhage which gives material for the bloody tumor. The disease consists in the collection of a mass of blood in the pelvis, either above or below its roof. Whatever be its source, such a collection constitutes the affection which engages us. Ordinarily, we find that the flow giving rise to it takes its origin from one of the three following sources: — 1st. Direct escape of blood from vessels in or near the pelvis ; 2d. Eeflux of blood from the uterus or tubes ; 3d. Transudation of blood in consequence of dyscrasia. It is evident that hematocele is not a disease, but a symptom of a number of pathological conditions. As, however, the source of the hemorrhage which results in the bloody tumor very often cannot be ascertained, we are forced to deal with its most promi- nent and significant sign, taking this as an exponent of a state which is beyond the possibility of diagnosis. In works upon practice written twenty years ago, we find dropsy treated of as a disease. In those of to day it is regarded only as a legitimate result of renal, cardiac, or hepatic disease. Obstetric writers, even as late as ten years ago, described puer- peral convulsions as a disease incident to parturition. Those writing ten years hence will probably regard them, as many do to-day, as one of the numerous consequences of renal disease. We may with good reason hope that the time will come when a similar improvement in description, based upon an advance in our knowledge of pathology, may connect itself with hematocele, but at present the etiology is often impossible. The special sources of the hemorrhage inducing the affection,. 26 402 PELVIC HEMATOCELE. which have been revealed by post-mortem examinations, may thus be presented at a glance. 1. Rupture of bloodvessels in the pelvis. Utero-ovarian ; Yaricose veins of broad ligaments ; Aneurism of artery ; Vessels of extra-uterine ovisac. 2. Rupture of pelvic viscera. Ovaries ; Fallopian tubes. 3. Reflux of blood from the uterus. Reflux of menstrual blood. 4. Transudation from dyscrasia. Purpura ; Scorbutus ; Chlorosis. All of these causes have been proved by post-mortem research to have resulted in hasmatocele, but it cannot be questioned that rupture of any bloodvessel which empties its contents into the peritoneum might also do so. Blood poured into the peritoneum from rupture of the spleen, for example, would gravitate towards Douglas's cul-de-sac, because it is the most dependent portion of that membrane, and coagulating would give all the signs of a bloody tumor in that locality. At times the affection is indica- tive of serious internal lesion, rupture of the ovary or tube ; at others it results merely from imperviousness of the cervical or tubal canal, which prevents the advance of menstrual blood and causes it to regurgitate into the peritoneum ; while in still a third class of cases, it is created by pouring out of impoverished and diseased blood from the vessels of the peritoneum. The last condition has been described as hemorrhagic peritonitis. Whatever be the source of the blood, it collects either in the most dependent part of the peritoneum, or in the pelvic areolar tissue beneath it. Here it remains for a time fluid, then under- goes partial coagulation, becoming a grumous mass like currant jelly, and lastly, all the fluid being absorbed, a hard, resisting tumor composed of fibrinous material remains. Should the col- lection have occurred in the peritoneum, its boundaries will be the walls of that cavity laterally and below, while a localized peritonitis forms for it a roof of effused lymph. If it collect in CAUSES — VARIETIES. 403 the areolar tissue of the pelvis, the effused blood will make its own nidus by percolating the loose structure and mechanically creating a space in it. In either of these positions it is entirely absorbed and reduced to a hard, firm tumor, which remains for a long time, or is discharged by the vagina or rectum, or into the peritoneum. The last point of evacuation is fortunately rare. Nonat 1 quotes Dupuytren for this very ingenious and plausible explanation of the method of such absorption, which he likens to the process of digestion. The vessels of the cyst which are in contact with the mass remove its fluid portion, and thus its hard surface comes in apposition with the sac. This excites effusion of serum, which softens the fibri- nous wall and renders it susceptible of absorption, which soon occurs. Then again contact excites a flow of fluid, and again this is removed until the whole mass is diminished or completely ab- sorbed. Causes. — A glance at the recognized causes of the disease will make it evident that congestion of the pelvic organs must, in an eminent degree, predispose to it. This explains the fact that it has been found most frequently to have occurred during the period of uterine activity and especially during a menstrual epoch. The predisposing causes are — The period of uterine activity, 15 to 45 ; Disordered blood state, plethora or anaemia ; The menstrual epoch ; Chronic uterine or ovarian disease ; The hemorrhagic diathesis. The exciting causes are : — Sudden checking of menstrual flow ; Blows or falls ; Excessive or intemperate coition , Obstruction of cervical canal ; Obstruction of Fallopian tubes ; Violent efforts ; Diseases impoverishing the blood ; Varieties. — There are two forms of the affection, subperitoneal and peritoneal, which are represented by Figs. 157 and 158. 1 Op. cit., p. 344. 404 PELVIC HEMATOCELE Fig. 157. Subperitoneal basmatocele. 3 uterus, c intestine, d bladder ; a represents the large of coagulated blood which has lifted the peritoneum above it. (Simpson.) Fig. 158 . Peritoneal hematocele, d bladder, b uterus, r. intestine ; a represents a large blood clot in the most dependent portion of peritoneum. The occurrence of the former has been denied by Aran, Yoisin, and others, but reports of autopsies substantiating it, by Simpson, SYMPTOMS. 405 Nonat, and others, place it beyond doubt. Who, for example, can question such autopsic notes as the following by Prof. Simp- son/ explanatory of the case represented in Fig. 157. " On dissec- tion I found the reflection of the peritoneum between the uterus and rectum raised up, as shown in this diagram, and a large mass of broken coagula of blood formed the tumor, having been extra- vasated behind the peritoneum forming the posterior covering of the broad ligaments, and, as it accumulated, having separated and pushed before it that portion of peritoneum and the utero-rectal fold of this membrane." Of the two varieties the peritoneal is probably the more frequent, at the same time that it is by far the more grave. Symptoms. — The absolute occurrence of hemorrhage is gener- ally preceded by symptoms which are premonitory, as fixed, dull pain over the ovaries, derangement of menstruation, metrorrha- gia, or prolongation of the menstrual discharge. The symptoms of the actual escape of blood will depend in great degree upon the nature and gravity of the accident which has given rise to it. Sometimes the affection occurs without any violent symptoms and almost without warning. It will be appreciated that this would be so if it were due to gradual reflux of blood on account of constricted cervix, or transudation, the result of purpura. Fre- quently a sudden manifestation of symptoms occurs, and the acci- dent is announced as rapidly as is cerebral apoplexy. Most prominent among the symptoms are — Severe pain in the pelvis ; Faintness and coldness of extremities; Nausea and vomiting ; Metrorrhagia ; Uterine tenesmus; Tympanites ; Interference with bladder and rectum ; Febrile reaction. The patient feels as if a large and heavy body exists in the pelvis, and instinctively strives to expel it by the vagina. At times the pain complained of is very acute; at others it is a dull and heavy aching. These symptoms abate in severity in a few days and are replaced by — 1 Simpson on Diseases of Women, p. 262. 408 PELVIC HEMATOCELE. Great exhaustion and feebleness ; Extreme paleness ; Tendency to chilliness ; Constipation ; Suppression of urine ; Great tympanites ; Apyrexia. All these symptoms point to two facts: 1st, sudden and exces- sive loss of blood; 2d, the existence of some substance in the pelvis which mechanically interferes with its viscera. A part of them might be produced by menorrhagia, a part by sudden retro- version ; but a union of the whole will strongly excite suspicion of hematocele and call for a physical exploration. Physical Signs. — Vaginal touch reveals a tumor, which is gene- rally posterior to the vagina, and which, to a greater or less extent, closes that canal. This is generally very marked, especially in the subperitoneal form of the disease, but sometimes, to detect the tumor, the finger must be carried into the fornix vaginae. The mass thus felt, if the examination be made within a day or two after its formation, will be found to be soft, smooth, and ob- scurely fluctuating. If a number of days have elapsed before it be touched, it will give the impression of irregularity, due to coagula surrounded by fluid blood. The uterus will be found pressed out of its position, generally upwards and forwards, so that the cervix will be above the symphysis. Sometimes, how- ever, it is forced out of the median line to one side. Nonat 1 dogmatically announces that the uterus is never found between the tumor and the rectum, that is to say, behind the mass of blood ; but Chassaignac 2 reports a case in which the san- guineous collection existed entirely between the bladder and uterus, and consequently must have forced that organ backwards. Kectal touch will merely show that the bowel is closed by pressure from the tumor. Abdominal palpation will reveal the presence of a hard mass which may extend only up to the superior strait, or as high as the navel. In cases where a small quantity of blood has been effused, and more especially where this has collected under and not in the peritoneum, an abdominal tumor may not be discovered. 1 Op. cit., p. 342. 2 Courty, Mai. de PUterus, p. 912. DIFFERENTIATION. 407 By the aid of conjoined manipulation the shape, extent, and character of the mass may be further ascertained. Differentiation. — The diseases with which hematocele may be confounded are — Pelvic cellulitis or abscess ; Eetroversion ; Extra-uterine pregnancy ; Fibrous tumor ; Dislocated ovarian cyst; Cancerous deposit in pelvic tissue. Cellulitis and abscess generally follow parturition, present a tumor of small size, develop slowly and with signs of inflamma- tion, and become soft as they develop. The contrary is true in reference to hematocele. Eetroversion may present the signs due to the mechanical results of haeinatocele, but not those due to loss of blood. If pregnancy coexist, conjoined manipulation will usually suffice for diag- nosis. If it should not, the uterine probe will elucidate the case. Extra-uterine pregnancy does not develop suddenly, but slowly, and is characterized by all the signs of pregnancy. In place of metrorrhagia there is amenorrhcea. Fibrous tumors grow slowly, are painless, and move with the uterus. They are irregular and hard. Displaced ovarian cysts are painless, show no signs of hemor- rhage, and cause no constitutional disturbance or metrorrhagia. Cancer in the pelvis is rare, and could hardly cause error of diagnosis. Its slow development, the absence of sudden and severe symptoms, absence of metrorrhagia, presence of cachexia, and general feebleness will serve as correct guides. It is always of great importance with reference both to prog- nosis and treatment to determine whether the case be one of peri- toneal or subperitoneal form. Differentiation may generally be made by the following comparison of symptoms: — SUBPERITONEAL HEMATOCELE. Tumor low and towards floor of pelvis ; Not so ; Bladder and rectum interfered with ; Not so ; Uterus elevated ; Vagina occluded ; Vaginal mucous membrane of violet color. PERITONEAL HEMATOCELE. Tumor high in pelvis and abdomen ; Constitutional disturbance very great ; Bladder and rectum often undisturbed ; Peritonitis marked ; Uterus pressed forwards or to one side ; Vagina not completely closed ; Vaginal mucous membrane of normal hue. 408 PELVIC HEMATOCELE. Course, Duration, and Termination. — Hemorrhage from the sources enunciated as those of hematocele, may be so great as to destroy life immediately. Five such instances are recorded by Voisin, and Ollivier d'Angers 1 mentions two in which death occurred in half an hour from rupture of a varicose utero-ovarian vein. Such a termination is, however, decidedly exceptional. The tumor generally disappears by absorption, is discharged by the rectum or vagina, or remains a hard, indurated mass for years afterwards. Discharge is most frequently followed by recovery, but sometimes putrefaction occurs in the walls of the sac, septicae- mia takes place, and death ensues. The process of absorption may be accomplished in three weeks, or six months may elapse before it is complete. Prognosis. — The prognosis is governed by the severity of the attack but in general is favorable. Death may result, but such an issue is rare. Of eight cases that I have seen, one ended fatally from general peritonitis, and seven recovered. Even this propor- tion of deaths is large. Nonat out of fifteen cases lost but one. In cases of peritoneal form a graver prognosis is called for than in the subperitoneal, for evident reasons ; and where a great deal of blood has been lost the dangers are greater than where the amount has been more limited. This is true not only from the fact that an excessive flow might cause death from exhaustion, but because the removal of so large an amount of coagulum, whether by ab- sorption or discharge, must necessarily expose the patient to great dangers. Complications. — The complications of the affection are — Peri-uterine cellulitis; Pelvic peritonitis; Displacement. Results. — These complications, by leaving the uterus bound in a vicious attitude by false membranes, often induce as results, which may remain permanently — Dysmenorrhcea; Sterility ; 2 Tendency to abortion. Treatment. — It will be rare that the physician will be called 1 Noeggerath, Bui. N. Y. Acad. Med., vol. i. p. 577. 2 Courty, op. cit., p. 917. TREATMENT. 409 upon to resort to treatment before the amount of blood which is destined to be lost has collected in the pelvis. He will, however, often be present to witness the great constitutional disturbance and excessive prostration and pain which immediately follow the hemorrhage. The diagnosis being made, the indications of treat- ment will be simple enough: — 1st. To check tendency to further loss ; 2d. To prevent death from prostration ; 3d. To relieve pain. To accomplish the first indication, perfect rest should be imme- diately secured. The clothes should be loosened, but no time spent in their removal, and the patient kept quiet upon the back. A bladder of ice, or cloths soaked in cold water, should be laid over the hypogastrium, and cold fluids given to drink if nausea should not exist as a symptom. In the fulfilment of the second indication, alcoholic stimulants and opiates should be freely used. Iced champagne or cold brandy and water should be given, and with them should be combined a solution of the sulphate of morphia or some fluid preparation of opium. In great nervous prostration, and more particularly when this has resulted from hemorrhage, opium proves a far more reliable and rapid stimulant than alcohol. In hematocele it is peculiarly applicable for the additional reason that it accomplishes at the same time the third indication, the relief of pain. Should pain be very severe or nausea exist, Magendie's solution of morphia should be injected hypodermically in the amount of ten minims, which may be repeated in twenty minutes if it fail to give relief. As soon as reaction has been fully established the attention of the practitioner should be turned to the decision of this important point, whether the accumulated blood should be evacuated or whether the case should be allowed to proceed without such inter- ference. Surgical Treatment. — Eecamier, in introducing the subject to the profession, inaugurated the practice of evacuating such tumors, and Nelaton indorsed and popularized it. But experience taught Nelaton that the procedure was not judicious, and " to-da} r he proscribes it in an almost absolute manner." 1 Immediate sur- 1 Nonat, op. cit. 410 PELVIC HEMATOCELE. gical interference presses its claims in consideration of the facts that — 1st. It is capable of cutting short a lengthy and dangerous dis- order; 2d. It may save the patient from the dangers incident to absorp- tion as well as discharge ; 3d. It removes from the peritoneum or pelvic cellular tissue a foreign body, which, undisturbed, would prove the focus of in- flammation. It is not surprising that it was the favorite plan in the infancy of the subject. When, however, pathologists had had an oppor- tunity of studying the natural history of the affection it was as naturally superseded for the following reasons : — 1st. It was discovered that, when not interfered with, haemato- cele very generally passes away rapidly. 2d. It was discovered that the dangers of puncture were greater than those of the tumor left undisturbed. 3d. Medical means were found to exert a marked controlling influence over its complications. Of course the special circumstances of each case must be the guide as to interference of this sort. In general terms all that can safely be stated is this : if great and prolonged pain threaten to exhaust the patient ; if the tumor be still fluid ; if, for any reason, rupture of a subperitoneal tumor into the peritoneum be threatened ; and if the case be an unquestionable instance of the subperitoneal form, evacuation may be advantageously resorted to. Indeed, under such circumstances, a neglect of this means would be culpable. Without such indications surgical interference should be avoided, and reliance placed upon medical resources, for it should be borne in mind that the collection of blood is usually in the peritoneum, and that incision of this membrane in addition to its own inherent dangers would always expose to those arising from admission of air. Methods of Operating. — The patient being placed upon the back, as if for lithotomy, a trocar and canula may be held in the right hand, guided to the most fluctuating and dependent part of the mass and plunged in. Or, the patient lying on the left side, the perineum and a part of the posterior vaginal wall may be lifted by Sims's speculum, and an incision made into the wall of the tumor by a tenotomy knife or small bistoury. Through the MEDICAL TREATMENT. 411 opening thus made, one or two ringers should be introduced and the clots removed. After evacuation by either method, the noz- zle of a syringe should be introduced into the sac and a stream of tepid water, or of this with a very small amount of carbolic acid, should be very gently and cautiously made to wash out the cavity remaining. This should be repeated once or twice in twenty- four hours, for prevention of septicaemia. Medical Treatment. — Reaction having taken place, perfect rest should be insisted upon. The patient should not rise from bed even for the calls of nature, the bladder being emptied by the catheter and the rectum by enemata, if necessary. Should the patient's strength permit of local abstraction of blood, leeches should be applied to the hypogastrium, and after their removal warm poultices of ground linseed should be constantly kept over the part. Pain should be quieted by opiates, and all the func- tions supervised. After the abatement of acute symptoms, a blister, four by six inches, should, unless some contra-indication exist, be applied over the hypogastrium, and this may with advantage be repeated every ten or twelve days. Its results will often be very marked, and although apparently harsh practice, it prevents much suffer- ing, while it causes none. If the stomach be not much disordered, the iodide or bromide of potassium in moderate doses may be employed. Should any tendency to hectic fever show itself or a tonic be needed, quinine, alone or combined with iron, will serve an excellent purpose. CHAPTEE XXIX. FIBKOUS TUMOES OF THE UTERUS. Definition and Synonymes. — This affection consists in the de- velopment of hard, resisting, and generally globular, masses in connection with the parenchyma of the uterus, with which they are identical in structure, except in the proportion of the ele- ments forming them. Since the true nature of these growths has been understood, they have been described under the names of fibrous tumors, uterine fibroids, fibroma, and, more recently, by Virchow and Klob, myoma. History. — Until the time of Dr. William Hunter, who wrote towards the close of the eighteenth century, the true nature of uterine fibroids was not appreciated. They were confounded with malignant growths, of which they were regarded as a variety. He described them under the name of fleshy tubercle, and con- tributed greatly to the knowledge of their pathology ; but it was not until the writings of Chambon, 1 Baillie, Bayle, and others, that the subject was fully elucidated. Sir Charles Clarke, in 1814, wrote an excellent chapter upon them, which would almost an- swer the requirements of our clay. Pathology. — Surprise that any confusion should have existed between these tumors and cancerous growths, will cease when the statement is made that their identity is boldly assumed by so careful an observer as Dr. Ashwell, as late as 1844. He gives five reasons for his belief, which he declares appear to him "con- clusive." His reasoning has failed to convince others, no writer since his time having adopted the view which Dr. Hunter suc- ceeded in abolishing, and no fact in Gynecology is now more fully settled than that of the non-malignancy of these tumors. There is another point in their pathology which is not so fully deter- mined ; that is, the possibility of the irundergoing cancerous de- 1 Nouat, op. cit. PATHOLOGY. 413 generation. Bajle and Lobstein have declared that they never do so, and the researches of Cruveilhier and Lebert tend to sup- port the view ; but Dr. Atlee, 1 of Philadelphia, and Prof. Simp- son, of Edinburgh, believe that malignant degeneration some- times occurs. If such alteration be possible, it is certainly ex- tremely rare, and is not an issue to be apprehended. Their number is almost unlimited, as is also their size. M. Courty reports one weighing fifty pounds, and Dupuytren another weighing twenty-five. I exhibited some years ago to the New York Pathological Society, the uterus of a negress which contained thirty-five tumors of every size between that of a foetal head and that of a marble. Fibroids may develop in any part of the uterus ; but the usual site is in the body or fundus. Mr. S. Lee examined seventy-four preparations in the London museums, and found that the rarest of all locations for them is the cervix. A very interesting in- stance of a large tumor developed below the os internum is reported by Dr. Murray, in the sixth volume of the London Ob- stetrical Transactions. Their structure differs very greatly not only from their original development being different, but from their being susceptible of several diseased states, which will very soon be mentioned, and which produce their characteristic alterations. The typical form is that of hard, resisting fibrous tissue, which creaks under the knife. Under the microscope this is found to consist of long, fine fibres, generally united in bundles ; of fusiform fibre cells analogous to fibro-plastic ele- ments ; and of round or elliptic granules of small size ; the whole being bound together by fine intercellular substance. This type is departed from by formation of cysts in the midst of the fibrous tissue, which constitutes the tumor one of fibro-cystic character. They are liable to a variety of diseases, among which the most frequent are oedema, inflammation, fatty, colloid, and calcareous degeneration and apoplexy. The last consists in rupture of small bloodvessels within the mass, and consequent accumulation of blood. Very rarely the whole mass becomes a ball of calcareous matter, which projecting in utero, and becoming detached from its uterine attachment, is sometimes discharged per vaginam. 1 MoClintoob, Diseases of Women. 414 FIBROUS TUMORS OF THE UTERUS. Fig. 159. This is the disease which was described by old writers as uterine calculus. The uterine attachment of fibroids of compound charac- ter is sometimes the seat of a species of varicose degeneration of the small vessels which causes the structure to resemble erectile tissue. Tumors thus affected have been styled by Yirchow, telangiectatic tumors. This vascular structure readily bleeds, and in one case I saw it the cause of a small hematocele. But large vessels are likewise discovered in the pedicles of fibroids ; Cail- lard reporting one the size of the radial artery. Klob has met with but one such vessel, which was the size of the uterine artery. Varieties, — Klob, whose excellent work on the "Pathological Anatomy of the Female Sexual Or- gans" has just been translated byDrs. Kammerer and Dawson, of this city, divides these growths into two classes — simple and compound. The first consists of one tumor, which is gene- rally spherical, and which is connected by loose connective tissue with the uterus. The second is a compound tumor, made up of a number of small fibroids, connected by loose connec- tive tissue. The second variety is more vascular than the first, and its surface is nodulated and not smooth. Both these classes present themselves clinically in three varieties which are created by the locality of the growths in the walls of the uterus. If they lie under the mucous membrane projecting into the uterus, they are called submucous ; if under the peritoneum, subserous ; if in the wall of the uterus, interstitial. Figures 159, 160, and 161, represent these forms. If a tumor be situated in the wall of the uterus, it may remain there until it assumes large dimensions. Should it be near its mucous or serous lining, it is subjected to contractile efforts on the part of the surrounding parenchyma, which are excited by its presence, and which often in time force it towards the uterine or abdominal cavity. Sometimes its connection with the mother Submucous fibroid. The tumor is seen jutting from the wall of the uterus into its cavity. (Sims.) (L VARIETIES. Fig. 160. TV 415 : : :: F 7> - ■ X w / r- k -^ III I Subserous fibroids. Tumors are seen under the serous membrane, lifting it in various directions. (Boivin and Duges.) tissue is kept up by a "broad base; Fi g- 161 « sometimes it is limited to a long, slender pedicle, which, in the case of the subperitoneal varieties, al- lows of great mobility. Should the mass be forced into the uterine cavity, and gradually assume a slender, pedunculated attachment, it receives the name of fibrous polypus, which is therefore a variety of submucous fibroid. Subperitoneal uterine tumors have been known to perform the most singular migrations. The pedicle being broken, they have at times been found rolling about freely in the peritoneum, and at others, having set up adhesive in- flammation, they have been found detached from the uterus, and attached to some other abdominal viscus. Interstitial fibroid. A solitary tumor is seen developed within one wall of the uterus. ■±16 FIBROUS TUMORS OF THE UTERUS. Causes. — The predisposing causes, or rather those generally regarded as such, are — Pace, the African being peculiarly liable ; Age, from thirty to forty-five ; Sterility ; Menstrual disorders of long standing. Concerning the exciting causes, one writing in the year 1866 may, unfortunately, quote the words of Sir Charles Clarke, re- corded in 181±: "Xothing is known respecting the cause of this disease." Fifty-two years of research have thrown no light upon its etiology. Complications. — The most frequent of the complications which show themselves in the course of the disease are — Endometritis : Displacement ; Cystitis ; Obstruction of the rectum ; Haemorrhoids ; Pelvic peritonitis. Symptoms. — This enumeration of complications is a sufficient explanation of the great number of rational signs which present themselves, for not only do we meet with the symptoms of fibrous tumors, but with those of a variety of disorders which they excite. Most prominent among the symptoms are — Menorrhagia or metrorrhagia : Irritability of bladder and rectum ; Pain throughout the pelvis ; Uterine tenesmus ; Profuse leucorrhoea ; Dysmenorrhea ; Signs of pressure on crural nerves and vessels; Watery discharge from uterus. These symptoms are not equally common to the three varieties of the affection. Subperitoneal tumors often, and interstitial tumors sometimes, are accompanied by none, or at least by very few of them. It is the submucous variety which most constantly and prominently develops them. Physical Signs. — Although the rational signs are so numerous and striking, they can never do more than excite a suspicion, which leads to investigation by physical means. DIFFERENTIATION. 