.i9 THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES GIFT OF SAN FRANCISCO COUNTY MEDICAL SOCIETY THE Pathology, Diagnosis, and Treatment OF THE Diseases of Women BY GRAILY HEWITT, M.D.Lond., F.R.C.P. PROFEJSOR OF MIDWIPEKV A.NMl DISEASES OF WOMEN, VNIVEHSITV COLLEGE. AND ODSTBTRIC fHVSlCIAN TO THE HOSI'll AL ; FOKMKRLV I'REMDEST OF THE OBSTETRICAL SOCIETY OF LONDON ; HONOHARV FELLnV OF TUB OBSTBTRICAL SOCIKTY OF BERLIN ; HONORARY FELLOW OF THK CYN/CKHLuCICAL SOCIETV OF U"ST>N; Hi.NORAKY FELLOW OF THE MEDICAL SOCIETV OF HELSINCFOKS A New American from the Fourth Revised and Enlarged London Editir^ With 236 Illustra ions Edited with Notes and Additions BY HARRY MARION-SIMS, M D. Attending Surgeon to St. Elizabeth's Hospital, New York, Etc VOLU ME I NEW YORK BERM INGHAM & CO. 1S83 Copyright. 188-'5. bj- Bermingham & Co. Liknn KJP EDITOR'S PREFACE. The autlior sent the proof-shceis of this edition of his book to me with the request that I would supervise their passage through the press, and add any notes I might clioose to make. Having known him from my early boy- hood, I accepted tlie compliment, and determined to give the book the widest circulation possible. The book has some points of peculiar interest. It insists on better nutrition. It advocates the mechanical pathol- ogy of some forms of uterine disease, viz., that pathologi- cal changes are produced by mechanical causes. The wood-cut illustrations of uterine displacements are of life size, which is an aid to the beginner. We have long known that the nausea of pregnancy is a neurosis, a refie.x symp- tom which the author shows very conclusively to be the result of some form of uterine distortion, and which is Nq^ always relieved by appropriate mechanical treatment. He N^ further demonstrates most satisfactorily that hysteria in V all its protean forms is a uterine refle.x symptom (not ovari- y* an as has been generally supposed), dependent always on fle.xion or malposition; and that to remedy the latter is to cure the former. Ni This book has many other features of interest, which the ' student will readily appreciate. The notes I have added are embraced in brackets in the text. Harry Marion-Sims. 267 Madison Ave., New York, April, 1883. ti2^2'j5 PREFACE TO THE 1-OURTII EDITION. Ten years liave elapsed since the last edition of this woriv was pul)lishe(i. What I have gained from observation ana experience during those ten years has been here faithfuliv ana truly set down. In the last edition of this work I endeavored to enunciate and demonstrate certain general principles as to the pathol- ogy of diseases of the uterus, more especially to show that ihe changes in the shape and position of the uterus are directly or indirectly responsible for the sufferings and dis- comforts attendant on the affections peculiar to the female sex. The conclusions expressed ten years ago have been tested and vcritictl by subsequent experience; and additional facts and observations on this subject will be found in this volume. I have, however, in the present edition advanced a step further, and have explained, to my own satisfaction at all events, how and why it is that changes in the shape and position of the uterus are so liable to occur: what, in short, are their predisposing causes. An extended experience has enablefl me to submit a further and, as I consider, a most important generalization on the subject. What I have to say, in fact, amounts to this, that alterations in Uie shape and position of the uterus are rarely witnessed ex- cept in individuals whose general strength has become seriously impaired by a systematic, and often a lengthenea, practice of taking little food. The term "chronic starva- tion" appropriately designates this condition; and a long course of observations has convinced me that it is a most important factor in the production of the class of diseases above alluded to. VI PREFACE TO THE FOURTH EDITION. These considerations are fundamental in regard to the subject of the pathology of the uterus, and they underlie all that is to be said, or that can be said, on the matter. In the present work, much attention l.as been bestowed on the development and application of the above-mentioned principle, which is, of course, nothing more or less than this — the dependence of local ailments on general ones. If there be nothing ver}^ novel in this doctrine, it may be at all events of some service to give it, in a more precise man- ner than has hitherto been attempted, a definite application to the class of maladies treated of in this work. The question as to the nature of Hysteria and Hystero- epileps)^ has much occupied my attention, and the present volume contains a collection of observations on the sub- ject, together with deductions, which I submit to the candid and dispassionate consideration of my readers. An important class of cases are those in which Pregnancy is associated with Flexion of the Uterus. This is a subject of great interest, as also a cognate one, viz., the cause of the Vomiting of Pregnancy. In the present volume will be found essays on these subjects, and an accumulation of evidence in the shape of cases in proof of the truth of the doctrines I some years ago enunciated on this latter ques- tion. A considerable number of new illustrations have been added to the new edition; and most of the new figures representing flexions and displacements of the uterus are drawn life size, and the various mechanical appliances for their treatment are drawn the actual size of the instru- ments, with the view of rendering the descriptions and directions for treatment more explicit and less liable to misinterpretation. The greater part of this new edition has been re-written. G. H. 36 Berkeley Square, October, 18S2. CONTENTS OF VOL. I. CHAPTER I. GENERAL CONSIDERATIONS RESPECTING THE DISEASES OF THE SEXUAl- ORGANS IN WOMEN. Relations Subsisting between General and Local Diseases. — Ira portance of Maintenance of proper Nutritional Power as aflcciing thf General Condition of the Patient — Nutritional Weakness of the Uteruf a Cause of Softness of the Uterus, and an Important Factor in causing other Diseases of the Organ — Relative Importance of Affections of tht Uterus and the Ovaries P^^'^ 32 CHAPTER II. NATURAL HISTORY OF THE UTERUS AND OVARIES. Natur.'M. History of the Uterus. — Effects of Menstruation — Preg- nancy — Sexual Intercourse. OvARiF.s : Phknomena of Menstruation and Ovulation. — Vascular and Erectile Apparatus of Female Sexual Organs: Bulb of the Vagina: Bulb of the Ovary — .Mechanism of Ovulation — Rougei's Researches — ■ Menstruation — Recent Researches by Kundrat. En>;clmann, VVilliami and Leopold as to the Nature of Menstruation — Source of the Blood- Phenomena observed — .Age — Periodicity, Duration, Quantity, and Quality of the Discharge yj CHAPTER III. examination of the uterus and ovaries. Digital Examination of the Uterus from the Vagina. — Position of the patient. DoiRLE Examination of the Uterus. Digital Examination of the Os Uteri and of the Vaginal Part of the Cervix Uteri. — Normal Condition of the Os and Cervix — Method of Examination — Apparent Absence of the Os Uteri; various Causes — Unusual Softness of the Os Uteri from Pregnancy or other Causes — Unusual Hardness of the Lips of the Os Uteri; its Causes — Size of the Os Uteri — Variations in the Length of the Vaginal Portion of the Cervix Uteri; Relation of Pregnancy to this Condition. Examination of the Uterus by Means of the Sound. — The Instru- 8 CONTENTS OF VOL. I. ment; Method of Introduction — Variations in the Length and Direction of the Uterine Canal detected by the Sound. Examination of the Os Uteri py Means of the Speculum. — General Rules— Method of Using the Instrument — Description of Various In- struments. Examination of the Ovaries 60 CHAPTER IV. symptomatology of diseases of the uterus. List of Symptoms Observed. — Uterine Dyskinesia, its Importance and Frequency — Hysterical Symptoms — Cerebral Symptoms 91 CHAPTER V. . general pathology of the uterus. Historical Summary. — The Mechanical System of Uterine Pathology — Definition — Laceration of the Cervix Uteri 94 CHAPTER VI. abnormal conditions of the tissues of the uterus — mal-nutrition of the uterus — abnormal softness. Mal-nutrition of the Uterus or Abnormal Softness. — Its true Pathological Nature — Evidence of Existence of General Mal-nutrition in such Cases — Effects in Predisposing to, or Causing Distortions of, the Uterus — Symptoms observed — Typical Cases 100 CHAPTER VII. congestion of the uterus and congestive hypertrophy. Peculiarities of the Circulation of the Uterus. — Effect of Com- pression at the Centre of the Uterus in producing Congestion at its Two Extremities — General Congestion : Causes — Acute and Chronic Varieties — Relation of Acute Form to Gooch's "Irritable Uterus" — Effect of Flexions in causing Acute Congestion — Chronic Congestion: Causes and Effects — Increase in Size of Uterus — Association of Chronic Congestion wiih Flexions no CHAPTER VIII. sub-involution of the uterus — atrophy and hypertrophy of the uterus. Sub-involution of the Uterus. — Nature and Treatment. Atrophy of the Uterus ; the Result of Sexual Involution— Premature Senile Atrophy or "Super-involution" of the Uterus — Mechanical Atrophy. Hypertrophy of the Uterus. — Result often of Defective Involution after Delivery — Hypertrophy, with Elongation of the Cervix.... 121 CONTENTS OF VOL. I. Q CHAPTER IX. TREATMENT OF THE VARIOUS TEXTURAL DISORDERS OF THE UTERIS — MAL-NUTRITION OF THE UTERUS— CONGESTION, CONGESTIVE HVPER- TRiJl'HV, ETC. General Preveniive Treatment — Dietary Necessani' — Importance of De- ficient Dietary as a Cause of Uterine Disease — Defects ^Qualitative and Quantitative — ■"Chronic Starvation" a Real Disease — Its Importance — Method of Dealing with it — Preveniive Treatment as refjanls Menstru- ation — Preventive Treatment in Child bed — CorResiion of the Uterus and Confjesiive Hypertrophy — General Treatment — By Alterinjj Posi- tion and Shape of Uterus — By Leeching. Scarifications, etc. — Use of Hot-water Injections — Baths and Waiering places — .\siringent and Caustic Applications to the Os Uteri — Internal Remedies 123 CHAPTER X. ABNORMAL CONDITIONS OK THE LINING OF THE UTERUS. General Employment of Term Endometritis — Explanation of these Cases — Cause most frequently Retention in Uterine Cavity of Irritating Discharges, Retention being due to Uterine Distortion — Importance of Drainage of Uterine Cavity — Fungous Condition <>( the Lining of the Body of the Uterus shown to be really Congestive Hypertrophy of the Mucous Membrane 144 CHAPTER XL ACUTE INKLA.MMATKiN OF THE UTERUS. Nature and Treatment 153 CHAPTER XII. DEFECTIVE DEVELOPME.NT OF THE UTERUS — CONGENITAL MALFORMA- TIONS. Diagnosis. List of Cases. — Absence of Rudimentarj- Formations of the Uterus — Infantile Uterus — Uterus Unicornis — Double Uterus — Absence of the Os Uteri 155 CHAPTER XIII. DISPLACE.MENTS, DISTORTIONS (FLEXIONS) OF THE UTERUS — I. NORMAL SHAPE, POSITION, AND MOVEMENTS OF THE UTERUS. Normal Shape, Position, and Movements of the Uterus. — Form and Shape, how preserved in a State of Health — The Proper Position of the Uterus: Discussion of various Opinions on the Subject: Schultze, Schrocder, De Warker. etc. — Conclusion arrived at — Normal Move- ments of the Uterus — Decree of Fi.xation of the Uterus — Motions De scribed ; I. Descent ; 2. Rotation on Transverse Axis ; 3. Flexion — Effect of Evacuation of Contents of Bladder considered 161 id CONTENTS OF VOL. I. CHAPTER XIV. DISPLACEMENTS, DISTORTIONS (FLEXIONS) OF THE UTERUS — 2. PATHOLOGY AND GENERAL HISTORY. Nomenclature — Flexion, Distortion, Version, Prolapsus — Complex Na- ture of Cases — Frequency of Distortions and Displacements — Statistics from Author's Hospital Practice — Statistics from Private Practice. 174 CHAPTER XV. DISPLACEMENTS AND DISTORTIONS OF THE UTERUS (FLEXIONS) — ' 3. ETIOLOGY. Etiology. — Statistics of Cases in Private Practice, showing Frequency of Mechanical or Physical Injury or Accident. Ci ASSIFICATION OF Calses. — I. Predisposing: Undue Softness of the Uterus from Mal-nutri'.ion (Chronic Starvation) — from Sub involution — Physical Prostration — Rupture of Perineum — Previous Pregnancy — 2. Exciting: Accidents — Over-exercise — Special Exercises — Special Occupations — Marriage — 3. General Causes 179 CHAPTER XVI. DISPLACEMENTS AND DISTORTIONS OF THE UTERUS (FLEXIONS) — 4. CLASSIFICATION AND PATHOLOGICAL EFFECTS. Classification of Flexions and Consequent Displacements. — Patho- locical Effects. I. The Seat of the Flexion; 2. Variations in the Condition of the Tissues of the Uterus; 3. Various Kinds of Flexion or Version (Rotation); 4. Varieties in Position of Uterus as a Whole. Pathological Effects of Flexions, Relation to Congestion, Relation to Hypertrophy of the Uterus— Contraction of the Cervical Canal — Changes in the Uterus, Atrophy, Compression at the Seat ot the Bent. Sensitiveness at the latter Spot — Persistence of the Distorted Shape of the Uterus — Changes at the Os Uteri 188 CHAPTER XVII. displacements and distortions of THE UTERUS (FLEXIONS) — 5. SYMPTOMS, INCLUDING STERILITY AND ABORTIONS. Pain, Spontaneous— Pain on Locomotion (Uterine Dyskinesia)— Explana- tion of this Symptom : Its Great Importance — Undue Tenderness of the Uterus to Touch — The " Irritable Uterus" of Gooch shown to be Acute Flexion. Dysmenorrhoea. Leucorrhoea, Menorrhagia, Amenorrhcea — Sterility — Aboriions — Statistics of Sterility and Abortions in Hospital and Pri- vate Practice. Disturbance of Functions of Bladder— of Rectum — Dyspareunia — Reflex Nervous Symptoms loy CONTENTS OF VOL. I. II CHAPTER XVIII. Displacements and distortions of the uterus (flexions) — 6. general principles of treatment. t*RlNCiPi.ES OF Treatment. — i. Indications — Restoration of General Sirenpth; 2. Restoration of Uterus to Proper Shape and Position. Difficulties Encdunterkp. — Question of Necessity for Examination — Definition of General and Local Treatment — Curability of Flexions — \'arious Causes of Difficulty. General Treatment. — Restoration of Nutritional Power and Activity — Rest, how to be carried out — Utilization of Intluciicc of Gravity — Attention to Condition of Bowels. L'TAL Treat.ment. — Positional or Postural Treatment — Prone Kneel- ing Position — Horizontal Position. Use of the Sound repeatedly — Cases adapted for it. Use of Sound combined with Dilatation of Cunal by Means of a Dilating Sound. Treatment by Means of Stems: Cases requiring it — Its Value and .Aprlicabiliiy. Use of Tents. Incision of the Uterine Canal. Vaginal IVssaries — General Method of Action — Cases suitable for. Necessity for conjoint Postural Trcatmenl and Use of Sound. Other Requirements when Vaginal Pessaries are em- ployed. Material of Vaginal Pessarit-s. General Summary. Pallia- tive Treatment. Use of Hot-water Injections. Opiates. Treatment of the Accompanying Ctmgestion 224 CHAPTER XIX. RETROFLE.XION AND RETROVERSION OF THE UTERUS. Severity of the Affection — Curability. Frequency — In Hospital and Private Practice — Compared with Ante- flexion — Single or .Married. Special Causes — Traumatic Influences — Dr .Squarcy's Views — Influence of Bladder — Pregnancy — -Strainmg ElToris in Dofiec.ilion. Varieties — Basis for Classification. i. Degree of the Flexion, first, second, third ; 2. The Degree of \'ersion (Rotation) — Substitution of Word "Rotation" for \'ersion — Degrees, one, two and three; 3. De- gree of Descent of Uterus as a Whole ; 4. Degree of Resistance to Replacement and Unbending ; 5. Degree of Congestion and Enlarge- ment. Progress. Complications — Adhesions — Congestion — Not to be Confounded with Rigidity — Prolapse of Ovary — Rupture of Perineum — Fibroid Tumor — Prolapsus of Rectum. Symptoms — Pain, Dysmenorrhoea. Menorrhagia, Leucorrhoca. Amenor- rhoea — Sterility — Abortions — Derangements of BladJer, of Rectum — Reflex Disturbances. Diagnosis 242 CHAPTER XX. RETROFLEXION AND RETROVERSION OF THE VTEKVS— {Continued). Treatment. — General — Local — Plan recommended — Outline and Details — Postural Treatment — .Mechanical Direct Reposition — Maintenance 12 CONTENTS OF VOL. I. of Proper Position by Vaginal Pessary — Form of Pessary recom- mended — Various Sizes required. Position of Patient — Use of the Sound — Conjoint Use of Sound and Pes- sary — Difficulties encountered in Treatment of Cases — Adjustment of Size of Pessary — How far Vaginal Pessaries are reliable — Action of the A. Smith Modification of Hodge Pessary — Necessity for Rest, and Gradual Elevation of Fundus in some Cases — Occasional Over-action of the Retroflexion Pessary — How long to be continued — Method ot Introduction — Change of Pessary — Various Modifications of Retro- flexion Pessary — Dilatation and ]\Ioulding for Cure of Retroflexion — Stem Pessary — Incision and Immediate Rectification — Radical Opera- tion (Koeberle) — Oophorectomy 262 CHAPTER XXI. anteflexion and anteversion of the uterus. Importance of Anterior Displacements and Flexions Considered. — Frequency with which these Conditions give Rise to Uterine Dys- kinesia — Great Frequency of this latter Symptom as observed in Prac- tice. Definition. — Difficulty hitherto Experienced in Definition — Owing to Existence of slight Anteflexion in Normal Uterus — Owing also to Mis- apprehension of True Nature of Congestion of Uterus associated with Anteflexion — Author's Definition: Exceptional Cases when the Defini- tion does not apply — Use of the Finger in making the necessary E.x- ploration — Precautions to take. Frequency. — Hospital and Private Practice compared — Single or Mar- ried — Age of 4S8 Cases in Private Practice. Etiology. — Predisposing Causes — Discussion of Schultze's Views as to Movement of Uterus when Bladder is emptied — Author's Dissent from Schultze's Conclusions — Importance of Softness of Uterine Tissues and Want of Rigidity as causing Anteflexion — Previous Pregnancy — Rupture of Perineum — General Physical Weakness and Prostration — Special or Exciting Causes: Traumatic Causes, their great Frequency — Previous Attacks of Parametritis— Schultze's "Pathological Ante- flexion" — General Perimetric Fixation result of Anteflexion of long standing 286 CHAPTER XXII. anteflexion and ANTEVERSION OF THE VTERVS—{Ccy>lfi/llH-J). Varieties— I. In Degree of Flexion; 2. Degree of Rotation of Uterus; 3. Degree of Descent of Uterus as a Whole; 4. Rigidity of Uterine Tissues — Various Combinations of these possible, hence' Infinite Dif- ferences in Cases— Three Principal Degrees of Flexion— Some Lead- ing Types Described— Various Conditions of Cervix— Anteflexion with Posterior Rotation— Severe Cases in which the Uterus is very low down, compressing the Recium— Variations in Rigidity of Uterine Tissue and Connections— Clinical Features of Different Cases— Illus- trative Cases given— Degree of Congestion present. Complications.- Congestion, Accessions of Acute Congestion— Disten- sion of Cavity— Adhesions— Cystocele— Cystitis— Constipation. CONTENTS OF VOL. I. 1 3 Symptoms — Uterine Dyskinesia — Illustrative Facts In Refjard to this ob- served in Thirty-three " Fertile" Women and in Thirty-five Single Cases — Spontaneous Fain — Tenderness of Uterus to Touch — Other Abnorm.il Sensations — Dysmenorrha-a. Menorrhagia. Lciicorrhcca. AtDcnorrhoca — Sterility — Abortions — Dysparcunia — Reflex Nervous Symptoms — Symptoms referable to Bladder; to Rectum. Diagnosis. — Various Difficulties— Method — Use of Sound — Precautions and Difficulties in introducing it in Diflcrcnt Cases 29S CHAPTER XXill. ANTEFLEXION AND ANTEVERSION OF THE UTERUS — {ConHttUfd). Treatment. — Important DifTcrcntiation of Cases in rejjard to Cause of the Affection — The A^e. the Duration of the Malady — lmpr>rtancc of General Treatment — Illustrations of Method of Treatment necessary in a Recent Case — Positional Treatment %'ery Important; How to be carried out — Sittinp Position to be avoided — A more Severe Case^ Combination of Local and General rrcatineiit — Use of "Cradle" Pes- sary and Sound — Case in which Uterus is very Rigid and Affection of some standing — Further illustrative Cases of Treatment of Anteflexion after Pregnancy. Employment of " Incisions" of the Cervix — Former Misconceptions as to Stricture of the Cervical Caral — Utility of the Operation in Cases of Flexions considered — Neressity for Uougies or Stems afterward — The " Stem" Treatment considered — General Conclusions — Difficulties in Absolute Cure of Long-standing Ca,scs 324 CHAPTER XXIV. ANTEFLEXION AND ANTEVERSION OF THE t'TERCS — {ContittUfd). TREATMENT — (<-i>/l //««<•/). Pessaries for the Treatment of Anteflexion and Anteversion. — The Author's "Cradle" Pessary — Principle of Its Action — Two Vari- eties, the "Bar Cradle" and "Crutch Cndlc" — Various Sizes re- quired — Various Materials — Modificati'in in Usr resembling Gehrung's Pessary — Introduction and Removal of the Cradle Pessary — Precau- tions in Regard to its Use — Dr. Gaillard Thomas's Pessaries — Other Pessaries: Playfair's, Galabin's, Fancourt-Barnes's, Gallon's — The Air- ball Pessary 337 CHAPTER XXV. lateriflexion, lateral displacement and alternating ante- and retroflexion of the uterus. Lateriflexion of the Uterus. — Treatment. Alternating Ante- and Retroflf,.\io.n. — Nature of these Cases^ Condition of the Tissues of the Uterus — Treatment, General and Me- chanical 351 14 CONTENTS OF VOL. I. CHAPTER XXVI. INCISION AND DILATATION OF THE CERVICAL CANAL OF THE UTERUS. — STEM PESSARIES. Incision or Division of the Os and Cervix Uteri. — Various Methods of performing the Operation — Means for maintaining the Canal open afterwards — Dangers of the Operation — Treatment of Cases of Imper- forate Os Uteri. Dilatation of the Canal of the Uterus.— Dangers of the Procedure — Means of effecting Dilatation — Various Kinds of Tents — Method of Introduction — Metallic Dilators. Stem Pessaries. — Various Kinds — Simple Stems — Stems with Support- ing Vaginal Framework 356 CHAPTER XXVII. association of pregnancy with flexions of the uterus. General Observations. — Frequency of Abortions in such Cases: Reasons for this — Difficulty of Expansion of the Uterus. Retroflexion and Retroversion of the Gravid Uterus. — i. Flexion Present before Pregnancy occurs — Natural History, Symptoms, and Effects; 2. Flexion occurring after Pregnancy has commenced — Diag- nosis — Treatment — Reduction by Positional Treatment; by other Means — Trea ment of the Bladder. Anteflexion of the Gravid Uterus. — A Frequent Condition and a Frequent Cause of Abortion — i. Cases where the Anteflexion occurs after Pregnancy lias begun — 2. Anteflexion precedes the Pregnancy — History of these various Cases — Reasons why the Complication is not generally recognized as an Important One — Diagnosis — Severe Sick- ness a Common Symptom — Author's Views on this Subject — Retention of Portions of Ovum another Result of the Flexion — Treatment in va- rious Cases according to Severity of the Case — Elevation of the Uterus, how to be effected — Relief of the Sickness — Modus operaudi of the Treatment — Ur. Copeman's Method — Dilatation of the Cervix for Cure of Sickness disci'ssed and explained. Subsequent Treatment 371 CHAPTER XXVIII. THE vomiting OF PREGNANCY. Author's Explanation, and Paper on Subject in 1871. Severe or Dangerous Vomiting in Pregnancy.— Historical and Critical Inquiry into the Subject, with Summary of Observations re- corded by Others — Account of Cases published — Dr. Copeman's Cases: Explanation of these — Cases observed by the Author — Aubert's Obser- vations on Influence of Movements of Uterus in producing Sickness — General Rhtint^ o{ the Subject. Treatment of the Vomiting of Pregnancy 391 CONTENTS OF VOL. I. 1 5 CHAPTER XXIX. DISEASES A.ND INJURIES OK THE OS AND CERVI.X UTERI. The " Ulceration" Theory of Uterine Disease — Laceration of the Cervix Uteri : Its Effects and Results — Dr. Etnmct's Views on the Subject — His .Method of Treatment — Importance of Evcrsion of the Cervical Lming: Causes of the same — Hypertrophy, Cystic Degeneration of the Os Uteri, etc. Ulcerations of the Os Uteri — Erosions — True Ulcerations — Syphilitic Ul- cerations 415 CHAPTER XXX. CHRONIC INVERSION OF THE UTERUS. Chronic Inversion of the Uterus. — Causes, Effects, and Varieties. Diagnosis. Treatment. — Reduction by Systematic and Continuous Pressure aided by Anxsthcsia — Treatment by E.\cision 426 CHAPTER XXXI. prolapsus of the uterus. Genfrai, Rkmakks on the Pathi>Io;;y of the Subject — Mechanism by wliiih the Uterus is kept in its Place — The various Conditions present in Cases of I'rolapsus — Illii- • ■ - of various Conditions and Com- plications — .Mechanism of ^ — Relation to Cystoceic, Recto- cele, and Flexions — Hypci: . >ngation of the Cervix and its V.iricties — S>mptoins and Progress of Prolapsus. Diagnosis. Treat.ment. — Must be adapted to the Peculiarities of the Case — Ticat- ment of Prolapsus from Hypertrophy of the Cervix — Excision of the Part — Other Forms of Prol.ipsus — .Measures directed (1) to the Condi- tion of the Uterus; (2) To the Condition of the Uterine Supports — Artificial .Means for maint.iining the Uterus in its Proper Place in the Pelvis, by Pessaries, by External Appliances, by Constriction of the Vaginal Aperture, or the Canal itself — Dcscrip<.ion of various Operative Procedures 43O LIST OF ILLUSTRATIONS IX VOL. L rlG- FACE I. Changes in Muscular Fibres of Uterus 40 The Ovarv, with Pampiniform Plexus of Vessels (Savage).. . . 44 Mucous .Nicmbrane of L'tcrus durinvj Menstruation 49 Uterus during Menstruation. 1 he Ovary exhibits a recently- ruptured Graafian Follicle 50 A Graafian Follicle preparing for Rupture (A. Farre) 51 Section of (Jvary ami Follicle in Fig. 5 51 Virgin <>s Uteri (A. Farre) 64 Section of Pelvis and Uterus showing position of Uterus (Life size) 65 Os Uteri at Eight Months of Gestation (A. Farrr) 67 Sectional View of Os Uteri at Eight Months of Gestation (A. Farre) 71 E.xamination of Uterus by Means of Sound 73 Lateral Sectional View of Uterus (.A. Farre) 76 Retrolie.\ion of a somewhat enlarged Uterus 77 Bivalve Speculum, in silu S4 E.xamination of Uterus by Sims's Speculum. Os Uteri drawn down by small hook 86 Bivalve Spoi uhmi (Cusco's modified by Weiss) 87 View (magnified) of Interior of Cervix Uteri (Tyler Smith). ... 89 Lateral Sectional View of Uterus (A. Farre) Ill Transverse Section of Uterus at Internal Os (.\. Farre) 112 Anteflexion of Uterus with Congestion 113 Kctrotlexion of the Uterus accompanied with Congestion 114 .Vnlcllexion of Uterus with Congestion, in a Case of Severe Chronic \'omiting 117 Chronic Congestive Hypertrophy with Anteflexion of the Uterus ii3 General Hypertrophy of Uterus and Cervix 125 Longitudinal Hypertrophy of Uterus (A. Farre) 126 Hypertrophy of Posterior Lip of Os Uteri 127 Defective Formation of Uterus (Rokitansky) 156 Uterus Unicornis (Pole) 158 Double Uterus (Kussmaul) 159 Uterus Bilof ularis (Kussmaul) 160 Normal Position of Uterus, Life size (see also Fig. 8) 165 Position of Uterus when Bladder is Empty (according to Schultze) 171 Normal Range of Movement of Uterus forward or backward 172 Lateral Sectional View of Uterus (A. Farre) 190 l8 LIST OF ILLUSTRATIONS IN VOL. I. 35. Anteflexion of Uterus with Congestion I9T 36. Acute, long-standing Retroflexion of Uterus 193 37. First Degree of Retroflexion of Uterus 205 33. Third Degree of Retroflexion of Uterus 205 39. Section of Pelvis. Life size, showing Severe Reiroflexior. vvith Congestion of Uterus, Patient in a Vertical Position 207 40. Same as Fig 39. Patient being in the Prone Position 2o3 41. Severe Retroflexion of Uterus 212 42. Third Stage of Anteflexion with Distention of Cavity and Thickness of Walls (Chronic Menorrhagia, etc.). Patient in Vertical Position 215 43. Same as Fig. 42, but Patient is supposed to be in Dorsal Posi- tion 217 44. Outlme of Patient in Genu-pectoral Position 230 45. Genu-pectoral Position showing Uterus Retroverted 230 46. Genu-pectoral Position. Position of Uterus changed by the Attitude of Patient 230 47. Speculum or Air Tube (Campbell's) to Facilitate Change of Position of Uterus in Genu-pectoral Position 231 48. Graily Hewitt's Uterine Dilator 233 49. Portion of Blades of Graily Plewiit's Dilator (actual size) 233 50. Tampons in Vaginal Canal (Thomas) 23S 51. First Degree of Retroflexion of Uterus 24^* 52. Second Degree of Retroflexion of Uterus 2-i3 53. Third Degree of Retroflexion of Uterus 249 54. Second Degree of Retroflexion, with Second Degree of Pos- terior Rotation of Uterus shown on Section of Pelvis (Life size) 250 55. Third Degree of Retroflexion and Third Degree of Posterior Rotation (Life size) 252 56. Three Degrees of Retroflexion of Uterus 25 3 57. Medium-sized Pessary as Employed by Author for Retro- flexion. Ground Plan and Sectional View (actual size) 26 « 58. Various Sizes of Rings from which Pessaries can be m^de. . . . 264. 59. Section of Pelvis showing action of the Retroflexion Pessary (Life size) 26^; 60. Oblique View of a Medium Hodsje Pessary (A. Smith type).. . 260 61. Five Sizes of the Retroflexion Pessary 267 62. Three larger Sizes of the Retroflexion Pessary 26S 63. Gehrung's Retroflexion Pessary 273 64. Greenhalgh's Padded Retroflexion Pessary 274 65. Thomas's .Modification of Cutter's Retroflexion Pessary 275 66. (Author's) Combined Stem and Hodge Pessary for Treatment of Retroflexion 270 67. Retroverted Uterus, with Simpson's Sound introduced 2S2 68. Retroverted Uterus, with a jointed Sound introduced 2S3 69. Marked Anteflexion (a Museum Preparation) 287 70. Acute Anteflexion and Congestion of Uterus 288 71. Normal Range of Movements of Uterus, in forward or back- ward Direction 293 72. Position of Uterus according to Schultze, when the Bladder is Empty 294 73. First Degree of Anteflexion of Uterus 299 74. Second Degree of Anteflexion 300 LIST OF ILLUSTRATIONS IN VOL. I. 1 9 75. Third Degree of Anteflexion 300 76. Complete Anteversion of Uterus 301 77. Three DcRrees of Anteflexion of Uterus 302 78. Severe Anteflexion (Emmcl) 303 79. Anteflexion with Posterior Rotation of the Uterus; Section of Pelvis 304 80. Outline of Uterus, Anteflexion with Posterior Rotation 305 81. Anteflexion of Uterus (Life size). First Degree, shown on Sec- lion of Pelvis 306 82. Second Degree ol Anteflexion (Life size), Section of Pelvis.. 307 83. Severe Chronic Anteflexion, showing much Hypertrophy. . . . 309 84. Anteflexion of Uterus and Congestion. (Case of severe Chronic Vomting) 311 85. Large Anicflexed Uterus 313 86. Chronic Anteflexion. Pouched Condition of Uterus 31S 87. Author's Cradle Pessary, tn situ 327 88. Cradle Pessary (large size), shown in Position, Uterus, etc. (Life size) 323 89. Triangles indicating Proper Relation of Sides of Cradle Pes- sary 333 90. Large size Bar Cradle Pessary 339 91. Large size Crutch Cradle Pessary 339 92. Outline of Cradle Pessary and Uterus (Life size), to show Ac- tion of Pessary 340 93. Large size Crutch Cradle, seen from above 341 94. Profile View of three sizes of Cradle Pessary 341 95. Medium size Crutch Cradle Pessary 342 96. Full size Crutch Cradle Pessary 342 97. Extra thick No. 3 size Spring Cradle Pessary 343 98. Another View of Pessary shown in Fig. 97 343 99. Large size Spring Cradle Pessary in Action 344 100. A Special .Mode of using Cradle Pessary 345 loi. Gehrung's Anteflexion Pessaries 347 102 and 103. Thomas's Anteflexion Pessaries 34S 104. Mundii's Modification of Thomas's Pessary 349 105 and 106. Pessary for Treatment of alternate Ante- and Retro- flexion 355 107 and 108. Barnes's Tent Introducer 3C2 109 and no. Graily Hewitt's Uterine Dilator 364 111. Priestley's Dilator 365 112. Marion-Sims's Dilator 365 113. Chambers's Stem, and Introducer 366 1 14. Granville Bantock's Stem, and Introducer 366 115. Godson's Stem 368 116. Lawson Tait's Stem 368 117. Graily Hewitt's Stem Pessary (so called " Padlock" Pessary). 