417 In the case of a large tumor no difficulty in diagnosis will pre- sent itself; for the results of vaginal touch, abdominal palpation, and conjoined manipulation will be so decided as to settle the character of the case definitively. When, however, a growth of small size exists, great difficulties will often attend diagnosis, which may be delayed until the case has been under observation for a long time. A thorough examination involves full and careful exploration, by touch, of the anterior and posterior sur- faces of the uterus, as well as of its cavity to the fundus. To examine the posterior wall the patient should be placed upon the back. The examiner then depressing the uterus powerfully by one hand placed over the hypogastrium, should sweep the index finger of the other over that wall, first by the vaginal and then by the rectal touch. While the finger is lying under the uterus, in the vagina or rectum, the fingers of the hand on the abdomen should be made to depress its walls so as to sweep from the fundus over the anterior surface down to the cervix. The finger under the uterus lifting it up will offer itself as an opposing force to the hand on the abdomen. This manoeuvre will expose to examina- tion the outer surface of the uterus, unless the patient be very fat. Should this be so, a tenaculum may be fastened in the cervix and the uterus drawn down by it so that the posterior wall will be within reach of rectal touch, and the anterior wall of vaginal exploration when the finger is pressed firmly against the base of the bladder. For investigating the interior surface of the uterus the neck should be fully dilated by tents of sponge or sea tangle, and im- mediately upon their removal, the uterus being depressed as for examination of the outer surface, the finger should be carried up to the fundus. Even without dilatation the presence of sub- mucous tumors may often be detected by careful examination by the uterine probe, and the attachment of a tumor may thus be ascertained. Differentiation. — The diseases which may be confounded with fibrous tumors are — Peri-uterine cellulitis or abscess ; Pelvic hematocele ; Anteflexion or retroflexion ; Ovarian tumors ; Fecal impaction. 27 418 FIBROUS TUMORS OF THE UTERUS. The tumor created by cellulitis is always immovable, very sensitive, accompanied by fever, comes on suddenly, and fixes the uterus. A fibrous tumor is the opposite of this in every respect. Hematocele occurs suddenly with violent symptoms. The tumor is sensitive and immovable, at first semifluid, and accom- panied by tympanites. Fibrous tumors show no such symptoms. Flexion may be determined by the uterine probe, and differen- tiation established between it and fibroids by conjoined manipula- tion and rectal touch. Ovarian tumors of solid form are the only ones which usually give difficulty in diagnosis. They are unaccompanied by me- norrhagia, can be pushed from side to side without affecting the position of the uterus as ascertained by vaginal touch, and are not themselves affected by movement of the uterus by means of the uterine sound. In cases where an ovarian tumor is firmly attached to the uterus, differentiation is not only difficult but often impossible. Fecal impaction presents a tumor which can be indented by pressure, is generally in the caput coli, does not move with the uterus, gives severe intestinal pain and disorder, and exerts no influence on the functions of the uterus. Prognosis. — The practitioner cannot be too cautious or dis- play too much reticence in pronouncing the prognosis of uterine fibroids. There are few diseases in which the young physician will be led into greater error or be made to regret more decidedly an over-confident prediction. Fibrous tumors, unless of great size, rarely end fatally, however gloomy the prospect may appear when they are first discovered. And yet death from them is not so infrequent as to warrant an entirely favorable prognosis. Frequency. — These facts are to a certain degree corroborated by an examination into their frequency. Were they as dangerous as is sometimes supposed, a large number of deaths would be annually produced by, them, for, to use the words of McClintock, " without question the most frequent organic disease of the uterus, if we except inflammation and its effects, is fibrous tumor." Bayle estimated that of all women dying beyond thirty-five years of age, twenty per cent, were thus affected. Even supposing that his assumption was an exaggerated one, an idea of the frequency of the affection may be gathered from the fact of his venturing upon it. COURSE, DURATION AND TERMINATION. 419 Course, Duration, and Termination. — As already stated, these growths may attain the enormous weight of fifty pounds. Fortu- nately they very rarely reach such dimensions, but even when they do not, they frequently exhaust the patient by metrorrhagia, leucorrhoea, hydrorrhoea, and a low grade of constitutional irrita- tion, often attended by hectic fever. But this termination, like the preceding, is exceptional. Having attained a moderate size they generally remain stationary, or increase slowly until the menopause, creating considerable inconvenience and depreciating the patient's strength by hemorrhage. Then undergoing a cer- tain degree of atrophy with the cessation of uterine and ovarian functions, they cease to be, to any great degree, a source of annoyance, or at least of danger. Even during the age of uterine activity, nature may, unaided, effect a cure by the following means : — Absorption or atrophy ; Direct expulsion by rupture of attachment ; Sloughing, from deprivation of nutrition, or inflammation ; Calcareous degeneration. The tumor is sometimes deprived of nutrition by inflammatory action occurring in the vascular structure of the uterine attach- ment which has just been described, collections of pus being sometimes discovered in it. Sometimes fluid collections take place within these masses, some morbid process destroying their tissue as if by liquefaction. The fluid thus collecting may be purulent, watery, or sanguine- ous. One of the most interesting of these instances is recorded by Dr. Sims, and represented by Fig. 162. Sims's view, that the growth was fibro-cystic, appears to me to be incorrect, though there is a difference of opinion with reference to these collections within fibroids. He describes it thus : "I passed a trocar into it at its lowest point, and in the direction of its long axis, and there were dis- charged more than twenty ounces of a colored serum. The punc- ture was enlarged for two inches, to prevent its closing. There was at once a sensible diminution in the size and tension of the abdomen. The discharge kept up for some time ; and this, together with occasional injections into the very fundus of the uterus, with the liquor ferri persulphatis, diluted with three or four parts of water, arrested very promptly the hemorrhages, and 420 FIBKOUS TUMORS OF THE UTERUS. the patient was dismissed in two months in a very comfortable condition, and with strength enough to walk six or eight miles." Fig. 162. f£>M\x Submucous fibroid. A large tumor is attached to posterior wall from os to fundus. A channel is seen to extend from the os along anterior wall. (Sims.) Palliative Treatment. — In the vast majority of cases the efforts of the practitioner are limited to palliation of the evils resulting from the growth. Mechanical interference is prevented by an abdominal supporter and a pessary ; menorrhagia and leucorrhcea by astringent injections into the vagina and uterus; and pain by opiates and rest. Curative Treatment. — Surgical means should be resorted to only under two circumstances : 1st, where the growth is so located as to render removal easy and safe ; 2d, where the disease is threat- ening the patient's life. In the removal of these growths the practitioner imitates the processes by which nature accomplishes a cure. Bringing to his aid the first three of her methods which have been mentioned, he adds to them others which she never develops. Uterine fibroids, whether submucous, subperitoneal, or inter- stitial, may frequently be removed by the following means : — Absorption ; Excision ; ficrasement ; Enucleation; Sloughing ; Gastrotomy. EXCISION. 421 Absorption. — Whether their absorption can be excited by any medicines at our command is very doubtful. Tumors have in certain instances been known to disappear while drugs have been employed, and perhaps they did so in consequence of their use. But no such effect can be looked for with any confidence. Indeed, with our present experience, such a result must be regarded as decidedly exceptional. Scanzoni, 1 after advising those medicines which are most popular as stimulants of absorption, says, "¥e do not remember a single case in which, with the means indicated, or with others, we have obtained the complete cure of a fibrous body." Whatever drugs be tried for this purpose should be con- tinued for many months, and even a year or two, before the trial can be considered fairly made, for their action is never immediate. Those in greatest esteem are iodine, the iodide and bromide of potassium, and the waters of certain mineral springs, as Kreuz- nach, Kissingen, Krankenheil, &c. All these may be employed externally in the form of hip-baths as well as internally. In the case of small submucous tumors absorption is sometimes effected by pressure from the foetus in utero, and the same result is attainable by systematic pressure by tents of sponge or sea tangle. Thus far very few successes have been reported, but the plan certainly promises good results, and is worthy of trial. Excision. — Should a small submucous fibroid project into the uterine cavity, it may be removed by the severance of its attach- ment, by means of the knife, scissors, or other cutting instrument. If it be within reach of the knife or scissors, after dilatation of the cervix by tents, it may be removed by them. In case it be attached higher in the uterine cavity, the polyptome of Aveling may be made to answer a good purpose (Fig. 163). Fig. 163. Aveling's polyptome. Removal may likewise be accomplished by the forceps of Nek- ton, represented in Fig. 161. This method of removal is, however, much more applicable to 1 Op. cit. 422 FIBKOUS TUMORS OF THE UTERUS those fibrous growths which, instead of preserving extensive con- nection with the uterus and coming under the head of tumors, Fig. 164. Nelaton's forceps. (Wieland and Dubrisay.) have only an attachment by a pedicle and are therefore classed with polypi. Ecrasement. — Under almost all circumstances where excision may be practised, Ecrasement becomes possible and should always be preferred. The operation consists in cutting off the mass, as near its attachment as possible, by the ecraseur. This instrument, the invention of M. Chassaignac, of Paris, consists of a flattened tube of steel which has two rods of the same metal passing through it to its upper extremity (Fig. 165.) Fig. 165. The ecraseur, straight and curved. To the end of each of these the extremity of a chain is attached. This is passed around the part to be cut off, and the rods are re- tracted by a ratchet movement at the other extremity. Steadily and slowly the chain tightens around the mass and cuts its way through it. The ecraseur not only presents the great advantage of preventing hemorrhage, but experience proves that after its use inflammatory action is much less likely to occur than after that of cutting instruments. Should the tumor be small and have passed out of the uterus into the vagina, the chain of the ecraseur may be passed over it as a noose, by the fingers. If it be small ECRASEMENT. 423 and in the cavity of the uterus, the chain may be passed by means of the porte-chaine attachment of Sims, represented in Figs. 166 and 167, which enables the operator by the aid of deli- Fig. 166. The arms of Sims's porte-chaine. (Sims.) cate arms extending beyond the ecraseur to spread it out to the greatest extent. Fig. 167. Sims's porte-chaine ready for encircling a tumor. (Sims.) Tiemann & Co. have constructed a simpler instrument, in which the chain is passed by the limbs of the ecraseur, which are elastic, and Dr. Emmet has improved this by making joints near the end of the instrument, as represented in Fig. 168. Fig. 168. Ecraseur with joints and elastic arms. The chain of the ordinary e'craseur may with great advantage be replaced by the wire rope, as suggested by Dr. Braxton Hicks, 424 FIBROUS TUMORS OF THE UTERUS, Fig. 169. Gooch's canulse armed with a ligature. or a very simple form of ecraseur, the constrictor of which is an ordinary wire, may be substituted for the more elaborate instru- ment. But if the tumor be of great size, whether in the vagina or uterus, it may be necessary first to pass a cord around it by means of canulse, and in this way to draw in place the chain, which may be subsequently attached to the ecraseur, as represented in Fig. 170. Fig. 170. Fig. 171. A tumor encircled by Gooch ; s canulas. The ecraseur at work. Sometimes the growth to be removed is so large that the chain of the ecraseur is too short to encompass it, under which circum- stances it may be replaced bj- a number of small wires called a wire rope, by a single large wire, or by a strong cord. Should the tumor be very large and fill the vagina completely. ENUCLEATION". 425 there are two methods by which it may be entirely removed: 1st, it may be drawn down by obstetric forceps and delivered ; 2d, it may be cut away, piece by piece, until its base be reached. By the first plan the uterus is temporarily inverted, the morbid growth removed by the knife, scissors, or ecraseur, and the uterus replaced, after the stump, should it bleed, has been seared by the white-hot iron. This process was first advised and practised by Desault and Herbineaux. Prof. Isaac E. Taylor, of this city, has several times resorted to it, and in one case I thus succeeded in removing a very large growth. The second plan is best carried out by the aid of the ecraseur. As much of the tumor as can be secured is seized in the chain and removed. Then another por- tion is engaged, and so on until a great part or the whole of the mass is cut away. Enucleation. — Excision is applicable to small submucous growths near the cervix, and ecrasement is only practicable when the attachment of the tumor is smaller than its body, and thus affords a surface for the support of the chain. Where neither of these conditions exists, or where the tumor is interstitial, resort must be had to other means. It has been stated that the attach- ment of submucous and even interstitial neoplasms to the uterine wall is not firm, they being surrounded by a layer of loose cel- lular tissue. This fact suggested many years ago, to the mind of Yelpeau, the possibility of enucleating them, and in 1840 M. Amussat put the theory into practice. Since that time the ope- ration has been resorted to by many surgeons, among the most successful of whom may be mentioned Dr. Atlee, of Philadelphia. A sufficient number of favorable results have been attained by it to render it a warrantable procedure ; but it is unquestionably one attended by great hazard, as it may be destructive to life by inducing exhaustion, hemorrhage, perforation of the uterus, pyaemia, or inflammation of the pelvic viscera. Dr. West reports twenty-eight cases in which it was performed, fourteen of which proved fatal. Prof. Fordyce Barker, of this city, has once per- formed the operation with complete success upon a large growth. " Peritonitis, phlebitis, and pyaemia," says Dr. West, 1 in esti- mating the prospects of success held out by enucleation, " the consequences of violence done to the uterus of women exhausted 1 Dis. Women, Eng. ed., p. 305. 426 FIBEOUS TUMORS OF THE UTERUS. by large and frequently repeated floodings, are dangers from which but few have altogether escaped ; under which I fear that correct statistics will show that most have succumbed." But the great dangers attending its performance should not deter the surgeon from resort to it in suitable cases, which absolutely re- quire aid. They should merely induce him to exhaust all pallia- tive means before resorting to this, which should be looked upon, in large tumors, as a last resource. The steps of the operation are as follows : — 1st. The cervix should be fully dilated by tents, or freely incised in two or three places, as practised by Dupuytren, Amus- sat, and Baker Brown. 2d. After checking hemorrhage, if any be created by incision, should this have been resorted to, the vagina being dilated by Sims's speculum, and the tumor held firmly by tooth forceps, an incision is made over its surface and through its capsule. This may be either straight or crucial. 3d. The fingers or a blunt instrument being passed into the opening thus made is swept around the mass, so as to sever its attachments and turn it out of its bed. At the same time it is lifted from below upwards by the forceps. If the mass be re- moved, all clots should be washed out of the uterus by a stream of water, and the patient quieted by full doses of opium. Sometimes a middle course may be followed with advantage in such a case as that represented in Fig. 172, for example. The os being dilated or incised, a long crucial incision is made over the presenting part of the tumor, and the lips of the capsule separated by the finger, in the hope that the body of the tumor may present through this species of os, and be expelled by ute- rine efforts. A most interesting case in which this occurred is recorded by Dr. Grimsdale, in the Liverpool Med. and Surg. Journal for January, 1857. Sloughing. — Mr. I. Baker Brown, of London, has proposed in imitation of a process sometimes naturally set up in fibroids, to create the tendency to sloughing by cutting a deep, circular hole in them and filling this with oiled lint. This he has styled gouging, and reports a number of cases successfully treated by the plan. We are informed by Dr. Sims 1 in his recent work, 1 Op. cit ,p. 121. GASTROSTOMY. 427 Baker Brown does not now himself with simply incising mutilate the the os and however, that, " Mr. fibroid, but satisfies cervix uteri." The dangers which must result from the presence of a large sloughing mass in the uterus are manifest, but it is equally so that in such a case as that represented in Fig. 172, it may become necessary to incur the attending risks rather than allow the patient to die from the continuance of the disease. Gastrotomy . — Subperitoneal tumors are much less amenable to surgical treatment than those which are submucous, but in corn- Fig. 172. :if pensation they are less injurious in their results. In some cases, however, they excite so many evil symptoms as to call for re- moval — and this has been effected by incision through the abdomi- nal walls. The operation is truly a formidable one, and yet, since it has been repeatedly successful in cases susceptible of no other means of relief, it is worthy of consideration. Indeed, should the steady decadence of the pa- tient's strength make it certain that a fatal issue must soon ensue, the operation in the case of a pe- dunculated subperitoneal tumor would become a matter of duty, and not remain one of choice. The prospects of success from it will depend very much upon the character of the attachment of the tumor to the uterus and other viscera of the abdomen. Unfortunately the extent of these cannot be accurately ascertained before abdominal section and investigation by touch, which of itself involves risk. This is by no means so considerable as would at first be supposed, and where doubt exists it should be resorted to. Dr. John Clay re- ports twenty-three instances in which it was adopted. Of these, sixteen recovered, three died, and of four no account was given in the reports. With reference to the propriety of the operation of gastrotomy Submucous fibroid. (Wieland and Dubrisay.) 428 FIBROUS TUMORS OF THE UTERUS. for removal of uterine fibroids the opinion of the mass of the profession is at present determinedly adverse. And yet it is not more so than it was twenty years ago with reference to ovari- otomy. It is highly probable that when experience has rendered the operation safer than at present it will be resorted to for the same reasons which to-day cause us to perform extirpation of the ovarian sac, and be regarded, as that operation is, as a practicable and expedient procedure. Not only is this opinion sustained by recent statistics, it is foreshadowed in the modified opinions ex- pressed by late writers. M. Courty, after stating the unfavorable results of the operation and the adverse impression concerning it left by them, goes on to add: "But recent operations tend to modify our opinion on this point as they have done upon ovario- tomy." 1 In saying this he appears to have anticipated what the future will bring forth. It is true that thus far statistical evidence does not favor it, but Prof. Storer declares, " that the mortality of the earlier uterine extirpations was no greater than that in many isolated groups of the other operation." It is not venturing too much even now to say that if the fibroid be pedunculated and unattached, its removal is no more danger- ous than the ordinary operation of ovariotomy. If it be com- pletely amalgamated with the uterus, or so bound to neighboring parts that removal proves very difficult, the operation may be abandoned, the patient having, without great risk, availed her- self of the only chance of cure. Even if the removal of the neoplasm involve that of the uterus and ovaries, we may still indulge in a hope of saving our patient, as the following table, arranged by Prof. H. K. Storer, 2 will prove : — 1 Op. cit., p. 977. 2 " On removal of the ivomb and both ovaries." The tumor which necessitated the operation weighed thirty-seven pounds, and was the largest ever extirpated. GASTROTOMY. 429 Operations. Deaths. Clay 3 2 Heath 1 1 Burnham ......... 9 7 Kimball 3 2 Parkman 1 1 Peaslee 1 1 Koeberle 1 Baker Brown ........ 1 1 Wells 1 1 Sands 1 1 Buckingham ........ 1 1 Storer 1 24 18 Percentage of recoveries 1 in 4, or 25 per cent. The statistics here displayed, although showing, as they do, a large mortality, would, I fear, lead one to take a more favorable view of the results of this operation than enlarging experience will warrant. Since their publication the uterus has been re- moved in this country with the following results : — Operations. Deaths. Storer, 1 of Boston 4 4 Cutter,' of Newark 2 2 Wood, 2 of Cincinnati ....... 1 1 Hackenberg, 2 of Hudson ...... 1 1 Atlee, 2 Philadelphia 1 1 Weber, 2 Cleveland 1 1 10 10 No operator should undertake gastrotomy for uterine neoplasms without being prepared, if necessary, to remove the uterus with the tumor, for sometimes the connection is so intimate that an exact localization of the tumor is out of the power of the most skilful diagnostician. Indeed, even after removal of the mass from the body, its relations to the uterus are often discovered only after patient and intelligent search. Dr. Farre tells of a case pre- served in one of the London museums as a solid ovarian tumor which, upon careful examination, he proved to be uterine by tracing the Fallopian tubes into it. It was also in this way that the nature of the tumor removed by Dr. Storer was identified, Prof. Ellis, after very minute examination, distinctly discovering 1 Personal communication. 2 N. Y. Med. Record, Jan. 18, 1SGS. 430 FIBROUS TUMORS OF THE UTERUS. the entrance of the tubes into the cavity of the body and thus settling the matter. The operation is performed in exactly the same manner as ovariotomy, and for particulars concerning it the reader is re- ferred to the chapter describing that procedure. The accidents which have generally produced a fatal termination in cases of gastrotomy are as follows : — 4 1st. Primary or secondary shock or collapse ; 2d. Hemorrhage ; 3d. Peritonitis ; 4th. Septicaemia. As Prof. Storer points out, we have now arrived at means for limiting the first ; the improved methods of haemostasis at our command diminish the danger of the second ; and the knowledge of the fact that carefully cleansing the peritoneum of blood and other fluids markedly diminishes the probability of the occur- rence of the third and fourth, will in future aid in avoiding them. I have endeavored to lay the facts connected with gastrotomy for uterine neoplasms before the reader in their true light, care- fully avoiding any partial or prejudiced representation concern- ing them. What position the future will assign to the operation no one can at present declare, but of this we may even now be sure, that they are culpably barring the way to advancement who refuse to attempt the only plan by which life may, at times, be saved, and screen themselves from blame in so doing by casting- censure and reproach upon those who endeavor to afford the patient every chance for life. In some cases surgical means fail to effect removal, and are resorted to merely for palliation. Where a large submucous fibroid is producing exhausting hemorrhage an incision directly across its most dependent point, and others cutting the superficial layer of fibres of the os, will often control the flow to a great extent. This probably results from disgorging the habitually distended vessels of both tumor and uterus. CHAPTER XXX UTERINE POLYPI. Definition. — A uterine polypus is a tumor covered by the mucous membrane of the uterus and attached to that organ by a pedicle or stem. History. — While so many uterine disorders of greater obscurity are described by the earliest medical writers, this, the diagnosis of which is often so self-evident and positive, attracted little attention. Hippocrates, Celsus, Galen, and even Aetius make no mention of it. By Moschion it was described in the third century, and called pulps or polypus, but it was certainly neither well un- derstood nor treated in his time, and we get no clear accounts of it until the revival of this branch of learning by the French School in the seventeenth century. Then Guillemeau, and subse- quently Levret, threw much light upon it, and in the latter part of the eighteenth and beginning of the nineteenth centuries many others contributed to place our knowledge upon its present basis. Varieties. — The student will meet with much difficulty in arriv- ing at definite ideas concerning the varieties of uterine polypi. Almost all authors differ in their classification, and the number of names which have at various times been applied to them is too large even for repetition. Let it be borne in mind that since these tumors are formed by excessive development of one of the tissues existing permanently or temporarily in the uterus, there are but four elements which can give rise to them : the parenchyma, the mucous membrane and cellular tissue, the glands^Sf that membrane, or some foreign mass which is retained in the uterus. It is true that by some a species of vascular polypus formed from development of the bloodvessels, a species of telangiectasis, has been described, but it is probable that this is only a form of the mucous variety. All classifications of these growths are to a great 432 UTEBIXE POLYPI. extent arbitrary, and hence in the present state of pathology none can become universal. That which I will adopt is this : — 1st. Cellular polypi; 2d. Glandular 3d. Fibrous 4th. Fibrinous " Each of these genera includes several species, the chief of which may thus be tabulated: — Cellular Polypi include, Fibro-cellular polypi; Soft Mucous " Yascular " Cellulo-vascular " Granular Polypi include, Vesicular " Cystic " Channelled Tubular " Fibrous Polypi include, Hard Muscular " Fibrocystic " Fibrinous Polypi include, Sanguineous " These varieties are subject to morbid changes which create other forms, as, for example, fatty, calcareous, and malignant polypi. Colombat refers to a large, hollow polypus which, when removed, leads the operator at first to fear that he has mistaken an inverted uterus for a polypus. He states that Eicherand and Jules Cloquet were once thus deceived, until the subsequent death of the patient enabled them to correct their error by post-mortem inspection. Mme. Boivin represents one of this character as shown in Plate 19 of her work. She calls it hollow polypus ; declares that before its removal by M. Dubois it was regarded as inversion by several physicians, and accounts for it by supposing that some plastic ele- ment had coated the uterus and been ripped off, except at its cer- vical attachment, and had become inverted by menstrual fluid collecting above. Some months ago Dr. Henschel presented to PATHOLOGICAL ANATOMY. 4:66 the New York Obstetrical Society a hollow polypus which was attached to the cervix by three points. It was referred to Dr. Noeggerath for examination and report, and his method of ac- counting for it was similar to that of Mme. Boivin in the case just mentioned. Pathological Anatomy. — The cellular polypus is a tumor, gene- rally of pear shape, varying in size from a marble to a hen's egg. It is covered over by mucous membrane, and consists within of cellular tissue in a state of hypertrophy or hypergenesis. Its Fie. 173. A cellular polypus with Ion (Boivin and Duges.) attachment is generally, though not always, to the wall of the cervix, and in its structure appears a certain amount of cervical fibrous tissue. Sometimes the pedicle of this variety is very long and slender, so that it hangs outside of the vulva. 28 Fig. 173 434 UTERINE POLYPI exactly represents one sent to me by Dr. Crane, of Elizabeth, N. J., for corroborative diagnosis, and which was afterwards re- moved by him. The glandular polypus consists in hypertrophy of the Nabo- thian glands or, according to Dr. Farre, of the utricular follicles. Several follicles are enlarged, and, being bound together by con- nective tissue, make up a tumor of pediculated form. It may arise either from the cervix or body, but very generally grows from the former, and is commonly gregarious. Fig. 174. Fig. 175. A cellular polypus attached within the cervix uteri. Glandular polypi within the cervical canal. (Boivin and Duges.) The fibrous polypus is a submucous fibroid, resembling closely those which are subserous and interstitial. Slowly extruded from the uterine parenchyma by its contraction, the tumor gradually acquires a pedicle and becomes the form of polypus under con- sideration. Fibrous polypi usually arise from the body of the uterus, though they are sometimes attached to the rim of the os. About the very existence of the fibrinous polypus there is some doubt. Kiwisch regards it as due to a collection of blood in utero, the serous portion of which is absorbed and the fibrin- ous organized. Scanzoni accepts this view, but regards the previous occurrence of pregnancy as necessary to it, and supposes PATHOLOGICAL ANATOMY, 435 d. Fibrous polypus growing from fundus. (Clarke.) Fig. 177. Fibrous polypus growing from lip of cervix. (Sims.) that the blood clot is attached to the placental site. The mass thus attached obtains vascular connection with the uterus, and presents the ordinary features of polypi. I have met with but two instances of this variety of polypus; in one, slight traces of the placenta were discoverable ; the other was a pure blood clot. 436 UTERINE POLYPI. Causes. — Any chronic inflammatory action, an}^ obstruction to escape of menstrual blood which causes uterine tenesmus, or any influence tending to keep up uterine congestion, will predispose to hypergenesis of the elements of the mucous membrane. But as for fibroids, so for fibrous polypi, no cause is known. Symptoms. — Polypi occasion two classes of symptoms; one dependent upon the mucous congestion which their presence ex- cites, the other upon the mechanical obstruction which they offer to the escape of menstrual blood. These two influences result in the following signs : — Leucorrhoea ; Pain in back and loins ; Menorrhagia ; Metrorrhagia ; Hydrorrhoea ; Dysmenorrhcea. The last of these is not a frequent sign, but sometimes presents itself prominently, as it did in the following case which occurred before we understood the use of tents as we do at present. A lady came from a distance to put herself under Dr. Metcalfe's care for dysmenorrhcea, characterized by severe tenesmus and expul- sion of clots. These symptoms had lasted for years, and had resulted in emaciation, and great nervousness and irritability. In time she came under my care; was treated by me for nearly a year, and went home unrelieved. At her next menstrual period she sent for the physician of the neighborhood, who examined by touch, detected in the vagina a small polypus which hung by a stem from the uterus, and twisted it off to her com- plete and permanent relief. This had been at last expelled after having rested upon the os internum, and acted as a ball valve for years. The uterus had been repeatedly examined before, but nothing could be discovered. Physical Signs. — These will depend in great degree upon the size and location of the growth. Should it be in the cavity of the body, and small, no signs will be afforded by the touch or speculum ; if, however, the body be explored by the probe, this will be found to be deflected by it. The cavity will be discovered to be much congested, and a copious flow of blood will often follow the withdrawal of the instrument. Should the tumor be large, the body will also be found to be displaced, increased in TREATMENT. 437 size, and the cervix somewhat dilated. Should the attachment of the tumor be cervical, it can often be felt hanging from the canal or in the os uteri. But no examination for uterine polypi can be considered complete until the cervix has been fully dilated by tents, and careful exploration been made by sight, touch, and the probe. Even then a number of attempts will often be requisite before small growths are detected. Differentiation. — Polypi must be differentiated from fibrous tumors even after the discovery of an intra-uterine growth has been made. The symptoms to which these affections give rise are very similar, and it is by physical means alone that differen- tiation can be effected. These means are the use of tents, the probe, and touch. By them, the mobility of the tumor, the point of its attachment, and the breadth of its base, may all be defi- nitely determined. Course and Termination. — Nature may cure a uterine polypus by ejecting the mass with so much force as to fracture its attachment and disconnect it from the uterus, or calcification or sloughing may occur. But none of these results can be looked for with any confidence. In the majority of instances, without surgical interference, steadily advancing anasmia will ultimately destroy life. Prognosis. — The prognosis is generally good, depending, of course, upon the possibility of removal. Complications. — Polypi create but two complications, namely, endometritis, and chlorosis of very grave character. Treatment. — In the treatment of polypi, these two indications present themselves : first, to cause the expulsion of the growth from the uterus, and second, to accomplish its removal when thus expelled, by means which will presently be considered. To cause the extrusion of the growth from the uterus into the vagina, the cervix must first be opened by tents, or by slitting its walls, and then the uterus must be stimulated to contractions by systematic and prolonged use of ergot. If it be possible to grasp the polypus by forceps, it may be drawn out in that way. The second indication may be accomplished by — Excision ; Torsion ; Ligature ; £crasement. 438 UTERINE POLYPI. Should the pedicle be within reach of knife or scissors, it may be divided ; or if higher in the uterus, the polyptome may be employed. Should the growths be so small as not to be suscepti- ble of seizure, they may be scraped from their attachment by the curette ; and should they be small and possess slender pedicles, they may be seized with forceps and twisted off. The ligature, lately so popular, is now rarely employed ; the tardiness of its action, and the fetid discharge which it excites, rendering it objec- tionable and dangerous, ficrasement constitutes the safest and most expeditious of all the operations. Sometimes, however, great difficulty attends the encircling of the tumor by the chain of the instrument. To effect this, it is often necessary to encircle the mass first by means of a ligature passed by Gooch's canulse, and then to draw the chain into position by tying it to the end of this, as represented in the chapter on fibroids. Whenever it is practicable, all manipulation should be delayed until expulsion of the tumor into the vagina is obtained ; but, unfortunately, operative procedure is sometimes called for before this can be effected. Then the operator works to disadvantage, and the patient is exposed to great hazard. I have in more than one instance seen life destroyed by such efforts, even when cautiously conducted. No sooner does the tumor escape into the vagina than the whole phase of the case is altered. Eemoval involves no danger- ous manipulation, and is simple and easy. For this reason it is advisable to use every effort to open the cervical canal and stimulate uterine action. Even if section of the cervix to the vaginal junction is needed, it would be safer to resort to it than to manipulate the tumor in utero. In case the growth be shut up in the uterus, it is always advisable, unless some urgent reason for immediate removal exist, to dilate the cervix by tents, and if necessary, by incision, and to cause the expulsion by steady and prolonged use of ergot. The directions for applying each of the means of removal re- commended are so fully given in the preceding chapter upon fibrous tumors, that, to avoid repetition, the reader is referred to it for details. CHAPTER XXXI. CANCER OF THE UTERUS. Malignant disease may affect the uterus in three forms : — Cancer ; Cancroid ; Epithelioma. The varieties of each may be presented at a glance by the fol- lowing table : — Malignant diseases of the uterus. Cancer. Encephaloid; Colloid ;(?) Scirrhus. Cancroid. Fibro-plastic ; Recurrent fibroid. Epithelioma. Corroding ulcer ; Cauliflower excrescence. Each of these will in turn engage our attention, the present chapter being devoted to cancer. Definition and Synonymes of Cancer of the Uterus. — This disease, which has been described under the synonymous terms of carci- noma uteri, and ulcerated carcinoma, may be defined as a degene- ration of the interstitial tissue of the uterus characterized bv grave constitutional implication, great tendency to molecular death, and a certainty of reproduction if removed by surgical means. Frequency. — According to Rokitansky, 1 the following average scale may be adopted as representing the preference of cancer for various organs. " First the uterus, the female breast,, the stomach, 1 Sydenham Trans., vol. i. p. 198, Am. ed. 44:0 CANCER OF THE UTERUS. the large intestine, and especially the rectum ; next comes cancer of the lymphatic glands," &c. The great frequency with which the uterus is thus affected, may be judged of by the statements of Prof. Simpson, based upon reports made under the Registra- tion Act, during a period of five years (from 1838 to 1842), for England, exclusive of London. Number of women who died of cancer . . . 8746 " " " " " " " of the uterus. 3000 These statistics further prove that cancer is nearly three times more frequent in women than in men, and more than three times more frequently met with in the uterus than in any other organ of the female. History. — M. Becquerel asserts that, " in spite of its great fre- quency, cancer of the uterus is not a disease of which the history has been long known." That it was not understood as we under- stand it to-day, is most true ; but the ancients surely had a great deal of very accurate knowledge concerning it. Hippocrates — de Morbis Mulierum — describes it at length, declaring it to be in- curable. Archigenes wrote an able chapter upon it, describing the ulcerated and non-ulcerated forms and the peculiarities of the discharges. His article is preserved by Aetius, who entitles it " De Cancris Uteri," and is copied verbatim by Paul of iEgina without the slightest acknowledgment. The Arabians likewise were familiar with it, Alsaharavius, Haly Abbas, and Rhazes, all alluding to its prognosis and treatment in a manner which leads us to believe that they understood its true nature. Upon the revival of Gynecology in France, the disease was confounded with fibrous tumors and parenchymatous inflamma- tion, or rather with its resulting hypertrophy. Astruc described " scirrhus" as the result of abortion, in 1766, and the confusion which attached to his description extended long after him. It characterized the times of Recamier and Lisfranc, and even so late as our own period we see the view indorsed by Drs. Ashwell, Montgomery, Duparcque, and many others. Messrs. Blatin 1 and Nivet, in expressing their belief that scirrhus results from chronic inflammation of the parenchyma, append the following foot-note : " Paul of JEgina, Galen, Andral, Broussais, Breschet and Ferrus, 1 Mai. des Femmes, Paris, 1842. PATHOLOGY. 441 Piorry, Bouillaud, &c, place scirrhus among the terminations of chronic inflammation ; some of them, however, admit the exist- ence of a predisposition." For the proper differentiation of true malignant disease from neoplasms and the results of inflammation we are indebted to no one so much as to Dr. Henry Bennet, of London. Although there are many points connected with the subject which are still undecided, the following may be laid down as generally accepted truths: — 1st. Cancer of the uterus bears no similarity to fibrous tumors, polypi, or parenchymatous engorgements ; 2d. It arises from a constitutional vice, and is never the result of chronic inflammation or any other purely local condition ; 3d. It is incurable, and if removed by surgical means will inevitably return. Pathology. — The affection probably originates in some peculiar blood state which we do not at present understand and which results in a local deposit of a morbid element. Rokitansky regards the abnormal condition of the blood as consisting mainly in a preponderance of albumen and a hypinosis or diminution of fibrine. Whatever be the peculiar state which gives rise to can- cerous deposit, it is certain that any form of the affection may arise from one and the same disorder. This is proved by the facts that several deposits of different varieties may coincidently exist, that one form may change into another, and that one being removed by surgical means a different one may replace it. -Not only is the uterus most frequently selected as a site by the disease; the cer- vix is almost always the part of this organ primarily affected. In some cases the body is the original seat of the deposit, but this is extremely rare. I have met with but two cases in which the cancer originated in the Cancer of the body of the body of the uterus. One, which is repre- uterus, sented in Fig. 178, 1 saw with Prof. Charles A. Budd. The other is now under the care of Dr. James L. Brown, with whom I have had an opportunity of examining it after dilatation by sponge tents. 442 CANCER OF THE UTERUS The tissue usually first affected by deposit is the submucous areolar tissue of the neck. From this point it spreads, invades the whole neck, and sometimes the body of the uterus, the ovaries, vagina, bladder, and intermediate tissue. Even the bones of the pelvis may be attacked. For a varying length of time the depo- sition goes on, then without assignable cause the lowly organized mass begins to die, and ulceration or molecular death occurs. The detritus gives rise to a fetid, ichorous, and bloody discharge, which excoriates the vulva and thighs and renders the patient disagreeable to herself and all aroand her. With greater or less rapidity the vital forces are sapped, and the patient succumbs ; not, however, in many cases, before the greater part of the uterus has been removed and the bladder and rectum opened into. Varieties. — Cancer may assume in the uterus any of its various forms. Scirrhus, or hard cancer, in which there is a preponderance of fibrous tissue; colloid or gelatinous cancer, in which an abund- ance of fluid is combined with epithelial cells in alveolae or loculi ; and encephaloid, medullary, or soft cancer, in which epithelial hypergenesis preponderates over the other elements of the deposit. Fig. 179. Scirrhus of anterior lip, not ulcerated. (Boivin and Duges.) The first of these is rare. The vast majority of cases present the features of the encephaloid variety. As to the second or colloid form of cancer, pathologists are rapidly altering their views, many not only doubting its true cancerous nature, but denying it entirely. SYMPTOMS. 443 Causes. — Those predisposing causes which are of undoubted authenticity may be thus enumerated : — Hereditary tendency ; Middle or advanced life ; Grief or other depressing mental influences ; Kepeated parturition ; Life in a large city ; Want of food, pure air, and exercise. Although cases have been reported at the extremes of woman- hood, it is generally admitted that few occur before twenty and after sixty. The most fruitful period is from 40 to 50 ; the next from 30 to 40 ; the next from 20 to 30 ; and the next from 50 to 60. The exciting causes are entirely unknown. As has been already stated, the view entertained by many a few years ago, that cancer is often a result of chronic inflammation is now generally repu- diated. In my own experience I have yet to find a case even remotely sustaining such a position. Symptoms. — The disease may pass through its period of incep- tion and make considerable progress towards a fatal issue with- out developing any symptoms which attract the attention of the patient. Or only slight leucorrhoea and hemorrhage may exist, which may have been passed over as trivial circumstances, not deserving treatment or investigation; but this is decidedly excep- tional. Usually the following symptoms develop themselves and become more and more prominent as destruction of the exudation advances : — Pain through the pelvis ; Tenderness upon movement or coition ; Menorrhagia and metrorrhagia ; Ichorous and fetid leucorrhoea ; Hydrorrhoea ; Dark, grumous discharge ; Constitutional debility ; Pallor and cachectic facies ; Vesico-vaginal or recto-vaginal fistulas. Pain and tenderness are not nearly so constant or severe as is often supposed, and they may both be entirely absent. Menorrhagia and metrorrhagia may exist even before ulcera- tion has occurred, resulting then from congestion of the mucous 444 CANCEK OF THE UTERUS. membrane. But it is not until after the inauguration of the pro- cess of destruction that they become alarming or excessive. Ichorous, watery, and grumous discharges very generally mark the advance of the disease. The first of these discharges produces erythema, erosions, vaginitis, and often a strong sexual appetite. The second exhausts the patient by draughts made upon the serum of the blood. The third creates fetor, and sometimes re- sults in septicaemia, for the material giving color and odor to the flow is a putrilage formed by the detritus of the decaying uterus. Constitutional debility and cachectic facies are the results, in part, of the malignant toxaemia which is the basis of the disorder, in part of exhaustion produced by loss of blood or some of its elements. Should the walls of the rectum and bladder become implicated, as they very often do, the functions of these viscera are deranged, and the feces or urine, or both, pour out through the vagina, increasing the misery of the patient. Physical Signs. — Suspicion is generally first aroused and physi- cal exploration prompted by these three symptoms, monorrhagia, fetid discharge, and ichorous leucorrhoea. They belong to the second or ulcerative stage of the affection, and, as Dr. Henry Bennet has well established, it is almost invariably in this stage that the physician is consulted. Before it no symptom generally exists which calls for physical exploration. I have examined but one case which I am positive was incipi- ent or non-ulcerated cancer. In that the diagnosis was made by the peculiarly hard, nodular feel of the cervix, and by the coinci- dent implication of the vagina. Without vaginal implication I should have hesitated in arriving at a positive diagnosis, and I feel sure that he who ventures upon a decision as to the nature of the disease at this period must expose himself to great risk of error. The mere fact of the cervix being excessively hard and nodular is not enough to warrant a diagnosis. This must be accompanied by other reliable signs, as menorrhagia, hydrorrhoea, and constitutional failure, to make even a hypothetical conclusion admissible. After ulceration has occurred, diagnosis is as simple and certain as it is obscure and uncertain before. The finger discovers an absolute destruction of tissue, and finds the walls of the deep and ragged ulcer producing it, covered over with a crumbling, brittle mass, interference with which causes hemor- rhage. The uterus is often fixed by secondary cellulitis, and the DIFFERENTIATION". 445 walls of the vagina near the uterine junction participate in the deposit. Sometimes there is a stricture of the rectum, which Fig. 180. Cancer in ulcerative stage. The rectum has been opened by the advancing disease. (Boivin and Duges.) especially engages the attention of the patient, who suspects no disease of the uterus or vagina. It is difficult to describe to another the peculiar sensation yielded by an ulcerating cancer, but it is easy to appreciate it by touch. He who carefully explores one case and marks the hard, unyielding border and brittle investment, with its marked tend- ency to crumble and produce hemorrhage, will rarely fail to recognize another. Differentiation. — Ulcerating cancer of the cervix is by no means difficult of diagnosis, and we are rarely called upon to decide as to the non -ulcerative form. The diagnosis of cancer of the body is not so simple, and I have known many errors of diagnosis made with reference to it. As examples, I have seen in practice the following errors com- mitted : — 446 CANCER OF THE UTERUS. A sloughing fibroid mistaken for cancer ; A placenta three months retained " A sponge left by accident in utero " Syphilitic disease of pelvic bones " Peri-uterine cellulitis " Syphilitic vegetations and stricture " Cystic degeneration of chorion (hydatids) " In such cases differentiation is attainable by one and only one resource — dilatation by tents, careful exploration by the fin- ger, and examination of the structure by the microscope. Prognosis. — The prognosis is pre-eminently unfavorable. Not only is it so from the fact that the disorder is cancerous, but be- cause that form which usually affects the uterus belongs to the most rapid and dangerous of its varieties. "Medullary carcinoma," says Kokitansky, "is, both in its development and in its subse- quent course, the most acute of all cancers." Fig. 181. Cancer in extreme degree of ulceration. The cervix is represented as entirely de- stroyed and the disease advancing into the body. (Boivin and Duges.) Course and Duration. — In some cases death will ensue in from three to six months, while in others it may not occur for five, six, or seven years. I have under my care at present, a working woman who has had the disease for four years. The average duration of life after the commencement of ulceration is, according to Sir James Simpson, from two and a half to three years. The ter- TREATMENT. 447 mination is always the same — death, which may occur from exhaustion, from hemorrhage, from irritative fever, assuming a typhoid type, or from some of the numerous complications which may develop themselves. Complications. — The following are the complications which most frequently accompany the disease : — Septicaemia from absorption of putrid fluid; Cellulitis ; Peritonitis ; Phlebitis ; Cancer in lymphatic glands or other organs. In rare cases, as has been pointed out by Beatty and Cruveil- hier, cancerous degeneration obstructs the ureters, and produces, in this way, uraemic poisoning. Dr. Theophilus Parvin records an instance of this character in which, for a week, no urine found its way into the bladder, and the symptoms of uraemia were well marked. Treatment. — The indications of treatment are these: — To amputate or destroy the diseased part ; To check hemorrhage ; To relieve pain ; To correct fetor ; To sustain the general strength. Ablation, which in cancroid disease is often indicated, is here only a forlorn hope. Indeed it is but rarely practicable in true cancer to accomplish complete removal, from its rapid tendency to involve adjacent parts. . And, lastly, experience proves that this operation is attended by grave dangers, and can at best prove only palliative. Hemorrhage may be checked by rest during menstruation ; cold vaginal injections; and the use of styptics, by injection and by application to the bleeding surface upon pledgets of cotton. Should the patient employ the syringe, the most appropriate styptics will be the sulphate of alum, infusions of tannin or oak bark, or a solution of the persulphate of iron, one or two drachms to the pint of water. Should the practitioner make the applica- tion himself, a bit of cotton saturated with pure solution of the persulphate of iron, or a little muslin bag filled with tannin or powdered alum, may be placed against the os. In doing this the use of the speculum should be avoided if possible, for its intro- 4-18 CANCER OF THE UTERUS. duction always tends to excite hemorrhage. In checking a flow due to this disease, the tampon should be resorted to only in case of absolute necessity, for its introduction often does great injury, and its removal would almost inevitably excite the flow which had been temporarily checked. All these are minor means, and fall far short of the careful use of caustics which produce only a superficial slough and for a time seal up the mouths of the bleeding vessels. Once in every two or three weeks the surface of the diseased mass may be lightly touched, after being cleansed by syringing with cold water, by the actual cautery, acid nitrate of mercury, or chemically pure nitric acid. Care must be taken not to create a deep slough, lest this being cast off the peritoneal cavity may be opened into. The relief of pain should be accomplished by the free, unre- stricted use of opium by the mouth, the rectum, the vagina, or under the skin. I often encourage my patients to become opium eaters, and urge them to obtain as complete relief as the use of this drug can afford. In place of opium other narcotics may be tried, but there is none which compares with it for efficiency. When opium produces the painful results noticed where an idiosyncrasy exists against it, the persistent use of it will often effect a tolerance. The fetor of the discharges may be, to a great extent, corrected by the use of vaginal injections containing disinfectant substances in solution. Solution of carbolic acid from one to two drachms to a pint of water, Labarraque's solution of soda in the same pro- portion, one drachm of powdered persulphate of iron to the pint, or a weak solution of the iodide of lead, will prove very useful. Of all these, carbolic acid is the most certain and effectual. The general strength should meantime be maintained by fresh air, residence in the country, generous food, alcoholic stimulants, iron, and bitter tonics, while the mind should be kept cheerful by lively company, and avoidance of the society of those who encourage conversation concerning the existing disease. As the digestion is weak, the most digestible substances should consti- tute the staple diet, and very often a patient who will become ema- ciated upon solid food and a mixed diet will improve upon the exclusive use of milk, beef-tea, and similar substances. So marked is this fact, that the milk diet strictly adhered to has been regarded, and is now, by many non-professional persons, as a means of cure for cancer. CHAPTER XXXII. CANCROID TUMORS OF THE UTERUS. Between cancer on the one hand and fibrous tumors on the other, there is a doubtful, debatable ground which is occupied by what are called cancroids or cancroid tumors. This term, which is derived from " cancer" and " si8o$," implies a great similarity between this disease and true cancer, and yet the two affections are far from being identical. Both have an interstitial origin, both affect the surrounding tissues, and both, if removed, are very prone to return. But they present these differences : cancer is not curable, presents a characteristic cell, and invariably poisons the surrounding parts. Cancroid is curable, does not present cells of such abnormal type, upon section shows no cancerous juice, and very slowly affects neigh- boring parts. Varieties. — The varieties of uterine growths coming under this category are the fibro-plastic and recurrent fibroid. Of the latter there are several species, as the myeloid, fibro-nucleated, &c. Fibro-plastic Tumors. To this class belong many tumors which in their commence- ment are curable, but in their progress develop features of malig- nancy, for example, malignant polypus. Pathology. — Although having, like cancer, an interstitial origin, they differ from it both clinically and anatomically. The charac- teristic cell is smaller and has a smaller nucleus. The cells of this morbid growth are larger, however, than those of any other lymph-tumor, excepting cancer. They are of an oval form, with one elongated extremity, and flask-shaped, as Mr. Paget has expressed it. Mr. Collis declares that as soon as the full disten- sion of the tumor is reached, its covering, whether of skin or mucous membrane, gives way, and an ulcer is formed, from which 29 450 CANCROID TUMORS OF THE UTERUS. a fungus protrudes, which by hemorrhage and discharge exhausts the patient's strength. Clinically this difference is noticed between it and cancer. While the latter is developed as a result of a vitiated blood state, the former exists for some time without affecting the system, and may before such a result has occurred be removed without return. But its tendency to return is marked, and the secondary growths are always more malignant than the primary. Upon section, fibro-plastic tumors leave a clear white surface, uncovered by fluid, and quite hard to the touch. Recurrent Fibroid Tumors. Definition. — This term has been applied by Mr. Paget to a tumor in many respects resembling fibrous tumors, and yet en- dowed with the unfortunate feature of recurrence after removal, and tendency to ulceration and fungous degeneration. Pathology. — " These growths," says Mr. Collis, " are of a firm, elastic feel, a more or less globular outline, and lobed sometimes by the pressure of an intersecting fascia or baud. They are unattended by any special pain, and free from glandular or con- stitutional complication." Like the fibro-plastic tumor they ulti- mately ulcerate, and a free flow of blood occurs. Then a fungous growth protrudes, which, by hemorrhage and discharge, exhausts the patient. Under the microscope the elements of this form of tumor appear to be elongated, caudate cells, interspersed with free nuclei and young cells. For most of the facts connected with this subject, and for the classification adopted, I am indebted to the work of Mr. M. H. Collis, of Dublin, upon Cancer and Tumors, to which I refer the reader. For the pathologist there is much to study in the various forms of uterine tumors belonging to this class. For the Gyne- cologist there is less, for the following are the only facts con- nected with the subject which are of clinical importance: — 1st. That there is a class of tumors resembling fibroids, yet presenting a tendency to ulcerate, develop fungus, and persistently refuse to heal; 2d. That this class, if removed, is almost as prone to return as cancer itself; 3d. That if this variety of tumor be removed in its incipiency, FREQUENCY. 451 the system may possibly be left unimplicated, while, if allowed to remain in situ for a longer time, it will become involved. Prognosis. — The prognosis is unfavorable, although there is a possibility that no return may take place after removal, if this be practicable. Frequency. — Fortunately recurrent fibroid tumors very rarely develop themselves in the uterus. Lebert declares that they may do so, and Dr. West 1 mentions several cases. I have myself met with but one case concerning which I felt positive, and even in this the conclusion was supported by clinical evidence alone. This patient I saw in consultation with Prof. Budd. The tumor, hard and elastic, was attached to the inner wall of the cervix, and extended upwards towards the cavity. It presented to the touch a hard, carcinomatous resistance, not unlike that of a fibroid, and, although not larger than a walnut, had undermined the patient's strength completely. It was in time attacked by ulcera- tion, from which profuse hemorrhage occurred, and destroyed life. 1 Op. cit. CHAPTEK XXXIII. EPITHELIOMA, OR EPITHELIAL CANCER OF THE UTERUS. Cancer of the uterus, like the same disease in other parts of the body, has two distinct stages, that of deposit and that of destructive ulceration. In the first of these a deposition of the materies morbi takes place in the interstitial portions of the structure affected, and as the second period becomes established this forms a connec- tion with the surface by ulceration. In certain cases the morbid influence, instead of exciting interstitial deposit, is exerted upon the mucous membrane itself, affecting its production of epithelial cells. In such cases no deposit occurs in the tissue underlying the mucous membrane. To this class the names of epithelial cancer, epithelioma, carcinomatous ulcer, and cauliflower excre- scence, have been applied. As Mr. M. H. Collis 1 remarks, its special name is unimportant, " i f its difference from cancer and its analogies to it be kept clearly in view." Although in many respects kindred to cancer, it differs from it so essentially in others as to call for a separate consideration of the two. The most marked differences existing between cancer and epithelial cancer are these : — Cancer Is deposited in the parenchyma : Invariably returns if removed ; Epithelial Cancer Begins with no interstitial deposit ; Does not return as a rule ; Is from the first a constitutional disease ; Is at first a local evil Soon affects neighboring parts ; Runs usually a very rapid course ; Is characterized by a peculiar cell. Slowly affects neighboring parts ; Progresses slowly ; Has no characteristic cell. Varieties. — Epithelial cancer may affect the uterus in two forms : — Corroding ulcer ; Cauliflower excrescence. Each of these will in turn engage our attention. 