369 118. Wynn Williams's Stem Pessary 370 119. Gravid Uterus, in a State of Retroflexion 378 120. Anteflexion of Gravid Uterus at about Fourth Month 385 121. Retained Ovum, or Clots, with Anteflexion of Uterus 387 122. Double Lateral Laceration of Cervix Uteri (Emmet) 417 123. Watch-spring Tourniquet for Operation of Restoration of Torn Cervix (Emmet) 419 20 LIST OF ILLUSTRATIONS IX VOL. I. 124. Shape of Raw Surfaces after Denudation. Operation for Restoration of Torn Cervix (Emmet) 420 125. Tenaculum Forceps for Operation of Restoration of Tom Cervix 421 126. White's Method of Replacing Inversion of Uterus 433 127. Aveling's Instrument for Replacing Inverted Uterus 434 128. Inversion of Uterus and large Polypoidal Tumor 435 129. Section of Pelvis, showing Relation of Uterus, Vagina, Peri- neum, etc. (Life size) 438 130. Complete Prolapsus with Retroflexion of Uterus 441 131. Anteflexion of Uterus with Cysiocele 443 f 32. Chronic Retroflexion with Rectocele 444 133. Supra-vaginal Hypertrophy, with Prolapsus of the Uterus. . 445 134. Hypertrophic Elongation of Infra-vaginal Cervix Uteri with Prolapsus 446 135. Another Case similar to that shown in Fig. 134 447 136. Hypertrophic Elongation of Cervix with Retroflexion 448 137. Prolapsus of Bladder with Prolapsus of Hypertrophied Cervix (A. Farre) 451 138. Ecraseur with Annealed Steel Wire, for Amputation of Cervix Uteri 455 139 and 140. Operation for Restoration of Perineum 463 141. Author's Method of Constricting Vagina, in Operation for Restoration of Perineum 466 142. Marion-Sims's Operation for Constricting Vagina 467 143. 144, and 145, show Emmet's Plan for Restoring the Rectal Sphincter in Cases of Laceration of Perineum 468 THE Pathology, Diagnosis, and Treatment OF THE DISEASES OF WOMEN. CHAPTKR I. General Considerations respecting the Diseases of the Sexual Organs in Women. Relations subsisting between General and Local Diseases. — Im- portance of Maintenance of proper Nutritional Power as afTicting tlie General Condition of the Patient — Nutritional Weakness of the Uterus a Cause of Softness of the Uterus, and an Important Factor in causing other Diseases of the Organ — Relative Importance of Afifcctions of the Uterus and the Ovaries. The performance of the functions of various organs of the body in a normal manner inij)Iics a general condition of health of all the organs, and disorder of one of them has generally a disturbing effect upon others. Thus symp- toms whicli at first sight appear to indicate local disease or disorder may, on more complete investigation, prove to be the manifestation of some more general disturbance. Hence a sound view of a particular case must of necessity be a broad view: there is room for reproach to anything like an exclusive view. Exclusiveness may be on either side. There can be no question that it is as much a mis- take to regard the "local " as the "general" element in the case exclusively; and while the importance of the " local " element may have been sometimes over-estimated in the practice of gynecologists, the fact remains that the "gen- eral " has also very much too frequently usurped the pro^ei place of the other in the practice of those who are not gynaecologists. The practitioner who refuses to look at the two sides dispassionately will possibly make great mistakes. 34 DISEASES OF WOMEN. He is certain, at all events, to lose many opportunities of doing good and relieving suffering. In the study of the diseases of the female sexual organs we meet with many and complex problems, and much un- certainty and diversity of opinion still prevail in regard to the decision of many of these problems. It is quite evi- dent that no decisive advance can be made in the settling of disputed points unless the primary one of the connection between "general" and "local'' disease be more satisfac- torily determined. It may be confidently expected that some of the more important of existing differences of opinion will be found reconcilable by full consideration of the facts adducible in reference to the manner in which "general" disease is capable of influencing or predisposing to or actually producing "local" diseases of the female sexual organs. It is the more likely that this satisfactory result will be attained, inasmuch as the explanations to be given involve concessions to both parties and give distinct credit to each of them. It may be said that it is no new thing to point out the importance of the " general " element in dealing with gynaecological cases. Many previous writers have dealt with it, some prominently so. But there are various important considerations in connection with this subject which it is my object to develop more particu- larly in the following pages, and for which some degree of novelty may be claimed. I refer to the subject of a de- ficient and defective nutrition of the body generally and its effects on the sexual organs, more particularly the uterus, in predisposing to or in the production of actual disease. There appear to be good grounds for believing that, ex- cluding accidents and injuries, the primary defect, the first step in the downward course, leading finally to established local disease, is a general weakening or impairment of the nutritional activity of the body generally. There is, first, a general weakness influencing more or less the whole of the organs of tlie body in an injurious sense; there is, in the second place, a particular and local weakness evidencing itself in the local disease and particular local symptoms. The clinical facts which are adducible in favor of this gen- eralization are before us, and its correctness may be attested without difficulty by simple observation of facts daily pass- ing under our eyes. It may be urged that the statement in the foregoing para- graph is a truism. It is so. But it is nevertheless a truth DISEASES OF THE SEXUAL ORGAN'S IX WOMEN. 35 wliich has yet to be applied to the explanation of various difficulties encountered by p;ynoecological pathologists. In the year 1S67 I adopted as the subject for an inaugural address at University College, " Nutrition the Basis of the Treatment of Disease."* I mention this as showing that my attention had been some time ago attracted to the im- [lortance of "general " views. But it was not until the last live or six years that the more advanced and complete gen- t'lalization as to the influence of general imjierfect nutrition in producing disease of the female sexual organs forced itself on my notice. I had been for a long time unable to account satisfactorily for the fact that in cases coming under my notice the uterus was so often found in a soft, flaccid stale. Observation of very numerous cases and careful inquiry into the antecedents of these cases gave so uniform a history of long-standing mal-nutrititm — a general kind of semi-starvation, in fact — that I gradually acquired the conviction that there was a real connection between them, and that the relation was actually one of cause and effect. In the last (third) edition of this work the very great fre- quency with which patients suffering from uterine symp- toms were found to present vari(ius forms and degrees of flexion of the uterus was pointed out, and the opinion ex- pressed that these sufferings are traceable to the altered shape and position of the uterus. But it was also insisted upon that " the change in the form and shape of the uterus is frequently brought about in consequence of the tissues of the uterus being previously in a state of unusual soft- ness." f The nature antl cause of this unusual softness of the uterus have, since the publication of the last edition of this work, much occupied my attention. This unusual softness, which had formerly much puzzled me to account for, I have since seen reason to trace to a previous geaeral weakness and want of nutrition of the uterus. It is met with in those individuals, for the most part, who had been imper- fectly and inadequately nourished for some time previously. Instead, therefore, of attributing this unusual softness to chronic inflammation, which was the best explanation of * In 1879 I delivered an address to the Harveian Society on "Chronic Starvation" (see Lancet, Jan., 1879), in which the same subject v;as further developed. t 3d ed. 1872, p. 2. 36 DISEASES OF WOMEN. the matter I could offer in the )'ear 1872, I now wish to sub- stitute for it the explanation just given. The foregoing remarks are anticipatory in a sense. And they apply for the most part to the uterus, which is only one of the female sexual organs; but they will indicate the view entertained by the writer as to the importance of the "general" and its relations to the "local " element in dis- cussing the subject of diseases of the female sexual organs. A further question is to be considered. The female sexual organs consist principally of two organs — the uterus and the ovaries. What is the comparative preponderance of these organs in the origination of disease, and what is the comparative importance of diseases of the one or other of them? Some gynaecologists attribute the greater degree of im- portance to the uterus, while others consider diseases of the ovar}' the more important. The difference of opinion is attributable, for the most part, to the different interpreta- tion of symptoms by advocates of opposing views. Thus, pain located laterally in the pelvis is considered to indicate ovarian irritation or inflammation by some authorities, whereas a different explanation would be given by opposing pathologists. It is necessary to weigh well the clinical and other facts adducible in favor of the uterine or ovarian origin of ob- served symptoms. The ovaries are undoubtedly most im- portant organs in the female economy, and have indeed a great influence, in an indirect manner, on diseases of the uterus. In one sense of the word the ovaries may be said indeed to be more important than the uterus. Yet the ma- jority of clinical observers are of opinion that uterine dis- orders numerically preponderate over the disorders of the ovaries. The ovaries are liable to one form of disease — cystic degeneration — which is a malady of very great im- portance; while the uterus is liable to alterations and dis- orders, many of v.hich involve continuous suffering and give rise to severe or troublesome symptoms. On the whole, it appears that symptoms are far more frequently traceable to the uterus than to the ovary as the offending organ. The inflammatory conditions of the peritoneum covering the ovaries or parts immediately adjacent are con- sidered by some pathologists as having special importance, "pelvic peritonitis'" being supposed to be a condition fre- quently present, and capable of giving rise to many of the HISTORY OF THE UTERUS AND OVARIES. 37 symptoms which are more ordinarily set down to the uterus. Tliese do not, however, appear to be good grounds for re- i^arding this condition as a common one. Of late years tlie introduction of Batiey's operation has been tlie means of acquainting us with the fact that the ovaries are, at all events, occasionally affected with contractions, degeneration of tissue, and other important changes. It seems certain that the list of ovarian diseases is undergoing an increase. CHAPTER II. NATfRAL History of the Uterus and Ovaries. Nati'rai. History ok the Utervs. — Effects of Mcnslruaiion — Preg- nancy — Sexual Intercourse. Ovariks: Phknomkna ok MK.NSTRfATloN AND Ovi'i.ATio.N. — Vasculaf and Erectile .Apparatus of Female Sexual Organs: Hulb of the Vagina: Bulb of the Ovary — Mechanism of Ovulation — Rouget's Researrlies — Menstruation — Recent Researches by Kiindrat, Enijclmann, Williams, and LeopoM as to the Nature of Menstruation — Source of the Hlood — Phenomena observed — Age, Periodicity, Duration, Quantity, and Qual- ity of the Discharge. NATURAL HISTORY OF THE UTERUS. The Uterus is an organ wliich has an extremely important position in the female economy, and the changes and modi- fications witnessed in its shape, si/e, and te.xture, in its vas- cular condition, and in its relations to the nervous centres, exercise a profound influence on the individual who is the subject of them. They produce discomfort of various kinds, they interfere with the natural performance of important functions, prevent procreation, and involve many other minor inconveniences; not infrequently they predispose to the occurrence of other disorders capable of shortening life or bringing it to a sudden and abrupt conclusion. Life in the woman is made up of three periods: i. The period preceding that of sexual activity; 2. The period of sexual activity; 3. The period following the cessation of sexual activity. The peculiarities appertaining to these three several periods appear to be almost wholly dependent on, and subordinate to, the condition of the sexual organs at the several periods in question. The sexual organs con- sist essentially of the uterus and the ovaries, the due exer- 38 DISEASES OF WOMEN. cise of the sexual functions being dependent on the presence of these two organs in their integrit)'. In the exercise of the sexual functions the ovary is the more essential organ of the two: physiological reasoning conclusively indicates this. It may be that alterations in the ovaries, impercepti- ble perhaps to us as observers, influence the economy at large in a profound manner; but wliat we know at present ratlier justifies the belief that, in cases where the disorder is dependent on the sexual organs, the uterus is the particu- lar organ most frequently at fault. Before puberty has arrived, the uterus is small and un- developed, and has, functionally, no existence. And it is remarkable that, during this period, and whilst it remains in its dormant condition, it is not liable to disease. Dis- ease of the organ only begins to sliow itself when it begins functionally to live. After the climacteric age has been passed, and uterine life has ceased, we find that the condi- tion of the uterus is one very closely analogous with that which subsists before the arrival of puberty. The uterus becomes atrophied — physiologically dead — and the liability to disease for the most part ceases. Thus, during the first and the third stages of the woman's life, equally, the uterus is an organ lying inactive and almost powerless in the economy. But this is not all. The uterus not only enjoys a life of its own, so to speak, but it has a life or a succession of lives within this. If the woman becomes impregnated, the uterus, previously developed and matured, forthwith starts on a new road of development, and after the term of gestation has been completed, relapses into its previous condition. The building up of the gravid uterus is not more wonderful than its subsequent destruction. Succes- sive pregnancies involve each the formation and destruction of the organ; for each pregnancy there is the life and death of an entire uterus. The uterus has thus a life of its own, distir.ct from, and in a certain degree disconnected with, that of other organs of the body. And from all these considerations it results that the diseases of the uterus have also peculiarities sep- arating them from diseases of other organs. In diseases of all organs of the body, wherever situate, we witness for the most part onl)^ alterations of natural processes; and the diseases observed in the uterus, in like manner, bear upon them the impress of their locality. It is not intended to imply that pathological processes and HISTORY OF THE UTERUS AXD OVARIES. 39 conditions, such as are met with in other organs of the body, may not be met with in the uterus. Such may un- questionably be the case: cancer, for instance, attacks the pylorus and the uterus, and the disease is in both positions integrally the same, although the tissues among which it makes its inroads are not of the same kind in the two cases. But it will be conceded, that the interpretation of the pathological and other changes in the uterus would be diffi- cult by one unacquainted with the peculiarities of its struc- ture and with the nature of the functions which it is called upon to perform in the economy. And it results from what has been now said that the peculiar structure and physio, logical functions of the uterus impress upon it pathological conditions and characteristics, with which we have nothing tlioroughly identical, and sometimes not even analogous, in the pathological conditions of other organs of the body. There are two great functions in which the uterus is prominently concerned, and which are most powerful dis- turbing influences in rc^gard to its textural condition; these are, menstruation and gestation. There is a third in which it is also concerned, viz., se.xtial congress, which is also capa- l)le, though probably in a less degree, of affecting its tex- tural condition. How, and why, the exercise of these functions respectively affects the physical condition of the organ, and leads to disease, must now be pointed out. Menstru.^tio.v. — During the whole of sexual life, the uterus is each month the seat of an unusual congestion of all its blood-vessels. Its circulation is more active, it en- larges, the sinuses — which are to be seen on making a sec- tion of the uterine walls as cavities of considerable size — become filled with blood, and its tissues engorged and ex- panded. It will be presently shown (see "Phenomena of Menstruation") how profusely the organ is supplied with blood-vessels; it is further to be remarked that the veins are unprovided with valves, tlje result of which is that con- gestion of the uterir\e plexuses readily occurs. The men- strual congestion of the uterus lasts for some days even in health, the duration being probably from first to last not less than a week, and where the period is prolonged it may be considerably over a week. Scanzoni estimates the ordi- nar)' duration of menstrual congestion indeed as nearly half of the whole four weeks which usually constitute the "period." Prolongation of the menstrual period, or un- usual intensity of the congestion for a shorter time, will 40 DISEASES OF WOMEN. Fig. I.* thus lead in the end to a chronic condition of engorgement; for if the heart be weak, or if other circumstances interfere with the quick removal of the excessive quantit)' of blood from the organ, the vessels do not recover their proper size, they remain permanentl)^ larger than they should be, and as a consequence the uterus itself acquires a size which is excessive and unnatural. Thus, under ordinary circum- stances the menstrual process tends to produce uterine conges- tion and enlargement, but when menstruation is disturbed, this congestion is intensified and per- petuated. Scanzoni — whose classi- cal treatise on chronic metritisf ap- peared almost simultaneously with the first edition of this work — con- siders sudden suppression of men- struation as one of the most impor- tant causesof chronic inflammation of the uterus; for the engorgement of the uterus natural to menstrua- tion becomes, when unrelieved, a true congestion, the blood stagnat- ing in the widely-open vessels, and thus leading to other important textural changes. The severe and troublesome headache not uncom- monly observed at the outset of the menstrual period, where there is a temporar}' obstruction to the escape of the blood from the uterus, indicates probably the transference of this conges- tion from the uterus to the head. Pregnancy. — The changes in the uterus which are the result of gestation are of a very important character. The most remarkable change is the increase of the .y/s^ of the organ which is observed; for after the foetus has been * Fig. I represents three conditions of the uterine muscular fibres: A. Fibres from the uterus in the non-gravid state; B. Fibres from the fully developed gravid uterus; and C. Fibres undergoing fatty degeneration after parturition. f " Die Chronische Metritis," 4to. Berlin, 1S63. HISTORY OF THE UTERUS AND OVARIES. 4I expelled and the uterus has been thoroughly emptied of its contents, its bulk greatly exceeds tiiat of the unim- pregnated uterus. Under favorable circumstances, as is well known, the size of the uterus rapidly diminishes dur- ing the few weeks following parturition, until it finally hecomes nearly, but not quite, as small as before the pro- cess of gestation commenced. This diminution in the size of the uterus is the result of a peculiar process, by which the very large muscular fibres, whose contractile power has l)cen exercised in expelling the uterine contents, become first affected with fatty dcgi-neration, and then undergo ab- sorption and completely disapj">ear. The vessels of the uterus also lieconie at the same time much reduced in size. The process by virtue of wliich the uterus returns to its normal condition is now known as the process of involution. The time occupied in involution is probaljly about two months, the greatest diminution in size occurring during Uie second week, after which time, under ordinary circum- stances, the enormous muscular fibres characteristic of the pregnant uterus have become disintegrated. Immediately after delivery the uterus has a thickness of one inch and a length of about eight inches; but by the end of the first month the reduction in size is nearly completely accom- plished. The muscular librcs begin to undergo transforma- tion into fatty molecules about four days after labor, and while the metamorphosis is proceeding the uterus is friable and soft. The new tissue of the uterus begins to be evi- dent at the end of four weeks after parturition, and shortly after this we may conclude that the uterus ought to be re- constructed.* During a month and upward after parturi- tion, the uterus is consequently unduly large and vascular, and it very frequently happens that circumstances interfere with the efficient and timely completion of its involution. If the placenta be not e.xpelled rapidly, and the uterus re- main unduly enlarged for a time, this circumstance gives rise to subsequent difliculties, for coagula form in the sinuses of the uterus, and even after expulsion of the placenta these coagula by their bulk interfere with the due contrac- tion of the organ. Again, if the expulsion of these coagula be deferred, as is not very uncommon, the return of the *See Heschl's valuable researches on this subject, "Zeits. der Gesells. der Acrzie." Wien. 1852. Also Dr. Farre. "Cycl. An. and Pliys.,"and Dr. Priestley " On the Development of the Gravid Uterus." Lond. i860. 42 DISEASES OF WOMEN. uterus to its normal size is proportionately interfered with. Again, when the nutritive changes of the body generally are in a low state, and when the individual is debilitated from any cause, the normal metamorphosis of the uterine tissue is' disturbed, the blood circulates less rapidh', the effete material is not removed, and the organ continues large, unwieldy, and congested. Defective involution of the uterus may thus be a consequence of various disturbing causes in operation after cliildbirth, all of wliich tend to leave it larger than it should be. The new uterus, con- structed by growth of new material, and built up in the existing large framework, is also too large and its blood- vessels too full, and this creates a very strong predisposi- tion to the perpetuation of an abnormal nutrition-process. This increased size leads to mechanical changes in its posi- tion and shape. It is almost unnecessary to mention how very important, in postponing the normal involution pro- cess, must be the occurrence of puerperal fever, uterine phlebitis, etc. Abortions are both an effect and a cause of defective involution of the uterus; but quickly repeated pregnancy undoubtedly tends to produce it, and thus to predispose to chronic inflammation; the reason being that before the uterus is thoroughly renovated, it is called upon again to undergo the gestation process. Quickly recur- ring pregnancies, especially when they occasionally result in abortions, both cause and are caused by a defective invo- lution process. Sexual Intercourse. — The erection of the uterus de- scribed by Rouget and others as occurring during ovulation (see " Phenomena of Menstruation") occurs also during the act of intercourse. At least this is highly probable. Sex- ual excesses predispose to chronic congestion of the uterus, inasmuch as they involve too frequently repeated, or too long continued, engorgement of it. In young women re- cently married it is by no means uncommon to meet with a condition plainly brought about by excess of the kind here alluded to, and but little is required under such cir- cumstances to produce a chronic engorgement of the organ, and the further train of evils usually following in its wake. It appears to be quite certain, also, that unnatural excita- tion of the generative organs in women leads to uterine mischief of various kinds, and promotes and maintains a chronic congestion of the organ and of its vessels, tending to give rise to various secondary disorders, HISTORY OF THE UTERUS AND OVARIES. 43 This brief retrospect of the mechanical results of ilie performance of the natural functions of the uterus will suf- fice to show the direction in which we are to look for the explanation of its various morbid conditions. The nutri- tion-process in the uterus is, as a consequence, very liable to derangement, this derangement resulting in the produc- tion of important alterations in the size, consistence, and structural condition of the organ. ovaries: natural history. — phenomena of menstrua- tion AND ovulation. The importance of the physiology of menstruation and ovulation in ihe study of the morbid processes witnessed in the female generative organs is obvious. All the generative organs are well supplied with blood. When in a state of rest they contain but a moderate supply of blood, but untlcr excitement this is very largely increased. This increase is effected by the distension of certain struc- tures — erectile organs — which are at other times compara- tively empty. The orifice of the vagina has on each side of it an elon- gated leech-sliapcd body, the bulb of the vai^ina, composed of a large numljcr of tortuous veins, closely packed together in a fibrous investment, prolonged upwards in the middle line to the glans clitoridis. This is a provision for erection, the blood being detained in the veins by the action of suit- able muscles. Further, the vaginal canal is surrounded with a belt of blood-vessels, forming a large plexus of veins. The arrangement of the vessels supplying the uterus is of considerable importance, and Rouget* has particularly in- vestigated this subject in a memoir of great value. The utero-ovarian artery, which supplies the uterus with blood, passes upward. Its first branches, to the cervix, are small; but opposite the body of the uierus it gives off suddenly twelve to eighteen short trunks, which pursue at once a spiral direction and divide into a large number of smaller branches. When injected, these vessels are seen to lie so close as to quite cover the sides of the uterus. The body of the uterus thus receives a very profuse arterial supply, and the spiral convolutions of the branches may be seen projecting into the sinuses of the uterine structure. The * " Recherches sur les Organes 6rectilcs de la Fcmme." Brown- S6quard's "Journ. de Physiol." torn, i. 44 DISEASES OF WOMEN. veins in which these arteries terminate are still more nu- merous and capacious, and they form a plexus covering the sides of the body of the uterus. Below, these veins end in the pudendal veins, in the middle they end in the uterine veins, and above in the spermatic veins. It results that the sides of the uterus are covered with a layer of considerable thickness, composed of blood-vessels having great capacity, and it is further to be recollected that the tissue of the uterus itself contains large sinuses — receptacles for venous blood. The ovaries are supplied with blood from the utero-ova- rian artery and from the spermatic. The arterial trunk passes along near the base of the ovarj'', and in its passage gives off a series of ten or twelve branches; these branches divide at once, assume a convoluted arrangement, and finally enter the ovary. The veins coming from the ovary form a special bulb, the bulb of the ovary, composed like the vaginal bulb of a series ^^^- ^- of tortuous veins, sus- ceptible of consider- able distension. The bulb of the ovary has an elongated form, its length a little exceed- ing tliat of the ovary, it is somewhat flatten- ..^r-^K-^^^i^^^^^^^^^ ed, not quite half an ^J-^^ti^.^i^ypf^^^Sy':-^ inch thick, and a little deeper than this; alto- gether its size is not much inferior to that of the vaginal bulb. The pampini- form plexus of veins, a further portion of the vascular ap- paratus here met with, lies below the ovarian bulb in the folds of the broad ligament. The bulb of the ovary is a structure only recently known. The first allusion to it seems to be in a paper communicated by Mr. Traer to the Anatomical Society of Paris. It is well depicted in Dr. Savage's beautifully illustrated work,* and in Rouget's memoir {loc. cii.) it is made the subject of an elaborate in- vestigation conjointly with those of the other erectile structures of the female generative organs (see Fig. 2). * " Illustraiions of the Surgery of the Female Generative Organs,' London, Churchill, 1863. HISTORY OF THE UTERUS AND OVARIES. 45 In the memoir of Rouget it is shown that the function of ovulation is probably greatly dependent for its efficient performance on the presence of muscular structures not before described in the human subject. Erecliliiy is de- pendent, as Rouget remarks, on association of structures for reception of a large quantity of blood, and for deten- tion of that blood. The bulb of the vagina is an erectile structure; the muscular apparatus connected with this is well known. And with reference to the bulb of the ovary, Rouget endeavors to show that there is a muscular appara- tus for the control of its vascular supply, and for constitut- ing it an erectile organ. In lower animals the ovary is brought into coaptation with the oviduct by a mechanism which is not quite the same, though on the same general plan, in different species. Thus in birds, where we find the muscular apparatus connected with the ovaries very well marked, the oviduct is surrounded by a muscular structure or envelope within which the coils of the ovitluct lie. The contractile fibres are so placed that a twofold effect follows from their contraction, viz., the infundibulum is opened out, and at the same time appro.ximated to the ovary in order to receive the ova. The muscles producing this effect are of the involuntary kind, and radiate after the manner of a fan in the folds of the membrane enclosing the oviduct. Rouget, after introducing other anatomical facts in ref- erence to the comparative anatomy of the subject, goes on to state that in the human female there are to be found muscular fibres arranged on an analogous plan; that they form a system covering the uterus, ovaries, and appendages; and that the muscular fibres belonging to this system pass from the lumbar region to the ovary and to the fimbriae near it, while others pass from the uterus over the ovary, and onward to the fimbriae of the Fallopian tube also, and that the simultaneous contraction of these two sets of fibres has necessarily the effect of bringing the fimbriae near the ovary. The mechanism of the process is, he contends, iden- tical in the case of the human subject and in animals lower in the scale. Thus then, the muscular fibres described, together with the vascular apparatus of the uterus and ovary, constitute together, if we follow Rouget, the erectile structure of the internal generative organs. Ovulation is accompanied by the following phenomena: the Graafian follicles being ma- ture, or nearly so, the muscular fibres above described are 46 DISEASES OF WOMEN. set in action and the fimbriae of the tube are thus made to grasp the ovary, at the same time that they induce and maintain a condition of erection of the ovarian bulb. This spasmodic erection is present so long as the ovary and the Fallopian tube remain in contact, and when the rupture of the Graafian follicle happens, the ovum passes into the proper channel. Ordinarily the ovipont occurs, because of the presence of ripe ova in ilie ovary; and with this process it has been almost generally admitted the phenomena of menstruation are associated, although of late years this view of the matter has been strongly opposed. It is probable that the act of congress often determines an ovipont, whicli without it would be postponed for a time. Here the act of intercourse induces erection of the external generative or- gans, and doubtless also that erection of the internal organs above alluded to, the result being escape of an ovule. Rouget contended that the uterus is equally with the ovary an erectile organ, that its erection occurs simultaneously with that of the ovary, and that the final result of this erec- tion, during which the uterus is kept gorged with blood, is exudation of that sanguineous fluid from the surface of its lining membrane, forming the menstrual discharge. This view of the cause of the haemorrhage has been of late seri- ously impugned. The action of the muscular apparatus in bringing the ovary to the open end of the Fallopian tube is probably greatly assisted by the engorgement of the ovary and of its bulb, for when the pelvic vessels are injected artificially after death, the effect is to bring the ovary close to the open mouth of the Fallopian tube; and it has indeed been assumed by some that the injection of the ovarian bulb is a principal agent in effecting the adjustment necessary for the ovipont. We thus see, in the vascular and muscular structures of the internal generative organs, provision made for the sup- ply of vast quantities of blood to these organs. In the hu- man female the engorgement and full distension of the vessels occur periodically, the period of engorgement being that of menstruation; while it would appear that it is liable — during sexual life at least — to occur also during inter- course. We may in the ner.t place consider briefly certain of the other phenomena of menstruation. The process known under the names "menstruation," the "catamenial discharge," etc., is one in the production of HISTORY OF THE UTERUS AND OVARIES. 4/ which two organs are concerned — the uterus and the ovary. Menstruation is usually an indication of the fact that the ovaries are in activity — in other words, that ova are being formed, developed, and maturated in the ovaries. That menstruatiun may occur in cases where the ovaries have been removed, appears possible from certain observations made in the last few years. By " menstruation" is meant a periodical discharge of a sanguineous fluid from the uterus, iliis discharge being attended, as already remarked, with an engorged or congested state of the uterus, ovaries, and adjacent organs, in most cases by hyperaesthesia of the parts in question, and by disturbances, of various kinds and degrees, of other functions of the body. It is, in a certaia sense, analogous to the icstrus in the lower animals, the presence of menstruation being an indication that the woman is capable of being impregnated; but the woman differs from these animals in this respect, that she is capable of being impregnateil, not at the time during which the discharge itself occurs only, but also during the intervals between the periodic discharges. Very important additions have been made to our knowledge of the physiology of menstruation during the last ten years. The minute anat- omy of the lining of the uterus at different periods had been studied carefully by Kundrat and Engelmann, by John Williams, Leopold, and others, and various important facts have come to light. An essential element in the question of the changes oc- curring in the uterine mucous membrane during menstrua- tion is the nature of the membrane itself, and its relation to the uterine wall. Dr. John Williams* points out that the uterus should be regarded as a mucous membrane, whose libre-cells have undergone great development. He considers that three fourths of the thickness of the walls of the uterus is really " mucosa," the tubules of this mu- cosa extending more deeply into the wall than is gen- erally supposed. He considers, therefore, that the terms muscular wall and mucous membrane as generally applied are misnomers. This view of the matter, supported by ar- guments derived from the analogy of the structure of the stomach, and of uteri of other animals, is original, and has important bearings on the vexed question as to the changes in the uterine mucous lining during menstruation. Kun- * " Obstet. Trans.," vol. xvj. p. 20^. ^8 DISEASES OF WOMEN. drat and Engelmann in 1873 published their researches on the changes in the uterus during the catamenia. The)' con- sidered that the uterus is active not onh- during the men- strual flow, but both before and after, and that the menstrual activity is, in other words, spread over a much longer time than that represented by the actual menstrual flow. They were of opinion that the haemorrhage of menstruation is due to fatty degeneration of the mucous membrane, the occur- rence of which degenerative change they substantiated by their observations. Dr. John Williams in 1S74* brought before the Royal Society of London the results of observation of the uteri of nine women who had died in different stages of the men- strual period — his conclusions being that menstruation con- sists in rapid growth and deca}' of the mucous membrane; the discharge consists of the debris of the mucous mem- brane; the bleeding is from the vessels of the body of the uterus; that, the mucous membrane having undergone fatty degeneration, blood becomes extravasated into its substance; the membrane then undergoes rapid disintegration and is entirely carried away with the menstrual discharge. In a Jater essay f Dr. Williams has published results of further investigations with observations of other cases, and in a third paper still further cases,! making nineteen observa- tions altogether. Barnsfather in 1875 § records his clinical experience, ex- pending over some time, with frequent microscopic exami- nations of menstrual secretions, and he finds exfoliations present in all cases, the exfoliations being thicker in cases of menstrual difficulty. Leopold II has given the results of his observations in several cases, which are to the efTect that the disintegration of the mucous membrane is. when it occurs, very slight, and affects only the great superficial layer of the mucous mem- brane; while in some cases, where death occurred a few days after the period, the mucous membrane was still of considerable thickness, Leopold did not find evidence of fatty degeneration in his cases. * The structure of the mucous mambrane of the uterus and its peri odical cnanges. — Pfvc. of Koyal Soc. 1S74. f " Obst. Trans.," vol. xvi. p. 206. XOhsUt. Jour., Dec. 1S77. ^ Cincinnati Med. A'eii'S. I " Die Uierusschleinihaut und die Menstruation." Leipzig, 1877, HISTORY OF THE UTERUS AND OVARIES, 49 The evidence which is to be gathered on the subject, al- though by no means uniformly pointing to the disintegra- tion and separation of a considerable thickness of the mucous membrane in normal menstruation, shows the ex- treme probability of a destruction and removal of the su- perficial layer in all cases. It is perfectly certain that the mucous membrane, at or about the menstrual period, is a ]iulpy, thick, exceedingly vascular substance. The haemor- rhage occurs either from the open mouths of the tubules, cither with accompanying disintegration of the superficial layer, or without it. That fatty degeneration does occur is undoubted, though it seems open to question if this is uni- versally the case. It does not appear that the whole thick- ness of the mucous membrane is ever removed; and, indeed, Fig. 3. 'i A this is hardly possible if we accept Dr. Williams's view that the mucosa, in a physiological sense, includes much of the muscular wall of the uterus. It is probable that further inquiries will reconcile the present apparent discrepancies between the results of late observers; some of ihcm are, indeed, explainable by want of accurate information as to the precise date of the last menstruation. Some years ago I had opportunities on four or five oc- casions of examining the uterus during menstruation. In the case of a woman who died while menstruating, after an operation for hernia, I saw the uterus lined by a deeply red, velvety soft structure, on the free surface of which were to be seen the open mouths of the uterine glands (see Fig. 3). 50 blSEA§ES OF \VOME!C. Fig. 4 represents the condition observed in a 3'oung woman who died, while menstruating, from the effects of a burn, in University College Hospital. In other cases I have found the mucous membrane in actual process of disintegration. The changes in the ovary coincident with menstruation may next be alluded to. Supposing matters take their ordinary course, the ovary produces on its surface, and periodically, matured Graafian follicles, one or more at a time, causing the ovary to present an elevation the size of a nut-kernel, and constituted by the follicle distended with blood and containing the ovule. This condition of the fol- licle is certainl}'^ frequently present at the time menstrua- FlG. 4. ^\\|'^. '^' tion occurs, but it is probable that such a matured condi- tion may be present at other times also. The next event is tlie rupture of this follicle and passage of its contents into the Fallopian tube — the ovipont — provided for in the man- ner already described. Fig. 5 (from Dr. Farre) shows a Graafian follicle preparing for rupture; Fig. 6 a section of the same follicle, exhibiting its cavity and a blood-clot with- in. Rupture of one or more follicles probably occurs at, or before, or shortl)'^ after, each menstruation, though not limited absolutely to that period. After the follicles have discharged their contents, the cavity of the follicle and the interior of the Fallopian tube may or may not remain in con- HISTORY OF THE UTERUS AND OVARIES. 51 nection with each other: if further bleeding from the inte- rior of tlie follicle occur?, the blood will or will not find iis way into the uterus, according to circumstances. It is ob- vious that the continuous application of the Fallopian tubes to the ovary is expedient during the whole time follicles are Fig. 5. liable to become ruptured, or there might be escape of the follicular contents into the peritoneal cavity. Such escape and consequent failure of the ovipont is not very uncom- mon, leading to sterility, to e.xtra-utorine foetaiion, to effu- sion of blood into the peritoneal cavity, and other disorders. Fig. 6. The Graafian follicle, having nischarged its contents, the blood within it ordinarily coagulates, the cavity shrinks up, and by the successive growth of follicles lying deeper in the ovarian stroma, the used-up follicle sinks back toward the middle of the ovary, becomes smaller and smaller, and dis- $2 DISEASES OF WOMEN. appears at the end of three or four months. The retrogreS-* sion of the follicle is marked also by changes of color due chiefly to the transformation the blood-clot undergoes, and to the changes in the very vascular lining of the follicle. After bursting, the follicle is known as 2^ false corpus luteum. From observations made in several subjects Dr. John Williams believes that ova are usually discharged from the ovary before the appearance of the monthly flow with which it is connected.* In ten out of fourteen, rupture of a follicle or haemorrhage into its cavity had occurred before the return of the catamenia; in one it was doubtful whether rupture of a follicle or the appearance of the discharge would have occurred first; in two a menstrual period had passed without maturation of a follicle, and in one a peri- odical discharge was imminent, though the ovaries con- tained no mature Graafian follicle. Leopold's observations tend also to show that the Graaf- ian follicle bursts before the menstrual period, rather than after it. On the other hand, observations are not wanting to show that the ovipont in some cases occurs after the com- mencement of the menstrual flow. On the whole it seems ]irobable that there is a variation in regard to the time of the ovipont, though it more often than not occurs near the menstrual period. It seems probable, from the observa- tions of Coste, that it is not uncommon!}- determined and brought about by sexual intercourse. The question of the ordinary time of the ovipont is interesting as bearing on that of the time of impregnation. The Hebrew custom is in favor of the view taken by Dr. Williams, but the known fact that the spermatozoa may remain active for several days after intercourse has occurred vitiates conclu- sions drawn from actual experience as to the efficiency of single acts of intercourse at particular periods. The commencement of the process of menstruation is usu- ally preceded b}' certain changes in the outward confor- mation and appearance. The general signs of the arrival of pviberty in the woman are thus eloquently enumerated by Brierre de Boismont: " Puberty at last arrives. An im- mense revolution takes place in the system of the young girl. To her slim lank form succeeds plumpness and c^race. Her step, uncertain and languid, becomes firm and spirited. * On the discharge of ova and its relation in point of time to Menstru- ation. — Proc. of Roy. Sec. 1875. ttlSTOkV or TltE UtEUCS AND OVAntES. 53 The soft glance of the eye reveals the fire of the soul. Changes not less remarkable take place in her physique. The chest, narrow and contracted, swells and expands. The lungs breathe more fully. The heart throws with greater force the blood to the extremities. The celUilo- adipose tissue develops the admirable contour which con- stitutes the beauty of woman. Of all the organs that feel the influence of puberty, the uterus and its annexes are those in which it is most evident. " Tiie uterus, ovaries. Fallopian tubes and breasts increase immensely. The bones and muscles partake of this gen- eral development. Even the moial offers differences not less marked. The young girl, truly an infant in her tastes, inclinations and desires, experiences all at once a complete metamorphosis. Restless and dreamy, she does not com- prehend the new sentiments that agitate her. All the senses are quickened; a soft glow pervades her whole nature. An unusual fulness is felt in the pelvic organs, the most important phenomenon of puberty, that which trans- forms the girl into the woman, now manifests itscTf by the catamenial flow which heralds the fitness for maternity."* There are also sometimes present in young women who are about to menstruate certain sensations, more or less marked in different cases, and most intense in those cases where the appearance of the menstrual discharge is a little delayed. These symptoms are known by the term molimiua menstniationis. The chief symptoms of the menstrual moli- men — the attempt at menstruation, the evidence of ovarian activity — are as follows: A sensation of weight and fulness in the pelvis and its neighborhood, together with a " bearing down" or dragging sensation; pains radiating from the loins downward toward the perinieum, and occasionally extending down the thighs; tenderness over the hypogastric and inguinal regions; a feeling of heat in these regions so intense as to be described "as burning" by some patients, irritability of the bladder, frequency of micturition, and inability to evacuate the bladder, are more rarely observed. The digestive system sympathizing, there are diarrhoea, or constipation, nausea, inappetency. Fretfulness, or change of temper and disposition, may also be noticed; in fact, many of those symptoms usually classed under the denomi- * " De la Menstruation dans ses rapports physiologiques et patholo- giqucs, 8vo. Paris, 1S42, p. i. 54 DISEASES OE WOMEN. nation " hysterica] " may be present. Tlie local symptoms are tlie most constant. Wlien symptoms of tlie above character are observed at intervals of three or four weeks, persisting in each periodic recurrence for two, three, or four days together, in a young woman who presents outward signs of liaving arrived at puberty, they are evidence of the existence of ovarian action, and constitute the menstrual molimen. The characteristic point about these symptoms is their periodicity. In some cases where menstruation is absent there is witnessed a periodical haemorrhage, or exudation of blood from some other part, as from the lungs, stomach, con- junctiva, surface of an ulcer, etc. In such cases there is said to be vicarious menstruatio7i. The a^e during which the catamcnial discharge occurs varies; but, as a rule, it begins during the ages of 14 and 16, and ceases between the ages of 40 and 50. For about thirty years of the woman's life this discharge recurs peri- odically. With reference to the age at which it com- mences, we have observations by Roberton,* Whitehead, f Brierre de Boismont,J and Szukits.§ In 358 cases observed by myself, menstruation occurred for the first time At the << age of 10 in 3 II " 12 " 12 " 29 " 13 " 43 " 14 " 73 " 15 " 62 cases At the age of 1 8 in 23 cases 19 " 10 " 20 " 6 '* 21 " 2 " 24 " I " << " 16 " 61 " 17 " 33 Total . . 358 Statistics of 2,696 cases at University College Hospital obtained from women who applied at this hospital to be attended in their confinements, and collected for me by Mr. Walter Rigden, are as follows: Of the 2,696 cases, menstruation occurred for the first time *" Observations and Notes on the Physiology and Diseases of Women, and on Practical Midwifery," 8vo. 1S51. f " On the Causes and Treatment of Abortion and Sterility," 8vo. 1847. X op. cit. § See an abstract of his observations in Schmidt's "Jahrb." bd. xcvii. p. 331. HISTORY OF THE Atth e age of 9 n 3 cases " 10 •' 14 •• " II " 60 " " 12 " 170 •' " 13 " 353 " " 14 " 560 " " 15 • 540 " " 16 " 455 " " 17 " 272 " OF THE UTERUS AND OVARIES. 5^ At the age of iS in 150 cases 19 " 76 " 20 " 29 " 21 " 7 " 22 " 3 " 23 " 2 " 24 " " 25 " " 26 " 2 " The mean ago is 1496, about. Tlie greater number of these cases were liospital out-patients. The mean age in 4,000 cases referred to by Whitehead was 15 years 6^ months. In 2,169 cases collected by Roberton, Lee, and Murpliy, the mean age was 14 years II months. Szukits found the mean age to be. in 6C5 women born in Vienna, 15 years Sfr months; and in 1,610 women born in the country, 16 years rl months, which re- sult, as regards the influence of town life in hastening the first appearance of the catamenia, agrees with that arrived at by Hrierre de Boismont in Paris. The latter observer states that amongst women belonging to the upper classes of society, the average age of commencement was as early as 13 years 8 months. Although the age 14-16 is the most common, yet there are numerous exceptions to this rule. In Roberton's 450 cases, ten began to menstruate as early as II years old. and nineteen at 12. The youngest of Szukits' cases was, in the town class 11 years and in the country class 10 years old. In three out of 35S cases noted by myself, menstruation began at the age of 10 years, and although the largest number of my own cases — 73 out of 358 — menstruated first at the age of 14, a very considerable number menstruated first as late as the age of 18. The mean age of the commencement of the catamenia appears to be about two years earlier in warmer than in more temperate climates. Thus in India the mean age in 597 cases collected by Roberton was 13 years. It was formerly supposed, on the assertions of Montesquieu and Ilaller, that Hindu women began to menstruate, as a rule, at 8, 9, and 10 years of age; but facts collected by Rober- ton conclusively show the- incorrectness of this opinion. It appears, however, from Rol)erton's tables, that " the pro- portion of Hindus who arrive at puberty at the ages of 12, 13, and 14," is far greater than is observed in women living in our own temperate climate. This early arrival of the catamenia is attributed by Roberton to the influence of 56 DISEASES OF WOMEN. race — to the fact, that for many generations (upward of three thousand years) it has been the custom of this people to give their daughters in marriage immediately on the arrival of puberty. This custom has, in Roberton's opin- ion; produced and perpetuated a kind of " family peculiar- ity." Montesquieu and Haller held that "climate" is the determining cause of this difference. More recent statistics are in the same direction. Thus Vogt's researches show that in Norwa)^ the average first appearance is the age of 1 6' 1 2. We may contrast this with the average at Univer- sity College Hospital of 14 g6. Toulin and Lagneau have collected observations on cases in various latitudes pre- sented to the International Medical Congress at Paris in 1867,* the general conclusions from which are in confirma- tion of the fact of the earlier appearance of menstruation in hot climates. And it would appear that climate is really the determining element in the difference observed, between extremely hot and extremely cold countries, a difference represented by from three to four years. The /afesf age at which the catamenia may commence is open to great variations; but, as a rule, it is not postponed beyond the age of 18. Brierre de Boismont found that, out of 352 "femmes de la capitale," twenty began to men- struate at 18 }'ears, six at 19, five at 20, two at 21, four at 22, and two at the age of 23. The latest age given by Roberton is also 23. Szukits gives the age of 22 as the latest at which the first appearance occurred in the Vienna class; but of those from the country one woman began to menstruate as late as 25. The latest age in my own series was 24. In a case quoted by Meissner, the catamenia first appeared at the age of 42. f The cessation of menstruation occurs in the majority of cases between the ages of 40 and 50. The number of cases in which the cessation takes place before 40 is greater than the number of those in which the final appearance of the catamenia occurs after the age of 50. (Brierre de Bois- mont.) There appears, however, to be a great diversitv in the results obtained by various observers on this point. Thus, in the cases, 181 in number, of the author just quoted the age at which the final cessation most frequently (18 out of 181) occurred, was 40; while in Roberton's cases it was * New S\'d. Soc, " Bien. Retrosp." for 1S67-8, p. 377. f Meissner, " Frauenzimmerkrankheiten," ii. 741. HISTURV OF THE UTERUS AND OVARIES. 57 most frequently observed (in 26 out of 77 cases) at the age of 50; in tlie majority of the cases observed by Szukits at 46-50. The earliest period at which the cessation may take place is shown by the following recorded facts: Of Brierre de Boismont's 181 cases, the cessation was noticed in seven before the age of 30, the earliest being at the age of 21. The earliest cessation in Roberton's 77 cases was at the age of 35. Szukits gives two cases at the age of 30. The following table shows the results of my observa- tions in 55 cases: Menstruation ceased at the age of 30 in i case 33 ' • I 34 * ' 2 35 ' ' I 37 ' ' I 33- 3 39 * ' I 40 • ' 2 41 ' ' 2 43 ' ' 3 44 ■ • '> 45 ' • 6 Menstruation ceased at the ape of 46 in 2 cases " •• 47 " 4 •• " •• 43 " 5 •■ " " 49 " 4 "and 1 still men- •' " 50 " 4 5J •' 3 53 " » ' sirualing at that age 'and I still men- — struating at that age Total 55 Perhaps the most interesting class of facts in connection with this subject has reference to the latest age at which menstruation may occur. There is very little doubt that some of the cases related as cases of late menstruation are not cases of menstruation proper at all; but it must be allowed that occasionally a discharge, sanguineous and periodic, may be present at a very late age. Gardicn re- lates the case of a woman said to have been perfectly regu- lar at the age of 75. Up to the age of 55 there are a sufficiently large number of cases; but after that age true menstruation is exceedingly rare. Brierre de Boismont gives five after the age of 55, out of 181, one being as late as 60. Roberton (. (//. p. 185) gives four out of 79 as occurring after 55, two of which were at the age of 60, and one as late as 70. Lastly, Szukits gives one case (his latest) at the age of 60. Some, apparently well authenticated, cases of menstrua- tion at very advanced ages, viz., at 91, So, 87, 59, and 70 years of age, are related in the work of the late Dr. D. D. Davis.* " Principles and Practice of Obstetric Medicine," vol. i. p. 239. Menstruation ceased at 65 in i case '• " 72 " I " Total . . q 58 DISEASES OF WOMEN. In reference to the foregoing statements, it is probable that many of the apparent exceptions to general rules quoted were cases in which pathological elements were more or less intermixed. Menstruation ceases earlier in India; but everywhere the duration in years is much the same. For about thirty years menstruation continues. Roberton is of opinion that early cessation is chiefly noticed in those cases in which the function has been established at an early period. In most of those cases, however, in which the function contin- ues to be exercised up to the age of 53 or 54, the period of commencement has not been unusually late; in such cases, the menstrual life far exceeds the average of thirty years. Dr. Beigel,* the able editor and translator of the two former German editions of this work, gave this observation on 500 cases: of 126 cases where menstruation had ceased, there were 9 cases of late menstruation. Menstruation ceased at 51 in i case 52 " 2 " 53 " I " 54 " I " 55 " 2 " Periodicity. — The usually accepted statement is that the time included between the day of the appearance of the discharge and the corresponding subsequent day is twenty- eight days — a lunar month; but the difference presented by individual cases in this respect is so great as to show that any rule generally applicable must have rather a wide range. Many women menstruate regularly every three weeks; and a less number menstruate every calendar month, or a little over. In another class of women there is great irregularity, the period varying from time to time consistently with health. It is only, then, in the majority of instances that menstruation occurs every lunar month. There is often evidence that peculiarities in respect to the menstrual period are transmitted from one generation to another. Number of Days duritig which Ihe Discharge continues. — In 562 cases examined by IBrierre de Boismont, the discharge continued 8 days in 172 individuals; the number of days next frequently observed was 3; the next 4. The conclu- sion arrived at by this author was that the menstrual flow * German edition of this work (Enke, Erlangen), p. 245. HISTORY OF THE UTERUS AND OVARIES. 59 continues longer in towns than in the country; and longer in small, nervous, delicate women, than in those who are tall, robust, and of a sanguine temperament; longer also in those who lead a sedentary, easy, voluptuous life than in those who follow active occupations, whose diet is condu- cive to health, and whose habits are regular.* In women who are beginning to menstruate, the discharge lasts gen- erally a short time for the first few months, its duration in- creasing subsequently. The time during which the dis- charge continues is, in general terms, three to seven or eight days; but the observer must be prepared to meet with great variations in this particular. Quantity. — Late observers (Magendie excepted) consider the typical quantity of sanguineous fluid which is lost at each period to be three to four ounces, or even less than this.f The older estimates considerably exceed this in amount. The quantity appears to be greatest about the middle of the period in the majority of cases. Sudden ces- sation for some hours together, followed by copious dis- charges, whether accompanied by coagula or not, is ab- normal; for when there is no impediment the flow continues persistently and uninterruptedly, though it may be more in quantity at one time of the day than another. Quality of the Fluid dischar^:;ed. — The researches of Dr. Whitehead, Donne, and others, have conclusively shown that the discharge observed is really composed of blood; and that when obtained immediately from the uterus, and before it has been subjected to the action of the acid mucus of the vagina, it is coagulable just as is ordinary blood. As an illustration of this fact we find that, when the menstrual flow is excessive, clots are not unfrequently discharged. Ordinarily, as it flows from the vulva, it has acquired an acid reaction, and is no longer coagulable. For the first few hours the discharge is paler, it then becomes of a deeper red, and again appea.-s of a lighter color as it is about to disappear. The odor of the menstrual secretion is peculiar; formerly extraordinary effects were attributed to it, which it is unnecessary to enumerate here. The vary- ing qualities of the vaginal and cervical secretions have l^robably more influence in altering the qualities of the menstrual fluid than any varieties of the fluid itself as it exudes from the uterus. 0^. (it. p. 143. f Farre, loc. cit. p. 663. 6o DISEASES OF WOMEN. CHAPTER III. Examination of the Ui'erus and Ovaries. Digital Examination of the Uterus" from the Vagina. — Position of the Patient. Double Examination of the Uterus. Digital Examination of the Os Uteri and of tub Vaginal Part of the Cervix Uteri. — Normal Condition of the Os and Cervix — Method of Examination — Apparent absence of the Os Uteri; various causes — Unusual Softness of the Os Uteri from Pregnancy or other Causes — Unusual Hardness of the Lips of the Os Uteri; its Causes — Size of the Os Uteri — Variations in the Length of the Vaginal Portion of the Cervix Uteri; Relation of Pregnancy to this Condition. Examination of the Uterus by Means of the Sound. — The In- strument; Method of Introduction — Variations in the Length and Di- rection of the Uterine Canal detected by the Sound. Examination of the Os Uteri by Means of the Speculum. — Gen- eral Rules — Method of Using the Instrument — Description of Various Instruments. Examination of the Ovaries. In order to obtain precise information as to the physical condition of the uterus and ovaries, a physical examination is indispensable. The examination is made by means of the finger introduced into the vagina, sometimes also into the rectum, and further information may often be elicited by means of palpation over the hypogastric region of the ab- domen. DIGITAL EXAMINATION OF THE UTERUS FROM THE VAGINA. To practice digital examination of the uterus from the vagina, the patient is usually placed on the side. The pa- tient should be laid on the side close to the edge of the couch, and the trunk of the body placed somewhat across the couch. The knees should then be drawn upward, so as to be quite at right angles to the bod3\ This position enables the observer to reach with the finger much higher in the interior of the pelvis than is possible in any other way. It is some- times necessary in cases of suspected pregnancy, DISEASES OF WOMEN. nal portion of the cervix be previously ascertained by digi- tal examination, this difficulty is less likely to occur. The Os is not pervious to the Instruvieiit. — This is a cause of difficult}^ which is generally anticipated by digital exami- nation, for the practiced touch easily recognizes the pres- ence or absence of the depression and opening of the os uteri. In cases where the finger fails to find an aperture, it is necessary to have recourse to the speculum, in order to ascertain by actual inspection of the part whether a mi- nute opening can be detected. The absence of an opening ^ is rare; such a condition is, in most instances, a congenital one, and the patient has never menstruated. In a few cases, however, the os be- comes sealed up, no trace of its existence being observed, in wo- men who have had children, and also, rarely, in women who have been subjected to operations the nature of which is such as to lead to contraction of the tissues around the OS uteri. Contraction of the Canal of the Cervix. — When the instrument is engaged in the canal, its further passage may be prevented by con- traction of the canal itself. It is not very common to meet with an obstruction to the passage of the instrument, from this cause at least, lower down than i inch or \\ inch from the os uteri, although the occasional existence of con- traction at this point, congenital or acquired, is not to be denied. The cavity of the cervix uteri is tolerably capacious, but at its superior termination — the internal os — the canal is ordi- narily narrowed; and in the nulliparous uterus it is custo- mary to find that when the instrument reaches the point of junction of the cavity of the cervix and the cavity of the body of the uterus, there is a slight resistance. The nature and kind of resi^ance here alluded to will be better under- stood by reference to Fig. 12, copied from an exceedingly accurate drawing by Dr. A. Farrc. It represents a section EXAMINATION OF THE UTERUS AND OVARIES. JJ of the uterine cavity, and the extent and direction of the cervical canal. In women who have had children, however, this kind of difficulty no longer exists. Without exercising anything like forcible pressure, any ordinary resistance is readily got over. It requires care to discriminate between contraction and those other conditions which may impede the progress of the instrument, next to be alluded to. The Point of the Instrument may become engaged in one of Fig. 13.