1 On Cancers and Tumors. EPITHELIOMA. 453 Ulcerating Epithelioma, or Corroding Ulcer of the Uterus. Definition. — The term corroding ulcer was applied by Dr. John Clarke, of Londou, and subsequently by his brother Sir Charles Mansfield Clarke, to a form of ulcer of the cervix in which nothing but rapid destruction of tissue is noticed as a pathological lesion ; in which there is no hardness of the part affected ; no induration or inflammation of surrounding organs, nothing but molecular death in the cervix uteri, and disappearance of its structure as if by liquefaction. Synonymes. — It has been described under the names of phage- denic ulcer, diffuse ulcerative cancer, epithelial cancer, and can- croid of the uterus. Frequency. — All authorities agree that this affection is compara- tively rare. Dr. Ashwell 1 remarks: "For one case of corroding ulcer we meet with ninety or a hundred of cancer of the uterus;" and he further states that in the appropriate ward at Gruy's Hospital at the time of his writing, not one example of the malady had appeared. In five hundred recorded cases of uterine disease in that hospital not one case of corroding uleer was to be found. This is the experience of all authors who make their reports, not from clinical, but from careful post-mortem evidence. Those who rely upon clinical observations alone report the disease much more frequently; but it is highly probable that, as Scanzoni 2 re- marks, an error has been made in such cases with reference to their anatomical characteristics. It should be borne in mind that many cases proved by the microscope in post-mortem inspection to be unquestionably cancerous, have run a course very similar to the epithelial form of the affection. Ashwell states that on seve- ral occasions where a diagnosis of corroding ulcer had been made, post-mortem examination gave evidence of true cancer ; and Scan- zoni tells of a case occurring in the clinique, at Prague, in which at an autopsy all present were inclined to reverse their diagnosis of cancer and adopt that of corroding ulcer, until the matter was settled by discovery of cancerous elements. It is only in view of these facts that I can account for the frequent reports of this dis- ease made in public societies and private conversations in this city. I have myself met with two cases presenting clinically all the cha- 1 Pis. of Women, p. 318. 2 Op. cit.. p. 226. 454 EPITHELIAL CANCER OF THE UTERUS racteristic signs of corroding nicer, but in neither was autopsic evidence obtained. Two very interesting cases are reported by Dr. Gardner, 1 in the American edition of Scanzoni, in one of which merely the peritoneal shell of the uterus existed at the time of death ; yet both are invalidated for science by want of microscopical investigation. Pathology. — Pathologists are now very generally agreed that this affection is a variety of epithelial cancer, as the following table will prove. In preparing it no author is quoted who wrote over twenty-five years ago. Authority. Dr. West . Dr. Graily Hewitt Dr. Churchill M. Aran Dr. Scanzoni M. Nonat M. Becquerel Dr. Ashwell . Dr. H. Bennet Dr. Tilt Dr. Byford . Dr. Lever Dr. Kiwisch M. Colombat de L'Isere M. Courty . Opinion as to Pathology. Epithelial cancer Quotes and appears to in- dorse West. " Essentially different" from cancer. Diffuse ulcerating cancer . Decomposed medullary can- cer. Epithelial cancer Epithelial cancer Similar to lupus Epithelial cancer No allusion to it Epithelial cancer Malignant ulcer . Decomposed medullary can- cer. Compares it to noli me tan- gere. Epithelial cancer Where reported. West on Diseases of Females, p. 270. Hewitt on Diseases of Wo- men, p. 259. Churchill on Diseases of Wo- men, p. 208. Aran, Mai. de l'Uterus, p. 937. Scanzoni on Diseases of Fe- males, p. 227. Nonat, Mai. de l'Uterus, p. 521. Becquerel, Mai. de 1' Uterus, torn. ii. p. 209. Ashwell on Diseases of Fe- males, p. 319. Bennet on Uterus, p. 386. Uterine and Ovarian Inflam- mation. Byford, Med. and Surg. Treat, of Women. Lever on the Diseases of the Uterus, p. 149. Scanzoni, Dis. of Females, p. 227. On Females. Mai. de l'Uterus, p. 875. Rokitansky 2 says : " We also find primary and syphilitic ulcers, cancerous ulcers that have resulted from the fusion of cancerous morbid growths, the so-called phagedenic ulcer of the os tincse, Clarke's corroding ulcer. The latter may be compared to the Op. cit., p. 228. 2 Path. Anat., Sydenham ed., vol. ii. p. 220. PHYSICAL SIGNS. 455 phagedenic, cancerous sore of the skin ; without having a morbid growth for its base it gradually destroys the cervix and even the greater part of the uterus, and may extend to the rectum and bladder." Mode of Development. — On this point nothing is known. The infrequency of the disease and the fact that the physician is called after it has progressed for some time, will explain our ignorance. No better proof of the uncertainty attaching to this point can be given than the fact that Kiwisch and Scanzoni 1 both regard the ulcer as the base of a decomposed encepha]oid cancer. Course, Termination, and Prognosis. — Like cancer the inevitable tendency of this affection is to death. As the process of destruc- tion advances through the mucous membrane into the parenchyma beneath it, and profuse hemorrhages occur, the patient is gradu- ally exhausted, and as the peritoneum in time becomes invaded, peritonitis of fatal type is excited. Unlike cancer, however, its course is often slow, and years may pass before death results. Upon these facts, and the additional one that the disease is in its commencement a local affection, a prognosis of very grave charac- ter, though somewhat less grave than that of cancer, may be con- fidently based. Symptoms. — The symptoms which mark its development are very similar to those of cancer, from which it can never be diag- nosticated except by physical means. The most prominent are — Hemorrhage ; Fetid, ichorous, and watery discharge ; Pain in back and pelvis ; Emaciation ; Slight fever. The character of the pain is much insisted upon by Sir Charles Clarke as diagnostic. He declares that it is hot and burning,, but not lancinating. Little reliance can be placed upon this sign, and to arrive at a diagnosis, physical examination is always necessary. Physical Signs. — Upon vaginal touch an ulcer, whose base is covered by minute and unequal projections, is found to have eaten away the cervix to a greater or less extent. Besides this nothing is discovered. The uterus is movable, no hardness is found above the ulcer, and no glandular or other induration exists in the pelvis. A corroding or gnawing ulcer, " ulcere rongeant," is found to 1 Op. cit., p. 227 Am e pregnancy. Successful .... Unsuccessful . . . 21 21 17 25 47 46 21 2 27 2 Total .... 42 42 93 48 4 The mental state of the patient has so marked an influence on the result that operators agree that a depressed and apprehensive mind generally produces an unfavorable issue. The greater the amount of solid matter in an ovarian tumor, the more favorable will be the prognosis as to rate of growth and the more unfavorable as to cure. The following is Dr. Clay's table in reference to the character of the tumor : — Class of cases. Monocvstic. Polycystic. Solid. Small. Medium. Large. Successful . . . Unsuccessful . 19 25 66 106 8 13 4 3 14 17 30 48 Total . . . 44 172 21 7 31 78 The greater the thickness of the abdominal walls the more extensive will be the surface which must unite to effect closure of the abdominal opening, and the greater the probability of sup- puration occurring between the lips of the wound and pus pour- ing into the peritoneum. The presence of adhesions greatly complicates the case, but as UNFAVORABLE CONDITIONS. 583 this can be determined only after abdominal section, its considera- tion will be postponed until that point in the description of the operation is reached. Mr. I. B. Brown first pointed out the importance of an abund- ance of albumen as a prognostic sign in ovarian cysts. " Believ- ing as I do," says he, " that the highly albuminous condition of the fluid exhausts the system in a similar way to that of albu- minuria from disease of the kidneys, I consider that it contra- indicates an operation as clearly as the latter disease. The nature of the contents maybe readily discovered by withdrawing a little by an exploring needle." I give this quotation, not for the pur- pose of indorsing the view, but to show how strongly Mr. Brown feels in reference to the matter. The two states between which he draws a parallel are evidently different in this, that in one case the drain of albumen ceases with the operation, while in the other it continues unabated. In two of my own cases, the fluid removed by tapping after abdominal section was gelatinous, and yet the sac being removed, the patients rapidly recovered without an unfavorable symptom. That an abundance of albumen gives an unfavorable, as its absence gives a favorable, prognosis, how- ever, cannot be denied. Conditions unfavorable to the operation. — The following circum- stances, although unfavorable to the operation, do not contra- indicate it unless they exist in the most exaggerated degree : — Obscurity as to diagnosis ; Great constitutional impairment ; Gastric or intestinal disorder ; Depression of spirits ; Multilocular character of cyst ; Presence of solid matter in tumor ; Highly albuminous character of contents ; Presence of extensive and firm adhesions ; Complication with other diseases. Grounds upon which a choice of operative procedures should be based. — Before proceeding to describe the operation of ovario- tomy, it will not be out of place to examine this question. Tapping is not a curative but a palliative operation, and need not detain us. Drainage. — When it is ascertained that a small cyst is uni- locular, and more particularly, when by explorative incision it 58-4 OVARIOTOMY. is known to be adherent, this operation may be resorted to either by the vagina or abdomen. Injection is applicable to unilocular cysts filled with clear and slightly albuminous fluid, or even to those containing pus or blood. It has not been found to produce good results in those containing thick, unctuous, and fatty matters. This plan may be combined with drainage. Incision. — This method of draining the cyst has its limited sphere in those tmfortunate cases of multiple and polycystic sacs which, on account of firm adhesions, cannot be removed, and from their multilocular character are not susceptible of treatment by drainage or injection. Partial Excision. — It is known that when a cyst containing a clear, straw-colored, non-albuminous fluid discharges itself into the peritoneum, recovery may take place, the effused fluid being eliminated and the sac contracting. Partial excision should be reserved for such cases and never employed in others, for where the contents of the sac are tenacious and albuminous it is more fatal in its consequences than ovariotomy itself. Dr. Clay has collected 24 instances in which the operation was performed. 10 patients recovered and 14 died, and of the 10 spoken of as recoveries only 7 were radically cured. Ovariotomy. — This operation is applicable to cases between those desperate ones of cystic disease susceptible of treatment only by incision, and those not susceptible of cure by injection or drainage. It also offers the only hope in cases of composite and solid tumors. Preparation for the Operation. — We know that the septic endo- metritis, which is the starting point of those symptoms which grouped together constitute puerperal fever, is often excited by the miasm attaching to the medical attendant from an autopsy, a case of erysipelas, typhus fever, or hospital gangrene. Although the fact that these miasms will exert a similar baneful influence on the parts exposed in this operation is not proved, it is at least so probable that no operator should expose a patient to the test. It is true that in the one case a mucous membrane altered by pregnancy and parturition is involved, and in the other a serous sac ; nevertheless there is sufficient probability that evil might accrue, to make us careful to avoid these sources of disease. Pre- vious to the operation the patient should be put upon a tonic PREPARATIONS FOR THE OPERATION. 585 course. Generous diet, iron, quinine, fresli air, cheerful sur- roundings, and gentle exercise should, unless impracticable from some peculiarity of the case, be prescribed. Drs. Simpson and Atlee speak highly of the use of the persulphate of iron as a tonic. A visit to the country or some quiet watering place will prove of great advantage. Above all things, the mind of the patient should be made calm and cheerful, and every hope as to the result of the operation encouraged. After a candid state- ment of the chances of success has been rendered her as material upon which to base her determination to accept or reject the operation, no doubt ought thenceforth to be expressed as to the result by physician or friends. The operation should be performed in a locality where the air is pure and salubrious — never in the wards of a crowded hospi- tal, and if a choice be offered, in the country rather than the city. The day selected should be clear, and neither very hot nor very cold. If the weather be cool, the temperature of the apartment should be kept at from seventy-eight to eighty, and the atmos- phere moistened by evaporation of water. A thoroughly experi- enced nurse should be in readiness to take charge of the patient. Two days before the operation a cathartic should be adminis- tered, in order to evacuate the bowels completely, and for three or four nights an opiate should be given at bedtime. This not only quiets the nervous system, but tests the patient's capability of tolerating the medicine. One hour before the operation, Dr. Atlee gives a dose of opium. The skin should be put into good condition by warm baths employed daily for a week or more, and its temperature kept equable during the operation by flannel drawers, as suggested by Mr. Brown. As the time for its com- mencement arrives, the bladder should be carefully evacuated, the patient anesthetized by sulphuric ether, and laid upon her back upon a table of suitable height and strength, which is covered by folded counterpanes or blankets and placed before a window affording a good light. The operator will require at least four assistants, one to admin- ister the anaesthetic, one to stand opposite to him and aid in mani- pulating the tumor and abdominal wall, one to take charge of the instruments, and one to apply ligatures, the actual cautery, &c, A fifth, to be at command in case of need, will alwaj^s be of advan- 586 OVAEIOTOMY. tage. Two or three pints of Peaslee's artificial serum, composed after the following formula, may be kept in readiness. I£. — Sodii chloridi, $iv. Albuminis ovi, gvj. Aquse, Oiv. — M. The Operation. — Although this operation has of late years been so fully discussed, and so free an interchange of sentiment con- cerning it has been afforded, there is not one point connected with it upon which operators are agreed. The extent of incision, management of pedicle, closure of wound and the other steps which will be alluded to, are still subjects upon which great variety of opinions exist. I shall avoid discussions, and hoping to be pardoned for any appearance of dogmatism which may result from so doing, give such a description as will, according to my view, best meet the requirements of practice. The steps of the operation are these: — 1st. Incision ; 2d. Examination for, and rupture of adhesions ; 3d. Tapping; 4th. Eemoval of the sac ; 5th. Securing the pedicle ; 6th. Cleansing the peritoneum ; 7th. Closing abdominal wound. The incision is made by a bistoury held by the operator, who stands at the right side of the patient. It should pass directly through the linea alba, and should extend from a little above the symphysis pubis, upwards for two or three inches. Passing through the skin and adipose tissue, layer by layer, it is con- tinued until the operator sees the fibrous sheath of the recti muscles. Sometimes it is difficult to distinguish this from the peritoneum. If any doubt exist, it should not be incised until exposure to the air and pressure by forceps, fingers, or sponges, have checked the venous flow occurring from the vessels exposed by the abdominal incision. Then the fibrous structure should be caught by a tenaculum, snipped with scissors, and a grooved director passed under it, upon which it may be slit. If this" expose the belly of one of the recti, it will be evident that the linea alba has not been struck by the incision. To reach it, a director should be pushed under the sheath across the muscle, and it will be arrested at the linea, where the incision may be OPERATION. 587 made. All hemorrhage having now ceased, the parietal perito- neum should be lifted, snipped, and slit upon the director for the length of the incision. Fig. 216. Position of operator. (Simpson.) At this point a slight flow of straw-colored serum will usually take place, after which either the shining wall of the sac will be exposed to view, or, as will sometimes be the case, a thin layer of omentum will be found spread out over its surface. This should not be cut, but lifted like an apron and put aside. Some- times, in addition to omentum, a loop of intestine may be found over the anterior face of the tumor, as happened in one of Mr. Baker Brown's cases, where it would have been incised had the operator not slit the peritoneum upon a director with scissors. Mr. Brown has laid down, in reference to the abdominal section, this important rule: it should always be regarded originally as an explorative incision. If any condition contraindicating the re- moval of the sac be found to exist, it may then be closed without exposure of the patient to great danger, while if it be found advis- able to enlarge it to proceed, this may be done to any necessary extent. Mr. Wells has removed one sac by an incision of one inch and a half, and rarely resorts to one of over five inches. On the other hand, Dr. Clay, whose favorable statistics have been alluded 5S8 OVARIOTOMY. to, prefers the long incision. The great dread which has always been entertained of cutting into and exposing the peritoneum, lends a degree of fascination to the short incision. When, however, it is borne in mind that it is to putrefaction of retained fluids that peritonitis and septicaemia are chiefly due, this feeling will diminish in force, for it is evident that the smaller the opening the more difficult will it be to discover and close bleeding vessels, and to cleanse the abdominal cavity. The shining wall of the cyst, covered by visceral peritoneum, being now under the fingers and eyes of the operator, he has an opportunity of verifying his diagnosis by palpation. If it be positively settled that the tumor is purely fluid, it may be re- garded as ovarian. If it be composite or solid, before proceeding further its relations to the uterus should be determined by pass- ing the uterine sound into that organ. Examination for, and Rupture of Adhesions. — The hands being rapidly cleansed of blood which has collected on them during the incision, should be dipped in a basin of tepid artificial serum, and two or three fingers passed around the tumor between the parietal and visceral peritoneum. Should they meet with slight adhesions, these should be gently broken ; if none be reached, a large steel sound, previously dipped in warm serum, should be swept around the tumor as far as the pedicle. Special attention should be given to attachments to the liver, large intestines, uterus, and bladder, which are of far greater moment than those to the abdominal walls. This exploration, like that by the fingers, may be made to rupture slight adhesions, but those which are strong and well organized should be left for careful examination and section after the inci- sion has been prolonged. If such be found, the short incision of two to three inches should be prolonged upwards into the median incision of five to seven, or the long incision of ten to twelve, the judgment of the operator deciding as to which is needful. If by a short incision, and the means of exploration already mentioned, the absence of adhesions can be decided on, nothing more is neces- sary, for this step of the operation is complete; but if it be found necessary, the incision should be prolonged, and the whole hand passed into the peritoneal cavity, in order that all the relations of the tumor may be clearly ascertained. The long incision having been made, as soon as all flow from the severed vessels has ceased, the operator should break all TAPPING. 589 adhesions within reach by carefully peeling off their attachment to the tnmor. Great care must be observed not to tear the cyst wall, lest escape of its contents or hemorrhage should occur into the peritoneum. In this way only moderate adhesions should be broken. Those of very firm and vascular character, should be dealt with after tapping. The patient should then, after the sug- gestion of Dr. Hutchinson, be turned on one side in order to cause the tumor to protrude through the incision, and fluid removed by tapping, to pour out of and not into the abdomen. Tapping. — If doubt exist as to the character of the contents of the tumor, a portion should now be drawn off with an exploring trocar, for if a clear, watery fluid containing no albumen be re- moved, the operation may be given up, and partial excision made to replace it ; while, on the other hand, a tumor supposed to be fluid may thus be proved to be solid or composite, without involv- ing flow of blood into the peritoneum. If this explorative punc- ture prove the tumor to contain fluid, a large trocar like that of Spencer Wells, represented in Fig. 217, may be plunged in, fixed Fig. 217. Spencer Wells's trocar and canula. to the wall of the cyst by its wings, and the fluid allowed to pour out into an appropriate vessel through a caoutchouc tube attached to the mouth of the canula. While the fluid is pouring out, compression of the abdominal walls against the tumor should be made by an assistant, who places one hand on each side of the abdominal incision, and the sac kept from collapsing by strong tooth forceps made to grasp its lips. When the first sac is emptied, the canula should be removed and the index finger introduced in order to ascertain the existence of other cysts, endogenous, exogenous, or multiple. These should be tapped in a similar manner, an incision, if needed, be- ing made in the cyst wall for the purpose of facilitating the 590 OVARIOTOMY. process. All the large cysts being emptied, the operator should at once proceed to the removal of the sac. Removal of the Sac. — The sac being now drawn out by the tooth forceps, tenacula, or pincers, which have been fixed in it to prevent its collapse, is seized by the fingers of the operator or assistant, and gently drawn forth through the incision. If an adhesion which has resisted the manual efforts already made to rupture the attachments, hold it in the abdomen, this should be severed by detaching it from the cyst wall by the fingers, which will now reach it readily ; by the actual cautery, as suggested by Mr. Brown, if it be long enough to avoid cauterization of the abdominal wall; by scissors, if a cutting instrument must be used; or by a small ecraseur, if it can be applied. No rule can be given as to the best method, for each case will require the plan specially adapted to its peculiar features. This maxim must be constantly borne in mind — that plan is best which severs the attachment without injuring viscera or leaving bloodvessels open, for these are the two evils to be feared. If a flow of blood follow the severance of the adhesion, the vessel should be ex- posed, freely touched with persulphate of iron, or with the actual cautery so lightly as not to create a slough. By the means recommended, adhesions will generally be severed without the application of ligatures, but now and then this is necessary. If it be so, silver wire should be employed when practicable, instead of silk, as less likely to induce inflammation. In some cases, however, the cyst adheres so strongly to some viscus that it cannot be separated. Under these circumstances a portion of the cyst wall should be cut out and allowed to remain upon the surface to which it so pertinaciously clings. M. Boinet 1 points out the propriety of removing the secreting surface of such a piece before leaving it. The tumor being freed from attachments is now drawn forth, and the pedicle seized in the fingers. Securing the Pedicle. — This, which constitutes one of the most important steps of the operation, is at times easily and satis- factorily accomplished, while at others it is invested with great difficulties. Unless the pedicle be excessively short, the sac may be drawn outside of the abdomen and this part grasped in the ' N. Y. Med. Record, July 1, 1867. SECURING THE PEDICLE. 591 fingers. It may then be managed after one of the two following methods : — 1st. It may be secured against hemorrhage and left between the lips and outside of the wound — a. By being transfixed by a double hemp ligature, one strand of which ties one half the stump and the other the other half, and fixed in wound by harelip pins. (Duffin) b. By compression by a clamp. (Hutchinson.) c. By amputation by the ecraseur. (Atlee.) 2d. It may be secured against hemorrhage and returned to the abdomen — d. By being secured by double ligature, as mentioned in a, returned, and ligatures allowed to hang out of lower angle of wound. ( Clay.) e. By being tied, cut short, and returned to abdomen. (Tyler Smith.) f. By being temporarily constricted by a metallic wire. (Koeberle.) g. By severance by the actual cautery. (Baker Brown) The prevention of hemorrhage by the ligature and clamp, a and b, are evidently identical in principle. The clamp, how- ever, has the advantage of being simpler and more easily applied. The clamp most commonly used is that of Mr. Wells, though many others are equally applicable. It is thus applied: the Fig. 218. / s s. >\ Spencer Wells's clamp. pedicle or neck of the tumor being held in the fingers, the clamp, Fig. 218, is adjusted so that one limb passes over one, 592 OVARIOTOMY. and the other over the other side of it ; the two branches are then closely approximated so as to obliterate the vessels, and the sac is amputated above this by a bistoury. The clamp is then laid flat upon the abdomen and the incision closed. Another very effective clamp is that of Koeberle, represented in Fig. 222. The pedicle is included by it in the space repre- sented in black and constricted by action of the screw which is seen below it. When the ligature is employed, the sac is amputated and the stump placed between the lips of the wound and transfixed by harelip pins, or the sutures which close this part of the incision. Writing to Dr. A. K. Gardner, in 1860, Dr. Atlee says of these methods: "The great objection to the ligature is that it not only strangulates the peritoneum, but it leaves a sloughing stump, both of which are constant foci of irritation. By means of the ecraseur and the styptic, persulphate of iron, all ligatures are avoided." When amputation is thus performed, the stump may be fixed in the wound by pins or sutures. This method is pecu- liarly applicable to small and non-vascular pedicles, but all appear afraid to trust to the haemostatic powers of the ecraseur in other cases. The plan by which Dr. Clay returns the stump to the abdomen is practised in the following manner: a double ligature is passed through the centre of the pedicle and then cut so as to leave two ligatures in position. One half of the pedicle is then tied with one and one with the other. The sac is then amputated, the pedicle returned to the abdomen, and the ligatures allowed to pass out through the lower angle of the wound. This method possesses these advantages: it absolutely prevents hemorrhage, as the ligature always does, at the same time that it furnishes a vent for fluids which may afterwards accumulate in the perito- neum. Dr. Clay still employs it, and has obtained by it the favorable results of eighty cures in one hundred and seventeen operations. Few of the leading operators now follow the method ; those who desire to return the stump to the abdomen following with some modifications the plan to which we now turn. Dr. Tyler Smith has lately succeeded in rendering popular a method which was practised, according to Dr. Peaslee, as long ago as 1829 by Dr. Eogers, and afterwards by Dr. Billington, of this city. It consists in ligating the stump, cutting both ligature and SECURING THE PEDICLE. 593 pedicle as short as possible, returning them to the abdomen, and closing the abdominal incision. In this way Dr. Smith has ope- rated upon seventeen cases, and lost only three patients. Dr. Peaslee, 1 whose success as an ovariotomist has been remarkable, says of the method : " I now again refer to Dr. Tyler Smith's method of treating the pedicle as the best of all methods, and the one to which all others will, in my opinion, ere long give place." Koeberle, of Strasbourg, employs the clamp when the pedicle is long, but when short, he compresses the stump by a species of constrictor which tightens a metallic wire that surrounds the pedicle. Fig. 219 will explain the mechanism of this instrument, which passes into the abdomen, the shank remaining in the wound. Fig. 219. Fig. 220. u Koeberle's constrictor. Baker Brown has of late practised amputation of the tumor by means of the actual cautery, and claims the astonishing results of twenty-nine cures in thirty-two operations. It is highly pro- bable that this method will accomplish a great improvement in the operation, and assume the position of a means of great value. Thus far it has not been extensively tried. In employing this method, Storer's clamp shield would answer an excellent purpose in protecting the parts. No rule can be given with reference to a choice between all these methods other than this : 2 when the pedicle is long and slender it does not appear to matter very much which plan is selected, for all have yielded and are daily yielding, excellent results; but when it is very short the external does not promise nearly so well as the internal method of managing the stump. 1 Op. cit.,p. 83. 2 In Lond. Med. Times & Gaz., Nov. 28, 1868, Mr. Wells reports thirty-six ope- rations and five deaths. Thirty were clarnp cases and none died ; six were treated otherwise and five died. 38 594 OVARIOTOMY, Fie. 221. Sfcorer's clamp shield. As to the special cases for applying the first and second plans the following suggestions (not rules) may be of service : — ■ a. The clamp is applicable to long pedicles, requiring powerful ligation, and presenting a large amount of tissue for suppuration and decay. h. The ecraseur may be relied upon where the pedicle and vessels are small. c. Clay's method is eminently adapted to cases in which con- siderable suppuration is anticipated, and a vent for pus is required ; as, for example, where many adhesions have been broken. d. Tyler Smith's method may be resorted to with confidence where the pedicle is small in volume, where no great disturbance of the peritoneum has occurred, and where we have no reason to anticipate suppuration. In my fourth case of ovariotomy I em- ployed it with complete success. e. Koeberle's constrictor is applicable to just the same class of cases as the method of Dr. Clay, and for the same reasons. /. The severance of the stump by the actual cautery presents REMOVAL OF SAC 595 many advantages, and may be "used in any case except where the vessels are very large. The statement just made as to its being immaterial whether the pedicle is returned or not, in ordinary cases, is based upon the comparative results of Wells, Brown, and others who do not return it, with those of Tyler Smith and other operators who do. The following analysis of a large number of cases is given with reference to this point by Dr. J. Clay : — ■ - Class of cases. Stated left within the abdomen. Inferred left within tne abdomen. Kept with- out by various methods. Tied in two or more por- tions. Simply ligatured. Stitched in wound. Ecraseur used to divide it. Successful .... Unsuccessful. 113 58 76 97 20 25 122 57 22 26 3 3 2 1 Total 171 173 45 179 48 6 3 The methods just enumerated are those by which hemorrhage from the vessels of the pedicle is prevented. The means by which the pedicle is sustained between the lips of the wound so as to keep its putrid extremity outside the body are these : it may be transfixed by one or two of the sutures or pins closing the abdominal wound ; it may be held up by a transverse rod of steel, as is done by Koeberle : or it may be sustained by the clamp and two pins or sutures which do not transfix it but pass on each side in close contact with it. Obstacles to Removal of Sac which may be discovered as the Opera- tion proceeds. — There may be no pedicle, especially in cases of solid or semi-solid tumors, an indissoluble union existing with the body of the uterus. At other times the sac is in part bound down so that it cannot be removed, while part of it can be drawn out of the abdominal incision. When this is so, that portion which is drawn out should be removed, the lips of the part re- maining stitched carefully to the abdominal walls, and the incision closed except at its lower angle, which should be kept free by the insertion of lint, or a caoutchouc tube by which disinfecting fluids may be thrown in to prevent septicaemia, as in ordinary drainage. This procedure is a modification of the operation of incision already alluded to. The omentum may be adherent to such an extent that its removal becomes necessary. When this involves considerable rupture of its bloodvessels, it may be cut 596 OVARIOTOMY. off by the e'craseur and its bleeding extremity touched with per- sulphate of iron or the actual cautery ; or it may be amputated and brought outside the wound as is done in case of the pedicle. Before proceeding to the next step of the operation the remain- ing ovary should always be carefully examined as to the existence of disease, for if cystic degeneration exist, it ought at once to be removed. If very minute cysts exist, not larger than marbles, for example, they should be incised, but if large ones are found, secretion from the walls of which might cause sufficient flow into the peritoneum to excite peritonitis or septicaemia, they should be removed, for the great dangers of the operation have already been incurred, and it would be unwise to leave the seeds of another tumor to develop. Cleansing the Peritoneum. — The sac having been removed and hemorrhage checked, all fluids contained in the peritoneal cavity should be carefully removed by soft sponges squeezed out of warm water. Not only the intestines and abdominal walls, but espe- cially the pelvis should be completely and thoroughly cleansed. This is a point of great importance, and may decide the issue of the case. Every particle of fluid left will undergo decomposition, and expose to the great dangers of septicaemia and peritonitis. So momentous does this appear to some operators that Koeberle, 1 after cleansing the peritoneum, always makes an opening through the recto- vaginal space to allow drainage of fluids which may collect, employing tubes of glass as drainage tubes. Closing the Wound. — This is accomplished by two sets of sutures, the deep and superficial. The first, composed of silver, are passed in the following manner : a thread of silver wire is passed at each of its extremities through a long and stout straight needle. One of the needles being grasped by strong needle- forceps is passed through the peritoneum of one abdominal flap near the edge of the incision and made to emerge through the skin one inch from the edge. Then the other needle is seized and passed through in a similar manner. The suture is then secured by twisting. If it be desired to use quilled sutures, it can be accomplished by passing a doubled silver thread after the same method. These deep sutures, placed at the distance of half an inch apart, will bring the whole incision into contact from 1 Courty, op. cit. CLOSING THE WOUND, Fig. 222. 597 Closure of the abdominal wound after Koeberle's plan. C shows the clamp grasping the mummified pedicle. (Wieland and Dubrisay.) the peritoneum to the skin, and favor healing by first intention. Koeberle employs the quilled suture as represented at Fig. 222. Besides these, superficial sutures or pins like those employed for harelip should be used, which pass through the skin and areolar tissue, but do not involve the peritoneum. Around them thread is wrapped in figure of 8. After this a long pledget of lint soaked in cold water should be applied over the surface of the wound, a bandage of flannel employed to keep this in place, a full dose of opium given, the patient put quietly to bed, covered warmly, and warmth applied to the feet. 598 OVAEIOTOMY. After 'Treatment. — The patient should be kept quiet and free from pain by opium, given either by the mouth or rectum, so soon as she has rallied from the anaesthetic; or, in case of great suffering, by the hypodermic method. Her nourishment should consist of milk, beef-tea, or some gruel with milk. Even these digestible substances should be given in small amounts and with caution. Should there be a tendency to nausea and vomiting, pieces of ice may be held in the mouth or swallowed, and if these symptoms be so severe as to threaten rupture of the sutures, the hypodermic use of morphia should be resorted to. The patient should be placed in bed so that the trunk will be more elevated than the pelvis, in order to limit the locality of fluids in the peritoneum. The evils which are chiefly to be feared as sequels of the ope- ration are, within the first forty-eight hours, hemorrhage )\ from second to thirteenth day, peritonitis; and from completion of operation to sixth day, nervous prostration. 1 Septicaemia, being the result, first, of the decomposition, and second, of the absorption, of fluids in the peritoneum, is not likely to occur for a number of days. In Dr. Peaslee's cases it appeared in from four to twelve days, but it may take place in two or three weeks after the operation. The effect of the operation upon the nervous system should be guarded against by the means just enumerated as general rules of management, and by administration of stimulants, as wine, brandy, or champagne, if the strength appear to be failing. In addition, the most complete quietude of mind and body should be afforded. All conversation and noise should be interdicted, the patient's hopefulness excited and fostered, and all muscular effort avoided. For four or five days the sigmoid catheter should remain in the bladder and the bowels be kept constipated by opium for ten days or a fortnight. The avoidance of cathartics during this time is essential to safety, a neglect of this precaution often producing a fatal issue. About two years ago I was present at the removal of an immense cystic sarcoma by Dr. John O'Reilly, who made an incision extending from the xiphoid cartilage to the symphysis, and after detaching many adhesions extirpated the mass. The 1 This calculation of periods is based upon one of Dr. Clay's tables constructed from one hundred and fifty cases of these accidents. AFTER TREATMENT. 599 patient did perfectly well for a week, and was in a fair way to recover. She was, however, very urgent that her bowels should be moved, and the doctor refusing to comply with her solicita- tions, she took surreptitiously a full dose of bitartrate of potash. This acted as a hydragogue cathartic, but its action was not limited as it usually is. Diarrhoea, and soon dysentery, super- vened and destroyed the patient's life. After the seventh or eighth day, tympanites may call for an alvine evacuation, which may be effected by an ordinary injection of soapsuds or an infusion of anise, chamomile, or fennel. Should hemorrhage be ascertained to be taking place, all dress- ing should be at once removed, and the stump, if out of the abdo- men, securely ligated or touched with the actual cautery. If it have been returned to the abdominal cavity, there is but one course available, that is, opening the wound, ligating the bleeding vessel, and cleansing the peritoneal cavity. Such a necessity is very unfortunate, yet this course holds out the only prospect of success. Peritonitis, which proves the cause of death in about one-quarter of all who die from this operation, is best avoided by leaving few or no ligatures in the cavity, by removal of all putrefactive matters, and by keeping the abdominal viscera at rest by prevent- ing vesical and rectal actions and applying a bandage. Should it occur in spite of these preventive means, it should be treated by full doses of opium, and if the patient's strength will bear it, the application of leeches and fomentations over the hypogastrium. Koeberle is in the habit of applying a bladder of ice on each side of the incision for a number of days after the operation, for the prevention of hemorrhage and peritonitis, but this plan is not followed by English or American operators. Septicaemia, which is, next to peritonitis, the most frequent cause of death, is, when once fully established, an almost hopeless state. It is ushered in by dizziness, excessive muscular prostra- tion, anorexia, great pallor, small, rapid, and very weak pulse, sometimes a low delirium, dry tongue, and a sweetish odor of the breath. It is probably this condition which is so often alluded to as a " typhoid state" after operations, and one cannot but sus- pect that many, if not most, of those cases quoted in Dr. Clay's tables as shock or collapse, occurring as late as the fifth, sixth, seventh, and tenth days, were really instances of this affection. 600 OVARIOTOMY. In one of my fatal cases, already alluded to as alveolar cancer, the patient was doing quite well on the evening of the seventh day. On the morning of the eighth I was struck by her wild, maniacal expression and cadaverous countenance ; upon examination I found all the symptoms of septicemia present, and she very soon succumbed to them. The gravity of this sequel has rendered all operators anxious to possess the means to avoid or remedy it. Most of the methods of avoidance have been already stated, the importance of the sub- ject will, however, excuse my again referring to them as — 1st. Completely cleansing the peritoneum; 2d. Checking all hemorrhage before closing the abdominal wound ; 3d. Establishing drainage through Douglas's cul-de-sac, should septicaemia appear imminent ; 4th. Establishing drainage at lower angle of the wound ; 5th. Mummifying the stump by persulphate of iron. To secure ready escape of fluids from the peritoneal cavity, Koeberle adopts two methods. The first consists in making an opening through the recto-vaginal space into the peritoneum, and leaving in it a glass drainage tube. The second, which is adopted when he returns the stump to the cavity constricted by the garotte, consists in introducing, down to the pedicle, a "dilator composed of two branches of lead, each of which is formed of two parts, one horizontal, destined to be applied on the skin, the other perpendicular, in the form of a gutter with a concavity within. These two valves, introduced separately into the wound, are kept apart by two transverse rods arranged upon a very simple plan." 1 He highly esteems the use of this instrument for drainage, which is kept in place after an operation until all discharge from the pelvis ceases. Drainage from the cavity is likewise effected by Dr. Clay's method, and by introduction of tubes of caoutchouc through the lower angle of the wound. Koeberle adopts the plan of mummification of the pedicle of the sac, and the omentum, if he has had to cut this off, by free application of strong solution of persulphate of iron, believing that this prevents putrefaction and absorption. These are pre- 1 Wieland and Dubrisay, op. cit. AFTER-TREATMENT. 601 ventive means. When the accident is at hand and its symptoms recognized, one of them has likewise been nsed as a curative measure by Keith, of Edinburgh. M. Courty thus reports it : After the clamp had been removed, peritonitis with effusion of fluid set in. On the sixteenth day after the operation a puncture was made through the recto-vaginal cul-de-sac, and a fetid fluid poured away with relief to the symptoms. In this case the ope- ration was resorted to for prevention of peritonitis. It may upon stronger grounds be employed for septicaemia. The most valuable suggestion with reference to this matter has emanated from Dr. Peaslee, who has unquestionably placed at the disposal of the ovariotomist a method which robs the operation of much of its danger. It consists in washing out the peritoneum with disinfectants. I cannot do better than describe it in his own words. "I first injected a solution of chloride of sodium (3j to Oj), into the peritoneal cavity of a patient much prostrated by septicaemia, in February, 1855. I began with one quart of the solution, and then drew out the same amount of fluid with the syringe; though I soon found I could inject that or a larger amount, even two quarts, through a flexible bougie, and then changing the position so as to bring the free extremity to a lower level than the one in the peritoneal cavity, convert it at once into a siphon through which all the fluid would freely flow out. The immediate relief from the first injection was very striking; the dizziness and stupor at once disappearing, though to return again in from eight to twelve hours. I repeated the operation twice daily, and then once daily for a week, when the returned fluid no longer presented any odor of decomposition. When the fluid was unusually fetid, I used a solution of the liquor sodae chlori- natae (3ij to Oj). The patient recovered rapidly from the time when the fetor of the fluid was overcome." "In September, 1862, I again resorted to the same practice in a second case of septicaemia after ovariotomy." * * * * " A third case of septicaemia, produced by blood oozing from the omental vessels after ovariotomy, occurred in my practice in September, 1863. The symptoms appeared in this case on the fourth day, and the injections were commenced on the seventh. The same kinds were used as in the preceding case, the solution of liquor sodae chlorinatae, even 3j to oiv of water sometimes, and it was found necessary to use them three times daily for twenty 602 OVARIOTOMY. days, to keep the patient from sinking ; then twice daily for twenty-one days, and once daily for thirty-three days more; mak- ing one hundred and thirty-five injections in all, in seventy-eight days. I found it better to inject a large quantity rapidly, and let it flow away immediately, usually injecting as much as the cavity would receive (one to two quarts at first). For the encourage- ment of others who may resort to this treatment, I should also add that it was persevered in, in the second case for four weeks, and in the third for three weeks, before any amendment in the character of the decomposed fluid could be perceived." A re- cognition of the importance of the principle demonstrated by these cases has induced me to give them full space. It would be at once simple and effectual to combine the cura- tive treatment of Peaslee 1 with the preventive measures of Keith and Koeberle. Probably an excellent disinfectant would be found in carbolic acid greatly diluted. As to the time at which the sutures are to be removed no fixed rule can be given, for it will depend upon the rapidity and per- fectness of union. Should union by first intention occur, some of them may be removed on the fifth, sixth, or seventh day. But great care should always be observed, and only those at points where the union is strong should be withdrawn. After with- drawal the lips should be firmly approximated by adhesive plaster. The clamp, if employed, or the ligature, if passed out through the wound, should be removed when they lose their hold by reason of sloughing, and drop away. No traction should be applied to them. The patient should be cautioned against rising too early after convalescence; and even after she is able to go about she should be very careful not to make any violent efforts. 1 Peaslee introduced a tube (as Keith afterwards did), at the time of the opera- tion in the first case, still septicemia occurred. CHAP TEE XLIY. FLUID OVAEIAN TUMORS— CONTINUED. Cysts of the Broad Ligaments. Definition and Varieties. — It was stated in the first chapter de- voted to ovarian tumors that they all belonged to three classes — fluid, composite, and solid ; and that the fluid ovarian tumors were of these varieties — hydatid cysts, ovarian cysts, and cysts of the broad ligaments. The first two of these varieties have been already investigated ; we come now to consider the last. Cysts contained in the broad ligaments are really not ovarian tumors, and classing them thus might with some reason be styled a mis- nomer. But clinically we have no means of distinguishing them, so that, while in a work on pathological anatomy a strict classi- fication would be proper, it would here only give an appearance of accuracy which would prove unreliable and delusive at the bedside. For the pathologist, all tumors, filled with fluid and existing over the site of the ovaries, are susceptible of absolute classifica tiou, for in his studies he cuts through the abdominal walls, and by sight and immediate touch learns the characters and relations of the morbid growths. But with the practical physician the case is different. For him, deprived as he is of the pathologist's means of observation, as a general rule, fluid tumors existing over the site of the ovaries are ovarian tumors until explorative in- cision teaches him otherwise. There are three forms of cyst which are found in the broad ligaments, that is, between the folds of peritoneum making up those ligaments: — Tubal dropsy ; Wolffian cysts ; Areolar cysts. Tubal Dropsy. — This condition, which is described under the 604 OVARIAN TUMORS. narges °f hydrops tubse and hydrosalpinx, consists in the dis- tension of the Fallopian tubes by nmco-serous fluid. It arises in this manner: some influence, for example, acute or chronic sal- pingitis, pelvic peritonitis, or cellulitis, occludes both extremities of the tube. The inflammation of the mucous membrane of the tube creating a muco-serous fluid, the canal is distended by this, generally irregularly, to the size of the finger or small intestine. Thus far the affection does not concern our present investigation, for there is no probability that such a growth would resemble ovarian tumor so closely as to lead to an error in diagnosis. As this distension goes on, the mucous lining of the tube takes on the physical and physiological characters of a serous membrane, and secretes plentifully a serous, straw-colored, and slightly flocculent fluid. At times the distension of the walls of the tube proceeds so far that the fluctuating tumor which results gives all the physical signs of ovarian dropsy. The testimony of authorities is almost unanimous that between this condition and ovarian dropsy there are no means of diagno- sis. M. Aran sounds the key-note to the general belief when he declares that, 1 " the tube distended by liquid, I am perfectly as- sured, does not give a sufficiently clear sensation to allow us to diagnosticate its existence." Prof. Simpson, however, assumes a Fig. 223. Tubal dropsy. (Hooper.) different position. 2 He declares that, although " in practice this form of tumor is usually altogether overlooked or is mistaken for some other kind of tumor," it is really diagnosticable by the following means: " 1st, its free and independent mobility; 2d, its 1 Op. cit., p. 633. 2 Op. cit., p. 432. WOLFFIAN CYSTS. 605 elongated form ; and 3d, its wavy outline." Let any one examine the shape of a large tubal dropsy, like that represented at Fig. 223, for instance, and he will see that both the shape and wavy outline will fail him. When it is remembered that the affection frequently results from pelvic peritonitis, the freedom of motion will evidently be often delusive. " The diseased tube," 1 says Courty, " is rarely free and without alteration at its periphery : generally it bears signs of old inflammation, which is adhesive, and this fixes it to the neighboring parts." I have met with the affection four or five times in autopsies, and this statement has always been sustained. The means of diagnosis just mentioned would be applicable to slight tubal distension, which is rarely productive of symptoms calling for examination. Few instances of diagnosis are on record, and even in cases where tapping has been supposed to substantiate it, it is by no means sure that such a disease existed. Prof. Simp- son reports but one case in his extensive experience in which he was able to come to a conclusion. He denies the possibility of great enlargement of these tumors, declaring that they rarely grow larger than a foetal head, and that we may justly be allowed to be skeptical as to cases reported as being much larger. Dr. Arthur Farre, 2 however, willingly admits the well-known cases of Bonnet and De Haen; the first of which contained thirteen pounds of fluid and the second thirty-two pounds. Scanzoni circum- stantially reports an instance in which the sac attained the size of the head of a child of ten years of age. Wolffian Cysts. — Within the external margin of the broad liga- ment where the two walls of the peritoneum pass from the fimbriae of the tubes to the ovaries, exists the body of Rosenmuller, par- ovarium, or Wolffian body, to which allusion has already been made as consisting of a number of little tortuous cords, some of which are perforated by canals. The slight secretion occurring from the walls of these tubes sometimes becomes greatly increased, and the containing walls becoming proportionately distended, a tumor is created. These cysts rarely attain a size greater than that of a large orange, and their distension generally stops short even of those dimensions. Numerous instances of this form of tumor are reported by 1 Op. cit., p. 987. 2 Supplement Cjc. Anat. and Phys., p. 619. 606 OVARIAN" TUMORS. authors. Dr. Bright, in his work on Ahdominal Tumors, delineates two striking examples, and in Mr. Spencer "Wells's recent work, an instance is mentioned where the tumor was observed close to the uterus and was incised and emptied. 1 It is curious to ob- serve how uniformly in describing them they are likened to an orange. Areolar Cysts. — Cystic degeneration is much more likely to occur in those organs which have as component parts of their structure, minute cavities lined by epithelium. Thus, the kidneys and ovaries are peculiarly liable to be affected in this way. But this kind of degeneration is by no means limited to such structures. It may occur in areolar tissue anywhere, and those organs, which, like the thyroid and mammary glands, are prone to production of new growths having areolar tissue as their basis, are likewise especially liable to it. It is believed by pathologists, 2 that under these circumstances the cyst is merely an expansion of the areolae of the areolar tissue. In various parts of the abdominal cavity such cysts are found under the peritoneum and classed, by Dr. Graily Hewitt, under the head of subperitoneal cysts. Mr. Safford Lee reports one case of a tumor which filled the abdomen, after having lasted for twenty-five years, and destroyed life. On post-mortem inspec- tion a large cyst was found behind the peritoneum, which had originated under the pancreas. He reports another which began on the right side of the abdomen, was tapped forty-eight times, and was found by autopsy to be omental. Throughout the literature of the subject of ovarian tumors, allusions, generally very obscure, will be frequently found to a kind of cyst, not ovarian and yet not Wolffian, which is occasion- ally met with in the broad ligaments. As no special name has been applied to this variety I have ventured to style them areolar cysts, which appellation designates them as different in origin from the other two forms, and points to their relation to the areolar tissue. Two instances of such cysts are mentioned by Mr. Spencer Wells, one in Case XCIII. and the other in Case CXI. The latter is thus minutely described by Dr. Eitchie, who examined it : "Between the folds of peritoneum, which connected this with the tumor, appeared a little, clear vesicle, one fourth of an inch in 1 Case XXX. 2 Wells, op. cit., p. 84. AEEOLAR CYSTS. 607 diameter. It moved freely between the folds, and, having no apparent connection, could, by careful manipulation, be pressed from one part by the broad ligament to another. * * * The Wolffian body surrounded it; but the most careful dissection failed to show that it was connected with it, or that the cyst was, as might have been supposed, a dilatation of one of the tubules of that body." Dr. Eitchie was at a loss to account for the cyst, and suggests the possibility of its being a partially developed ovum. The other case was examined by Dr. Wilson Fox. It was a large cyst, about twice the size of the adult head. The ovary was healthy and not connected with the cyst. Scanzoni commences his article upon " Cysts formed between the folds of the broad ligament," thus : " Cysts are sometimes formed by a collection of liquid in the canals of the organ of Eosenmuller; sometimes they are completely independent." I know of no other pathological proof, such as that afforded by the evidence taken from the work of Mr. Wells, that these cysts ever assume very large dimensions. The largest with the record of which I have met is that described by Dr. Fox, which was twice the size of a man's head. Nevertheless, it appears to me that, from the clinical evidence before us, we may assume that they sometimes become very voluminous. Dr. Peaslee tells me that he has met with several large ovarian cysts filled with clear, non- albuminous fluid, which were cured by tapping. This would probably not have been the case had they been developed in the proper tissue of the ovaries. He states, likewise, that in conver- sation he understood Mr. Spencer Wells that he had had the same experience. Mr. Baker Brown accounts for many if not most of the cures of ovarian cysts effected by one tapping upon this supposition, and the confidence of Dr. Washington L. Atlee in the belief may be judged of by the following instance. About four months ago I saw Dr. Atlee cut down upon a sac which held a number of gallons of fluid, tap it by an exploring trocar, and await the chemical test of the liquid drawn off. While this was being- made, he stated to the large concourse of physicians present, that should the fluid prove non-albuminous, he would view the cyst as one developed in the broad ligament, and not in the ovary ; and instead of performing ovariotomy, he would then cut out only a small portion of the cyst wall in order to secure the dis- 608 OVARIAN TUMORS. charge of its contents into the peritoneum, and close the abdomi- nal wound. The fluid was found clear and non-albuminous, when the operator did as he had proposed, and the wound was closed. 