* the Lacunce or Depressions of the Cervix Uteri and its further progress arrested thereby. This is one of the most common causes of difficulty in introducing the uterine sound. By gently withdrawing the instrument and again introducing it, at the same time slightly altering the direction in which it is pointed, this difficulty wilj be readily overcome. pig. ;3 represent? retroflexion of the uterus, 78 DISEASES OF WOMEN. The point of the instrument may be arrested by the cxisf- ence of curvature or distorlion of the canal of the uterus. When the uterus is benl backward (retroflexion) or forward (ante- flexion), the instrument is stopped abruptly at the seat of the flexure. When the resistance met with is due to retro- flexion, a tumor may be felt behind the upper part and back of the vagina — the fundus uteri; and it is necessary, before introducing the sound, to turn it so that the concav- ity is directed not forward, but backward. With a little management, the sound then passes round the curved part of the uterine canal, and backward into the centre of the fundus uteri. In like manner, in the case of anteflexion, the obstacle to the introduction of the sound is to be re- moved by giving the instrument a sharper curve forward than usual, the concavity in this case being directed an- teriorly or by pressing the handle backward. Further re- marks on the subject of the use of the sound when the uterus is flexed will be found in the chapters on Flexions of the Uterus. In cases when the sound does not readily pass, it is a good plan to use the speculum, to draw the anterior lip of the os down gently by means of a small tenaculum, and then to introduce the sound. The canal is thus drawn more nearly straight and the entry of the sound facilitated (see Fig. 15). In the use of the sound we have, of course, a very com- plete and easy method of measuring the /crgih of the cavity of the uterus. These variations are themselves signs of great value in the diagnosis of uterine disease; the deduc- tions to be drawn therefrom are now to be pointed out. Pi-ofessor Simpson has, in one of his original memoirs on the uterine sound, so fully considered this branch of the subject as to leave little to be added. I have chiefly fol- lowed tiie account given in the memoir in question. The usual length of the uterine canal from the os to the fundus is 2^ inches, but a slight increase or a slight diminution of this measurement {e.g., to the extent of \ inch) is very fre- quently observed, and quite consistently with the uterus being in a healthy state. THE LENGTH OF THE UTERINE CANAL GREATER THAN USUAL. This may be caused by any one of the following condi- tions: Recent Delivery. — If the woman has had a child, the in- EXAMINATION OF THE UTERUS AND OVARIES. 79 creased length may be due to a persistence of the hyper- trophy with which the uterus is affected in consequence of pregnancy. After dehvcry tlie uterine cavity measures from six to eight inches, and this measurement is found grad- ually to diminish, until after six or eight weeks it resumes, under ordinary circumstances, its previous size. Lo/i_s:itii(ii'ial Hypcrtrop/iy 0/ the [/tents \s another condition of the organ in which the sound passes inward for a greater distance than usual. This species of hypertrophy occurs quite independently of pregnancy. For the most part the cervix of the uterus is the portion affected: this is length- ened out and extended, whereas the cavity of the body of the uterus remains nearly as usual, or participates but little in the change. In many cases where the uterus is apparently prolapsed, the OS uteri being very low down, this does not proceed from prolapsus of the whole organ, but from the presence of hypertrophy and elongation of the cervix alone, of that part of the cervix which is above the vagina. The sound, when used under these circumstances, is a most valuable me^ms of diagnosis. In prolapsus constituted by hyper- trophic elongation of the cervix, the sound can be made to ]iass upward for a much greater distance than usual. Sir James Simpson mentions cases in which it passed inward to a depth of four or five inches; and Muguier, whose observa- tions are more recent and extensive, in an average of a large number of nses, found the length of the uterine canal to be 4J inch s; in extreme cases, a length of 9 inches was attained. In cases which I have examined, with the object of testing riuguier's statements, I have found the length of the ute» me canal to amount to as much as G\ and 7 inches. There is a fallacy connected with the use of the sound in these cases, with which it is well to be acquainted in order that an erroneous inference may not be drawn. The sound is sometimes arrested two inches or so from the OS uteri, by the curve which the lengthened cervix uteri makes at this point, and in one instance I found it neces- sary to pass the finger into the rectum, when, by pressing against the convexity of the curve in question, the sound readily passed inward between two and three inches further. We have two categories: [a] those in which the (•(V-rvV^/ cavity is lengthened and at the same time pro- lapsed; and {b) those in which the uterine and the cervical cavity are both lengthened, the os uteri remaining at or about 80 DISEASES OF WOMEN. its usual place, at the summit of the vaginal canal, or not remaining in this position. I have seen a case in which tumor of both ovaries was present, the upper part of the uterus was dragged up, and at the same time the lower part was pushed downward. The canal of the uterus had an excessive length. (See Prolapsus.) Fibroid Tutiiors of the litems frequently occasion a con- siderable increase in the size of the cavity of the organ — a circumstance rendered evident by the use of the sound. The size of the tumor may, however, be considerable, and the size of the uterine cavit)^ remain unaffected. The in- crease in the length of the uterine cavity due to the pres- ence of fibroid tumor may reach to such an extent that the sound passes in to a depth of 6, 7, or 8 inches, a possible fallacy Sir J. Simpson calls attention to in connection with this subject. In long-standing cases it sometimes happens that the pressure produced by large fibroid tumors occa- sions the opposite sides of the uterine cavity to adhere, and the sound is arrested some distance below the real position of the fundus uteri. The diagnosis between lengthening of the cavity caused , by dragging of the fundus of the uterus upward, and that caused by the presence of fibroid tumor in the walls of the uterus, turns on the relation which is found between the sound while in the uterus, and the tumor occupying the pelvis and projecting upward in the hypogastric region. As a general rule, when an ovarian tumor is dragging the fundus uteri upward, and thereby lengthening its cavity, the sound is found to be anterior to the tumor. To this rule there may be occasional exceptions; and when the tumor is situated laterally in reference to the sound, this means of distinguishing between the two is not available. When the tumor dragging up the uterus is extra-uterine, one side and corner of the uterus is generally more drawn up than the other: this gives the course of the sound up- ward a certain obliquity, often characteristic. Fibroid Polypus of the Uterus. — When the polypus remains within the cavity of the uterus, the length to which the sound can be introduced is increased in proportion to the size of the polypus. By means of the sound, a very perfect idea can sometimes be obtained of the relations and place of attachment of the polypus, for the point of the instrument can be made to travel round the included mass between •t find the uterine walls. Q^\'^ must be cxerci^^d not to EXAMIXATION OF THE UTERUS AND OVARIES. 8l fall into the error of taking the pedicle of the polypus for t'.ie summit of the uterus; it is possible for the point of the sound to be arrested at this point when first introduced. Hypertrophy of the Uterus. — The increased length of the uterine cavity may be due to hypertrophy of the organ, a condition wliich is now and then found to be present, unas- sociated witli any of the conditions causing lengthening of the cavity hitherto described. The lengthening which oc- curs in connection with this condition is never very consicl- erable in amount, the measurement not generally exceed- i"& 3i to Z\ inches. This hypertrophy and consequent lengthening (jf the canal maybe due to long-continued con- gestive hypertrophy of the uterus, repeated miscarriages, or to defective involution persisting for a long time after delivery. In cancer of the funJus of the uterus, the organ might be found unduly lengthened, without marked evidence of dis- ease of the same kind at the cervix. In the very rare dis- ease, tubercle of the uterus, elongation and increase in the size of the organ have been observed to be present. Lastly, in cases of undue patency of the Fallopian tube, the sound may pass to an unusual length. It is always neces- sary to examine carefully into the previous history of the patient, and to compare the results of examination by the sound with those derived from examination of the hypo- gastric region of the abdomen, and it is advisable to come to no conclusion until a combined examination by the sound internally, and by the hand placed over the hypogas- trium, has been performed. THE UTERINE C.WAL IS SHORTER THAN' USUAL. When the depth to which the sound can be introduced ir. less than usual, this may proceed, following Sir James V. Simpson's classification, from one of the following causes: Preternatural Shortness of the Organ generally, a congenital Condition. — This congenital shortness of the canal is met with where the uterus is imperfect!)* developed, the whole organ being smaller than usual, or in cases in which the organ is unequally developed on the two sides. The con- dition of the external generative organs may be apparently quite normal, and the sexual instinct present to the usual degree, and yet there may be imperfect or defective devel- opment of the uterus itself. The uterus may be double, or S2 DISEASES OF WOMEN. one side only may be developed, or one side may be devel- oped to a certain degree, and on the other side may be found a less fully developed cornu. These conditions are not fre- quently met with in practice,* but the possibility of their occurrence must be kept in view, or the results of examina- tion by the sound might prove embarrassing. Stricture of the Uterine Canal or Partial Ol'litcration due to Pressure of Tumors, etc. — The apparent shortening of the canal due to stricture has been already alluded to in speaking of the difficulties attending the introduction of the sound. In old people the internal os uteri, which is the point at which the stricture, when present, usually exists, is often obliterated (Mayer, Matthews Duncan). The cavity of the uterus proper — that is to say, the portion above the inter- nal OS uteri — may also be obliterated, and the sound is then arrested at the same point. When the canal is obliterated hy pressure, as by large fibroid tumors growing in the walls of the uterus, shortening of the canal may be a consequence. Partial Inversion of the Uterus. — The shortening due to partial inversion could not possibly be mistaken for that due either to stricture or imperfect development of the uterus. In partial inversion, there is a tumor projecting from the os uteri; the sound passes into the os uteri by the side of this tumor, but cannot be introduced so far as usual. Practical experience has shown that, in some cases, the diag- nosis between partial inversion and polypus of the uterus is one of the extremest difficulty; but with the aid of the data obtainable by a careful use of the uterine sound, we may hope to s^irmount this difficulty. The important diag- nostic fact is that the sound passes inward to a less depth than usual on all sides of the projecting mass. If the case be one of polypus, the sound passes inward to the usual ex- tent, and the hand over the hypogastric region discovers the fundus of the uterus in its usual place. When polypus is combined with partial inversion tlie difficulty is greatly in- creased, and in such a case careful measurement of the depth of the cavity, examination of the tumor itself, examination fer rectum, and of the hypogastric region, must all be brought to bear in forming a decision. Atrophy of the Uterus is in rare instances observed after * For further information on this subject the reader is referred to the work of Kcssmaul, "Von dem Mangel, der VerkUmmerung und Verdop- pUing der Gebiirnjuiter." WUrzburg, 185S. feXAMIXATlON' OF THE UTERUS AND OVARIES. S3 labor; here also the cavity of the uterus is found to be shorter than natural. Lastly, the caution may be repeated, that flexion of the canal, causing arrestment of the proj^re^s of the instru- ment, may be confounded with actual sliortening. EXAMINATION OF THE OS UTERI BY MEANS OF THE SPECULUM. By the use of the instrument known as the "speculum. " we are able to obtain ocular evidence of the condition of that part of the uterus which projects into the vagina, ami of the orifice or os uteri. The speculum should never be used without a previous digital examination. The digital examination will be the means of informing us whetlier the state of the parts be such as to render it unadvisable or impossible to use this instrument. Further, a knowledge of the size, length, etc., of the vagina, ascertained by means of a digital examination, is necessary in order that the instrument selected may be adapted to the peculiarities of the case. The use of the speculum is objectionable in the case of young unmarried wtmien, especially in those in whom the hymen is intact. For purposes of diagnosis the use of the instrument can but rarely be considered necessary under sucii circum- stances. In cases of cancer of tlie uterus the instrument should be used with great care: haemorrhage of a serious character may be set up by careless employment of the speculum under these circumstances. [There is no such danger with the Sims speculum used properiv.] The cases in which tlie speculum is most commonly used for purposes of diagnosis are the following: Cases of obsti- nate leucorrhoca in which there is reason to suspect the presence of an abnormal condition of the cervix uteri and of the glands there situate: cases of menorrhagia, or re- curring haemorrhage, for the purpose of ascertaining the presence or absence of small polypoid growths within the OS uteri, and which may be so small as not to be detected by digital examination; cases in which it is considered advisable to examine ocularly the condition of the poiiio vaginalis and os uteri, and tlius of obtaining evidence as to the presence and nature of ulcerations, abrasions, excoria- tions, lacerations, etc.. of the parts in question. It is em- ployed in cases in whicli it is considered aflvisable to ex- plore the interior of the uterus itself, to facilitate, in some 84 DISEASES OF WOMEN. cases, the use of the uterine sound, and it is essential in the performance of some operations involving the cervix or os uteri. Method of using the S eculuni. — The mechanical con- trivances for getting a view of the os uteri are ver)' numer- ous. Simple tubes, tubes slit up into two or three seg- ments, and lastly the duckbill univalve instrument — known as Marion Sims's — have been successively employed. It is needless to describe these various instruments in detail. The two instruments which are, in my opinion, best Fig. 14. adapted for the purpose are a short bivalve instrument (a modification of Cusco's speculum) and Sims's speculum. The modified Cusco's speculum I have used for some time, but the one I employ is large at the mouth, and very portable. Messrs. Weiss have improved the method of separating the blades, and it is now a very complete instru- ment (Figs. 14 and 16). It has the advantage of bringing tlie OS uteri near to the ostium vagina;, a most impoitant point, and the aperture or mouth being large (i^ in. by if in.) great facilities for operations are offered. Its length is only four inches. It is kept in place by its own action and requires no assistant. EXAMINATION OF THE UTERUS AND OVARIES. 85 In using this instrument, the patient should be placed on the side with the knees drawn up, and the hips, a little higher than the thorax, should be quite at the edge of the examining couch. The speculum, previously oiled and warmed, is introduced in the collapsed shape, and care .taken to direct it backward. The chief difficulty is at the ostium vagina;, but this is overcome by drawing the four- chette a little back with the forefinger of the left hand, and inserting the speculum just at first a little obliquely as re- gards the plane of the aperture. It should be passed as far as possible before screwing the blades open, and when the screw has been turned about three times it should be as- certained whether the os uteri is in view. It frequently happens that the speculum has nt»w to be directed a little more backward, in order that the os may be brought into view. The further separation of the blades is then effected. When the vagina is very long and narrow this speculum does not answer quite so well, but if the vaginal aperture be dilatable it is of great service, for in separating the blades the os is brought down into view by a mechanism which will be sufficiently obvious. In* cases where the ostium vaginae is very narrow, a smaller-sized instrument of the same kind would be required; but under such cir- cumstances the use of the speculum is not often necessary. In withdrawing the instrument it is best to allow the blades to collapse to within half an inch of each other, so as to prevent the vaginal walls being caught between tiiem. The drawing (Fig. 14) shows the position of the instru- ment when introduced and the blades separated to an aver- age extent (i| in.). It will be observed that a good deal of the length of the instrument is expended on the vulva. A great merit of this instrument is that it expands the vulvar part of the canal. Dr. Meadows's speculum made by Ma\'er and Meltzer, somewhat resembles Cusco's, but two lateral additional blades are provided so as to separate the vaginal walls laterally. Further, the distal end is smaller, so that it is a little more easy of introduction than the one above de- scribed. Another speculum is that of Dr. Marion Sims, and a most valuable one it is. It is kept in two sizes, giving thus the advantage oi four blades, each of different width. This instrument requires the aid of an assistant. It is necessary to pay particular attention to the placing the patient in a 86 X)ISEASES OF WOMENf. proper position. The patient must be placed as follows: Having been brought quite to the edge of the couch, which should be about the height of an ordinary table, she is laid on the side, and the knees drawn up to the abdomen. The left arm is then placed at full length behind the back. This throws the chest a little forward. I have found it best also to raise the hips by means of a thin hard pillow or other- wise. The speculum is then introduced, care being taken to keep tiie point of the blade close to the posterior wall or floor of the vagina. The larger or smaller blade is used according to circumstances. When the blade is /// siiu, the instrument is pulled backward in such manner that the floor of the vagina is pree:sed against the rectum. Tiie perinaeum is thus stretched, and at one and the same mo- ment the ostium vaginae and the vaginal canal are dilated. The fundus of the uterus falls a lilllc forward in conse- EXAMINATION OF THE UTERUS AND OVARIES. 87 t^uence of the position of the patient, and air of course enters the vagina. It is found tliat in some cases a perfect view is now given of the os uteri. In others the bladder and anterior vaginal wall project backward so as to impede the view, and when this happens the uterine sound or the finger must be used to pusli the projecting part aside, or, what is still better, a hook may be fixed into the anterior lip of the OS and the uterus gently drawn down. Dr. Sims uses a small delicate tenaculum hook for this purpose. The one here figured (Fig. 15), and which I have been in the habit of using, is a little firmer and stronger, and more bent back. It will be found that in drawing down the uterus it is necessary simultaneously to draw the speculum a little in the same direction. Fig. 16. A self-retaining Sims speculum has been a good deal em- ployed in America. By the use of this instrument the aid of an assistant can be dispensed with. Both Mr. Spencer Wells and Dr. Savage have also introduced instruments constructed on the same principle. The view of the os and cervix uteri afforded by the Sims speculum is exceedingly good. Manipulations on the parts in question are effected with extreme facility. The use of the hook is not attended with any bad result, but when the patient is straining, as not unfrequenily happens during the exhibition of anaesthetics, care is required not to lace- rate the parts. Fig. 15 represents the large blade in situ, as when first introduced. The hook having been inserted is drawn down 8S DISEASES OF WOMEN. about an inch in the direction of the vulvar aperture, bring- ing the OS uteri with it. In some cases tlie bivalve instrument is better than the univalve; but where assistance is easily procurable the lat- ter is very much to be preferred. The bivalve instrument (Fig. i6 — Cusco improved by Weiss), as above described, is so superior to the older bi- valve instruments, that I do not describe them. The tubu- lar glass speculum — known as Ferguson's speculum — is also very inferior to it. Neugebauer's is a bivalve specu- lum, the two blades being distinct and separate. Dr. Barnes ("Obstetrical Transactions," vol. xiv. p. 309) de- scribes and delineates an improved form of this instrument. In a few instances, as when the speculum is used to ex- plore the condition of the vesico-vaginal septum in cases of fistulae, it is advisable to place the patient on her hands and knees, so as to give the observer a good view of the roof of the vagina. The Sims speculum is the best to use in this class of cases. The bivalve speculum may be used with the patient in the lithotomy position, but the other plan is far preferable. It is generally necessary, by means of a dossil of lint held at the extremity of a pair of long dressing forceps, to re- move the secretions with which the surface of the exposed part is covered, in order that the mucous membrane itself may be inspected. APPEARANCES AT THE OS UTERI OBSERVED BY THE SPECULUM. The ^^ OS uteri" is the lower opening of the canal of the cervix. It is a round opening, occasionally, however, trans- verse in shape, bounded by two " lips," an anterior and a pos- terior; tlie lips are smooth, uniform, and regular, when the woman has had no children, but the surface is more or less fissured, the os uteri being bounded by less regularly formed lips in women who have borne children. The vir- gin OS uteri is, when normal, uniform, the vaginal portion regular and conical in shape; that of multiparae is larger, irregular, and usually softer. The appearances presented by the surface of the os uteri it is particularly important to bear in mind. The lips of the os uteri — that is to say, the surface of these lips — pre- sent an appearance very different from that which is ob- served in the interior of the os uteri, and under ordinary EXAMINATION OF THE UTERCS AND OVARIES. S9 circumstances the view obtained by the specuhim is not simply that of the labia of the os, but of a portion of the interior of the cervix also, which has a tendency to be opened out by the action of the speculum. The surface of the interior of the cervix differs greatly in appearance from that presented by the surface of the labia, both in regard to the color and in other essential particulars, and there is an abrupt line of demarcation always evident and generally remarkably so, between the surface of the interior of the cervix and that of the labia of the os uteri. The lining of the cen'ix uteri — the minute anatomy of Fig. 17.* which was first thoroughly described by Dr. Tyler Smith — is not smooth, but furrowed and plicated so as to present numerous depressions and elevations (Fig. 17), by which the amount of surface is very largely increased. The ar- rangement of the folds or plicae varies in different cases. There are usually four prominent elevations longitudinally placed, and four columns of rugce or folds of mucous mem- brane; and lateral transverse branches are given off from these, the whole thus acquiring a palmated aspect ; and between these different elevations are seen others more minute, the whole surface thus presents a cribriform aspect. * Fig. 17 is a magnified representation of the interior of the cervix Uteri. (From Tyler Smith.) 90 DISEASES OF WOMEN. The observer, under ordinary circumstances, sees the lower and a small portion only of the surface of the interior of the cervix. Contrasting with the cribriform irregular surface just described, the labia of the os uteri present a smooth uni- form mucous surface. The labia may themselves be lobu- lated, and thus irregular, but the surface itself is smooth and uniform. The epithelium covering the labia is of the squamous variety, identical with that lining the vagina, but luiihin the cervix the epithelium changes, and the sur- face is covered by cylindrical epithelium. Higher up with- in the cervix, and therefore usually beyond observation by means of the speculum, the epithelium becomes ciliated. The surface of the labia of the os uteri is covered by a somewhat thick layer of squamous epithelium, as already remarked. Beneath this epithelium is a fine basement membrane, and these two cover certain important struc- tures — the villi ox papillcB. These are long, single, or bifur- cated, vascular bodies, sometimes so large as to be visible to the naked eye. They are rendered evident by macerat- ing the cervix uteri in water, when, the epithelial covering becoming detached, the villi are seen forming an irregular fringe over the whole surface. Within the cervix there are also villi of a somewhat analogous character, but not bound down and hidden by epithelium as in the other position, and the villi are three or four times larger: they contain in both situations looped blood-vessels. The interior of the cervix further differs from the labia of the os uteri in being provided with an enormous number of mucous crypts capa- ble of pouring out secretion in large quantity, whereas there appears to an almost entire absence of these glandu- lar organs in the mucous membrane covering the labia. Thus, if tb.e whole of the epithelial covering were re- moved from the surface of the labia of the os uteri there would be presented to the eye a bright red, somewhat ir- regular, surface constituted by the free extremities of the villi in question. An appearance somewhat similar to this is normally presented in the cavity of the cervix by the villi there situate, but in the latter position the cervix is more irregular, due to the large size of the villi, and of a deeper red, owing to their greater vascularity. EXAMINATION OF THE OVARIES. In a state of health it is not easy to determine the outline SYMPTOMATOLOGY OF DISEASES OF UTERUS. 9I and position of the ovaries by means of the touch, in con- sequence of their position. Ordinarily there is sufficient space between the upper part of t!ie vagina and the ovary to prevent the finger easily touching tlie ovary. In order to practice digital examination of the ovary, the patient should be placed on the side with the knees well drawn up, and the finger passed as high as possible in the vagina. The point of the finger may tiien be pushed in the direction the ovarv is known to lie in until its presence is made evi- dent. The resistance of the tissues is in a state of health considerable, and much pressure may be required to reach the surface of the ovary and define its outline. The ovoid shape of the ovary and its size, together with a certain degree of mobility, are the characteristics to be sought for. When the ovary is displaced from its proper position, or when it is enlarged, it is much more readily felt. On the other hand, when it is bound down by adhesions it may be difficult to recognize it. In some cases a double examination is practicable, the fingers of the other hand being pressed downward from above through the brim of the pelvis. The success of this manoeuvre depends on the abdominal muscles being lax and tliin, and on the absence of a layer of fat in the parietes of the abdomen. In a few cases, by means of the double touch, as above described, the outline and size of the ova- ries can be very accurately determined. There are other objects liable to be met with on exercis- ing a digital examination. In cases when the Fallopian tube is enlarged or dropsical the enlargement might be confounded with the ovary, or portions of the intestine descending into the Douglas pouch might possibly simulate the outline of the ovary. CHAPTER IV. Symptomatology of Diseases of the Uterus, List of Symptoms Observed. — Uterine Dyskinesia, its Importance and Frequency — Hysterical Symptoms — Cerebral Symptoms. The method ordinarily pursued in describing the diseases of the female sexual organs is to arrange the subjects under various heads — some of these heads representing the diseases regarded from a pathological point of view, others 92 ■ DISEASES OF WOMEN. beinf^ mereh' names of symptoms. "Inflammation of the uterus" and " Leucorrhoea" may be given as specimens of this nosology — the first, pathological; the second, symp- tomatic. The method of clinical observation I have pursued has made me acquainted with certain important omissions in regard to the symptomatology of uterine diseases. I have always adopted the practice of questioning patients par- ticularly as to the sensations or pains or discomforts which they experience. These are found to constitute some of the more important of the symptoms presented by patients, and when due care is taken to put no leading questions, but to allow the patient to give her own reasons for obtain- ing medical advice, and in her own w'ords, very valuable data can be obtained — data which when properly arranged are highly instructive and often capable of throwing great light on the diagnosis of the case. The following is a list of svmptoms of all kinds which may be observed in con- nection with diseases or affections of the female sexual or- gans, these symptoms being placed as nearly as possible in their order of frequency. This list of symptoms I have on another occasion made the basis of a clinical discussion of the subject,* and I here reproduce it: Pain (in the region of the uterus, or near it) — 1. Spontaneous. 2. Produced by motion (uterine dyskinesia). 3. Undue sensitiveness to the touch. Leucorrhoea. DysmenorrhcEa. Menorrhagia. Amcnorrhcea. If married — Sterility, abortions. Various reflex phenomena: 1. Sickness or nausea. 2. Hysteria. 3. Convulsions. 4. Cephalalgia. 5. Melancholia. Disturbance of functions of the bladder. Disturbance of functions of the rectum. Disturbance of sexual functions (dyspareunia). * Harveian Lectures, " The Mechanical System of Uterine Pathology. ' J^ongmans, 187S. SYMPTOMATOLOGY OF DISEASES OF UTERUS. 