1 In a communication upon this subject which I have received from his brother, Dr. John L. Atlee, the following views are ex- pressed concerning these growths: — "It is very difficult, previous to tapping, to distinguish cysts arising from the broad ligament from true ovarian cysts. The former are invariably, in my experience, unilocular, and do not displace the uterus to the same extent as the ovarian, although in these latter there is sometimes but little displacement. The cyst wall is thinner, and the impulse on palpation is more sensibly felt. The absence of albumen in the fluid removed, its resem- blance to ascitic fluid, its translucency, and slightly purplish tint when exposed to the sun's rays, are very strong indications that the cyst is peritoneal. These cases, of which I have had six or seven, perhaps more, get well by tapping, alterative treatment and counter- irritation, with pressure. They sometimes burst from external violence, and the fluid is absorbed, and are erroneously called spontaneous cures of ovarian cysts. It is in these cases, as in hydrocele, that iodine injections have done good ; in true ovarian cysts, in my opinion, seldom or never." Prognosis. — The prognosis of cysts of the broad ligament is, if their character be recognized after explorative incision, very favorable. It is not a rare occurrence for them to undergo spon- taneous cure, the cyst undergoing rupture from violence, and dis- charging into the peritoneum. Treatment. — No medical treatment has any efficacy. The surgi- cal treatment consists in tapping by the vagina or abdomen, drain- age, injection of iodine, and partial excision, so as to allow escape of the contents of the cyst into the peritoneum. The method proposed by Prof. Simpson, of tapping, closing the abdominal puncture and daily pressing fluid from the tumor into the peri- toneum, would likewise be very appropriate. In no case would ovariotomy be necessary. This completes the subject of fluid ovarian tumors. ! This cyst subsequently refilled and the patient died. SOLID TUMORS OF THE OVARY. 609 Solid Tumors of the Ovary. This class comprises those ovarian tumors, the structure of which is entirely solid — no cysts or other collections of fluid matter entering into their composition as a characteristic feature. Varieties. — The following list represents the varieties of this form of disease : — / Dermoid; Histoid tumors. 1 •< Pileous ; ( Adipose. Fibrous tumors. Cancerous tumors. Histoid Tumors. — Tumors containing fat, hair, teeth, bones, skin, in fact all the harder textures of the body, are not unfrequently found in the ovaries. For these, from the close resemblance of their contents to the normal texture of the animal economy, the name of histoid tumors {tato^ " organic texture," and f i5os, " like,") is appropriate. It was formerly supposed that these developments were always dependent upon conception, the product of which, instead of passing into the Fallopian tubes, had been retained and under- gone increase in the ovaries. But this view is fully contra- dicted by the fact that such tumors have been frequently discovered in other organs than the ovaries, in undeveloped females, and even in males. Cruveilhier accounts for them upon two hypotheses ; 1st, by ovarian pregnancy, followed by death of the foetus and proliferation from the skin, which thus becomes analogous to the blastodermic membrane of the impregnated ovum ; 2d, by what the French style, " inclusion parasitaire," or, as we would term it, foetal intussusception. This consists in the following occurrence : as a foetus develops, a fructified ovum becomes enveloped in some part of its structure. The more advanced ovum goes on growing, and in time makes the future being. The smaller one also undergoes development, but, being placed under unfavorable circumstances, soon ceases to advance according to fixed laws, and its tegumentary envelope produces 1 I am forced to create this term, from the fact that no name exists for this family of tumors. 39 610 OVARIAN TUMORS. some of the textures of the body. It is manifest that the first of these hypotheses is tenable only upon the supposition that conception has once occurred; the second is so without it. M. Pigne has analyzed eighteen cases with reference to the period of life at which they were found, with the following results : — 5 existed in virgins under twelve years ; 6 " " children from six months to two years ; 4 " " the female foetus at term ; 3 " " foetuses cast off at eighth month. Both the theories here advanced in explanation of this singular phenomenon are highly unsatisfactory. Opposed to the first are the following considerations : there is never in the tumor any trace of secundines ; they occur in undeveloped females and males ; and they exist in other parts of the body than the ovaries. Against the second view appear these facts : such tumors are more common in the ovaries than in any other part, and only a portion and not all of the tissues of the body are represented. To meet the want felt for an explanation, Lebert has advanced the theory that from the elements present, spontaneous generation of a portion of skin occurs, and this being given, we have, as Dr. Farre expresses it, "the basis out of which many of these pro- ducts spring." Histoid tumors vary in size from that of a hen's egg to that of the adult head, but very rarely grow larger. They are hard and generally globular. One ovary is usually affected, and by only one tumor ; but instances are on record where a single ovary con- tained a large number. They usually consist of fat, long hairs, teeth, skin, and traces of bone intermixed. The teeth are usually imbedded in the cyst wall or attached to pieces of bone, and are sometimes very numerous. Schnabel 1 records a case in which they exceeded one hundred in number, and Ploucquet 2 one in which they amounted to three hundred. When the predominating element of the mass is hair, these tumors are called pileous or piliferous ; when fatty matter, adi- pose ; and when skin, dermoid cysts. Histories of such cases are so rare that I transfer the following from Prof. Kiwisch's work : " A girl, seventeen years of age, was 1 Kiwisch, op. cit. 2 Becquerel, op. cit. SOLID TUMORS OF THE OVARY. 611 attacked with a swelling of the left ovary which, after twenty-one years, measured four ells in circumference, and reached below the knee. After her death, which took place in her thirty-eighth year, it was found that the sac alone of the ovary weighed four- teen pounds, and contained forty pounds of a thick, adipose, honey-like mass, which was mixed with many hairs of different lengths, among which curls were found two inches long, and as thick as a thumb, very like elf locks ; the internal surface of the sac was set with short hairs. There were also found eight bony concretions of irregular shape, one of which was seven and another ten inches long, and about two inches broad ; the form of one of these bones was polygonal, and set with six molar teeth and one incisor, and nine separate bones were present besides. The teeth had the size, perfectness, and firmness which they generally have in a girl twenty years of age." Histoid tumors are harmless, except in so far as they mechani- cally interfere with the surrounding parts in different movements of the body. Yery often they are discovered by accident only. Physical exploration reveals a hard, round mass, painless upon touch, and unless its size prevents it, perfectly movable. Although in themselves innocuous, and not likely to increase rapidly or to attain any great development, they sometimes set up very serious and even fatal disturbance by one of three methods : by creating suppuration and abscess on account of the irritation kept up by a foreign mass ; by perforation and dis- charge into the peritoneum ; or by the cyst which contains the histoid elements secreting fluid and changing its character to that of a fluid tumor. No treatment is required, a fortunate circumstance, since none would be at all effectual except extirpation. This would be eminently inadmissible, since there are not sufficient dangers attendant upon the tumor to warrant a resort to so hazardous a procedure. Dr. Graily Hewitt 1 refers to an instance in which Dr. Alexander Simpson injected one with iodine, but says that the result was not such as to encourage a repetition of the plan in future. Fibrous Tumors. — This form of tumor is rarely met with in the ovary, and never attains a very great size. Kiwisch reports two 1 Op cit., ]'. 577. 612 OVARIAN TUMORS. cases, one the size of a child's and the other the size of a small adult head. When it is borne in mind that uterine fibroids are strictly homologous with the organ from which they spring, and that they absolutely contain as structural components the peculiar muscular fibre of the uterus, it will be appreciated why such growths are much more rare in the ovaries which contain no muscular fibres whatever. Dr. Farre discredits the reports of large ovarian fibroids which are upon record, and believes them to have been in reality either cancerous tumors or growths con- nected with the uterus which so encroached upon the ovaries as to seem to have sprung from them. When the disease does affect the ovary it differs in no essential degree from the same affection of the uterus, except that pediculation does not occur as in the latter organ, and that the growth of the tumor is much more limited. The reader must be reminded that these remarks apply to the pure fibroid and not the fibro-cystic ovarian tumor, which will often attain an immense size, and is always to be regarded as a serious disease. They likewise apply to the development of this tissue into true fibrous tumors, for in the walls of cystic and cys- toid growths fibrous tissue is commonly developed. Yery often even a portion of the wall of a simple cyst contains a dense mass which is thus composed. No medical treatment accomplishes anything in this disease, and surgical means are not called for. Kiwisch describes enchondromatous and osseous tumors of the ovary, but since no other pathologist has met with them, except as the latter has been confounded with calcareous degeneration, and since Scanzoni has examined the only two cases with which Kiwisch ever met, and differs entirely with him as to their cha- racter, they may well be left without further mention. As the statement made above as to the rarity of fibroids was limited to the formation of tumors, so this remark must not be understood as applied ' to cartilaginous and calcareous, commonly called osseous, formations in this organ, but only to tumors properly so called. Such formations are by no means rare in the walls of cysts and intermixed with cancerous growths. Cancerous Tumors. — Solid cancerous tumors of the ovary are either scirrhus or medullary. The former, in which the fibrous element of cancer predominates very largely over the cellular, is COMPOSITE TUMORS OF THE OVARY. 613 very rare, and even the latter is by no means common as a pure and distinct solid tumor. It generally exists as a composite tumor in combination with cystic degeneration. When unassociated with cystic degeneration they very rarely grow to a large size ; thus scirrhus rarely grows larger than a child's head; but when combined with fluid accumulations they sometimes attain as extensive dimensions as ordinary cystic disease. All cancerous affections of the ovary are likely to be associated with the same kind of degeneration in the uterus or some neigh- boring part, though in rare cases they are primary. With refer- ence to the etiology, coarse, and prognosis of ovarian cancer there is nothing more to be said than that there is no difference between them when the affection is ovarian and when it has its seat in some other organ of the body. The tendency of the malady is in all cases to a rapidly fatal termination, very few cases extending beyond a year. The deposit of the cancerous elements is not always the same ; at times it is infiltrated throughout the organ, whilst at others it is confined in loculi disseminated through it. The most frequent complication is peritonitis, and ascites re- sulting from chronic inflammation of the peritoneum is often present. The circumstances which point to the disease are the follow- ing:— An ovarian tumor of rapid growth ; " " accompanied by ascites ; " " with lancinating pains ; u " chlorosis and oedema pedum ; " " " great constitutional enfeeblement ; " " " cachectic appearance. In its incipiency the affection is so insidious that either no symptoms appear, or they exist to so slight an extent that a diag- nosis is often impossible until the disease has advanced. Treat- ment, both medical and surgical, is of no avail in these cases. Composite Tumors of the Ovaries. This class includes all those tumors which are composed of both soiid and fluid elements. In some cases where there is a great 614 OVARIAN TUMORS. deal of fluid and very little solid, or considerable development of solid material and very little fluid, it is difficult to draw the line of distinction, but for clinical purposes the recognition of this as a distinct class will prove of signal service. The following are the varieties of the affection : — Cystic sarcoma; Cystic cancer ; Alveolar or colloid degeneration. Cystic Sarcoma. — In speaking of the pathology of ovarian cysts, it was remarked that there exist two theories upon which their occurrence was explained, one a dropsy of the Graafian follicles, another, the dilatation of the areolae of the stroma and effusion of fluid within the spaces thus created. In a manner similar to the latter of these, cysts form likewise in the connective tissue of fibrous growths, and the combination of the two elements has received the appellation of cystic sarcoma, derived from xvotis, " a bladder," and aapg, " flesh." As the name implies, this form of tumor consists of fibrous tissue combined with cysts. Dr. Hewitt quotes the report of a microscopial examination made of a speci- men shown at the London Pathological Society, as follows: "It- consists of a delicate, fibrous stroma, forming round, or oval alveoli, the latter lined by densely grouped epithelial cells form- ing a zone, inclosing an area loosely packed with cellular ele- ments of a similar form." Kiwisch believes that even in this form of tumor the cystic portion may be due to Graafian dropsy, but this view is not shared by other pathologists. The cysts often grow to a very large size. In Mr. "Wells's ninety-first case of ovariotomy the operation was preceded by tapping, which removed thirty eight pints of thin, dark fluid, containing much cholesterine. Dr. Fox, who examined the tumor, states that the cysts which were emptied by tapping represented one-half the bulk of the mass, which, even after this, weighed thirteen pounds. The structure of the solid portion of the tumor was very complex, the cysts being of every variety of size and grouped together in great confusion. In some the fluid was clear, and in others like pea soup. The proportion between the cystic and fibrous elements governs the character of these masses to such an extent that it is often difficult to classify them. TThen the former is much in the ascendency, the growth resembles a COMPOSITE TUMORS OF THE OVARY. 615 fluid tumor: when the latter predominates, it appears perfectly solid. The contents of the cysts may be colloid, purulent, serous, or sanguinolent, and blood is sometimes effused between the fibrous interstices so as to cause a rapid increase in size. The cystic sar- coma sometimes attains very large, or, as Kiwisch expresses it, 11 colossal," dimensions. In Mr. Wells's case, just alluded to, the tumor filled the whole abdomen, and extended two inches above the ensiform cartilage by its upper margin, but its growth was not nearly so rapid as that of pure cystic disease. This case had lasted for seven or eight years, slowly increasing until 1863, when it developed at the following rate ; June to July, one inch, July to August, one inch, August to September, one inch, September to October, half an inch, October to November, one inch. The tendency of these growths is to death, by exhaustion of the vital forces, by menorrhagia, or by interference with the func- tions of the abdominal viscera. In rare cases, however, a well developed tumor may undergo absorption, a fact which I have recently had impressed upon me by the following case. On the eighth of September, 1866, Dr. Wohlfarth requested me to see, in consultation with him, Mrs. W., who had been under his care since April of the same year, for a solid tumor of the right ovary, which had been rapidly increasing in size. The patient was a florid, handsome German woman, of 28 years, and married. Upon examination I found a hard, globular tumor, larger than the adult head, in the abdomen a little to the left side. It was slightly movable, evidently not connected with the uterus, as proved when this organ was moved by the sound, and obscurely fluctuating in spots. I diagnosticated a cystic sarcoma of right ovary. Having an appointment to examine a case in a few days with several physicians, I requested Dr. W. to have his patient meet me then. Accordingly she was a short time after- wards carefully examined by Professors Chas. A. Budd, Foster Swift, and Drs. Finnell, Eoth, Wohlfarth, and myself, with the unanimous verdict of cystic sarcoma. I am thus particular, because I desire to remove all doubt as to the diagnosis. All agreed that operative procedure was not indicated or advisable, although the patient urgently demanded it. In the succeeding month of December, the patient fell while 616 OVARIAN TUMORS. walking, and was so much stunned as to be taken up and carried home insensible. A severe and almost fatal attack of peritonitis, with a slight attack of pleuro-pneumonia followed, from which she recovered in three weeks. Some weeks after this Dr. Wohl- farth examined, and was amazed to find that the tumor had dis- appeared. I saw her on June 28th, and upon careful examina- tion discovered only a tumor at the site of the left ovary, the size of a goose's egg. This case was fully and minutely examined, was in itself a very plain and unmistakable one, and there exists in my mind no doubt whatever that the injury done to the tissue of the sarcoma by a violent blow caused its removal by absorption. Should one or more large cysts be detected, relief to many of the symptoms arising from mechanical interference may be ob- tained by tapping. The results of the operation are, however, more dangerous than in fluid tumors, hemorrhage and subsequent inflammation often taking place in consequence of it. Another disadvantage attending it is that the operator is more limited as to choice of the point to puncture. Besides this means our efforts at palliation must consist in relieving symptoms as they occur, in giving support to the mass by an abdominal bandage, and in enjoining quietude during menstrual epochs. The only curative treatment with which we are acquainted that avails anything for this form of tumor is removal by ova- riotomy. The operation is not so promising as in case of cystic degeneration, and should not be undertaken until the evil results of the disease and its tendency to destruction of life are fully manifested. It requires, generally, the long abdominal incision, and is very likely to be complicated by adhesions; still, the prospect of success is such as to render the operation in many cases of grave prognosis not only admissible, but incumbent upon us. Cystic Cancer. — The formation of fluid collections may occur with cancer of the ovary in three ways : 1st, cysts may develop in the structure of scirrhus and medullary cancers, as they do in that of sarcomata; 2d, a fluid or cystic tumor, primitively benign, may develop malignant material in its cyst wall ; 3d, a large me- dullary cancer may, by disintegration at its centre, form within itself a mass of fluid, or putrilage, as it has been termed. The condition may consist then in cancer complicating cystic degene- COMPOSITE TUMORS OF THE OVARY. 617 ration or in cystic degeneration complicating cancer. According to Scanzoni, the cancerous mass may develop in the tissue of the cyst walls and project either internally or externally, or it may grow from the walls by pediculated or sessile tumors filled with medullary material, which are soft, tumefied, and very vascular. In the same tumor both colloid degeneration and medullary can- cer may be met with. The ovarian limits do not always confine these fatal growths. At times they surpass them, and affect the peritoneum or other neighboring parts. This tendency to eccentric development ac- counts for the protuberances, the size of the fist, so often serving as means of diagnosis of ovarian cancer. The distinguishing characteristic of cystic cancer is its rapidity of development.. In a few months it often attains a size which sarcoma or even cystic degeneration would not attain for several years. The frequency of these and other ovarian tumors may be judged of from reference to some statistics accumulated by Scanzoni and which have been already referred to : — Number of cases examined 1 ....... 1823 " ovarian tumors among them .... 97 " cases submitted to autopsy 41 fluid tumors 25 " colloid tumors 9 " cysto-sarcomata 5 " cystic cancers ....... 2 Erom this it will be seen that the affection which we are now considering is rarer than sarcoma and very much rarer than colloid or alveolar degeneration. No treatment, either medical or surgical, holds out any hope of cure. If such tumors be removed, their return is inevitable, and the operation of ovariotomy is too grave a procedure to be adopted merely for the prospect of a few years of life depending upon its success. The prognosis of this disease is graver and the limit of life shorter than in any other affection of the ovaries. Alveolar or Colloid Degeneration. — For a long time the generally 1 To avoid confusion in the mind of any one examining the original table, I would remark that Prof. Scanzoni applies the term "composite" not as I do, but as I employ "multiple." 618 OVARIAN TUMORS. accepted opinion with reference to colloid (xow.a, " glue," and ei8o$, "like") or jelly-like tumors was that they were of cancerous nature, but both in their minute structure and in their clinical features they are so far removed from true malignant disease that the belief is becoming very prevalent that they are not of that character. This view is now adopted by Drs. Farre, Gr. Hewitt, Kiwisch, Collis, 1 Becquerel, and most of the more recent writers upon the subject. In speaking of ovarian colloid tumors Dr. Hewitt remarks: "The latter designation (colloid cancer) is not a good one, for an attentive consideration of the facts leads to the conclusion that the affection is not cancer at all." M. Becquerel 2 seems to have placed the question in its proper light when he says, " Several diseases have been confounded under the indefinite name of colloid cysts; it is therefore essential, before advancing, to distinguish these different varieties. We shall now endeavor to do this after them (Yirchow and Scanzoni), previously remark- ing that under the name of colloid matter some have not at all intended to signify a cancerous product, while others have assigned it such an origin." Yirchow 3 evidently alludes to this fact when, in speaking of the difference between the form and nature of growths, he says, "You may therefore say, colloid cancer, colloid sarcoma, colloid fibroma. Here colloid means nothing more than jelly-like." He then goes on to remark that no confusion should exist between such growths as colloid cancer and colloid degene- ration of the thyroid gland as to pathological significance. Yirchow's description of the condition is thus quoted by Becquerel: "Small pouches, which are filled with gelatinous matter and whose walls are lined by a layer of epithelium, are found in the parenchyma of the ovary. These vesicles develop in every direction, but more especially at the periphery of the ovaries where they form masses of irregular shape. Some of them are isolated, while others are grouped together in the follow- ing manner. The walls of these vesicles disappear by atrophy of cellular tissue, when they are only formed by their epithelial lining. This becomes infiltrated with fat, and the walls forming the connection are easily ruptured. Those of the large cyst re- main intact and become hypertrophied. * * * In other cases 1 Op. eit., p 205. 2 op. cit., p. 226. 3 Cellular Pathol., p. 512. COMPOSITE TUMORS OF THE OVARY. 619 the vesicles rupture by over-distension ; from this results hemor- rhage, and blood is found in the vesicles." Kiwisch describes it as a breaking up of the stroma of the ovaries into the cellular cavities, alveoli, closely aggregated together and inclosing a jelly- like, semifluid mass. By others it has been likened to a sponge or a honeycomb. It is safe to conclude, from the present aspect of the subject, that, while colloid deposit may coexist in the ovary with ence- phaloid cancer, the peculiar breaking up of the stroma into alve- oli which we have just described, is not a malignant affection, but one which seems to constitute a connecting link between cancer and the benign degenerations. Alveolar degeneration frequently complicates cancer, sarcoma, and fluid tumors. "We have observed," says Kiwisch, "alveolar degeneration of considerable extent remain in the system for a long series of years, without any remarkable bad effects." Nevertheless the prognosis of the affection is always grave. Should a large cyst be discovered anywhere, and the size of the tumor require diminution on account of interference with surrounding parts, paracentesis may be practised ; but in a pure alveolar tumor, no such accumulation will be discovered. Under these circumstances, if the disease steadily advance and the con- stitution suffer in consequence, we should be encouraged by recognition of its non-malignant nature to practise ovariotomy. CHAPTEE XLV. DISEASES OF THE FALLOPIAN TUBES. The following diseases of the Fallopian tubes will now be con- sidered : — Inflammation; Stricture ; Distension ; Displacements. Inflammation of the tubes, or salpingitis, consists in inflamma- tion of their mucous membrane, and may be either acute or chronic. The acute variety generally results from puerperal endome- tritis, or from gonorrhoea, which has extended through the uterine mucous membrane. I have twice seen this disease almost destroy life by attacking the uterine mucous membrane, and subsequently producing pelvic peritonitis, doubtless reaching the peritoneum by traversing the tubes. Chronic salpingitis is one of the sources of uterine leucorrhoea, and often a cause of tubal obstruction and dilatation. The great danger of both varieties is pelvic peritonitis, which may spread and destroy life. This arises from escape of the con- tents of the inflamed tubes into the peritoneum. Of the symptoms very little can be said. The chronic variety may continue for years, and result in dilatation of the tube with no symptoms which arrest attention ; while the acute form so quickly produces local peritonitis, that its symptoms are lost in those of that affection. No special treatment is applicable to it except the adoption of means to prevent peritonitis, as rest, opiates, leeches, and strict avoidance of sexual intercourse. The great obscurity of the diagnosis of tubal diseases renders the subject one upon which it is not profitable to speak further, although as a pathological study it is one of great interest. STRICTURE — DISTENSION. 621 Stricture. — The Fallopian tubes, which are often imperfect or wanting when the uterus is absent or undeveloped, may, even after full development, be affected by stricture. The condition may be produced by these causes : — Calcific deposit ; Senile atrophy ; Salpingitis ; Pelvic peritonitis; Tubercle or fibrous tumors. Partial obliteration of the canal results in sterility if it affect both sides simultaneously, and sometimes, by causing the accumu- lation of fluids, it produces tubal dropsy. It is not rare for rup- ture of the tubes and consequent hematocele and peritonitis to result from imprisonment of menstrual fluid in them. M. Puech analyzed two hundred and fifty-eight cases of congenital atresia of the genital organs, and found that in fifteen cases the Fallo- pian tubes were dilated, and in five were ruptured. The condi- tion is rather a study for the pathological anatomist than for the gynecologist, for it can neither be diagnosticated nor relieved by treatment. Distension. — The tubes may be distended by accumulation of mucus, pus, menstrual blood, or a muco-serous material secreted Fig. 224. Tubal dropsy. (Boivin and Duges.) by the altered mucous membrane accompanying great and pro- This condition owns invariably as its moving- longed distension. 622 DISEASES OF THE FALLOPIAN TUBES. cause, stricture, which prevents the tube from emptying itself into the uterus. When very great distension takes place, the accumulated fluid either forces its way out of the uterine ex- tremity, constituting the profluent dropsy of Eokitansky, or passes out of the fimbriated extremity into the peritoneum, or a rupture of the tube occurs. Such an accumulation may produce a tumor equal in size to the head of a child of ten years, and some say even much larger, though there is doubt as to the authenticity of the latter cases. Fig. 225. Tubal dropsy. (Simpson.) The diagnosis in advanced cases, where, for example, the tumor has developed to the extent just mentioned, is difficult and often impossible. Sometimes, however, it may be made by the follow- ing means; an elongated, fluctuating, movable tumor is felt in the retro-uterine space a little to one side; in its outlines the tumor is wavy, and it can be separated from the uterus. Scanzoni quotes Kiwisch as declaring that, in such cases, the presence at the side of the fundus of a mammillated, elastic, and elongated tumor, justifies the diagnosis of tubal dropsy, but he differs with him, and regards the positive diagnosis as impossible. In case the diagnosis can be arrived at, the most appropriate treatment would consist in tapping per vaginam. Displacements. — The tubes may pass with hernial contents into the inguinal or crural openings, and, in case of inversion of the uterus, may descend into the cavity of the displaced organ. It is generally in company with the ovary that the tube leaves its place, but at times it descends alone. Dr. Scholler 1 reports an 1 Courty, op. cit. OTHER DISEASES OF THE TUBES. 623 instance in which, in a child who died twenty days after birth, a tumor was discovered which extended from the inguinal region to the right labium, and contained the Fallopian tube, which was non-adherent. A crural hernia of the tube alone which ended fatally is likewise recorded by M. Berard. Prof. Kokitansky, 1 and Dr. Turner of Scotland, have both re- cently drawn attention to severance of the tube from the ovary by traction from increased weight of the latter or from false membranes. The former cites twelve instances in support of the fact. Other Diseases of the Tubes. — In addition to these diseases the tubes are sometimes affected by cancer, tubercle, fibrous tumors, abscess, and accumulation of blood in their canals from hemor- rhage from the mucous membrane. There is so strong an analogy between these disorders and the same in other organs, that it is not deemed necessary to enter upon their consideration. 1 Sydenham Soc. Year-Book, l c 61. CHAPTER XLYI. CHLOROSIS. Definition and Synonymes. — This disease is probably a neurosis of the ganglionic system of nerves. Disordering the control which this system exerts over the functions of organic life, it produces, as symptoms of its existence, impoverishment of the blood, constipation, dyspepsia, palpitation, and menstrual de- rangements and irregularities. Although it has been stated that it may occur in the male as well as the female; that it is sometimes met with in women who have passed the age of puberty, and as an exceptional occurrence has been known to affect young children, the ordinary period of its invasion is the time of puberty, when the dormant func- tions of the ovaries are being aroused, and the girl is rapidly passing into the state of womanhood. This fact has led many observers to suppose that it is dependent upon some derangement in ovulation and menstruation, but it is more probable that torpidity of the uterus and ovaries is, like the peculiar blood state which is so characteristic of the disorder, merely a symptom of functional disease in the sympathetic system of nerves. Chlorosis has been described under a variety of names, as, for example, Anaemia or Spansemia, a kindred disorder with which it has been commonly confounded by writers; Chloro-anasmia, Green Sickness, Cachexia Yirginum, Morbus Yirgineus, and many others. Frequency. — It is an affection of great frequency in all civi- lized and refined communities. The greater the tendency devel- oped by a society to luxurious and enervating habits the more frequently is it encountered. Thus in large cities and the higher walks of life it is of much more frequent occurrence than in country places, and among the lower classes, where a more natu- ral and healthy existence is passed. History. — The characteristic feature of the disorder being PATHOLOGY AND SYMPTOMS. 625 readily recognizable, and of such a nature as to excite not only attention but anxiety, it has, from the remotest times, received some attention at the hands of physicians. Although, however, allusions to it will be found even in the writings of Hippocrates, Valleix declares that F. Hoffman, 1 who wrote in the middle of the eighteenth century, was the first who ever gave a full and satisfactory description of it. Sydenham, 2 who flourished in the middle of the seventeenth century, describes " The Green Sick- ness," but disposes of the whole subject, symptomatology and treatment, in exactly ten lines. During the last century the subject has attracted great attention, and, thanks to the inves- tigations of Andral, Becquerel, Eodier, and many others, our knowledge of the pathology of the condition is fully equal to that of other diseases. Pathology and Symptoms. — Before approaching this part of our subject special allusion must be made to a fact which has been already mentioned, that chlorosis and anaemia are frequently treated of as identical affections under the latter appellation. The pathological condition found to exist upon chemical analysis of the blood in the two diseases is often the same, a diminished amount of red corpuscles and in time diminution of all the solid elements of the blood. Many of their symptoms are also the same, as, for example, pallor, palpitation of the heart, dyspnoea, the exist- ence of a loud systolic cardiac murmur, &c. In spite of these facts it will be noticed that even those writers who treat of the two conditions under the name of anaemia are forced to note the cir- cumstance that there is a peculiar form of the disease which occurs about the period of puberty, to females only, and which has characteristics not displayed under other circumstances. Prof. Flint, 3 in treating of the etiology of anaemia, says, " The ob- vious causes may be arranged into the three classes just stated, viz : First, causes which involve an actual loss of red globules, as in hemorrhages ; Second, causes involving a defective supply of material for assimilation ; Third, causes which occasion expendi- ture of those constituents of the liquor sanguinis on which the production of red globules is dependent. 1 De Morb. Virgin. 2 Syd. Soc Ed. of Works, vol. ii. p. 2S8. 3 Flint's Practice of Med., 2d ed., p. 62. 40 626 CHLOROSIS. "The causes are not always apparent. Anaemia is apt to occur in females at or near the age of puberty, when there has been no loss of blood, no deficiency in alimentary supplies, and no unu- sual expenditure of blood plasma. Under these circumstances it constitutes the affection to which the name Chlorosis was applied before the anaemic condition was fully understood. If the name be retained, it should be considered as denoting anaemia occur- ring under the circumstances just stated." I have introduced this quotation not merely for the purpose of citing the views of the eminent author from whom it is drawn, but as illustrative of the position of those who look upon these disor- ders as identical as to pathology, and differing only in the period of life at which they are developed. As I proceed with the de- scription of the symptoms, course, and treatment of chlorosis, I hope to be able to justify myself in following the example of Becquerel, Yalleix, and many other French writers in looking upon them as essentially and entirely different in nature. Several French pathologists, under the lead of Becquerel, of Paris, have of late years advanced the view that chlorosis differs from anaemia mainly in this ; that the latter is merely a blood state, while the former is a disease'of the nervous system which may or may not produce the latter. The most striking differences between the two diseases may be thus contrasted: — AX^MIA I CHLOEOSIS Is merely impoverishment of the Is a disease of the nervous system, blood from want of nourishment, from I and may occur with or without the pro- some drain upon the system, or from duction of its most common symptom, some poison in the blood. ; anaemia. Can usually be accounted for by dis- j Cannot usually be accounted for by covery of some special cause. discovery of special cause. Occurs at all periods of life, to men, ; Occurs in true type only to girls about women, and children. ; time of puberty. Is readily curable by removal of '■ Is affected favorably only by remedies cause, good diet and administration of which act upon the nervous system, as iron. alteratives and tonics. Is always characterized by impover- , Sometimes exists without impoverish- ishment of blood. ment of the blood. Produces a puffy and pale appear- Produces a light green color, ance. Does not produce sadness or great Produces sadness and nervous dis- nervous disquietude. quietude. PATHOLOGY AND SYMPTOMS. 627 Is unaccompanied by visceral neu- ralgia. Fibrin diminished in blood. No special affection of solar plexus of nerves. Iron always does good. Symptoms of ovulation will be no- ticed without menstruation. The cause of the disease being re- moved, patient will rapidly improve. CHLOROSIS Is constantly accompanied by visceral neuralgia. Fibrin increased in blood. Pain, uneasiness or distress commonly referred to solar plexus. Iron often increases discomfort. Neither symptoms of ovulation nor menstruation will be observed. If supposed cause be removed, patient will often improve but slowly. The period of development by which the girl becomes a woman and the boy changes to the man is at once one of the most striking, important, and interesting physiological processes which take place in the animal economy. The special altera- tions occurring at this time do not need enumeration here. All that it will be necessary to say is that all this change is coinci- dent with the development of the ovaries in the one case and the testicles in the other, so that the former set of organs becomes capable of casting off matured ovules, and the latter of secreting fructifying zoosperms. If any accident occur so that growth and development do not take place in ovaries or testicles, the result is that the girl never becomes a fully developed woman, and the boy grows up a shrill-voiced, beardless, effeminate eunuch. In the lower order of animals, and more especially in the males of many species, interference, by castration, with development at puberty, gives us still more remarkable results. If two colts be bred in the same stable and from the same stock, and one be castrated and the other left entire, the former will develop into the gentle, slender gelding, while the latter will grow into the strong-necked, majestic, and vicious stallion. A still more strik- ing contrast will be found to exist between the ox and the bull. This process of development, which we term puberty, is under the control of the ganglionic, or sympathetic system of nerves, which, at that time, must necessarily be in a condition of exces- sive susceptibility. It is probable that in that state of exalta- tion, it is, in the female, often affected by a functional derange- ment which creates the collection of symptoms to which we give the name of Chlorosis. I say it is probable, for I freely confess that the theory which I have here stated is merely an hypothe- sis suggested by clinical observation of such cases, and not supported by post-mortem or other physical evidence. 628 CHLOROSIS. To state this view in other words ; at the critical age of puberty, when a series of important and peculiar changes are being effected through the instrumentality of the sympathetic system of nerves, this system seems, in the female, to be liable to a morbid influence, which, in great degree, paralyzes it, and impairs its functions. Sadness, nervousness, and irascibility mark its onset; then neu- ralgia develops itself in the limbs, the head, and the viscera; the appetite is impaired; digestion becomes weak, and dyspepsia, flatu- lence, and depraved tastes are encountered. The young girl craves the most unpalatable and innutritious substances, as, for example, chalk, clay, slate, and other articles of alkaline character ; while, at other times, the taste prompts her to consume acids, as vinegar, lemon -juice, pickled vegetables, &c. Usually the process of blood- making is soon disordered, and anaemia sets in, coincidently with amenorrhcea, constipation, palpitation of the heart, sensitiveness along the spine, distress in the solar plexus of nerves, coldness of the hands and feet, and irregular and excessive flushing of the face. Upon pressing along the spine, a point of great sensitiveness will usually be found near the seventh cervical vertebra, and others are often discovered above and below this. Auscultation reveals a loud basic systolic cardiac murmur, and along the arte- ries the bruit de souffle can be detected. It is not rare to find the sternum and clavicles very sensitive to pressure, as, likewise, the intercostal spaces. Most of these are symptoms which mark the effect of the disease upon the nervous system. The peculiar blood state usually engen- dered, has, however, received special attention, and been, by many excellent authorities, regarded as the main element of the disease. Becquerel, 1 in his excellent article upon this subject, thus sums up the changes which are ordinarily effected in this fluid. 1st. The water of the blood is notably augmented, which diminishes the density of this fluid. The amount is represented by the same figures as in anaemia. 2d. The proportion of the globules is diminished. 3d. The fibrin is usually found to be normal in amount. 4th. The fatty and saline constituents retain their normal pro- portions, as does usually the albumen. In very severe and obsti- nate cases, however, the albumen is diminished, when we see drop- sical swellings as a result. » Mai de l'Uterus, t. ii. p. 490. causes. 629 Mode of Development. — Chlorosis generally develops itself very insidiously. In a girl who has previously been in good health, languor, sadness, and aversion to company usually first attract attention. These are followed by palpitation of the heart after exertion, scantiness of the menstrual flow, and a characteristic pale or greenish complexion. Alarm is ordinarily excited by these evidences of approaching disease, and careful scrutiny soon discovers others which have been already alluded to. According to my observation, the first suspicion which usually takes posses- sion of the minds of the friends of the patient, is, that pulmonary consumption, or heart disease, is about to develop itself. In some cases, an effusion of serum takes place into the areolar tissue of the body, into the pleural cavities, or into the peritoneum, when even the medical adviser is deceived and fears that dropsy from Bright's disease, cardiac disease, or chronic peritonitis, is about to show itself. If an error in diagnosis lead to neglect of appropriate treatment, or if, still worse, the symptoms of the disease be mistaken for those of plethora, as I have more than once known them to be, the gravest features of the affection will show themselves, and a most critical condition be established. Causes. — The predisposing causes are well known, sex and age ; but those which absolutely excite the disorder, are not so easily ascertained. The causes which are here recorded, are probably those which most frequently prove active; but it must be specially stated that, in the majority of cases, no cause whatever can be assigned for the disease. Great grief, or mental anxiety ; Depressing home influences ; Great fear suddenly excited ; Deprivation of pure air, exercise, and light ; Disappointment in love ; Erotic excitement without gratification ; Prolonged watching and loss of sleep ; Nostalgia ; Excessive mental labor. The most marked instances of the disease which have fallen under my observation, have occurred under the influence of great grief for the loss of a relative, disappointment in love, or home- sickness. Dr. W. H. Hammond, in an interesting article upon 630 CHLOROSIS. this subject published in the Psychological Journal for July, 1868, records a striking instance arising from sudden and extreme fear. Before leaving this part of the subject, it is proper that I should state that Becquerel, who has done more for the advancement of our knowledge of this interesting affection than any other modern authority, admits these causes with considerable reserve. They " can, if they do not produce, at least favor the development of chlorosis," says he in reference to most of those causes which I have recorded. Varieties. — I know of no good reason for dividing chlorosis into varieties. In one set of cases, certain symptoms are predominant ; in others, a different set of signs assume the ascendency. It may, however, prove useful to the reader to lay before him the six forms which have been adopted by Becquerel. They are as follows: — 1st form, simple chlorosis ; 2d form, chlorosis with predominance of cephalalgia ; 3d " " " " " dyspnoea and palpitation ; 4th " " " " " gastralgia; 5th " " " " " menstrual disorder ; 6th " " " " " general feebleness. Differentiation. — An aggravated case of this disease may be con- founded with anaemia, cardiac disease, tubercular pleuritis or peritonitis, or even with the first stage of tubercular phthisis. From all these a careful and intelligent search for the evidences of organic lesions will usually distinguish it in time; but without watching the progress of the case for a considerable period, it is often impossible to decide as to the diagnosis. The physician is often deterred from arriving at a positive conclusion as to the existence of chlorosis, by imagining that the disorder is identical with anaemia. Drawing from the veins of the patient a drop of blood, he puts it under the microscope, and to his surprise finds it to contain red globules in normal amount, and concludes that his suspicions were incorrect. It is a well-known fact that the disease may exist in aggravated form with little or no blood change. Complications. — Chlorosis may be complicated by hysteria, hypochondriasis, hypertrophy of the heart, and tuberculosis. In one case which I now have under treatment, chlorosis developed TREATMENT. 631 itself with most unmistakable symptoms, and then violent chorea showed itself, which has lasted for five months. Prognosis. — Unless some serious disorder complicate it, the prognosis is always good ; but the course and duration of the disease cannot be predicted. If all the surroundings of the patient, both social and physical, be altered, and all causative influences removed, recovery will usually be rapid and complete; but if these circumstances cannot be brought about, the affection may last for an indefinite time. Treatment. — Treatment should consist, not in fruitless attempts to overcome one, or even two of the results of the disease, amenorrhcea and anaemia, for example, but in a systematic effort to accomplish these three ends: — 1st. To remove the cause of the disorder ; 2d. To cure the neurosis itself; 3d. To repair the damage which it has effected in the system. If any of the causes which have been enumerated be found to exist, it should as far as possible be promptly and entirely removed. In many cases the cause cannot be discovered, and in many, if discovered, cannot be removed ; but if search be always made for it, a sufficient number of successes will occur to reward the effort. Even where the special cause cannot be detected, recovery may be accomplished by removing the patient from home, and sending her to a distance from objects and people connected with the sad- ness and depression attendant upon the inception of the attack. A visit to some agreeable watering place or lively country resort, if the patient live in a city ; or to some large and busy city, if she inhabit the country, will often do more in the way of cure, than can be effected by any amount or kind of medication. A sea- voyage and visit to a foreign country will often produce a most excellent result, and sometimes cause complete cure. Well-regulated exercise in the open air is of great importance. Horseback exercise, rowing, bowling, walking, playing at ten pins, &c, constitute some of our best nervous tonics. Sea-bathing, and more particularly surf-bathing, is very useful, and should, when attainable, be faithfully tried. All of these are, however, inferior in value to cheerful, congenial, and new society. This accomplishes a change in the nervous system which nothing else so surely effects. 632 CHLOROSIS. In the mean time, nervous tonics of medicinal kind should be freely given. The best of these are the preparations of arsenic, strychnine, and quinine. Should the patient bear it well, the con- tinuous electric current should be employed, and general electri- zation, as practised by Drs. Beard and Kockwell, of this city, often proves very beneficial. As anaemia is usually a complication of the disease, iron is generally indicated. Some of the best preparations are, the sac- charated carbonate, iron by hydrogen, and the bitter wine of iron. A very excellent combination is offered by the following prescrip- tion : — R. — Ferri vini amari, §vijss ; Tr. nueis vomicae, ^iv ; Solut. potassse arsen. 5ij- — ML S. — A dessertspoonful, in a claret-glassful of water just after each meal. The diet should be extremely nutritious, consisting of meat, milk, animal broths, eggs, and vegetables, with wine, whiskey, or malt liquors, if these appear necessary on account of great ex- haustion. INDEX. Abdominal supporters, 151 in chronic corporeal metritis, 267 in anteversion, 318 Abortion, induction of, iu gelation to ute- rine disease, 58 Abscess, pelvic, definition of, 394 pathology of, 394 causes of, 394 symptoms of, 394 physical signs of, 394 course, duration, and termina- tion of, 395 differentiation of, 395 prognosis of, 396 treatment of, 396 propriety of opening, 397 time for opening, 398 point for opening, 398 methods of evacuating, 398 means for closure of sac of, 399 ovarian, 538 causes of, 538 symptoms of, 539 differentiation of, 539 treatment of, 540 Air pessary, 36, 151, 308, 319 Amenorrhcea, definition of, 493 frequency and varieties of, 493 pathology of, 493 influences causing, 494 causes of, 494 differentiation of, 496 treatment of, 496 cupping the cervix in, 499 galvanic pessary for, 500 Ansesthesia in physical diagnosis, 66 Anteflexion of uterus, definition and fre- quency, 330 period at which it is most frequent, 331 varieties of, 331 pathology of, 331 causes of, 332 symptoms of, 333 diagnosis of, 333 prognosis of, 334 treatment of, 334 means for preventing recurrence of, 334 Anteflexion of uterus — stem-pessaries in treatment of, 335 means for obviating, 337 complications of, 337 operation for, 338 Anteversion of uterus, definition, and fre- quency of, 312 causes of, 313 symptoms of, 314 course, duration, and termination of, 315 varieties of, 315 degrees of, 315 diagnosis of, 315 differentiation of, 316 prognosis of, 316 treatment of, 316 means for reduction of, 317 means for retaining uterus in normal position after reduction of, 318 pessaries in, 319 elytrorrhaphy in, 319 Ascent of uterus, 296 Atresia of vagina, 138 history, pathology, and varieties of, 138: causes of, 139 symptoms of, 139 differentiation and prognosis of, 140 treatment of, 141 different modes of operating for, 141 period for operating for, 143 Auscultation, in diagnosis of uterine dis- ease, 86 B road ligaments, cysts of, 603 varieties of, 603 dropsy of, 604 Wolffian cysts of, 605 areolar cysts of, 606 prognosis and treatment of, 60S Cancer of uterus, 439 forms and varieties of, 439 definition and synonvmes of, 439 frequency of, 439 history of, 440 differentiation of, 441 pathology of, 441 634 INDEX. Cancer of uterus — tissue first affected, 442 varieties of, 442 scirrhus, 442 causes of, 443 symptoms of 443 physical signs, 444 ulcerative stage of, 445 differentiation, 445 errors in diagnosis of, 446 extreme degree of ulceration of, 446 course and duration of, 446 complications of, 447 treatment of, 447 checking hemorrhage of, 447 opium in, 418 epithelial, 452 varieties of, 452 differences between epithelial and true cancer, 452 ulcerating, 453 frequency of, 453 pathology of, 454 course and termination of, 455 symptoms of, 455 physical signs of, 455 differentiation of, 456 treatment of, 456 vegetating, 457 of ovaries, 613 Cancroid tumors, of uterus, 449 varieties of, 449 Catheter, Sims's, for urinary fistulse, 174 Cauliflower excrescence of uterus, defini- tion and synonymes of, 457 frequency of, 457 anatomy of, 458 pathology of, 458 site of, 459 symptoms of, 460 physical signs of, 461 differentiation of, 461 prognosis of, 461 treatment of, 461 Cellulitis, peri-uterine, 364 history of, 364 definition, synonymes, and frequency of, 365 anatomy of, 365 pathology of, 366 stages of, 366 parts affected in, 367 seat of purulent collection in, 368 complications of, 369 course, duration, and termination of, 369 course of, after suppuration, 370 mode of escape of pus in, 370 prognosis of, 370 causes of, 371 symptoms of, 372 Cellulitis — symptoms of chronic, 372 physical signs of, 373 differentiation of, 374 consequences of, 374 treatment of, 375 leeches in, 375 opiates in, 375 blisters in, 376 iodide and bromide of potassium in, 376 mercurials in, 376 warm douche in, 377 Cervix uteri, slitting of, in vesico-uterine fistulse, 184 in relation to vesico-utero-vagi- nal fistulse, 185 dividing line between body and. 200 leeches to, in acute metritis, 213 chronic inflammation of mucous mem- brane of, 214 frequency of, 215 normal anatomy of mucous mem- brane of, 215 glands of, 216 rugee of virgin, 217 villi of, 217 pathology of chronic endometri- tis of, 217 causes of chronic endometritis of, 218 symptoms of chronic endome- tritis of, 219 complications of chronic endo- metritis of, 219 physical signs of chronic endo- metritis of, 220 differentiation of chronic endo- metritis of, 221 emollient applications in chronic endometritis of, 224 alterative applications in chronic endometritis of, 224 dilatation of, by tents in chronic endometritis of, 224 cleansing of, in chronic endome- tritis of, 225 importance of cleansing, in chro- nic endometritis of, 225 mode of applying escharotics to in chronic endometritis of, 226 choice of alterative applications in chronic endometritis of, 226 medicated sponge-tents in treat- ment of chronic endometritis of, 230 resume of plan for applying caustics and alteratives to the canal of, in chronic endome- tritis of, 231 chronic metritis of, 232 INDEX. 635 Cervix uteri, chronic metritis of — condition of, in, 233 course and termination of, 233 pathology of, 233 differentiation of, 234 prognosis of, 234 complications of, 235 treatment of, 235 depletion of, in, 236 scarification of, in, 237 emollient and sedative applica- tions to, in, 238 vaginal injection to, in, 238 vaginal suppositories in, 240 alteratives to, in, 241 counter-irritation to, in, 242 mode of blistering the, in, 243 cauterization of, in, 243 caustic potash to. in, 244 method of applying the actual cautery to, in, 245 corporeal endometritis caused by inflammation of, 250 ulceration of, 272 varieties of, 272 granular ulcer of, 273 causes of, 273 eversion of, as a cause of, 275 operation for eversion of, 278 follicular ulcer of, 280 inflammatory ulcer of, 281 syphilitic ulcer of, 282 corroding ulcer of, 284 cancerous ulcer of, 284 division of posterior wall of, for relief of anteflexion of uterus, 338 polypi of, 433 epithelioma of, 459 obstruction or contraction of canal of, a cause of dysmenorrhoea, 478 treatment of constriction of, 480 Priestly's dilator for, in dysmenor- rhoea, 481 incision of, in dysmenorrhoea, 482 dry cupping of, in amenorrhoea, 499 leucorrhoea of, 503 abnormal shape of, a cause of ste- rility, 509 longitudinal hypertrophy of, 514 amputation of, 513 dangers of, 514 conditions demanding, 514 varieties of operations for, 514 method of performing, 515 by bistoury or scissors, 515 by e"craseur, 515 by galvano-caustic, 516 cases of latter, 518 Chlorosis definition and synonymes, 624 pathology and symptoms, 625 Chlorosis — comparison of symptoms, 626 mode of development, 629 causes, 629 varieties, 630 differentiation, 630 complications, 630 prognosis, 631 treatment, 631 Chorion, cystic degeneration of, 466 pathology of, 467 causes of, 467 symptoms of, 467 physical signs of, 467 differentiation of, 468 prognosis of, 468 treatment of, 468 Clitoris, anatomy of, 87 Coccyx, anatomical relations of, 109 Coccyodinia, 108 causes of, 110 symptoms of, 110 treatment of, 110 operation for, 111 Conception, prevention of, in relation to uterine disease, 58 Curette, Sims's, for removal of fungous growths in uterus, 492 Recamier's, 491 Cystocele, 148 as a complication of prolapsus uteri, 300 Cysts, ovarian, 542 pathology of, 542 varieties of, 543 unilocular, 543 multilocular, 544 multiple, 544 fluid contained in latter, 544 size of, 545 causes of, 545 symptoms of, 546 physical signs of, 546 questions for aid in diagnosti- cating, 547 affections simulating, 548 differentiation between uterine fibroids and, 549 differentiation between ascites and, 550 diagnosis of multilocular, 552 natural history of, 553 prognosis of, 553 mortality of, 554 cause of fatal termination of, 555 treatment of, 555 tapping of, 556 mortality after, 557 advantages of, 556 indications for, 558 636 I^DEX. Cysts, tapping of — performed through the abdomi- nal walls, 528 through vaginal walls, 559 advantages of latter, 560 mode of performance through vaginal walls, 560 through rectum, 560 drainage of, 561 Kiwisch's method of, 563 Schnetter's method of, 563 West's method of, 564 trocars for, 564, 565 incision of, 566 results of, 567 treatment of sac after, 567 injection into sac after tapping, 568 partial excision of, 570 methods of latter, 571 pressure in, 572 removal of, 574 tapping after exposing, 589 Wells's trocar and canula for latter, 589 securing pedicle of, in, 590 Wells's clamp for securing pedi- cle of, 591 Storer's 594 Wolffian, of broad ligaments, 605 areolar, of broad ligaments, 606 Depressor, Sims's, 72 Diagnosis, means of physical, 66 vaginal touch in physical, 66 conjoined manipulation in physical,67 abdominal palpation in physical, 69 rectal touch in physical, 69 vesico-rectal exploration in physical, 70 speculum in physical, 70 Dilator, Sims's vaginal, in vaginismus, 126 Diseases resulting from pregnancy, 463 Displacements, of uterus, 287 history of, 287 views of Gynecologists of present day in regard to, 288 definition and synonymes of, 290 normal anatomy, 290 varieties of, 291 causes of, 292 influences favorable to, 292 as a cause of sterility, 508 of vagina, 144 of ovaries, 529 of Fallopian tubes, 622 Dress, improprieties of, in relation to ute- rine disease, 55 Dropsy, ovarian, 542 pathology of, 542 varieties of, 543 causes of, 545 symptoms of, 546 Dropsy, ovarian — physical signs of, 546 affections simulating, 548 differentiation between uterine fibroids and, 549 differentiation between ascites and, 550 prognosis of, 553 mortality of, 554 cause of fatality, 555 treatment of, 555 tapping in, 556 mortality after, 557 indications for, 558 through abdominal walls, 558 trocar for performance of latter, 558 through vaginal walls, 559 advantages of latter, 560 mode of performance through vaginal walls, 560 through rectum, 560 drainage of cyst in, 561 Kiwisch's method of, in, 563 Schnetter's method of, in 563 West's method of, in, 564 trocars for, 564, 565 incision of cyst in, 566 table of results of, 567 treatment of sac after, 567 injection into sac after tapping in, 568 tubal, 621 diagnosis of, 622 Dysmenorrhea, definition of, 472 pathology of, 472 varieties of, 473 seat of pain in, 473 neuralgic, 473 causes of, 474 symptoms of, 474 differentiation of, 474 prognosis of, 475 treatment of, 475 congestive, 476 causes of, 476 symptoms of, 476 differentiation of, 476 prognosis and treatment of, 476 inflammatory, 477 causes of, 477 symptoms and differentiation of, 477 prognosis, 477 treatment of, 477 obstructive, 478 pathology of, 478 causes of, 478 symptoms of, 479 steps of development of, 479 differentiation of, 480 prognosis of, 480 INDEX. 