93 A noticeable fact in connection with the symptomatology of uterine diseases with which my observations liave made me acquainted is the remarkable frequency of a symptom which lias attracted very little attention at the hands of writers on gynaecology, but which is so frequently present that I have come to regard it as very important. I refer to the symptoms standing second in the list justenumerated — viz., pain in the neigiiborhood of the uterus produced by motion. I have termed it uterine dyski/ieia. By this is meant a painful sensation, or actual pain, or discomfort of any kind, and felt either at the back of the pelvis, or in front, or at the side, but always produced, or originated, or ag- gravated by some movement of the body by standing, or walking, or stooping, sometimes even by sitting. This uterine dyskinesia is really more commonly observed than almost any other symptom. I think it desirable to draw attention thus prominently to it, not only on account of its great frequency, but on account of the fact that it appears to be so important a symptom. Important for two reasons: firstly, because patients themselves so constanth' allude to it, and desire to be relieved of it; and secondly, because it suggests at once the importance and preponderance, as causes of suffering and discomfort, of distortit;)ns, fie-xions, and changes of position of the uterus. The frequency of the symptom has led me to carefully investigate its source and origin, and with the result that I have been led to re- gard these distortions of the uterus as playing a part in the female economy second to no other in causing suffering, pain, discomfort, and chronic incapacity for work and vari- ous kinds of exertion. Although in a few cases the dyski- nesia is traceable to disease of the ovary, in the verj' large proportion of cases it is the uterus which gives rise to the occurrence of the symptom in question. Another symptom in the above list is undue sensitiveness of the uterus or parts adjacent to the touch. One class of cases is that in which the condition present is that termed by Dr. Gooch the " irritable uterus." These cases, as will be found fully set forth in later chapters, can be now satis- factorily explained and shown to be cases of acute flexion of the uterus accompanied with congestion, the extreme sensitiveness and tenderness being due to this congestion and distortion of the organ. A series of symptoms often observed in women are the •'hysterical symptoms" so called. In truth the relation of 94 _ DISEASES OF WOMEN. the nervous s\'Stem to the sexual organs in women is one requiring a separate and full consideration if tliere were time and opportunity for it. These so-called hysterical symptoms are deserving of a very attentive inquiry in view of the recent adtlitions to our knowledge of the diseases of the sexual organs. The more rational and simple explana- tions which can now be given of various hitherto obscure symptoms liable to be observed in women will be found to extend themselves to the peculiar nervous manifestations hitherto described as " hysterical;" and for my own part I am quite convinced by the numerous carefully observed facts which have come under my notice, that many of these hysterical symptoms can no longer with any degree of ex- actness be regarded as " fanciful " and intangible and in- explicable, but that they will be found susceptible of a simple interpretation. We may even go further than this. There appear to be very good grounds for the belief that some few at all events of the cases of " mental " disease, long regarded as calling only for the attention of the alienist physician, are really insanities produced by diseases of the sexual organs, sus- ceptible of treatment and relief at the hands of the gynaecol- ogist. This is a subject which has attracted some attention in the United States at the hands of Dr. Storer, Dr. Fallen, and others. Dr. Peaslee recently stated in a discussion at a medical meeting in New York that he had met with, in asylums for the insane, several cases of women where the cause proved to be curable ovarian or uterine disease.* In my own practice I have encountered cases of a like char- acter. CHAPTER V. General Pathology of the Uterus. Historical Summary. — The Mechanical System of Uterine Pathology — Definition — Laceration of Cervix Uteri. Many important points in relation to uterine pathology, which have been subjects of much dispute, are now in process of settlement. At least it may be said that some things may now be taken for granted which were violently *"Amer. Jour. Obstet.," vol. x. pp. 206, 284. GENERAL PATHOLOGY OF THE UTERUS. 95 contested some seven years ago. The force of opinion is at present on the side of what may be termeci new views of uterine pathology, although there are not wanting authorities who are still content to travel on the old lines. It may be necessary to recapitulate a little, but in setting forth what appears to be a just and proper representation of uterine pathology as it stands to-day, the main object will be rather to represent the present, and to endeavor to connect it with the futnre, than to go at any great length into historical reminiscences. It appears probable, judging from hints and statements scattered through the writings of the older physicians, that the existence of displacements of the uterus have long been known — not merely the severe external displace- ments which could not of course have escaped recognition, but those less severe internal displacements only to be recognized by a skilled observer. But the fact remains that if the existence of these internal displacements were known, they were not properly and sufficiently described until comparativel}'^ recent times. It is probable that knowledge in regard to the importance of these (Hs])lacements would have made greater progress some years ago but for the fact that attention was drawn off from them by the advent of other pathological novelties. In the first place, the " inflammatory" theory was applied to the subject of uterine diseases, and little else was then thought of than accounting for the various discomforts and effects which they produce. In the next place, the dis- covery, or rediscovery, of the speculum played an important part in diverting attention from the subject of displace- ments. Attention was then concentrated on the appear- ances presented on inspection of the os and that part of the cervix uteri which could be exposed to view by its means. It is probable that in regard to advancement of the pathology of the uterus the speculum was as much a loss as a gain. The novelty of inspecting the os uteri and the work of classifying the various appearances there met with forthwith occupied almost the sole attention of the gynaecologist. Everything wrong in the feelings of the patient, every discomfort and incapacity, were set down to ulceration or inflammation of the os and adjacent portions of the cervix uteri. The use of the sight was thought all that was necessary, and the position, the shape and almost the very existence ot tie body of the uterus was icnoreU, q6 . DISEASES OF WOMEN. or at a\l events disregarded. The excessive and too exclu- sive use of the speculum after a time excited a reaction, but its influence is still apparent, and the evil effects of an ex- clusive employment of tins method Of observation are even now to be witnessed. [The advocates of exclusive mechani- cal treatment of uterine displacements sometimes make the mistake of not using the speculum. I have seen many cases that had been treated by pessaries for months witliout improvement, where there were eversion and erosion of the cervical membrane, and other inflamma- tory conditions which would have been detected if the speculum had been used, and which were readily cured by appropriate treatment. It is well to use every means for correct diagnosis.] The too exclusive attention which the os and cervix uteri had arrogated to themselves, simply because it was so easy to inspect them by the eye aided b)^ the speculum, was after a time shown to be erroneous by the influence of the writ- ings of Scanzoni, who first insisted on the great importance of the bodv of the uterus, and who directed inquiry to this neglected part of the organ. At the same time the condi- tion of the interior of the canal of the cervix uteri was made the object of attention by Tyler Smith. While, however, " inflammation" of the various parts of the uterus was occu- pying the attention of many observers, the displacements of the organ began to attract notice. At the very time when in France the ulceration and inflammation of the os uteri were by many regarded as of first-rate importance, Velpeau, in 1S54, expressed himself to the effect that, ac- cording to his experience, the majority of women treated for other affections of tlie uterus have only displacements, and tliat nine out of ten such patients in whom the affection is diagnosticated as inflammations are affected by displace- ments. The late distinguished professor at Edinburgh, Sir J. Y. Simpson, contributed greatly to the increase of knowledge on the subject of displacements of the uterus. The inven- tion of the uterine sound rendered the diagnosis of these displacements easy, and he was well acquainted with the grave importance of Lhese lesions. His beneficial influence in extending knowledge on this subject would possibly have been greater but for the fact that an instrument he had in- vented for the treatment of one variety of displacement GENERAL rATHOLOGV OF THE UTERUS. 9; proved to be dangerous to life in some cases where it was employed. It is difficult to assign accurately to different workers in the field ttieir proper share in the more modern advances which have been made in regard to the knowledge of dis- placements. Much has been done in the United States much, particularly of late, in Germany, but most of all i ■ England. It is strictly accurate to say that England au' America share between tiiem the chief merit : in Americ there has been a wider reception of some of the doctrine.'- originated on this side of the water than in England itself. [Our author claims too much for England on the score of priority. The distinguished Professor Hodge of Philadel- phia, the author of "Hodge's Pessary," and the no less dis- tinguished Professor Meigs, of Jefferson Medical College, both antedate Professor Simpson and his followers by many years. And Dr. J. Marion Sims informs me iliat Professe'r Hodge was preceded by Dr. Jennings of Baliimore, who always accused Hodge of appropriating his ideas on the mechanical treatment of displacements of the uterus.] In the last edition of this work, published in 1S72, I en- deavored to bring more precisely to a focus the conclusions which my own reading and careful observation had induced me to arrive at, and the exposition of the " Mechanical Sys- tem of Uterine Pathology" therein contained was the result of this attempt. The conclusion to which I had arrived in substance amounted to this, that the large majority of the discom- forts, pains, and inconveniences complained of by patients and referred to the generative organs, can be traced to, and shown to be dependent upon; the presence of mechanical changes in the uterus, and to the effects of such mechanical changes. The distortions of the uterus, together with the displacements of the organ, more or less associated, are thus made responsible for such pains and discomforts and various other symptoms as make up, when put together, the greater part of the affections of the generative organs in women. The conclusions seemed at first of so sweeping and gen- eral a character that I hesitated for some time to believe that such simplicity belonged to a subject which had always ap- peared so difficult; but as time went on, it was plain that there could be no mistake about it, and the more I saw, the 9§ DISEASES OF WOMlEN; more exactly and truly did the principles in question seem to apply themselves naturally to observed fresh facts. These conclusions were embodied in the three following propositions: " I. Patients suffering from symptoms referable to the uterus are almost universally found to be affected with flex- ion or alteration in the shape of the uterus easily recog- nized, but varying in degree. "2. The change in the form and shape of the uterus is frequently brought about in consequence of the tissues of the uterus being previously in a state of unusual softness [or what may be often correctly designated as chronic in- flammation.] "3. The flexion once produced is not only liable to per- petuate itself, so to speak, but continues to act incessantly as the cause of the chronic inflammation present."* Since that time nothing has occurred to shake my confi- dence in the substantial truth of the conclusions just stated; I have had, on the contrary, more reason than ever to be satisfied of their accuracy. The part enclosed in brackets, and which refers to " inflammation" alone, requires to be al- tered, as I have now a more complete and satisfactory ex- planation to give of that condition alluded to as " softness." There has been much misconception in reference to the word " mechanical," as used in the phrase "mechanical sys- tem of uterine pathology" — a misconception which it is neces- sary that I should at once deal with. The word mechani- cal is here employed to convey an idea as to the origin and nature of the disorder. B)^ it is intended to be conveyed the importance of the share which acquired distortions and alterations of pobition of the uterus — in a word, mechanical changes — have in the production of uterine suffering. The word mechanical has, however, apparently led some who have criticised the doctrines which I have upheld, to im- agine, quite unjustifiably, as I shall b}' and by show, that it has been my intention and desire to inaugurate the uni- versal and indiscriminate employment of instruments and mechanical appliances in the treatment of uterine disease. Nothing can be farther from my object. The principal argument employed by those who .^^'ill re- sist the idea of accepting the mechanical system of uterine pathology is that, admitting the frequency with which al- * See Third Edition of this work, p. 2. Longmans, 1872. GENERAL PATHOLOGY OF THE UTERUS. 99 terations of the shape of the uterus occur, these alterations are never of any consequence unless associated with " chronic inP.ammation," or, as some prefer to term it, " congestion," of the uterus. They affirm that the patient suffers not from the fle.xion, but from certain accompanying conditions, and go even so far as to say that fle.xion by itself produces no synptoms. The whole question will be discussed later on; here, how- ever, it may be mentioned that the point really in dispute is tiic connection which exists between the flexion and the other condition (termed variously chronic inflammation, con- gestion, etc.). There is no dispute as to the importance of this " other cou'lition." (In the three propositions above quoted, reference is specially made to it.) It is incumbent on those who controvert the mechanical theory to explain h >w and why it is that the uterus becomes affected with this "other condition," which they consider, and, from one point of view justly so, as so potent in producing suffering. No attempt has been made, so far as I am aware, to give this explanation. The only substantial criticism which has been made is to the effect that patients are relieved by treat- ing the congestion alone, the (listortion of the uterus being allowed to take its course. That relief to a certain extent is thus obtained is no doubt true. But this is no answer to the statement, demonstrable by clinical facts unlimited in number, that flexions are indubitably the principal cause of the congestion. Indeed, the congestion may often be at once removed by restoring tiie uterus to its proper shape. These subjects will of course be fully discussed later on. The question as to the nature of this "other condition" so liable to be associated with flexions is of the greatest interest. It is one v.hich has occupied my attention very particularlv, and an intelligible account of it can, I think, be now given. In substance the explanation is: 1. The uterus is very liable to fall into a state of passive congestion when it has become distorted and bent upon it- self, though it may become congested from other causes. 2. The uterus is very much more liable to become dis- torted when its tissues are in a soft, flaccid condition. 3. Softness and flaccidity of the uterus generally indicate malnutrition of the organ. 4. The so-called chronic "inflammation" is generally chronic congestion, the result of flexion of the uterus. Attention has been latelv attracted in the United States loo DISEASES OF WOMEN. to the effects of laceration of the cervix uteri during labor as a fertile source of various discomforts and serious changes in the uterus. Dr. Emmet, it appears, first practiced an oper- ation for the relief of this condition in 1862, and he pub- lished a paper on the subject in 1874. Dr. Emmet gives a full account of his researches and numerous operations for its relief in his lately published large treatise. He states that Roser first described an ectropium of the cervix result- ing from laceration. Dr. Emmet attaches very great im- portance to this lesion, and is of opinion that many of tlic recorded so-called cases of " ulceration" of the os uteri were really cases of this kind. There is no doubt that the sub- ject is one deserving of careful and close attention. This lesion has been curiously overlooked, and much benefit will accrue from a fuller acquaintance with its nature and treat- ment. A more particular account of this subject will be found in a later chapter of this work. CHAPTER VI. Abnorisial Conditions of the Tissues of the Uterus — Malnutrition of the Uterus — Abnormal Softness. Malnutrition of the Uterus or Abnormal Softness.— Its true Pa- thological Nature — Evidence of Existence of General Malnutrition in such Cases — Effects in Predisposing to, or Causing Distortions of, the. Uterus — Symptoms observed — Typical Cases. Under the older nomenclature the terms "congestion" and "inflammation" were those mostly employed in describing changes in the uterus of a pathological character. These terms are no longer equally appropriate. "Congestion" of the uterus is a term which can still be employed, but " in- flammation of the uterus" cannot be longer considered as an appropriate designation. There are two conditions which appear to stand out prom- inently as subjects for particular discussion: (i) A condi- tion of " undue softness" of the uterine tissues. (2) That condition of the tissues for which the term "congestion" is still appropriate. It seems proper to describe under these two heads the principal pathological changes in the uterine tissues. THE TISSUES OF THE UTERUS. 101 ABNORMAL SOFTNESS OF THE UTERUS. One of the results of long'continued observation of dis- eases of the uterus has been to make me acquainted wiih tlie fact that the uterus is frequently found in a condition of abnormal softness. This softness affects the tissues of the uterus universally. It is met with in various degrees of intensity in different cases. It is to be recognized by the touch. On digital examination in the ordinary manner it is found that the tissues of the os and cervix uteri have lost their natural healthy firm feel, and this alteration is usually traceable upward as far as the finger extends. The softness is sometimes so intense that the outline of the os uteri is difficult to recognize. The tissues of the cervix when so softened readily allow the finger to sink inward, having lost the normal firm resistant condition. It is well known that during pregnancy the tissues of the OS uteri become softened, and the softening, which can be readily recognized in women two or three months pregnant, becomes progressively intensified as pregnancy advances. The softness of the os uteri now under discussion is not dependent on the presence of pregnancy, though pin'sically there may be little to distinguish between tlie softness due to pregnancy and that observed in other cases. It is my object to point out that extreme degrees of softness may be observed in cases where no pregnancy exists. Abnormal Softness of the A^iilUparous t/terus. — Typically, the unusual softness now alluded to is met with in young women who are the subjects of great constitutional weakness, or who have been subjected to the influence of long-con- tinued insufficiency of food. It may be encountered also in women who are married, or indeed in women who have had children, but for the purposes of analysis it is conveni- ent to limit the consideration for the moment to softening of the uterus observed in young women, and apart from the influence or consequences of pregnancy. In the typical uncomplicated cases there is no consider- able increase in the bulk of the uterus; the organ is not necessarily enlarged thereby. The soft uterus is very liable to become swollen and therefore increased in size; but it is necessary carefully to separate the two conditions: (i) Sim- ple softness; (2) Softness ////j' congestion. The softness has long been familiar to me as a fact, and I was for I. long time unable to account for it or to give a sat- 105 DISEASES OF WOMEN. isfactory explanation of it. In the valuable work by Scan- zoni, " Die Clironische Metritis," this autlior forcibly dilates upon the circumstance that the so-called chronic intlanima- tory changes in the uterus should be more correctly lo<.ked upon as chronic nutrition-disturbances. This remark was the hint to which I am indebted, I believe, for the explana- tion I have been since led to give of this abnormal softness of the uterus; for an extended observation of cases soon led me to the conclusion that this softness was so frequently associated with deficient nutritional activity of the body gen- erally, that there could be little doubt that it was really an effect of such deficient nutrition; and the conclusion 1 was thus led to form was to the effect that this abnormal softness of the uterus observed in young women suffering from uter- ine symptoms was an evidence of the presence of malnutri- tion of the uterus. This abnormal softness appears to be the result of what may be termed " chronic starvation," and the essence of it to be malnutrition of the uterus. Tlie age of puberty is one of great growth and development. Much nutritive material is required to build up the frame and to provide for the great increase in bulk and in weight which the transition from the condition of the girl to that of the woman involves. The patients who present this softness and atonic condition of the uterus are almost invariably, according to my experi- ence, to be convicted of non-observance of the laws of sup- ply and demand. They are found to have either taken too little nourishing food, or to have largely and profusely ex- pended their vital forces at this critical age, or to have erred in both particulars. From fourteen to seventeen 3-ears of age seems to be the time during which, for the most part, mis- chief is done in this way, and it is fortunate if errors of this kind do not leave their mark on the individual for the re- mainder of life. The above are generalizations on the subject which have taken long to mature, and which are based on very numer- ous observations, including careful inquiry into the previous history, the mode of bringing up, and the various possible predisposing circumstances, of many patients who have been found to be affected with this nutritional disorder of the uterus. This softness of the cervix of the uterus is recognizable by the touch. But the tissues of the body of the uterus are not open to investigation in the same way as those of the os THE tiSSUES OF THE l-fERUS. 10^ and cervix. Vet the clinical eviilence adducible shows that the softness in such cases extends to the bodyof the uterus. This evidence consists in the fact that in these cases tlie uterus is found to possess a very abnormal degree of pli- ability. Tlie softness is associated in fact with evidence of this abnormal pliability in the presence of flexions, or it is found by actual experiment that the organ does possess a very undue degree of pliability. This lias a most impor- tant relation to the etiology of flexions, as will be pointed out later on. In the worst cases that have come under my notice, the general health was almost invariably in a very weakened state. The patient had for a lengthened period eaten very little. The condition of the muscles generally, the absence of fat, the great languor, general debility, want of appetite, and other not less significant symptoms, showed that these patients were suffering from chronic starvation and that the tissues of the uterus were thereby weakened in common with tliose of the other organs of the body. The weakening influences of an in'-ufficient dietary show themselves in different ways in different cases. The result- ing atrophy and weakness usually, however, affect more de- cidedly one organ in particular — in one case the lungs, in another the brain, and sometimes, as in the cases above described, the uterus. The imperfectly nourished uterus is, I believe, always un- duly soft. The softness is probably in great part due to actual deficiency of the muscular element in the tissues, but it may be partly due to defective nerve action, to impair- ment of the vaso-motor apparatus. There is a condition of the uterus to which it may be desirable to call attention in this place as bearing on the question as to the cause of the softness. When the uterus is gravid the tissues of the os and cervix during the early months of pregnancy possess a certain firmness and resistance, but if abortion occurs, as the process of evacuation of the contents of the uterus goes on, the lips of the os arc observed to become very soft and lax to the touch. In fact the process of dilatation of the cer- vix — a part of the process of abortion — appears to be con- nected with a loosening and softening of tlie tissues of the cervix. There is of course no analogy between the two conditions: there is only a resemblance so far at least as the physical properties appreciable to the touch are con- cerned. t04 ' DISEASES OF WOMEN. I am gratified to find that so experienced an observer as Dr, T. Gaillard Thomas indorses very completely the state- ments I have made as to the effect of chronic starvation in producing a soft condition of the uterus. In the fifth edi- tion of his work (1880), Dr. Thomas says, "The form of the uterus — that is, its muscular strength and power of resist- ance — is decidedly affected by want of sufficient nutritional material, and flexions are a frequent consequence; as Dr. Graily Hewitt has ably pointed out (p. 51). ... It is no exaggeration to maintain that the American woman, except in our cities, is at least half-starved " (p. 51). As a matter of clinical experience, undue softness of the uterus is very frequentl)' found associated witJi true congestion of the tissues of the uterus, but it is a quite distinct condition from the latter. It is very frequently also found associated wdth flexions of the uterus; one very remarkable class of cases is that in which the uterus readily, in consequence of its great softness, changes from one form of flexion to an- other. These latter are rare cases and will be found de- scribed in a later chapter as "alternating flexions." Undue softness of the uterus would perhaps hardly be considered a disease in the ordinary sense of the word. And yet clinical experience would indicate that it is a pow- erful factor in the production of disease. As such it de- serves careful consideration and adequate recognition. The importance of the condition lies chiefly in this, that the uterus being thereby more pliable than usual is apt to become altered in regard to its shape, and this alteration of shape may become permanent after the condition of un- due softness has disappeared. Abnormal Softness following Pregnancy. — The foregoing re- marks apply for the most part to the nulliparous uterus. Pregnancy is a condition which may leave behind it a de- gree of softness of a peculiar character. After the uterus has expelled its contents, it remains softer than usual for a variable time. During the process of involution it is proba- ble that its tissues are softer than at other times. When the process of involution is a protracted one, the uterus may be found larger and undul)'^ soft some time after the end of the pregnancy. Clinically this is a circumstance which is now and then observed. And a complex condition, made up partly of imperfection of contraction of the utei-us and partly of undue congestion of the organ, is liable to be witnessed under such circumstances. Tlius the uterus may THE TISSUES OF THE UTERUS. 10$ be found to be unduly larrje and unduly soft also. The facts observed in cases of this kind seem to leave very little doubt that we have before us a nutritional weakness as in tlie former class of cases. Here the disintegration of the uterus is slow; its reparation is slow also, and apparently from the same cause, viz., a deficient activity of the nutri- tion processes in the uterine tissues. This deficiency of action can be traced very frequently indeed to the insufli- ciency of diet and to want of pro[)er food. The symptoms observable in cases of undue softness of tlie uterus may ne.xt be ct^sidered. These symptoms pre- sent an interesting field for study. One of the most con- stant of these symptoms is presence of pain during locomo- tion, or a pain produced by movement of the body. There may be simply discomfort produced by movement. This symptom is one which I have particularly observed in its most intense degree when the softness is associated, as it ver\' frequently is, with flexion of the uterus. This uterine dyskinesia appears in these cases to depend upon the unnatu- ral flexibility of the organ; a slight motion of the budy gives rise to a temporary flexion of tlie uterus, and this produces tlie pain. Another symptom very frequently present in cases of undue softness of the uterus is siikrifss or nausea. This symptom is one productive of great misery to the pa- tient, and by its continuance is liable to lead to very great weakening of the system. It exists in all degrees. It is worst in cases where there is flexion also. The very worst cases I have seen were cases where the uterus was exceed- ingly soft and the flexion had been overlooked because it was of a temporary character. Nausea does not necessarily prove the presence of softness of the uterus, because it may be produced by flexion without concomitant softness. The most insidious form of this symptom is that where the nausea is slight in degree but very constantly present. There is a constant disinclination for food, though there may be no actual vomiting. The patient falls into the habit consequently of taking less food than is required; chronic starvation is the result. At the meeting of the British Medical Association held at Manchester, 1877, I read a paper on "Abnormal softness of the uterus as a factor in the etiology of uterine distor- tions, and as a cause of impairment of locomotion."