637 Dysmenorrhoea, obstructive — treatment of, when dependent on cervical constriction, 480 dependent on flexion or ver- sion of uterus, 484 dependent on vaginal stric- ture, 485 dependent on polypi, fib- roids,or obturator hymen, 485 membranous, 485 symptoms of, 486 prognosis and treatment of, 486 Elytrorrhaphy, 307 Sims's operation of, 310 Emmet's operation of, 311 Endometritis, acute, 205 frequency of, 205 causes of, 205 symptoms of, 206 physical signs of, 207 pathology of, 207 course, duration, and termination of, 207 prognosis of, 208 treatment of, 208 chronic cervical, 214 definition of, 214 pathology of, 217 causes of, 218 symptoms of, 219 complications of, 219 physical signs of, 220 differentiation of, 221 course, duration, and termination of, 222 prognosis of, 222 treatment of, 222 general regimen in, 222 emollient applications in, 224 alterative applications in, 224 dilatation of cervix by tents in, 224 cleansing cervix in, 225 importance of cleansing cervix in, 225 mode of applying escharotics to cervix in, 226 choice of alterative applications in, 226 medicated sponge tents in, 230 chronic corporeal, 248 frequency of, 248 pathology of, 249 causes of, 250 obstruction to escape of men- strual blood, as a cause of, 250 parturient process a frequent source of, 250 inflammation of the cervix some- times excites, 251 Endometritis, chronic corporeal — sexual intercourse as a cause of, 251 symptoms of, 252 physical signs of, 254 pathology of, 255 prognosis of, 255 contrast between favorable and unfavorable symptoms of, 256 complications of, 256 treatment of, 256 alterative applications in, 257 methods of cauterizing cavity of uterus in, 257 caustics which may be employed in, 258 ointments in, 259 mode of introducing latter, 259 lunar caustic in, 259 injections into cavity of uterus in, 260 mode of using latter, 260 as a cause of sterility, 508 Endoscope, 85 Enterocele, 149 Epithelial cancer of uterus, 452 Epithelioma of uterus, differences between cancer and, 452 varieties of, 452 ulcerating, 453 frequency of, 453 pathology of, 454 course, termination, and prog- nosis of, 455 symptoms of, 455 physical signs of, 455 differentiation of, 456 causes of, 456 treatment of, 456 vegetating, 457 definition and synonymes of, 457 frequency of, 457 anatomy of, 458 pathology of, 458 section of, 459 site of, 459 causes of, 460 symptoms of, 460 physical signs of, 461 differentiation of, 461 prognosis of, 461 treatment of, 461 Examination, management of patient dur- ing physical, 65 Exploration, vesico-rectal, in physical diagnosis, 70 Exploring needle, 85 Fallopian tubes, diseases of, 620 inflammation of, 620 stricture of, 621 displacements of, 622 638 INDEX. Fallopian tubes — distension of, 621 other diseases of, 623 Fibrous tumors, 412. (See Tumors.) Fistulge of female genital organs, 154 varieties of, 154 urinary, 154 vesico-vaginal, 155 urethro-vaginal, 155 vesico-uterine, 155 vesico-utero-vaginal, 155 causes of, 156 symptoms of, 159 physical signs of, 160 complications of, 160 prognosis of, 160 history of, 161 Sims's discoveries in treatment of, 163 Gosset's procedure in the treat- ment of, 164 Metzler's method in treatment of, 165 means for obtaining a natural cure of, 167 treatment of, 167 cauterization in, 167 suture in, 168 Sims's operation for, 168 paring edges of, 169 passing sutures in, 171 time for removal of sutures in, 175 Bozeman's operation for, 177 Mastin's operation for, 180 elytroplasty for cure of, 181 closure of vagina for cure of, 182 requiring special treatment, 183 vesico-uterine, 184 vesico-utero-vaginal, 184 •with extensive destruction of base of bladder, 185 fecal, 188 varieties of, 188 causes of, 188 symptoms of, 189 physical signs of, 189 examination for, 189 prognosis of, 189 treatment of, 190 entero-vaginal, 191 simple vaginal, 191 peritoneo- vaginal, 191 perineo-vaginal, 192 blind vaginal, 192 Flexions of uterus, 330 anteflexion, 330 retroflexion, 340 lateroflexion, 344 compound, 344 frequency of the different varieties of, 345 Flexions of uterus — as a cause of sterility, 509 Gastrotomy, 427 propriety of the operation of, 427 percentage of deaths and recoveries in, 429 causes of fatal termination in, 430 Genital organs, diagnosis of disease of, 62 rational signs of disease of, 63 fistulge of, 154 varieties of, 154 Gland, inflammation of vulvo-vaginal, 93 anatomy of vulvo-vaginal, 93 causes of inflammation of vulvo-vagi- nal, 94 symptoms of inflammation of vulvo- vaginal, 94 of the cervix uteri, 216 Gonorrhoea, 132 pathology of, 132 causes of, 133 symptoms of, 133 physical signs of, 133 differentiation of, 134 complications of, 134 Hematocele, pudendal, 99 history of, 99 pathology of, 100 causes of, 100 symptoms of, 100 differentiation of, 101 prognosis and treatment of, 101 pelvic, definition and synonyrnes of, 400 history of, 400 pathology of, 401 sources of hemorrhage in, 401 causes of, 403 varieties of, 403 sub-peritoneal, 404 peritoneal, 404 symptoms of, 405 physical signs of, 406 differentiation of, 407 course, duration, and termination of, 408 prognosis of, 408 treatment of, 408 surgical treatment of, 409 operation for, 410 medical treatment of, 411 Hemorrhage, pudendal, 98 causes of, 98 treatment of, 99 methods of checking, in inversion of uterus, 357 sources of, in pelvic hematocele, 401 Hernia, pudendal, 102 definition of, 102 INDEX. 139 Hernia, pudendal — symptoms of, 102 treatment of, 103 vaginal, 148 vesico, 148 recto, 149 entero, 149 treatment of, 150 Hydatids of uterus, definition of, 466 pathology of, 467 symptoms of, 467 physical signs of, 467 differentiation of, 468 prognosis of, 468 treatment of, 468 Hymen, anatomy of, 88 Hysterotome, Simpson's, 482 Stohlman's, 482 White's, 484 Hysterotomy, cervical, for dysmenorrhoea, 483 Inflammation, of vulva, 88 of vulvo-vaginal gland, 93 phlegmonous, of labia majora, 96 of vagina, 130 of the uterus, 193 varieties of uterine, 198 acute, of mucous membrane of ute- rus, 205 of parenchyma of uterus, 209 chronic, of the cervix uteri, 214, 232 of the cavity of uterus, 248, 261 of ovaries and uterus a cause of peri-uterine cellulitis, 371 of ovaries, 530 of Fallopian tubes, 620 Inversion of uterus, definition of, 346 varieties of, 346 pathology of, 347 mechanism of, 347 causes of, 348 symptoms of, 351 physical signs of, 351 differentiation between polypus and, 352 differentiation between fibroid tumors and, 352 course, duration, and termination of, 352 prognosis of, 353 treatment of, 353 methods of reduction of, 353 methods of checking hemorrhage in, 357 methods of amputating in, 358 objections to amputation in, 358 statistics of amputation in, 360 Labia majora, anatomy of, 87 minora, anatomy of, 87 phlegmonous inflammation of, 96 Labia majora — symptoms of phlegmonous inflamma- tion of, 96 treatment of phlegmonous inflamma- tion of, 97 Lateroflexion, 344 treatment of, 344 Leucorrhoea, definition of, 501 history of, 501 pathology of, 502 varieties of, 502 microscopical appearance of, 503, 504 characteristics of, 503 causes of, 504 results of, 505 treatment of, 505 Manipulation, conjoined, in physical diag- nosis, 67 practice of conjoined, 68 Marriage, with existing uterine disease, 59 Menorrhagia, definition of, 487 pathology of, 487 causes of, 487 differentiation of, 489 prognosis of, 490 results of, 490 palliative treatment of, 490 curative treatment of, 491 empirical treatment of, 492 Menstruation, imprudence during, in re- lation to uterine disease, 57 sudden suppression of, a cause of acute metritis, 210 disordered, a symptom of corporeal endometritis, 250 imprudence during, a cause of pelvic peritonitis, 384 excessive, 487 absence of, 493 excitants of, in amenorrhoea, 497 Metritis, acute, 209 frequency of, 209 causes of, 210 symptoms of, 211 physical signs of, 211 pathology of, 212 treatment of, 212 chronic cervical, 232 causes of, 232 symptoms of, 232 physical signs of, 233 pathology, 233 differentiation of, 234 prognosis, 234 complications of, 235 treatment of, 235 depletion in, 236 scarification of cervix in, 237 cupping of cervix in, 237 emollient and sedative applica- tions in, 238 6±0 INDEX. Metritis, chronic cervical — vaginal injections in, 238 vaginal suppositories in, 240 why the two latter are beneficial in, 241 alteratives in, 241 counter-irritation in, 242 mode of blistering the cervix in, 242 cauterizing the cervix in, 243 caustic potash to the cervix, in, 244 method of applying the actual cautery to the cervix in, 245 chronic corporeal, 261 frequency of, 261 causes of, 261 symptoms of, 262 physical signs of, 263 pathology of, 263 differentiation of, 263 prognosis of, 265 treatment of, 265 alteratives in treatment of, 269 mode of using latter in, 269 counter-irritation in, 270 manner of applying latter in, 270 Metrorrhagia, definition of, 487 pathology of, 487 causes of, 487 differentiation of, 489 prognosis of, 490 results of, 490 palliative treatment of, 490 curative treatment of, 491 empirical treatment of, 492 Moles of uterus, 463 definition of, 463 history of, 464 pathology of, 464 causes of, 465 symptoms of, 465 physical signs of, 465 differentiation of, 465 prognosis and treatment of, 466 "YTervous system, excessive development 1M of in relation to uterine disease, 54 peration, time for, for ruptured peri neum, 116 Baker Brown's, for ruptured peri- i neum, 118 Sims's, for vaginismus, 126 Emmet's improvement on Sims's, for vaginismus, 127 Burns', for vaginismus, 127 Simpson's modification of Burns', for vaginismus, 128 Gosset's, for urinary fistula?, 164 Sims's, for urinary fistulse, 168 Operation — Sims's, for prolapsus uteri, 310 Emmet's, for prolapsus uteri, 311 for anteflexion of uterus, 338 for evacuation of pelvic abscesses, 398 of hysterotomy, 483 for amputation of neck of uterus, 513 of paracentesis for ovarian dropsy, 566 of ovariotomy, 586 Os uteri, condition of in chronic cervical endometritis, 220 plugging of, in applying leeches to the cervix, 236 plugging of, in applying caustic pot- ash to cervix, 245 obstruction of, a cause of chronic corporeal endometritis, 250 dilatation of, a corroborative sign of chronic corporeal endometritis, 254 ulceration of, 272 Ovarian apoplexy, definition of, 528 symptoms of, 529 prognosis of, 529 treatment of, 529 Ovaries, diseases of, 519 anatomy of, 520 varieties of diseases of, 521 absence of, 522 imperfect development of, 523 treatment for latter, 524 atrophy of, 525 causes of, 525 treatment of, 526 hypertrophy of, 526 symptoms of, 527 treatment of, 528 apoplexy of, 528 symptoms of, 529 prognosis of, 529 treatment of, 529 displacement of, 529 treatment of, 530 inflammation of, 530 varieties of, 531 acute, 531 chronic, 537 treatment of, 536, 537 abscess of, 538 causes of, 538 symptoms of, 539 differentiation of, 540 treatment of, 540 tumors of, 540 hydatid cysts of, 540 ovarian cysts of, 542 pathology of, 542 varieties of, 543 size of, 543, 545 causes of, 545 symptoms of, 546 physical signs of, 546 INDEX. 6±1 Ovaries, ovarian cysts of — affections simulating, 548 differentiation between uterine fibroids and, 549 differentiation between ascites and, 550 character of, 550 prognosis of, 553 mortality from, 554 causes of fatal termination of, 555 treatment of, 555 tapping, 556 mortality after, 557 indications for, 558 performed through abdominal walls, 558 through vaginal walls, 559 advantages of latter, 560 mode of performance through va- ginal walls, 560 through rectum, 560 drainage of, 561 Kiwisch's method of, 563 Schnetter's method of, 563 West's method of, 564 trocars for, 564 incision of, 566 results of, 567 treatment of sac after, 567 injection into sac after tapping, 568 partial excision of, 570 methods of latter, 571 pressure of, 572 removal of, 574 solid tumors of, 609 varieties of, 609 histoid, 609 size of, 610 treatment of, 611 fibrous, 611 character of, 612 cancerous, 612 complications of, 613 composite tumors of, 613 cystic sarcoma of, 614 contents of, 615 tendency of, 615 cystic cancer of, 616 distinguishing characteristic of, 617 alveolar or colloid degeneration of, 617 Ovariotomy, 574 definition of, 574 history of, 574 varieties of, 577 advantages of, 577 dangers of, 577 causes of death after performance of, 577 statistics of, 579 41 Ovariotomy — when unadvisable, 581 conditions favorable to, 581 preparations for, 584 treatment of patient before, 585 operation of, 586 mode of incising in, 586 trocar and canula of Wells, for tapping cyst in, 589 removal of sac in, 590 securing pedicle of cyst in, 590 Wells's clamp for latter, 591 obstacles to removal of sac, in, 595 closure of wound in, 596 after-treatment of patient in, 597 causes of death after, 598 means of avoiding peritonitis after, 599 treatment of septicaemia follow- ing, 599 Ovaritis, 530 varieties of, 531 acute, 531 pathology of, 535 causes of, 535 symptoms of, 536 differentiation of, 536 prognosis of, 536 treatment of, 536 chronic, 537 symptoms of, 537 prognosis of, 537 treatment of, 537 Palpation, bimanual, in physical diag- nosis, 67 abdominal, in physical diagnosis, 69 abdominal, in diagnosis of pelvic hae- matocele, 406 Paracentesis, for ovarian dropsy, 556 mortality after, 557 indications for, 558 through abdominal walls, 558 trocar for performance of, 558 through vaginal walls, 559 advantages of latter, 560 mode of performance through vaginal walls, 560 through the rectum, 560 Parturition, imprudence after, in relation to uterine disease, 57 Pelvis, means for exploring the viscera and tissues of, 86 abscess in, 394 Percussion, in diagnosis of uterine dis- ease, 86 Peritonitis, pelvic, definition and history of, 378 resemblance to cellulitis, 380 frequency of, 381 pathology of, 382 U2 INDEX. Peritonitis — stages of, 382 causes of, 383 varieties of, 384 symptoms of, 385 physical signs of, 386 course, duration, and termination of, 388 differentiation of, 388 diagnostic signs between peri-uterine cellulitis and, 389 importance of differentiating from cel- lulitis, 390 prognosis of, 390 results of, 390 treatment of acute, 390 treatment of chronic, 391 evacuation of purulent and serous collections, 393 methods of latter, 393 Peri uterine-cellulitis, 364. (See Cellu- litis.) Perineum, rupture of, 113 normal anatomy of, 113 results of rupture of, 114 varieties of rupture of, 114 prognosis of rupture of, 115 treatment of rupture of, at time of occurrence, 116 time for operation for rupture of, 116 . treatment of rupture of, after cica- trization, 117 Baker Brown's operation for rupture of, 118 Sims's operation, 120 support of in prolapsus uteri, 305 Pessary, air, 86, 151, 308, 319 uses of, in prolapsus uteri, 305 Coxeter's, 306 Zwanck's 306 Roser's, 307 Scanzoni's, 307 Hoffman's, 307 Bourgeaud's, 308 Gariel's, 308 Hodge's closed lever, 327 Hodge's open lever, 327 Scattergood's, 328 Sims's block tin, 328 Cutter's, 328 Meigs's, 329 Peaslee's stem, 336 Detschy's stem, 336 Scattergood's, in position, 343 galvanic, 500 iPolypus, uterine, definition and history of, 431 varieties of, 431 species of, 432 pathological anatomy of, 433 cellular, 433 glandular, 434 Polypus — fibrous, 435 causes of, 436 symptoms of, 436 physical signs of, 436 differentiation of, 437 course and termination of, 437 prognosis and complications of, 437 treatment of, 437 removal of, 437 Pregnancy, diseases resulting from, 463 Probe, uterine, 77 Sims's smallest, 80 method of using, 80 Sims's silver probe for applying caus- tics to cervical canal, 227 Budd's elastic, 228 Leute's silver caustic, 230 Procidentia, 296. (See Prolapsus of Uterus.) Prolapsus, of vagina, 144 definition of, 144 pathology of, 145 causes of, 146 varieties of, 146 course, duration, and termina- tion of, 147 prognosis of, 147 symptoms of, 147 treatment of, 150 surgical procedures for, 152 of the uterus, 296 pathology of, 297 varieties of, 297 degrees of, 297 causes of, 297 course, duration, and termina- tion of, 298 symptoms of, 298 physical signs of, 299 differentiation of, 299 prognosis of, 300 complications of, 300 symptoms of sudden, 301 treatment of, 301 methods of replacing, 302 methods of sustaining the uterus in, 302 means for accomplishing a cure of, 303 recumbent posture in treatment of, 304 astringents and tonics in, 304 perineal support in, 305 pessaries in, 305 Pruritus, of vulva, 103 pathology of, 104 causes of, 104 treatment of, 106 Kectocele, 149 as a complication of prolapsus uteri, 300 INDEX 643 Retroflexion of uterus, definition and fre- quency of, 340 pathology of, 340 varieties of, 341 causes of, 341 symptoms of, 341 diagnosis of, 342 differentiation of, 342 treatment of, 342 manner of reduction of, 342 sustaining of uterus in, 343 use of pessary in, 343 Retroversion of uterus, definition and fre- quency of, 320 causes of, 321 varieties of, 322 symptoms of, 322 physical signs of, 323 degrees of, 323 differentiation of, 323 prognosis of, 324 results of, 324 treatment of, 324 means for reduction of, 324 Sims's repositor for reduction of, 324 means for retention after reduction of, 326 pessaries in, 327 Rupture of perineum, 113 Sound, uterine, first mention of, 35 Valleix's and Kiwisch's, 77 method of introducing, 77 facts ascertained by use of, 78 Simpson's and Sims's compared, 79 Sims's smallest, 80 hard rubber, for dilating the cervix in obstructive dysmenorrhcea, 481 Speculum, first mention of, 34 ancient, 38 Sims's, 49, 73 Fergusson's, 70 Thomas's telescopic, 71 Emmet's, 74 Thomas's modification of Sims's, 74 Cusco's modified, 75 Sims's with fixed depressor, 75 method of introducing valvular and cylindrical, 75 introduction of Sims's, and its varie- ties, 75 position for introduction of Sims's, 76 choice of, in cauterizing cavity of ute- rus, 257 Sterility, as a result and sign of chronic corporeal endometritis, 254 definition of, 507 history of, 507 causes of, 507 differentiation of, 510 prognosis of, 510 Sterility- treatment of, 511 Sub-involution of uterus, 468 pathology of, 469 symptoms of, 469 prognosis of, 469 treatment of, 469 Superinvolution of uterus, 470 pathology of, 470 treatment of, 471 Supporters, abdominal, 151, 267 skirt, 266 Suppositories, in vaginitis, 137 in acute endometritis, 208 in chronic cervical metritis, 240 Sutures, silver, in operations for ruptured perineum, 120 in treatment of urinary fistulse, 168 passing, in Sims's operation for cure of urinary fistulae, 171 Tampons, in ulceration of cervix and os uteri, 279 in cancer of uterus, 448 Tents, sponge, first used by, 81 object of the use of, 81 mode of preparing, 81 Nott's manner of preparing, 82 sea tangle, 83 preparation of, 83 mode of introducing, 84 dangers of, 85 sponge in chronic cervical endometri- tis, 224 medicated sponge in chronic cer- vical endometritis, 230 medicated sponge, in chronic cor- poreal endometritis, 257 sponge, in neuralgic dysmenor- rhea, 475 Tumors, fibrous, of uterus, definition and synonymes of, 412 history of, 412 pathology of, 412 situation of, 413 varieties of, 414 submucous, 414, 420 subserous, 415 interstitial, 415 causes of, 416 complications of, 416 symptoms of, 416 physical signs of, 416 examination for, 417 differentiation of, 417 prognosis of. 418 frequency of, 418 course, duration, and termination of, 419 palliative treatment of, 420 curative treatment of, 420 absorption of, 421 644 I^ T DEX, Tumors, fibrous — excision of, 421 Aveling's polytome for removal of, 421 Nelaton's forceps for removal of, 422 ecrasement of, 422 Gooch's canulse for removal of, 424 enucleation of, 425 sloughing of, 426 gastrotomy for removal of, 427 propriety of latter, 427 percentage of deaths and reco- veries in this operation, 429 causes of fatal termination in gastrotomy, 430 cancroid of uterus, 449 varieties of, 449 fibro-plastic of uterus, 449 pathology of, 449 recurrent fibroid of uterus, 450 pathology of, 450 prognosis in, 451 frequency of, 451 fluid, ovarian, 541 varieties of, 541 solid ovarian, 609 varieties of, 609 composite of ovary, 613 XJlceration as a cause of fistulee of vagina, J 158 of os and cervix uteri, 272 varieties of, 272 Ulcer, granular, 273 causes of, 273 symptoms of, 274 physical signs of, 274 pathology of, 275 treatment of, 276 applications to, 278 tampons in, 279 caustics in, 280 follicular, 280 pathology of, 280 causes of, 281 treatment of, 281 true inflammatory, 281 prognosis and treatment of, 281 syphilitic, 282 frequency of, 282 course, termination, and differ- entiation of, 283 treatment of, 284 corroding, 284 cancerous, 284 scrofulous, 285 corroding of uterus, 453 frequency of, 453 pathology of, 454 symptoms of, 455 Ulcer, corroding — physical signs of, 455 differentiation of, 456 treatment of, 456 Urinary fistulas, 154 causes of, 156 symptoms of, 159 physical signs of, 160 complications of, 160 prognosis of, 160 history of, 161 Sims's discoveries in treatment of, 163 Gosset's procedure in treatment of, 164 Metzler's method of treatment of, 165 means for obtaining a natural cure of, 167 treatment of, 167 cauterization in, 167 suture in, 168 Sims's operation for, 168 passing sutures in, 171 removal of sutures in, 175 Bozeman's operation for, 177 requiring special treatment, 18 Uterus, Bennet's views of disease of, 44 inflammation of, views of Paulus iEgineta, 44 Tyler Smith's theory of disease of, 45 Velpeau's views of disease of, 46 author's views of disease of, 47 etiology of disease of, 52 predisposing causes of disease of, 53 improprieties of dress conducive to diseases of, 55 imprudence during menstruation ex- citing disease of, 57 imprudence after parturition causing disease of, 57 rational signs of disease of, 63 means for physical diagnosis of dis- ease of, 66 method of probing, 80 means for exploring, 86 inflammation of, 193 parts affected in, 197 varieties of, 198 prognosis in affections of. 198 dividing line between the cervix and body of, 200 reasons for frequency of failure in treatment of diseases of, 200 imperfect diagnosis of diseases of, 201 erroneous prognosis of disease of, 201 inefficient therapeutics in diseases of, 201 acute inflammation of mucous men- brane of, 205 INDEX. 645 Uterus — acute inflammation of parenchyma of, 249 chronic inflammation of mucous mem- brane of the cervix of, 214 pathology of, 217 causes of, 218 symptoms of, 219 chronic inflammation of the paren- chyma of the cervix of, 232 pathology of, 233 treatment of, 235 counter-irritation to the cervix of, 242 mode of blistering the cervix of, 243 cauterization of the cervix of, 243 actual cautery to the cervix of, 245 chronic inflammation of the mucous membrane of the body of, 248 frequency of, 248 pathology of. 249 causes of, 250 symptoms of, 252 treatment of, 256 cauterization of the cavity of, in, 257 caustics which may be employed to cauterize cavity of, in, 258 ointments in, 259 mode of introducing solid caus- tics into cavity of, in, 259 injections into cavity of, in, 260 mode of introducing latter, 260 chronic inflammation of parenchyma of, 261 causes of, 261 symptoms of, 262 physical signs of, 263 pathology of, 263 differentiation of, 263 treatment of, 265 abdominal supporters in, 267 depletion hi, 268 alterative applications in, 269 counter-irritation in, 270 ulcers of the os and cervix of, 272 displacements of, 287 varieties of, 291 causes of, 292 ascent of, 296 cause of, 296 descent or prolapsus of, 296 pathology of, 2 ( .<7 varieties of, 297 degrees of, 297 causes of, 297 course, duration, and termina- tion of, 298 symptoms of, 298 physical signs of, 299 Uterus, descent of — differentiation of, 299 prognosis of, 300 complications of, 300 symptoms of, sudden, 301 treatment, 301 methods of replacing, 302 methods of sustaining in, 302 means for accomplishing a cure of, 303 means for diminishing weight of, in, 303 means for strengthening supports of, in, 304 recumbent posture in, 304 astringents and tonics in, 304 perineal support in, 305 pessaries in, 305 ante version of, 312 causes of, 313 symptoms of, 314 course, duration, and termina- tion of, 315 varieties of, 315 diagnosis of, 315 differentiation of, 316 prognosis of, 316 treatment of, 316 means for reduction of, 317 means for retaining uterus in normal position after reduc- tion of, 318 pessaries in, 319 retroversion of, 320 definition and frequency of, 320 causes of, 321 varieties of, 322 symptoms of, 322 physical signs of, 323 degrees of, 323 differentiation of, 323 prognosis of, 324 results of, 324 treatment of, 324 means for reduction of, 324 Sims's repositor for reduction of, 324 means for retention of uterus in place after reduction, 326 pessaries in, 327 anteflexion of, 330 period at which it is most fre- quent, 331 varieties of, 331 pathology of, 331 causes of, 332 symptoms of, 333 diagnosis of, 333 prognosis, 334 treatment of. 334 means for preventing recurrence of, 334 m INDEX. Uterus, anteflexion of — stem pessaries in treatment of. 335 means for obviating consequences of, 337 complications of, 337 operation for, 338 retroflexion of. 340 pathology of. 340 varieties of, 341 causes of, 341 symptoms of, 341 diagnosis of. 342 differentiation of, 342 treatment of 342 manner of reduction of, 342 sustaining of, in, 343 use of pessaries in, 344 lateroflexion of, 344 treatment of, 344 compound flexion of, 344 inversion of, 346 varieties of. 346 partial. 346 complete. 346 normal anatomy of, 347 pathology of, 347 mechanism of, 347 causes of. 348 symptoms of, 351 physical signs of, 351 differentiation between polypus and, 352 differentiation between fibroid tumors and. 352 course, duration, and termina- tion of, 352 prognosis of, 353 treatment of, 353 methods of reduction of, 353 methods of checking hemorrhage in, 357 methods of amputating in, 358 dangers of amputation in, 358 fibrous tumors of, 412 polypi of. 431 cancer of. 439 cancroids of, 449 fibro-plastic tumors of. 449 recurrent fibroids of, 450 epithelioma of, 452 corroding ulcer of, 453 moles of, 463 pathology of, 464 causes of, 465 symptoms of, 465 physical signs of. 4 r >5 differentiation of, 465 prognosis of. 466 treatment of, 466 hydatids of. 466 lefinition of, 466 Uterus, hydatids of — pathology of. 467 symptoms of, 467 physical signs of, 467 differentiation of, prognosis of, 468 treatment of, 468 subinvolution of, 468 history of, 468 pathology of. 469 causes of, 469 symptoms of, 469 prognosis of. 469 treatment of. 46$ superinvolution of. 470 definition of, 470 pathology of. 470 causes of, 470 symptoms of, 470 physical signs of. 470 differentiation of, 471 results of, 471 treatment of. 471 functional disorders of, 472 flexion and version of, as causes of dysmenorrhoea. 478 dysmenorrhoeal membrane of, 486 examination of, in menorrhagia and metrorrhagia. 489 treatment of fungous degenera- tion of mucous membrane of. 491 amputation of neck of, 513 history of. 513 dangers of. 514 conditions demanding. 514 varieties of operation for. 514 methods of performing. 515 by bistoury or scissors, 515 by ecraseur, 515 by galvano-caustic, 516 statistics of, for inversion. Yagina. normal anatomy of, 129 filiform papillae of. 129 inflammation of, 129 epithelium of. in vaginitis, 131 atresia of, 138 historv. pathology, and varieties of, 138 causes of, 139 symptoms of. 139 differentiation of. 140 treatment of, 141 different modes of operating for, 141 period for operating in, 143 prolapsus of, 144 definition of, 144 pathology of, 145 causes of. 146 varieties of. 146 INDEX. 647 Vagina, prolapsus of — course, duration and termination of, 147 symptoms of, 147 treatment of, 150 complications of, 148 surgical procedures for, 152 hernias of, 148 fistula of, 154 closure of, for cure of urinary fistulse, 182 operation for closure of, 182 simple fistulse of, 191 constriction of, for cure of pro- lapsus uteri, 307 stricture of, as a cause of dys- menorrhoea, 478 Vaginismus, 123 anatomy and pathology of, 123 causes of, 124 symptoms of, 125 treatment of, 125 Sims's vaginal dilator in treatment of, 126 Sims's operation for, 126 Emmet's improvement of Sims's ope- ration for, 127 Burns' operation for, 127 Simpson's modification of Burns' ope- ration for, 128 as a cause of sterility, 508 Vaginitis, 129 varieties of, 130 simple, 130 causes of, 130 symptoms of, 131 physical signs of, 131 differentiation of, 132 complications of, 132 specific, 132 pathology of, 132 causes of, 133 symptoms of, 133 Vaginitis, specific — physical signs of, 133 differentiation of, 134 complications of, 134 granular, 135 pathology of, 135 causes of, 136 symptoms of, 136 treatment of all varieties of, 136 Versions of uterus, 312 ante version, 312 retroversion, 320 inversion, 346 as a cause of sterility, 509 Vestibule, rupture of bulbs of, 97 normal anatomy of bulbs of, 97 plexus of veins of, 98 Vulva, diseases of, 87 anatomy of, 87 inflammation of mucous membrane of, 88 varieties of latter, 88 purulent affection of, 88 follicular affection of, 90 gangrenous affection of, 92 eruptive diseases of, 95 pruritus of, 103 treatment of pruritus of, 106 Vulvitis, 88 varieties of, 88 purulent, 88 causes of purulent, 89 symptoms of purulent, 89 treatment of, 89 follicular, 90 causes of follicular, 90 symptoms of follicular, 91 physical signs of follicular, 91 treatment of follicular, 92 gangrenous, 92 causes of gangrenous, 92 symptoms of gangrenous, 93 treatment of gangrenous, 93 THE END 3477 ^O,. 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