* In ♦Published in Brit. McJ. Jour., Nov, 3, iS"' I06 DISEASES OF WOMEN. that paper I gave particulars of twelve typical cases (nulli- parous), and I here subjoin a few of them as illustrative of the history of such cases and of the nature and course of the symptoms observed. Case I. — A governess, aged 20, had, when she first con- sulted me, been ill for over two years. The difficulty in walking, which had existed for longer than this, had finally become so great that she was almost paraplegic. There was great general feebleness. The amount of food taken daily was exceedingly small, on account of the nau- sea the idea of food produced. She had, after struggling to continue her avocation as a teacher, been obliged to give up entirely. Menstruation was painful and scanty. Great prostration invariably followed any effort. There were great emaciation, sleeplessness, and much mental de- pression. The uterus was soft to the touch, entirely want- ing in that firmness the healthy uterus possesses; it was re- markably anteflexed. The treatment adopted was, firstly, very careful administration of soup, beef-tea, and small quantities of meat at frequent intervals; secondly, mainte- nance absolutely in the recumbent position; and, thirdh', re- position of the uterus by the aid of the sound, and continu- ous wearing of a rather small-sized cradle pessary. In a month she removed to the country. Five months later, her condition was very markedly improved for the better. The pessary was continued, and the " rest" treatment, together with the careful feeding, persevered in. Iron in the shape of phosphate was ordered from the first. This patient was able to resume her occupation to a great degree when I next heard of her some months later, and has been steadily and certainly gaining ground, her ultimate complete cure being apparently certain. In this case, the initial element was, in my opinion, imperfect nutrition, whereby the tis- sues of the uterus were rendered soft, pliable, and atonic. The next important element was over-exertion, whereby the uterus was pushed downward and its shape altered. The anteflexion became more and more decided; the nausea prevented adequate consumption of food; and a third most important element was added, namely, starvation in a chro- nic form. [The use of the sound to rectify anteflexion is not customary with us; at least not among the followers of Dr. J. Marion Sims. He has always taught us to straighten up an anteverted or anteflexed uterus by manipulation alone (bi-manual). He passes the point of the left index THE TISSUES OF THE UTERUS. 10/ finger to the anterior vaginal cul de sac, resting it just against the anterior face of tiie cervix, and then pushes it up between tlie anteverted fundus and inner face of the pubic arch. This lifts up the cervix and throws the fundus backward, rotating the whole organ back on its transverse axis. Sustaining it immovably there by the left index, the fingers of tlie riglit hand are tlien pressed deeply down on the abdomen above the pubes, where tliey feel the anterior face of the uterus, and push it back in a line toward the promontory of the sacrum. The riglii hand then holds the fundus back while the left index is quickly changed from the anterior to the posterior portion of tiie cervix, moving it posteriorly even as high as the os internum, and lifting it up against the abdominal parietes. The left index holds tlie cervix firmly against the parietes, while the right hand pushes back the fundus, and thus the uterus is held be- tween the two hands and moulded, straightened, and mas- saged as long as we please without pain or suffering. The use of the sound in flexions, whether anterior or pos- terior, is often painful, always unnecessary, and sometimes positively injurious, and should be abandoned. The only use for the sound is as a probe. The Marion Sims method of rectifying retroversions will be given under the appro- priate head.] Case J I. — The patient, aged 19, had been very ill for two years when I first saw her. A constant liability to vomit- ing was the principal symptom, this tendency being most marked on lying down. Four years ago she had an attack of fever, and has never been well since. She is extremelv feeble, and any exertion is distressing. Formerly,she could walk three miles a day easily. The nausea set in rather suddenly; it is now present two or three days in a week, nausea or vomiting occurring the whole day long, but most intensely — and this is a curious feature in the case — on lying down in bed at night. Her appetite is pretty good. The uterus is found to be very sensitive to the touch and softer than usual; the body of the organ is enlarged. There flid not appear at this time to be much anteversion present. The further observation of the case showed that the uterus was very unnaturally mobile, and that it was subject entire- ly to the action of gravity, the body of the uterus moving to an abnormal degree forward or backward, according to the position in which the patient lay. It was found most difficult to deal with this element in the case; for, while it I08 DISEASES OF WOMEN. was evident that steadying the uterus produced an ameli- oration in the symptoms, this steadying of the organ was most difficult to maintain, owing to the great laxity and size of the vaginal canal. The uterus was too irritable to allow of a stem-pessary. The treatment was discontinued after a time, removal to the country for the benefit of a change of air being necessary; and the further history is not known to me. This patient was treated at the All Saints Institution, and Dr. John Williams also saw the pa- tient several times. The attack of fever was the primary element in this case; the uterus was weakened thereby, in common with the body generally. The tonicity of the uterus was destroyed, and the nausea and vomiting were occasioned by the incessant bending of the uterus backward and forward which the motions of the body produced. Case III. — The subject of this case was an American, about 20 years of age, who had been, to use her own ex- pression, "ill all her life." For some years her health had been such that she could not enter into society or visit, or walk more than a few yards without extreme inconven- ience. The first occasion of the illness appears to have been dancing during a catamenial period. Menstruation is now very irregular, the interval being sometimes as much as three months. Nausea is very commonly present. There is a very troublesome leucorrhoea. Of late, menstruation has become painful. There is a high degree of " nervous- ness," and this has much increased of late. There is constant pain in the back, and frequently pain in the groins. The uterus is congested, softened, anteverted, and so low down in the pelvis that the fundus of the organ is felt through the vaginal roof almost im- mediately on introducing the finger. The sound does not enter easily. The treatment consisted in rest; use of the sound, by which the uterus was gradually elevated; and constant wearing of a cradle-pessary. After two months' treatment the patient left, and was found, at the end of six months, so much better that she was considered to be prac- tically cured. The use of the pessary was continued in all about eight months. Locomotion was easy and natural, and the result extremely satisfactory. In this case, over- exertion in dancing at the menstrual period gave rise to an- teversion and descent of the uterus. The symptoms were produced by this unnatural position of the organ; and the congestion, also a very important element in the case, ap- THE TISSUES OF THE UTERUS. lOQ peared to be kept up by this position. Very little was done except to replace the uterus and to maintain it in its place; but the symptoms, so long continued and intracta- ble, were by these measures subdued, and the natural ac- tivity of body restored. Case IV. — The patient was single, aged 23. The illness, in its present form, has lasted six months. Menstruation was irregular from the first, the interval being occasionally six months. Latterly, the periods have been regular; but since four years ago, at which time she injured herself by a leap, the periods have been painful. The patient is now un- able to sit upright, and she can only walk a few minutes without suffering. She had previously been active. There is a constant pain in the back. The uterus was found to be soft, congested, and anteflexed; introduction of sound painful. The treatment at first consisted in dorsal decum- bency and occasional use of the sound. Later on, a cradle- pessary was used, and the patient went to the country. Complete restoration to health was the result, the power of walking gradually returning. In this case, the general liealth was not much impaired. The case was a well- marked instance of displacement of the uterus occurring suddenly and rendered chronic. The morbid condition had latterly become aggravated, and the power of locomotion destroyed. Case V. — In this case, the patient, who had formerly been able to walk for as much as two hours at a time, was single, aged 27. Catamenia formerly very irregular. Walking is productive of great uneasiness and pain; a bearing-down sensation always follows. There is frequent nausea on sit- ting up the first thing in the morning. It is evident that the chief illness dates from a period of three years ago, when the patient injured herself in drawing a cork from a bottle. This gave great pain at the time, which continued to be felt in the side for some weeks afterward. There is leucorrhoea, occurring in the form of occasional gushes of fluid, evidently from the cavity of the uterus. The uterus is half an inch too long, anteverted; but the sound passes in easily, and reduction is easy. The organ is soft and pli- able. The general health is bad; there is great feebleness. The general treatment ordered was restorative; rest was enjoined, and the uterus supported anteriorly by means of the cradle-pessary. In satisfactorily effecting this latter object, great difficulty was experienced, owing to the ab- no DISEASES OF WOMEN. normal length of the uterus. A certain degree of improve- ment for a time followed such treatment as I was able to carry out, only seeing the patient once at intervals of a few months. The general nutrition of the body had received a shock, which was difficult to withstand; and the patient has not yet recovered from the extremely feeble condition to which she had been reduced. This case is a most impor- tant one, as exemplifying the occasional severe form which uterine disease may assume. The general health had be- come so much affected that little or no restorative power was at command, w^hile the peculiar mechanical difficulties of the case also conspired to interfere with the efficiency of the treatment. [The final result of this case was restoration of locomotion and to fairly perfect general health.] The subject of treatment will be discussed in connection with the treatment of congestion of the uterus. CHAPTER VII. Congestion of the Uterus and Congestive Hvper- TROPHV. Peculiarities of the Circulation in the Uterus. — Effect of Com- pression at the Centre of the Uterus in Producing Congestion at its Two Extremities — General Congestion: Causes — Acute and Chronic Varieties — Relation of Acute Form to Gooch's " Irritable Uterus" — Effect of Flexions in Causing Acute Congestion — Chronic Conges- tion: Causes and Effects — Increase in Size of Uterus — Association of Chronic Congestion with Flexions. Congestion of the uterus implies a fulness and distension of the blood-vessels of the organ, which may be slight in degree or considerable. The congestion may be partial, affecting some portions of the organ more than others, or it may affect the whole organ. The congestion may be temporary and evanescent, or it may be continuous and persistent. Congestion of the uterus may also be simple or compli- cated. When it has assumed a chronic form it is almost always complicated, the tissues of the uterus becoming altered in other w-ays also. In discussing this important question it is necessary to direct attention to the peculiarities of the circulation of the uterus; these peculiarities having a direct bearing on the nature and etiology of uterine congestion, CONGESTION OF THE UTERUS. I I I The vessels of the uterus enter for the most part along the sides of the organ. The arteries are derived from the uterine artery, which passes upward from below, along the sides of the uterus, giving off very numerous branches which pass inward to the uterus, and the greater number of them about 'he situation of the internal os uteri. These branches of the uterine artery are mainly concerned in giv- ing arterial blood to the uterus, but not entirely so, for there is a free inosculation at Fig. i8. liie junction of the Fallopian tube and the fundus uteri, be- tween the extremity of the uter- ine artery and that branch of the spermatic artery wiiich sup- plies the Fallopian tube itself. Were it not for this inoscula- tion, which is effected, however, through a vessel small in calibre, cutting off the circulation in the uterine arteries would deprive tlie body of the uterus of blood.* The veins issue from the sides of the uterus, forming large plex- uses around the organ. It fol- lows from these considerations that compression of the uterus about its middle, such as would be produced for instance by ap- plying a ligature round it at that situation, would, according to the degree of tightness of the ligature, obstruct the circulation in the part of the uterus near the middle, viz., the body of the uterus. It is evident also that if the constricting liga- ture were widened so as to compress also the vessels a little above and a little below the middle of the organ, there would arise an obstruction to the circulation, both in the body and in the cervix of the uterus. The uterus is liable to a form of compression which acts more or less exactly as an artificial compress might be made to act, when it is bent upon itself and thrown into a state of flexion. It ; h K *The arteries of the uterus ars well delineated in Plate 5 of Dr Savage's work, 2d ed. 112 DISEASES OF WOMEN. is true that the vessels are outside of the uterus, and it may be conceded that the bending of the uterus itself may leave the main trunks still patent as ever, but the moment they enter the tissues of the organ they inevitably fall under the effect of compression. A disturbance in the cir- culation in the body of the uterus thus results — a disturb- ance which the small anastomotic branch connecting the spermatic and uterine arteries cannot adequately rectify. The veins going from the fundus uteri to the ovarian bulb appear to be entirely insufficient to relieve congestion of the body of the uterus produced by impediment to the circulation existing at the centre of the uterus. Indeed if the outlet toward the ovaries were sufficient, congestion of the body of the uterus would not occur. That it does occur shows the insufficienc}' of the ovarian outlet as a means of emptying the veins of the body of the uterus. The accompanying drawing (Fig. i8, from Dr. A. Farre) represents a section of the uterus, and exhibits the thickness of the uterine walls. A second figure (Fig. 19, also from Dr. Farre) exhibits a Pj^ jq transverse section of the uterus at the situation of the internal os, and the sec- tion of the uterine vessels as they lie at the sides of the uterus is ver^' well shown. With these two figures before us it is easy to under- stand what happens when the uterus come^ to be acutely bent. The next drawing (Fig. 20) represents the condition present in anteflexion of the uterus, and the effects of the flexion in compressing the uter- ine tissues at the concave side of the bend. The walls of the uterus are also drawn thicker, and the dark shading is in- tended to show the congestion which results in the whole of the upper part of the uterus from the compression of the vessels, and also at the os uteri and cervix, below the part where the compression is exercised. General congestion of the uterus will be first described. Here the whole organ is too full of blood, and as one re- sult it becomes larger and heavier than usual. It seems certain that a condition which may be termed a normal general congestion exists at the time of menstruation, and CONGESTION OF THE UTERUS. II that, as Rouget first pointed out, there is as a result a quasi- erection of the whole organ at this period. It would be proper to use the term " menstrual congestion" to designate this condition, which simply implies that at the time of menstruation there is a certain amount of congestion and fulness of the vessels of the uterus. In health this degree of congestion is probably slight, but doubtless in disease it is capable of easily extending itself, so to speak, and thus the congestion may be extensive both in degree and in duration. General congestion of the uterus may arise from general im.pairment of tlie circulation, especially such as produces Fig. 20. interference with the abdominal viscera. One of the com- monest varieties of it, for instance, is that met with in Eu- ropean women living in India. General diseases, of what- ever kind, capable of lowering the force of the heart's action may lead to general congestion of the uterus; a loaded con- dition of the bowels; mechanical pressure of abdominal tu- mors; excessive sexual indulgence, — are some of the other more important determining causes. General congestion of the uterus may be acute or chronic. In the acute form it is rare unless associated with an actual mechanical disturbance in the organ itself, as, for instance, in cases of acute retroflexion; but there is one class of cases in which probably what may be termed acute general congestion of the uterus occurs, viz., those cases in which the patient, while menstruating, or just before, or just after the period, receives a violent chill from sitting in a cold 114 DISEASES OF WOMEN. bath, bathing in the sea, standing on a wet floor, etc., and there results a severe and general congestion of the whole uterus. It is true that in some of these cases of sudden chill or shock the mischief produced thereby may not be always precisely the one here indicated. Acute general congestion of the uterus, however, produced in this way, is a very serious affair, and though not perhaps always imme- diately productive of grave results it may leave behind it a permanent and troublesome disease. It does not Fig. 21.* appear that such acute attacks are common except at or near menstrual periods. The most important class of cases of acute congestion of the uterus is that in which the uterus is distorted and its shape altered, and there arises in connection with this an acute congestion of the uterus, which affects, according to circumstances, some parts of the organ more than others. It is met with in association with retroflexion in its most severe form, but anteflexion is sometimes conjoined with very acute congestion. The class of cases now alluded to comprises those which were formerly described by Dr. Gooch, under the term * Fig. 21 represents acute "traumatic" congestion in a case of retro rle.xion. CONGESTION OF THE UTERUS. II5 "irritable uterus." It is now some years since I published a paper on this subject, the object of which was to point out what I considered to be the true pathology of these cases. The subject will have to be alluded to in the chap- ter on Flexions. Here it may be sufficient to say that acut? flexions are liable to be attended with very acute congestion of the uterus. The organ becomes swollen, hard, exces* sively tender to the touch — so much so that the patient cannot bear even the idea of an examination being made. The body of the uterus, which can be felt by the finger cither in front or behind the cervix, according to the kind of llexion present, is the most abnormally sensitive. The os uteri and cervix participate more or less in the congestion present, and they may be found swollen and enlarged also. The whole uterus is of course in a state of the greatest irri- tation under such circumstances. The irritation persists along with the congestion. The congestion may be very pro- tracted if the condition is unrelieved by treatment, but it may rapidly pass away if judiciously managed. The phe- nomena observed under these circumstances convey the most valuable information in regard to the potency of flex- ions in causing congestion of the uterus, and in maintaining it. The contrast offered by the former complete want of suc- cess in remedying these troublesome cases, and the present rapidly successful treatment is the best proof that could be offered of the accuracy of the above pathology. The con- gestion appears to be acute in proportion to the degree of bending which the uterus undergoes. Here we have the application to make of our knowledge of the peculiarity of the circulation in the uterus spoken of at p. iii. Tiie in- tense swelling of the body of the uterus produced by the compression of the flexion is sometimes so severe as to jus- tify the use of the term " strangulation of the uterus," to which I called attention some years ago.* It is quite analo- gous to the congestion of the hand and forearm which is produced when the fillet is tied round the arm for the oper- ation of venesection. The blood is detiiined in the vessels, particularly the capillaries and veins, and congestion thus arises. And it is the fact that the removal of the com- pression, which can be effected more or less quickly by straightening the uterus, has the effect of relieving the congestion in a manner strikingly speedy and satisfactory. * Brit. Med. Assoc. Meeting at Newcastle-on-Tyne. Il6 DISEASES OF WOMEN. The fact that flexions are thus capable of determining and causing severe congestion of the uterus is a radical one in regard to its importance: it is one which has been noticed by Klob: Thomas fully endorses it in his edition of 1873. It will be found to have a wide application in gynaecologi- cal practice. Probably the best term to use to designate congestion of the uterus produced in this way is " trauma- tic congestion." Dr. John Williams,* in an interesting pa- per on " The Relation between Congestion of the Uterus and Flexion of the Organ," points out that when the uterus is retrofiexed, the fundus is liable to be caught and con- stricted by the utero-sacral ligaments, and that under such circumstances there would arise a further mechanical cause of congestion. Acute congestion of the uterus may produce a very great increase in its size. Thus in some cases of flexion I have found the uterus almost as large as the fist, and it may at- tain this size in a comparativeh' short space of time. The following is a case of this kind which came under m}' notice quite recently: Miss , aet. 19, has always been weak and delicate. Of late she has been incapable of walking, and during the last few weeks has suffered from severe pains in the hypogastric region, with difficulty and frequency of mic- turition. On examination it Avas found that there was apparently a large tumor, smooth and hard. occup3-ing the pelvis, pushing down the vaginal roof in front of the uterus, of which it seemed a part. The size of this W'as so great that I thought it was really a tumor, and a more complete examination under anaesthesia was evi- dently necessary. Meanwhile the patient was ordered to lie down and keep quiet. After the lapse of a week further examination was made. It was then found that the supposed tumor had almost disappeared ; it had re- solved itself into a moderately large anteflexed uterus. The rest and recumbent position had produced this effect. Any one making an examination on the first occasion would have been entirely unprepared to find in a few days such a change in the size of the uterus as undoubtedly occurred in this case. Chronic congestion of the uterus must next be considered. In its first stage chronic congestion is little more than a * " Obst. Trans.," vol. xvi., p. 203. CONGESTION OF THE UTERUS. 117 slight engorgement of the uterine vessels, with increase in its weight. There is at first nothing beyond increase in the size and fulness of these vessels, without any particular molecular change in the tissues of the uterus. When present in a slight degree, general congestion of the uterus at first may produce a certain degree of softness of the tissues of the uterus, the organ becoming enlarged and looser than usual in texture. In other cases, on the other hand, it becomes firmer than ordinary. The dilfer- FiG. 22.* ence seems eo be explainable by attention to the condition of the uterus which existed before the congestion set in. Thus, in cases of undue softness arising from malnutrition of the uterus nothing is more common than to find that congestion is added to, or affects the already soft uterus. A large, flabby, unresisting condition of the uterine tissues will then result. But in the case of a uterus in a state of health previously, the addition of congestion will produce * Fig. 22 shows congestion and enlargement, with anteversion, in a patient, act. i3, affected for nearly one year with severe vomiting. ii8 biSEASES OF WOMEN\ a different effect ; the tissues of the organ will then by con- tinual congestion be made harder and firmer than they were before. There are certainly these two types of cases observable in practice. Another precedent or concomitant condition which may be taken into account is defective in- volution of the uterus after delivery or after abortion. Here the organ is large and heavy, and the condition is one Fig. 23.* of continuous general congestion, because the vessels are large and the uterine solid constituents of undue bulk. Defective involution of the uterus is thus one of the causes of chronic general congestion of the organ, and there are good reasons for the belief that the sluggish manner in which the uterus involutes itself is due to general impair- * Fig 23 shows chronic congestive hypertrophy, with anteflexion of tlie uterus of many years' standing. CONGESTION OF THE UTERUS. Itg tlierit of the nutritive processes in the body generally, and in the uterus in particular. CONGESTIVE HYPERTROPHY. A common effect of general chronic congestion of the uterus is an increase of the solid constituents of the uterus. At first there is simply undue fulness of the blood-vessels, but after a time there is addition to the solid parts. The addi- tion consists in increased growth. The result is, that the organ as a whole is larger, heavier, and thicker than before. The tissues of the uterus consist of unstriped muscular fibre and fibre cells, and intervening cellular tissue. These, together with the vessels, nerves, and lymphatics, compose tlie uterus. In chronic general congestion the connective tissue appears to undergo after a time decided increase in quantity. The increase in bulk is in all jirobability due in part also to the further growth of the muscular element, l)ut the general impression is that the cellular tissue is most affected. The uterus becomes after a time harder tlian the normal uterus. It is thus both larger and harder than before attacked by chronic congestion. And when a section of it is made, the tissues are seen to be decidedly hard and to resist the knife. This condition of the uterus has been described as "chronic inflammation," "chronic metritis," etc. Professor Thomas of New York terms it "areolar hyperplasia." Klob describes it as "continual hypersemia." The term which appears to me most cor- rectly to define the condition in question is "congestive hypertrophy." The increase in bulk and the consequent hardness result- ing in the production of the condition now described as congestive hypertrophy, is a further stage of gt^neral con- gestion of the uterus. Chronic congestive hypertrophy of the uterus is a very common affection. It is not, however, very common unas- sociated with alteration of shape of the organ. It is liable to h& partial, involving one part of the uterus more than another. A common variety of it is the uterus distorted by a flexion of long standing, the fundus in a state of conges- tive hypertrophy, the lips of the os uteri swollen and also in a state of congestive hj'pertrophy, but generally one lip more decidedly swollen than the other. Such a uterus is liable to take on at any time z further congestive action — 120 DISEASES OF WOMEN. there occur, in fact, repeated attacks of congestion, as it is termed, the repetition of which attacks has the effect of increasing gradually the size of the organ. The uterus be- comes moulded and swells in the direction of least resist- ance, and becomes literally hardened in its evil ways. This is a common type. A really general congestive hypertrophy of the uterus, the uterus still retaining its normal shape, is not common ; but such a condition sometimes results from defective in- volution of the uterus. Chronic congestive hypertrophy of the uterus is not easy to distinguish from defective involution of the uterus after delivery. Microscopically, however, there would probably be a difference, the muscular element predominating in the latter case, and the connective tissue element in the for- mer. The hypertrophic condition of the uterus, as already re- marked, is very frequently noted in cases of flexion or dis- tortion of the uterus ; and by some authorities (Dr. Thomas of New York, e.g.) the hypertrophy is looked upon as the cause of the displacement. Undoubtedly this ex- ])lanation applies to that variety of hypertrophy, the result of defective involution after delivery, but it is probably not generally the case in other instances. The size which the uterus attains in cases of chronic con- gestive hypertrophy is sometimes very great. Thus, I have met with cases of anteflexion in which the uterus was so wide from side to side that it seemed almost to fill the anterior half of the pelvis, having the size of a cricket-ball, or even larger. Fig. 23 represents a case of long-standing general hypertrophy of the uterus, associated with anteflexion. Hypertrophy, to an equal extent, is not often witnessed with retroflexion. Chronic hypertrophy often affects the lips of the cervix uteri ; the os uteri is then surrounded with tissues some-' times enormously thickened. This hypertrophy of the vaginal portion of the cervix may be associated with flexion of the uterus or may be the result of a former flexion. Ii may also be produced by laceration of the cervix. It seems to me very probable that many of those cases in which the os uteri presents rounded projecting lips of con- siderable size have their origin in such laceration. At all events it is certain that such rounded hypertrophy of the lips of the OS uteri is observed in cases of lacerated cervix. SUB-INVOLUTION OF THE UTERUS. 121 The congestive hypertrophy in these cases appears to de- pend on the interference with tlie circulation in tlie tis- sues produced by the laceration, for I have seen it rapidly disappear when the laceration has been repaired and the normal circulation restored. CHAPTER VIII. Sub-involution of the Utf.kus — Atrophy and Hvper- TROPHV OK THE UtERUS. Sub-involution of the Uterus. — Nature and Treatment. Atrophy of the Uterus; the result of Sexual Involution — Premature Senile Atrophy or "Super-involution" of the Uterus — Mechanical Atrophy. Hvpertrophy of the Uterus. — Result often of Defective Involution after Delivery — Hypertrophy, with Elongation of the Cervix. SUB-INVOLUTION OF THE UTERUS — NATURE AND TREAT.MENT. The condition of the uterus described under the term sub-involution has been already incidentally alluded to. But it is convenient to give it a distinct and separate con- sideration, inasmuch as it is a factor of considerable impor- tance in many cases of uterine disease. Sub-involution of the uterus may be observed after par- turition at full term or following an abortion. The uterus does not return to its proper size, but remains larger than it should be. That is to say, that process of diminution in bulk which is natural under such circumstances is delayed beyond the proper time. The uterus may be found, for in- stance, as large at the end of a month after parturition as it should be at the end of a week from the time of labor. The persistence of a bulky condition of the uterus under these circumstances means either that the metamorphosis of the large uterine muscular fibres into fatty material, and ab- sorption thereof, is delayed, or it means that there is a delay in the metamorphosis together with congestion of the uterus. It is probable when a few weeks have elapsed and the uterine bulk is still considerable, that the case is one of arrested metamorphosis////5' considerable congestion, rather than arrested metaiTiorphosis alone. At first the uterus, in a state of sub-involution, may be soft and spongy to the touch, but later on it is not so, and 122 DISEASES OF WOMEN. the condition is one rather of hardness than softness. After a time, in fact, the condition becomes merged into one of congestive hypertrophy, or, as it would be termed by Dr. Thomas, "areolar hyperplasia" of the uterus. The microscopic condition of the uterus will be found to vary according to the time which has elapsed since parturi- tion or abortion; for if the examination be made early mus- cular fibres in excess will be found, whereas later on there will be a superabundance of cellular connective tissue ma- terial. Displacements, especially flexions of the uterus, are causes of sub-involution of the uterus. Thus, I saw a case of acute displacement of the uterus backward, occurring very soon after labor, where the uterine fundus must have retained its abnormal size, in this retroverted condition, for manj^ days after the displacement occurred. The sub-involution in this case was thus caused by the displacement; probably in consequence of the arrest of the circulation in the uterus thereby produced. I have seen several other cases of some- what similar character. It is not, however, necessary that the uterus should be displaced in order that sub-involution may occur, for cases are encountered where there has been no such dislocation. Of the other causes of sub-involution of the uterus probablj' mal-iiiitrition and weakness are most common. The weakness may be of long standing or it may be the result of excessive loss of blood at the time of labor or of miscarriage. The feebleness of the patient is the cause of the want of vigor in the uterus, the contractions of which do not occur in due force. Hence protraction of the process of involution. Sub-involution readily passes into a condition of chronic congestive hypertrophy; the shape of the uterus, the thick- ness of its walls, may remain the same, but it then becomes harder and firmer. But in some cases this change into a condition of hardness does not occur, the uterus remaining abnormally soft, spongy, and flaccid for a considerable time. Cases in which this latter occurrence is observed are those in which the nutritive force is at a very low ebb; re- paration is slow, and a passive congestion results. Sub-involution is observed sometimes in conjunction with inflammatory conditions of the parts around the uterus. Thus, in pelvic cellulitis, following labor or abor- tion, the uterus remains large and heavy; and although in some cases the bulk of the uterus may be partly due to ?ffi4- SUB-INVOLUTION OF THE UTERUS. I23 sion of lymph in its tissues, yet the greater part of it is evi- dently simply sub-involution. The disturbance going on in the immediate vicinity of the uterus, compression and swelling of lymphatics, etc., arrest the process of involution in these cases of peri-uterine cellulitic inflammation. Treatment. — There are two principal indications, i. To remove any impediment which may exist to the easy and free circulation of the uterus. 2. To quicken and invigor- ate the nutritive process in the body generally. There are also subsidiary measures to be taken. 1. If there be a displacement it must be rectified. If the bowels are in a chronically loaded state they must be re- lieved by daily gentle aperients or injections. The hori- zontal position may be required. 2. The food must be plentiful and of a highly nutritious character. In short, a liberal diet is necessary, and when the appetite is bad, food must be given frequently and in small quantities at a time. 3. SiibsiJiary Measures. — Warm injections or the douche of warm water once or twice daily. Ergot, either alone in small doses once or twice a day, or together with iron, fre- quently proves very useful. Warm sponge baths, warm sea-water baths, friction of the skin, fresh air, and such general hygienic measures as may be specially required, should not be forgotten. If the case be seen some weeks after labor or miscarriage, the general treatment required is much the same as for chronic congestion of the uterus. Bromine and iodine are valuable medicines in the later phases of the disorder. Quinine and iron are of great ser- vice in many cases. It is prubal)le that electricity would prove serviceable in some instances. ATROPHY OF THE UTERUS. Atrophy of the uterus, in the true sense of the word, im- plies not a congenital defect as regards size, but an acquired smallness. Atrophy of the uterus occurs at a period of se.xual involu- tion; the organ ceases then to exercise the ordinary func- tion, menstruation and the capability of impregnation com- ing to an end. The walls of the uterus become under these circumstances thin, and the whole organ smaller than before. These changes are attended with the further con- sequence that the uterus is less vascular and less sensitive than before. The organ has ceased to play its part, and its 124 DISEASES OF WOMEN. condition functionally very much resembles that before puberty. Morbid processes affecting the tissues of the uterus are not unfrequently arrested by the occurrence of this, which may be termed its natural atrophy. But it ap- pears that the uterus may undergo this senile change at an unnaturally early age, thus constituting a condition which Chiari* described as "premature senile atrophy." Sir J. Y. Simpson f ascribed tliis to " super-involution" after de» livery — a questionable theor3\ Premature atrophy of the uterus might be expected to be found in women who have prematurely ceased to men- struate, but its occurrence in association with still persist- ing ovarian activit}' is, as would be expected, extremely rare. Tlie uterus affected with atrophy of the character alluded to is universally small, the cervix participates in the change, the vaginal portion becomes shorter, and the os uteri smaller. The tissues of the organ become somewhat harder. Atrophy of the uterus of another kind may be produced by the operation of external influences. Thus, when the organ is pressed upon by tumors in the neighborhood, the walls may become very thin. I have found the organ ex- cessively small from this reason in some cases of ovarian tumor and of fibroid tumor. Local atrophy occurs in cases of flexions of the uterus, the walls becoming in many cases very much diminished in thickness at the part which is the seat of the flexion. Another kind of atrophy is that accompanied with exces- sive dilatation of the uterine cavity, such as now and then occurs from fluid or gaseous distension of the organ. The uterine walls may be found in such cases excessively thin. The form of atrophy here alluded to has been described as "eccentric atrophy" of the uterus. HYPERTROPHY OF THE UTERUS. Congestive hypertrophy has alread}' been described (see p. no). Hypertrophy may, however, exist without conges- tion. Like many other organs of the body, the uterus is liable * " Klinik der Geburtsk." 1855, p. 371. f Clinical Lecture on Amenorrhoea. j\/cJ. Times and Gaz. 1861. SUB-INVOLUTION OF THE UTERUS. 12: to variations in size. This variation is, however — in indi- viduals in a slate of health — limited. During the catamenial period, the organ becomes enlarged, but this enlargement is normally only temporary, and a general and persistent addi- tion to its bulk only occurs under abnormal circumstances. The very considerable growth which the uterus undergoes during the period of gestation is of course an exception to this statement. Fig. 24.* The simplest form of hypertrophy of the uterus is that witnessed in cases where the uterus is, and has been, influ- enced by pregnancy or by the presence of a tumor or tumors within its walls. This subject has been more fully considered elsewhere (p. 119) in connection with the subject * Fig. 24 represents a case of general hypertrophy of the uterus, and of the cervix uteri, in a patient affected wiih menorrliagia. Amputation of the vaginal portion of the cervix was performed in this case. 126 DISEASES OF WOMEN. of chronic congestion of the uterus, with which condition this simple hypertrophy is generally associated. Here the enlargement affects the body and the cervix of the uterus pretty equally. The most common, and indeed the most marked form of hypertrophy of the uterus is witnessed in women who have been pregnant, and just described (p. 121) under the term "Sub-involution." When this "involution" does not occur regularly and promptly, the organ is liable to become affected with hypertrophy of a persistent character. Even Fig. 25.* in these cases, however, the degree of hypertrophy wit- nessed, if there be no other cause in operation, is not very great. In hypertrophy of the uterus due simply to "defec- tive involution" after deliveries, abortions, etc., the increased length of the organ does not, I believe, ever exceed one inch. (It is necessary to observe that this does not apply to any measurement taken within the first two or three weeks after the labor or miscarriage.) One inch increased * Fig. 25 (from Farre) represents longitudinal hypertrophy of the cervix, of a marked character. Other illustrations will be found in the Chapter on Prolapsus. SUE-INVOLUTION OF THE UTERUS. 127 Fir, 26* length usually implies, however, considerable addition to the general bulk of the organ, and entails various incon- veniences, which have been already particularly described. Hypertrophy, the result of chronic congestion and defective involution, one or both, is most palpably evident in the cervical region, as this can be easily reached and inspected, but it is rarely limited to this portion. Hypertrophy of the uterus is especially liable to occur in association with growth of fibroid tumors within the walls of the organ. A fibroid tumor of the uterus, growing in the middle of the thickness of the wall, not unfrequenily produces great hypertrophy of the uterus, for the uterus may expand and grow not merelj' around the tumor, but in every other part also. The bulk of the uterus may, under such circumstances, equal that of a cliikl's head, but the greater part of the bulk would then be made up of the tumor. In cases of fibrous poly- pus of the uterus, the organ grows sometimes to a very large size, but in such cases the uterine walls have less thickness. Hypertrophy of the uterus to a slighter degree is wit- nessed when fibroid tumors grow from its outer surface. Again, it is not rare to meet with enormous fibroid tumors growing from the ex- ternal surface of a uterus, itself even smaller than usual. Partial hypertrophy of the vaginal portion is sometimes observed. Hypertrophy with Elongation.— ^\\t uterus not unfrequently undergoes, in consequence of pressure, or in consequence of traction in a particular direction, an elongation to which the term hypertrophy has not always been very correctly applied. This elongation more particularly affects the cer- vical portion of the organ, not simply that part which projects into the vagina, but the cervix properly so called. Hypertrophic elongation of the cervix constitutes one of * Fig. 26 represents hypertrophy of the posterior lip of the os, malignant character. of non- 128 DISEASES OF WOMEN. the forms of prolapsus of the uterus (see Prolapsus), but it is also sometimes witnessed when an ovarian tumor pushes the body of the uterus upward, and thus elongates the cervix. In such cases the walls of the canal do not usually grow, and the effect of the traction is thus to ren- der them actually thinner. The cervix of the uterus may, under such circumstances, become three, four, or five inches in length. The lower portion of the cervix — i.e.^ the vag- inal portion — sometimes, however, undergoes a true hyper- trophy, the result of which is that a conical or snout-like substance of considerable size is then found occupying the vagina, nay, even projecting beyond the ostium vaginae. A more limited hypertrophy is depicted in Fig. 26. CHAPTER IX. Treatment of the Various Textural Disorders of the Uterus — Malnutrition of the Uterus, Congestion, Congestive Hypertrophy, etc. General Preventive Treatment — Dietary necessary — Importance of defi- cient Dietary as a Cause of Uterine Disease — Defects Qualitative and Quantitative — "Chronic Starvation," a Real Disease — Its Importance — Method of dealing with it — Preventive Treatment as regards Menstrua- lion — Preventive Treatment in Child-bed — Congestion of the Uterus and Congestive Hypertrophy — General Treatment — By Altering Posi- tion and Shape of Uterus — By Leeching, Scarifications, etc. — Use of Hot-water Injections — Baths and Watering-places — Astringent and Caustic Applications to the Os Uteri — Internal Remedies. The first and most important question to be dealt with is \\\^ preventive treatment. Observation has led me to the conclusion that it is rare to tneet with congestion of the uterus together with its vari- ous complications, in cases where the uterus was previous- ly in a state of health. An attempt has been made to indi- cate this " previous state" of the uterus under the head of " mal-nutrition" (undue softness) of the uterus. That sub- ject here finds its practical application. TREATMENT OF MALNUTRITION OF THE UTERUS. Whatever tends to maintain the body generally in a state of health tends also to maintain the integrity of the uterus. General treatment good for the body at large is good for a part of it also. TREATMENT OF MAL-NUTRITIOX OF THE UTERUS. 12^ It will not be credited by any one who lias not taken the trouble to inquire carefully into the previous habits and history of patients suffering from the ordinary diseases of the uterus, how common it is in these cases to meet with evidence of the strongest character of a long-continued in- sufficiency of dietary, this insufficiency being in operation up to the time of the patient coming under observation, or having been in operation for a very considerable period at a former time. It is thus quite easy to track the process of commencing ill-health to its source, and the facts elicited by cross-examinations will almost invariably enable the in- quirer to say not only that the disease began at such and sucli a time, but to state why it was so. It does not appear that what may be termed elementary nutritional deficiency has been assigned, as yet, its due place in the etiology of uterine diseases. I am more and more convinced that the part it plays is a most important one. The dietary must then be the first object of attention. In a growing girl the dietary should be a generous one. Two mistakes are liable to be made in the matter of tiie dietary: one relates to the quality of the food given; the other to the quantity. I. As ri\i^arcis the Quality of the Food. — It is not uncommon to meet witli cases where for one reason or another the food given is defective in quality during what may be termed the developmental period of growth of the uterus, viz., between the ages of twelve and sixteen or seventeen. This defect is more likely to consist, so far as my experience shows, in an insufficiency of meat food. The ordinary bread and butter wliich constitutes the principal food in many boarding- schools is not adapted for the production of healthy tissues. Meat is the article of diet which I have generally found to have been deficient in the dietary of young women who have presented evidences of mal-nutrition of the uterus later on. Motives of economy sometimes operate to the exclusion of a liberal meat dietary. But in the middle and higher classes of society these motives are non-operative, and it is not rare to meet with cases of young women brought up in what is termed a luxurious manner, who have never been permitted during the growing age to have more than one meal containing meat in the day. This practice appears to me, judging from numerous cases whose details could be 130 biSEASES OF WOMEN. mentioned, to have inflicted in those instances the greatest injury on the constitution, and to have predisposed to the grave evils for the relief of which advice was sought years later. 2. The Qi/afitity. — It is well known and generally admitted that robust health is associated with good appetite. A good appetite insures the taking of sufficient food — when it can be procured. The appetite is, however, too often taken as the guide in the opposite case, where it is deficient, absent, or capricious, and it is too generally supposed that if there is no appetite for food there is no necessity for it. This mistake — a grievous one — is common amongst the public at large, but it does not appear that it is sufficiently recognized as a mistake even in professional circles. The human machine is kept going by a process of repair. There is an incessant waste, and there must bean incessant repair to make good the waste, or evil necessarily foUoAvs. It is true that the quantity of food taken is often reduced for a considerable time without the individual apparently suffering materially. The human frame is so full of re- sources that it resists for a long time the deteriorating in- fluences of a lessened dietary. The waste affects some non- vital part and life goes on. But there is a limit to this endurance. When the diminished dietary has been in op- eration for a long time — some months for instance — it is almost certain that in case of an individual of only average stamina mischief will result. Of necessity, the actual quan- tity of food required per diem is larger at the time the growth is most rapid, and consequently deficiency in quan- tity is most felt at this period. In the case of boys and young men there is not generally any reluctance to indulge an appetite which should be a large one, but in the case of girls it is not uncommon to find that there is a sort of feel- ing that the possession of a good appetite, or at all events the innocent gratification of it, is a thing to be deprecated. And it is the fact that many young women do themselves mischief by deliberately taking less than is required to maintain the body in a state of healthy growth. It has been already stated that the appetite is often mis- leading. This appears to be a point which requires to be emphasized. If the appetite is wanting or defective, there is probably something wrong, and steps should be taken to ascertain what has destroyed or lessened the appetite. There are many possible causes for a want of appetite — de- TREATMENT OF MAL-NUTRITION OF THE UTERUS. 13I fective hygienic conditions of various kinds, actual disease of some part of the body, etc. But what should be recog- nized is, tliat neither patient nor doctor should sit down and simply allow things to go on in this unsatisfactory manner. Such neglect will lead eventually to disaster. The want of appetite is perhaps the first in a chain of symp- toms which become graver and more serious as the body becomes month after month debilitated by the slow starva- tion whicli it causes. There is much reason for the belief that the most impor- tant of the diseases wliich prove fatal to young persons — the tubercular affections — have their origin in deficient feeding. It is, at all events, ceitain that this is one of tiie most im- portant of the factors concerned in the production of these diseases. If we take the^case of a young woman growing up under such defective alimentary conditions as have been above described, it is uncertain what precise effect the clironic starvation of which she is the subject will have upon her — or, in other words, what organ of the body will first feel the attack. It may be the lungs, or it may be the uterus. In the one case pulmonary consumption occurs, in the other, disease of the uterus. My own experience has brought very numerous instances of the latter result under my notice, and from some well-marked cases of the other kind which I have seen I have been led to attribute the first step downward to the same cause in each class of cases, viz., defective alimentation. It is rational to conclude that deficient alimentation will have a tendency to affect all parts of the body; but it is in accordance with experience that it affects some organs more than others, various accidental circumstances influencing the body — habits, temperament, surroundings of various kinds, determining which particu- lar organ shall feel the impetus of the blow in the first in- stance. Judging from experience it seems to me very desirable that "chronic starvatioji" should be admitted into the list of recognized diseases. When alimentation is always defi- cient the condition of the body is one of chronic starvation,* and this is the preliminary — in the majority of cases per- haps a necessary preliminary — to the advent of the various * See Annual Address to the Harveian Society, "On Chronic Starva- tion." Lancet, Jan., 1S79. 132 DISEASES OF WOMEN. serious disorders recognized in medical classifications of dis- ease. There are, of course, hygienic laws to be complied with. Fresh air, sufficient clothing, exercise well adjusted to the capabilities and requirements of the body — all these are very necessary, but the maintenance of the proper degree of nutritional activity is of the first importance. Change of air, change of scene, visits to watering-places, baths, etc., change of occupation — these are often beneficial; but why? Because they restore the lost appetite; and if they fail in this, comparatively little benefit is derived. Having treated many cases of commencing uterine dis- ease, characterized as above described by softening and weakness of the uterus, I have seen the great benefits of careful and assiduous feeding in the class of cases requiring it, and have found this method of treatment so universally successful that it can with the greatest confidence be recom- mended. The principles which apply in cases when the malady has to be cured are, of course, available in the pre- ventive treatment. The foregoing remarks indicate the importance which I attribute to food and feeding in the treatment of chronic uterine maladies. In a paper read before the Obstetrical Society of London in 1880, I stated that at the All Saints' Institution during seven years I had treated sixty-seven cases, the majority of which were cases of uterine chronic disease associated with great general weakness and a con- dition of "chronic starvation." "The first principle of the treatment was rest." The next was to improve the general nutrition of the body. Most of the cases afforded marked instances of chronic starvation, sometimes of several years' standing.* I give the above quotation to show the lines which my practice of late years has followed. In connection with this subject it is next to be stated that Dr. Weir Mitcliell,f of Philadelphia, has for some years car ried out a method of treatment in cases somewhat resem- bling those treated by me in All Saints' Institution, consist- ing in rest, massage, electricity, and food, all very systemat- * See Report of Sixty-seven Cases of Uterine Distortion, etc. " Obst. Trans.," vol. x.xii. t " Fat and Blood: and how to make them." London edition, Lippin- cott, 1878. TREATMENT OF MAL-NUTRITION OF THE UTEROS. I33 ically and persistently used, and with results the success of which I can quite understand from what I have observed in my own cases. Dr. Playfair lias recently* made the pro- fession in this country better acquainted with Dr. Weir Mitchell's very practical and successful method, and has published cases showing the great success which has fi>l- lowed his adoption of Dr. Mitchell's treatment. Dr. Playfair heads his paper on tlie subject "Nerve Prostration and Hysteria connected with Uterine Disease." The cases are those in which the patient has become a cr half an hour at a time at first, anil later on for an hour and a half. 3. Electricity by the interrupted current twice daily, the sponges being so employed as to work all the muscles suc- cessively. 4. Diet. At first milk is given every three hours — in small quantities at first, later increased. Then more ordi- nary food of all kinds is given, the quantity being gradually increased, and soon very large quantities are capable of being taken, the massage and electricity, as it is considered, enabling the patient to take food in gradually increasing quantities until, as in cases related by Dr. Playfair, a very enormous amount is taken daily. The system of treatment as above described has the effect of quickly improving the strength, in restoring the lost adi- * Lancet, iSSl. 134 DISEASES OF WOMEN. pose tissue, and enabling the patient to move about, and restoring, in fact, the lost vitality and locomotive power. The massage and electricity are two elements in the treatment of which I have had but limited experience. I have employed baths and friction of the skin as a regular part of the treatment in cases of great nutritional impover- ishment, in addition to the rest and feeding, and have thus obtained extremely good results; but it seems to be proved by Dr. Mitchell's cases that massage and electricity are extremely important additional means, and there is no doubt that they are likely to help materially in promoting healthy nutritional changes. It is to be remarked that the incapacity for locomotion observed in the class of cases described by Dr. Mitchell is, to my mind, evidence that the condition of the uterus in his cases was, as a rule, that wliich I have described as abnormal softness of the uterus. The so-called " hysterical " element in these cases is one which will be discussed more properly in the clmpter on the Neuroses of the Uterus. TREATMENT OF CONGESTION OF THE UTERUS. Congestion is frequently associated with other conditions from which it is impossible to dissociate them in practice. Flexions of the uterus, softening of the organ, or hardening and a certain degree of hypertrophy are the principal other conditions likely to be met with. The congestion has to be treated with due regard to the proper relation subsisting between it and the other condi- tions possibly, and generally, present. According to my experience, the cases are few in which real good can be effected without a careful attention to the general treatment, by the restoration of the nutritional activity to its proper healthy state as an integral part of the treatment. There is frequently present a condition of great general debility out of which the patient has often to be slowly dragged, as it were, by persevering efforts in this direction. A patient who has been persistentl)' underfed for three or four years will not be capable of restoration to strength in a short time; and when the uterine congestion is associated with such long-standing debility, much time may have to be spent in feeding the patient before the local ailment is satisfactorily relieved. The method of feeding a patient so reduced, which I have TREATMENT OF MALNUTRITION OF THE UTERUS. 1 35 long practiced, is to give food very often, of such a kind that it can be easily digested, and in very small quantities at a time, sometimes every two hours. Liquid food, soups, milk, eggs beaten up, etc., are best at first; solid food, also in very small quantities, to be given later on. The diges- tive power is tlien improved and the appetite often returns with unexpected rapitiity. The aadition of massage and electricity, according to Dr. Weir Mitchell's plan, promises to be very serviceable in expediting this nutritional improve- ment. The important principle of endeavoring to make up for past deficiencies by careful diet cannot be neglected if success is to attend our efforts to cure the patient. My experience has taught me much as to the power of food in curing disease, particularly in the cases coming before me which have been mostly uterine. And in fact I may say that I have been thus taught some very important lessons in regard to their pathology. The efficacy of general treatment in cases of uterine dis- ease — the "constitutional" treatment as it has been termed — has been insisted on by the late Dr. Rigby, Dr. Henry G. Wright and other gynaecologists. So far as I have been able to determine, the "constitutional" treatment is bene- ficial in direct proportion as it helps to more vigorously nourish the body and every part of it, including the uterus. Whatever conduces to this end is likely to be of service. I-'ood is in fact the great constitutional remedy. PREVENTIVE TRE.\T.MENT DURING MENSTRU.\TION. The promotion of regularity as regards quantity and time of appearance of menstruation is very important in order to prevent congestion of the uterus. Care during menstruation is incuinbent on all women, and even those in apparently good health cannot disregard themselves in this respect without danger. It is highly important that tlie natural congestion, as it may be termed, of menstrua- tion should not be protracted. If there is the slightest ten- dency to disease of the uterus rest should be taken at the period, and violent exercise avoided, especially in conjunc- tion with outward application of cold. Sitting in wet clothes or wet shoes, standing on damp or wet floors are all sources of danger. In the work of Mary Putnam Jacobi * * "The Question of Rest for Women during Menstruation." By Mary Putnam Jacobi. New York, 1877. 13^ DISEASES OF WOMEN, will be found the results of extensive inquiries as to th^ necessity for rest from mental and other work during the period of menstruation. The general conclusion is that work cannot be advantageously continued during the men- strual period in the majority of cases. PREVENTIVE TREATMENT IN CHILD-BED, Congestion of the uterus has so frequently its starting- point in a "bad getting-up," as it is termed, after parturi- tion, that some special remarks are required on the subject of the preventive treatment. Above all it is necessary to secure healthy and rapid in- volution of the uterus, whereby its bulk is reduced, the nu- tritive changes hastened, and the restoration to its normal size and bulk effected. The patient should maintain the liorizontal posture for some days, and should not be al- lowed to perform movements calculated to strain the ab- dominal muscles. And as soon as possible after the lochia have ceased, the use of the hip-bath, or of the vaginal douche should be commenced. Great care should be taken to pre- vent constipation of the bowels. The diet should be very carefully supervised. In women who have been in a good state of health previously it is simply necessary to give or- dinary food and in ordinary quantities, not omitting to do so even on the day following the delivery. In those patients who are weakly food must be given very often; and liquid nourishment-, as soups, eggs, beef- tea, etc., are to be given frequently and between the ordi- nary meals. Night feeding is very necessary in weakly wo- men during child-bed, great exhaustion often setting in about four or five in the morning; exercise should be taken in moderation at first; walking should not be commenced until two or three weeks have elapsed. It is usually advis- able to apply a moderate support to the abdomen by means of an elastic bandage. Very great benefit will be derived from attending to these simple rules, and it is very certain that a neglect of them has frequently the result of originat- ing a troublesome and painful disease. It is important, as a further means of securing perfect contraction of the uter- us after delivery, to induce the patient to suckle her child, although this course cannot from the debility of the patient always be recommended. In women who are liable to abortions, the majority of whom are affected with uterine flexion, it is necessary to take double precautions; we fre- TREATMENT OF MAL-NUTRITION OF THE UTERUS. 1 37 quently find that the uterus becomes diseased from the fact that the pregnancies rapidly succeed each oilier, the uterus not having recovered its natural size when it becomes again occupied by an ovum. In such cases, unless care be exercised, the liability to abortion is perpetuated, and the local evil intensified. We must insist on the necessity for allowing the uterus a period of rest; this is equally neces- sary after an abortion, and after an ordinary labor; in many cases the habit of abortion is only to be broken through by enforcing a separation of the husband and wife for some months, during which time efforts are to be made to re- duce the uterus to its normal size and to its natural condi- tion. There can be no doubt that by judiciously watching over and supervising the function of parturition, and reg- ulating the conduct of the patient afterward, we can effect much good in cases where the uterus is liable to fall into a state of chronic enlargement and congestion. The congestion which is apt to occur after labor is of a passive kind; the large size of the uterus enables it to hold much blood. It is also softer than usual, and the great danger of this undue softness and weight of the organ is that there thus arises a strong predisposition to severe dis- placement of the organ. The order of events is frequently: I. Defective involution; 2. Congestion; 3. Displacement, including fle.xion; 4. Congestion created and kept up by the flexion; 5. Hindrance to further perfection of the invo- lution by the other already mentioned conditions. GENER.A.L TRE.ATMENT OF CONGESTIOX AND CONGESTIVE HVPERTROPHY OF THE UTERUS. It is undoubtedly the fact that distortions of the uterus are in great part the cause of congestion of the uterus as we meet with it in practice. When the congestion is a me- chanical congestion it can be quickly and materially re- lieved by removing the cause — that is to say, by taking steps to restore the uterus to its normal shape and position, thus allowing the blood in the uterine vessels more freely to circulate. The uterus is in many cases extremely amen- able to mechanical influences acting from without. Thus in a case of anteflexion the placing of the patient on the back will help to remove congestion associated with dislo- cation, whereas in cases of congestion due to retroflexion the reverse treatment will be necessary. So, again, the knee and elbow position, by raising the fundus uteri, often 138 DISEASES OF WOMEN. SO assists the uterine circulation tiiat congestion is thereby relieved. These points will be more fully enlarged upon in the chapter on the Treatment of Flexions. This method of treating congestion of the uterus is of primary importance, and it can frequently be carried out without resort to in- struments at all. The effects producible are sometimes ex- tremely rapid, and the principle of treatment is so simple that it is readily understood and applied in practice. The practice of leeching the uterus in order to remove congestion is in its way a mechanical method of treatment. It is one which was very much practiced a few years ago, and it is still largely employed by practitioners who are not practically aware of the intimate connection as cause and effect subsisting between flexions and chronic congestion of the uterus, and who have not had opportunities for observing the extreme rapidity with which the congestion as a rule subsides when the uterus is so treated that its circulation is no longer obstructed. The withdrawal of blood from the congested os uteri by leeches removes for the moment the congestion of that part (though it has less effect on the con- gestion of the body of the uterus), and when the process is repeated for some weeks two or three times a week, has, no doubt, an appreciable effect of a beneficial character. But if the same result can be obtained by other and more sim- ple means, and without taking away blood, and therewith strength, the simpler method will in the end com.e to be preferred. On the view which supposes the congestion to be a sort of disease of itself, the leeching would undoubted- ly commend itself as rational; but if the congestion be a mere mechanical result of some other condition of the uter- us, obviously the rational course to pursue will be to deal with that other condition, in the first place at all events. Leeches will, however, be found useful in cases where the uterus has become hypertrophied as well as congested. Certain manipulations necessary in applying leeches must be mentioned. Unpleasant or inconvenient results are apt to occur when the leeches attach themselves either within the OS uteri, or on the w'alls of the vagina. A moderate- sized speculum is to be first introduced, so that its upper extremity touches the vaginal portion of the cervix at every point, and a small piece of lint is next inserted in the os it- self. The leeches (three or four in number) are then pushed up the tube, and allowed to fix themselves on the exposed portion of ilie cervix. It may be necessary to use an injeg- TREATMENT OF MAL-NUTRITION OF THE UTERUS. 1 39 tion of tepid water previously to applying the leeches, and to remove the discharge covering the surface of the cervix by means of a piece of lint. Wlien the leech attaches itself to the interior of the os, or to tiie vaginal wall, the patient usually experiences, especially in the former case, sharp pain. To detach the leech under such circumstances, an injection of salt and water is to be used. It must not be forgotten that the bleeding from leech bites on the os uteri is sometimes very profuse, it may be even alarming. Scarifications o\ punctures of tiie congested uterine cervix, either externally on the surface of the vaginal portion, or within the canal, are of great use in some instances, espe- cially in reducing the size in cases of hypertrophy of the part. The remedy is applicable to the same class of cases as those requiring leeches. A number of slight scarifica- tions are better than two or three deeperones. In perform- ing scarification of tlie cervical canal, a small knife of pecu- liar shape and construction is necessary. Use of Hot-water Injections. — Of late years the efficacy of hot-water injections — temperature 100° to 110° — has been frequently observed in the treatment of uterine congestion. Dr. Emmet, of New York, largely employed it, and I have for the last two or three years rather extensively recom- mended it. On the whole there seem to be good reasons for avoidance of cold water for injections or affusions to the uterus. There was formerly a notion, which I myself shared, that cold water was a good application in cases of conges- tion of the uterus. I no longer think so. The hot-water high-temperature douche may be employed twice a day; the quantity used may be one or two pints or more. In cases of congestive hypertrophy of the cervix uteri; when the os presents nodular masses instead of the natural- shaped orifice, the repeated use of hot water as above men- tioned is a valuable assistance in promoting absorption. [As bearing on this subject I insert here Dr. Emmet's re- marks on the use of hot-water vaginal injections in uterine disease. (Emmet's "Principles and Practice of Gynaecol- ogy," second edition, pp. 81 and 119.) " Hot- water vaginal injections, of different degrees of temperature, according to the circumstances of the case, will prove an invaluable aid in the treatment of all uterine diseases. It is, therefore, of the greatest importance that tiiey should be administered properly. When given in the upright, or sitting position, the effect is very little mgre I40 DISEASES OF WOMEN. than to wash out the vagina. The full benefit cak be or;- TAIXED BY ADMINISTERING THEM ONLY WHILE THE PATIENT IS LYING ON HER BACK, AND SHE CANNOT EFFICIENTLY GIVE THEM TO HERSELF. It is ALSO NECESSARY THAT HER HIPS SHOULD BE ELEVATED, and the quantity of water used should not be less than half a gallon for each injection. '' A bed-pan of proper shape and size is indispensable to protect the clothing of the patient. The one known in the Crocker}' shops as the English bed-pan, but now somewhat out of use, answers the purpose very well. For temporary use, the India-rubber inflated-cushion bed-pan will answer, but it is liable to stick together from the effects of the hot water. "The shovel-shaped French bed-pan, more in general use in the sick-room, does not answer for this purpose, as it al- lows the clothing of the patient to become wet. When using the regular bed-pan, it is necessary to place the pa- tient so far forward on it that her weight will not tilt it up. Or the handle, which is hollow, may be turned to one side, and a piece of large India-rubber tubing stretched over it to allow the water to pass off into a receptacle placed along- side of the bed. For use in my private hospital I have this form of bed-pan made of copper, and, instead of so large a handle, there is a small spout wliich can be kept closed when not needed, by a cap over it. When a large injection is given, the cap can be removed, and a small piece of tubing placed over the spout will carry off the water. "The injection can be better administered to the patient after she is undressed for the night and in bed. She should be placed near the edge of the bed with her hips elevated as much as possible by the bed-pan, and a small pillow under her back, the lower limbs being flexed. Her body must be covered, to protect her from cold, and her position made perfectly comfortable; when the bed is a soft one, a broad board should be placed under the pan to prevent it from sinking down by the weight of the patient, and to keep the hips elevated. The vessel of hot water is placed on a chair by the bedside, and the nurse passes the nozzle of the syringe over the perineum into the vagina, directing it along the recto-vaginal wall until it has reached the pos- terior cul de sac. The water must be thrown in, at first, very carefully, until the vagina has become distended. If the nozzle is not properly introduced, the stream of water may be thrown directly into the uterine canal. The forci- TREATMENT Ot MAL-NUTRITION OF THE UTERUS. I4I ble entrance of any fluid into the undilated uterus causes intense pain, and frequently alarming symptoms of nervous prostration or collapse; and sometimes it is the cause of an attack of cellulitis. At the completion of the injection, the vagina can be emptied by depressing the perineum for a few seconds, with the finger on the noz/Ac of the syringe be- fore withdrawing it, and, as the bed-pan is removed, a nap- kin should be placed against the vaginal outlet to absorb any water which may have been retained. "When circumstances prevent the injections being thus administered, it is better to use a fountain, siphon, or syringe, than that the patient should attempt to give them to herself. This mode, however, can only be regarded as a substitute, for it is never as efTicacious. In any event the same elevated position of the hips is necessary. A steady stream is never as serviceable as the interrupted current from a Davidson's syringe. " Hence it would seem as if, in addition to the heat of the water, the jet from the syringe acts as a stimulus to e.xcite the blood-vessels to contraction."] Baths and \]'ateriih:;-placcs. — In obstinate cases, the great- est benefit is sometimes derived from the internal and ex- ternal use of mineral waters of various kinds; the effects produced being dependent partly on the change of scene and occupation, partly on the increased activity of the skin induced b\' the use of the baths, and partly on some special action of the waters used. The choice of a watering-place is a matter of some moment. In cases complicated with dyspepsia and with defective action of the abdominal cir- culation, Vichy or Hombourg may be recommended. Where the action of the abdominal viscera is sluggish, and where there is great constipation, the baths of Carlsbad or Marienbad are very useful, especially in the case of patients who have been in the habit of indulging too much in the pleasures of the table. Many others might be mentioned, equally efficacious in improving the condition of the ab- dominal circulation and the state of the digestive organs, such as the waters of Plillna, Seidlitz, Purton, etc., which contain sulphate of magnesia and soda, and are therefore of an aperient character. In cases where we desire to act chiefly on the skin, and to effect a derivation to the surface, thermal waters offer advantages; the waters of Wildbad, Schlangenbad, Gastein, Clifton, Buxton, etc., deserve men- tion in this respect. Warm sea-water baths act in like 142 DISEASES OF WOMEN. manner; they are very efficacious, and have the additional advantage of being accessible. There are cases in which the uterus and pelvic organs generally appear to be in an atonic relaxed state, and for the relief of this class of pa- tients chalybeates are found most serviceable. The waters of Schwalbach, Pyrmont, Spa, Driburg, Kissingen, Fran- zensbad, and Fachingen, are the best adapted for patients suffering from the above symptoms, associated as they usually are with anaemia, pallidity of the surface, tendency to headaches, etc. The iodo bromated w^aters of Kreuz- nach, Hall, Durkheim, and Krankenlieil, are specially to be recommended in cases of the more chronic kind, especially when the uterus is the seat of indurations, however caused. The Woodhall Spa in Lancashire enjoys a reputation for qualities analogous to those of Kreuznach. For neuralgic or rheumatic cases, Wiesbaden, Baden-Baden, Ems, and Bath enjoy deserved repute. In cases where it is consid- ered desirable to administer iron in small quantities, to- gether with an aperient, waters such as those of Kissingen or Selters are the best. The baths of Driburg have been found peculiarly efficacious, taken during pregnancy, in cases where there is a tendency to disease of the foetus; the waters in question are chalybeate, but contain also lime in solution.* Astringefit and Caustic Applications to the Os Uteri. — As subsidiary measures these local applications are frequently of great service. Solutions of alum or of tannic acid, or the latter in form of oak bark decoction, are the astringents' most commonly employed in the form of an injection used once or twice daily. Many other astringents have been also employed with advantage. Caustic applications have been very fre- quently employed in cases where the malady supposed to be present was ulceration of the os uteri, and in another class of cases also where the lips of the os are hypertrophied (congestive hypertrophy). The caustic agents used have been of various kinds, from the solid nitrate of silver, com- paratively mild in its action, to the acid nitrate of mercury or caustic potash. The stronger caustics have been rather frequently employed to melt down and actually destroy the nodular projecting lips of the os uteri as well as to produce *For further information on the subject of baths, see Dr. AUhaus' work, " The Spas of Europe," London; TrUbner. TREATMENT OF MAL-NUTRITION OF THE UTERUS. 1 43 a healing of the so-called ulcers. The use of severe caus- tics in this manner had a powerful effect, and, in not a few cases, not only removed the hypertrophy but produced a closure of the aperture of the os uteri, with consequent grave inconveniences. When the lips of the os are fissured deeply, and present nodular projections, the best treatment consists in first of all reducing the bulk by persevering with daily injections of hot water, and afterward repairing the lacerations by a plastic operation (see chapter on Lacera- tions of the Cervix Uteri). The waters of Kreuznach are specially serviceable in the concentrated form in cases of chronic congestive hypertro- phy of the uterus and cervix, their use being continued for some few weeks at a time. The milder caustic agents are of service in accelerating the removal of hypertrophies of the lips of the os uteri. The solid nitrate of silver and the iodine liniment, or the liquor (which latter is the weaker) of the British Pharma- copoeia, are the agents I prefer. Strong solution of bromine is also a useful agent for the purpose. These agents are applied on cotton- wool by means of the speculum: the os and cervix being well exposed, the secretions are to be re- moved and the surface well dried by means of a piece of lint or cotton-wool, and the caustic then applied. The only cases in which stronger agents seem admissible are those in which there is a small growth which requires actual removal — for instance, those in which the interior of the OS presents those excrescences or developments of the mucous membrane known as mucous polypi; those cases also in which the mucous follicles around the os become swelled out and distended, presenting the little round enlargements known as the Nabothian bodies. In the application of the stronger caustics, we have an expeditious mode of dealing with the pathological conditions in question. Whenever the strong caustics are used, very great care is necessary to prevent the tissues adjoining the cervix uteri from being injured. These tissues must be guarded in a suitable manner during the operation, and precautions used to prevent the caustic applied to the surface of the cervix from coming into contact with the opposed surfaces of the vagina, when the operation is over, and the speculum with- drawn. The actual cautery has been a favorite remedy, especially in France, in the treatment of chronic induration or inflam- 144 DISEASES OF WOMEN. mation of the vaginal portion of the cervix uteri. The ap- plication is made through a horn speculum, specially con- structed for the purpose, and is repeated at intervals of a* few days, each portion of the indurated surface being thus successively covered with eschars. Internal [Remedies. — On the supposition that proper meas- ures are being taken to remove the cause of the congestion and improve the uterine circulation, we have to consider what other internal treatment is required. Ergot given at intervals in small doses, or by the subcutaneous method is one of the internal remedies most appropriate for reducing chronic uterine congestion. Probably next in order stands bromine, or mineral waters containing it. The Kreuznach water is one of these, and its use continued over many weeks has a considerable effect in most instances. Bromide of potassium may be given as a medicine, ten or fifteen grains twice a day. It may also be used as an injection for the vagina. The Kreuznach water (in the more or less concentrated form) can be very usefully thus employed. Its topical action on the uterus is undoubtedly good, espe- cially in cases where there are hypertrophies of the os uteri present. A mild mercurial course, following the suggestion of Dr. Oldham, has been often employed in order to reduce the size of the organ in cases of chronic congestive hypertro- phy. The remedy is undoubtedly efficacious in some in- stances. But it requires care, for, if the patient be very weakly, it may do more harm than good. Relief of Pain. — There are many cases of congestion of the uterus in which immediate treatment of a palliative character is required for the relief of pain. The remedies, opiates, fomentations, etc., which may be advantageously employed under such circumstances will be described in the chapter on Treatment of Flexions. CHAPTER X. Abnormal Conditions of the Lining of the Uterus. General Employment of term Endometritis — Explanation of these Cases — Cause most frequently Retention in Uterine Cavity of Irritating Discharges, Retention being due to Uterine Distortion — Importance THE LINING OF THE UTERUS. I45 of Drainage of Uterine Cavity — Fungous Condition of the Lining of the Body of the Uterus shown to be really Congestive Hypertrophy of the Mucous Membrane. The terms endometritis, endocervicitis, have been em- ployed to designate the condition of the lining membrane of the interior of the body of the uterus and of the cervix, respectively met with in cases of so-called inflammation of the uterus. And these affections (endometritis and endo- cervicitis) constitute for several gynaecologists of repute substantial, important, and independent diseases. The piesence of pain, coupled with a copious discharge from the uterine cavity, is taken to imply that the aft'ection is mainly endometritis, and, further, that it is a primary affection. But there are good grounds for disputing the accuracy of this view. Endometritis does probably occur as a separate and dis- tinct ailment. Thus, one of the effects of a severe chill is to set up a morbid condition of the lining of the uterus, which becomes irritated in common with the tissues of the uterus generally. The lining of the uterus may also be irritated and inflamed by various applications from without. And there is no doubt also that traumatic influences acting on the lining of the uterus — laceration by the point of the sound, for instance — may set up dangerous irritation. In the latter case, however, we have a real pyaemic process introduced. Apart from traumatic influences, it may be said that endometritis is, as a distinct disease, not by any means common. The importance which " endometritis" holds in the esti- mation of some uterine pathologists necessitates a discus- sion in this place of the whole question. Those who, reject- ing as unphilosophical and untrue, when tested clinically, the theory of all uterine maladies being situated at the cervix, and who have contended for the body of the uterus having a little more attention paid to it, have been them.- selves divided into two camps. Some have held that the tissues of the walls of the body of the uterus are affected with inflammation; others consider \.\\^ liuitig of the body of the uterus to be the principal seat of the disorder. I have all along expressed my agreement with those who, like Scanzoni, contend for the importance of the affections of the body of the uterus. The absence of a free outlet for the uterine secretions is a fertile source of irritation of the uterine lining. Thus the I46 DISEASES OF WOMEN. flexions of the uterus are causes of such irritation, leading; as they do so frequently, to a partial and valvular closure of the internal os uteri. The fluid collects in and dis- tends the body of the uterus, is retained and becomes irri- tating. Excessive discharge from the interior of the body of the uterus is in so many cases obviously connected with an obstruction at the internal os uteri leading to retention of the secretion within the uterus, that it is impossible to escape the conclusion that it is this obstruction which is responsible for the excessive secretions. Under the head of '• Flexions" of the uterus this matter will require further development; but here I would state that the facts and the results of that special treatment for endometritis which is in favor with some practitioners equally fall in with this view of the case. Accepting, therefore, the assertion — which is undeniable — that in certain cases the lining of the body of the uterus is in a disordered state, evidenced by purulent or offensive discharges therefrom; and, putting on one side cases of cancer, cases (very rare) of tuberculosis of the uterus, cases of gonorrhoea and s\'philis, I continue to hold the opinion, expressed in the last edition of this work^ that this disor- dered state of the lining of the body of tlie uterus is gener- ally the result of retention of natural secretions and the irritation proceeding therefrom. Any one who has treated cases of flexion of the uterus is familiar with the fact that the uterine body is frequently enlarged and distended by accumulation of fluid within it. This fluid escapes from time to time^ but until this flexion is relieved the accumulation is apt to recur. When men- struation occurs under these circumstances the menstrual products are also apt to be detained in utero. The ''pe- riod " is protracted and may be ver}^ painful. The retained products irritate the interior of the uterus, become broken up, mixed with further secreted watery fluid, and finally escape in gushes as a puriform fluid. Dysmenorrhoea, menorrhagia, leucorrhoea, are all symptoms which may be mixed up with such retention of fluid in utero, and there- fore it is impossible to dissociate their consideration from the question of possible endometritis, and the possibly altered condition of the lining of the uterus must of course be considered in conjunction with these symptoms and their connec'"ion pointed out. In this place we are concerned THE LIXIXG OF THE UTERUS. I47 with the question as to the substantiality of endometritis as a distinct disease. It really appears to be, in the major- ity of cases, but an effect, an accident — so to speak — of other concomitant disorders of the uterus: important, no doubt, as an effect, but still an effect. Constituting indis putably a source of discomfort and giving rise to various symptoms, but not a primary condition in the proper sense of the word. The key to the proper understanding of most of the cases of so-called endometritis is the due recognition of the im- portance of drainage of the uterine cavity. Provision must be made for escape of the secretions, and the conditions capable of producing retention of these products must be understood. When the uterus has a shape resembling that of a retort the circumstances are not favorable to free and easy drainage of its interior, and attentive observation of two or three cases of chronic flexions of the uterus, associ- ated with so-called endometritis, will make it evident to the inquirer that the real relation subsisting between the bend- ing of the uterus and the presence of fluid and profuse secretions from the uterine interior is one of cause and effect. The analogy between puriform discharge from the uterus and chronic cystitis due to stricture of the urethra, is, so far as possible, complete. In both we have distention of a muscular organ to an unnatural degree with secreted pro- ducts, irritation of the interior by the retained product, alterations of the fluid secreted, etc. The stricture of the urethra is analogous to the bend in the uterus — both ob- struct excretion. The various effects witnessed in cases of so-called endo- metritis are then explainable on the deficient drainage hypothesis. The view here expressed has been opposed and criticised in many quarters, but it is sufficient to exam- ine the details of cases published with the endeavor to con- trovert these views, in order to obtain evidence corroborative of their accuracy. The endometritis theory of uterine dis- ease has suggested the necessity of making applications of caustic or other materials to the interior of the uterus in order to get at the root of the supposed disease. This treatment has been found very serviceable in relieving pa- tients of the symptoms which they presented. But the very process adopted of application to the interior of the uterus of the cauterizing agents, of necessity so alters the 148 DISEASES OF WOMEN. shape of the uterus as to abolish for the time being the retention. The instruments inserted are generally nearly straight. The canal of the cervix is indeed sometimes arti- ficially dilated in order more easil}' to apply the remedy, and by these means the flexion, which previously existed, is of necessity more or less destroyed. Thus one effect, at all events, is produced, viz., a complete and perfect drain- age of the uterine interior. The patient is, we will sup- pose, cured after repetitions of tliis process; but now comes the question, How much of the cure depends on the straightening of the canal, with the consequent complete, if only temporary, drainage of the uterus, and how much on the internal cauterizatior. ? One method of answering the question is by an examina- tion of the results of treatment limited to the straightening of the uterine canal. It is the fact that these results are of the most satisfactory kind, and they undoubtedly prove that intra-uterine medication, so much insisted on as neces- sary for the cure of endometritis, is not required, and that the supposed good effects of it would be equally witnessed after more simple treatment. The following remarks of Dr. Thomas in the last edition of his work (1880) on applications to the uterine cavity in cases of endometritis may here be quoted. Dr. Thomas says: " Enlarging experience during the past five years has led me to become skeptical as to the utility of the course. Observation and experience have so changed my own prac- tice that I find myself very rarely resorting at present to applications above the os internum uteri. They very gen- erally fail in curing the disease, and they are by no means void of danger." And with regard to the effect of the "curette treatm.ent for fungosities," he says, " in a great man}' cases he has had to repeat the operation of scraping about once a year for a long time" (p. 349). Fungous Conditio}!, of the Lining of the Uterus. — It has been found in many cases of so-called endometritis that the mucous membrane lining the body of the uterus has pre- sented a fungous condition. Under such circumstances there frequently occurs profuse losses of blood at the menstrual period and saniouo leucorrhoea at other times. These fungosities have been frequently removed by the curette, and the roughened surface scraped awa)', thus removing the fungosities, and no doubt, in many instances, THE LIXIXG OF THE UTERUS. I49 with results which have been found encouraging to tlie fur- ther prosecution of tliis method of treatment. These fungosities appear to consist essentially of the mu- cous lining of the uterus in a swollen hypertrophied condi- tion, whereas they seem to have been treated as foreign bodies. In other words, they do not appear to be of a poly- poid character or to resemble those growths which are lia- ble to be met with in the interior of the uterus, ami for which actual removal is the proper and the accepted method of treatment. A short time since a case came under my notice which enabled me to make an observation which seems to have an important bearing on the question as to the cause and na- ture of the condition described as fungoid excrescence or growth of the lining membrane of the uterus. The subject of this case was an unmarried lady, 42 years of age. Up to four years ago she had had moderately good health, though never strong. At that time — four years ago — she was one day in a sailing-boat on the sea for a few hours. She became violently sick, and felt something give way internally. She remained ill for some time, after being carried ashore. anossible, unless it is duly regarded^, to make any advance in knowledge of the subject. Cases as they are met with in practice are generally complex: they are as a rule complex in more than one sense of the word. The complexity is not merely a mechanical one — there are also various vital or functional disturbances entering into and complicating al- most every case. Thus, flexions and displacements of the uterus are almost invariably only a part, though a very im- ])ortant part, of the affection. The condition of the general liealth, the condition of the uterine tissues, are qualities liable to vary exceedingly in different cases, and when we consider the number of possible varieties in the shape and position of the uterus, it is evident that the number of pos- sible complications is almost endless. Thus, to say that a particular patient is affected with an anteflexion of the uterus is to convey very little actual information; the case may be trifling in importance, or it may be serious; it may be safely left to itself, or it may require much and skilful attention to be remedied. We should require to know the history of the case, the precise degree of the anteflexion, the precise position of the uterus as a whole in the pelvis, 1/6 DISEASES OF WOMEN. the physical condition of the tissues of the uterus, the size and thickness of its walls; and, in forming a due estimate of the case, the general condition and activity of the nutritive process would form a ver}' essential element. Frequency of Distortions and Displacements of the Uterus. — It is a matter of considerable interest to de- termine the actual frequency with which these disorders of the uterus are met with in practice. The following is a contribution on this subject from my own experience: During a period of a little over four years, from August, 1865, to December, 1869, I kept notes of all cases treated in my out-patients' room at University College Hospital. The number of recorded cases of all kinds is 1,205.* Of these, 714 presented uterine symptoms. Of these 714, 620 were subjected to an internal examination, and the diagnosis thus arrived at. In 94 no such examination was made. Of the 620 examined cases, 61, or 9.8 per cent, were set down as suffering from absence or malformation of uterus, or various symptomatic affections only. In 182, or 29.3 per cent, the patients were found to be suffering from fibroid tumor, cancer, or pelvic cellulitis. In 377, or 60.8 per cent, the shape of the uterus was ma- terially changed or its position markedly changed. These 377 cases are further resolved into Flexions j Retroflexions, 112 > ^ . I Anteflexions, 1S4 f '^o Prolapsus 81 377 Further, " the flexion cases were very generally attended with textural alterations of the uterus, congestive hypertro- phy, etc., which, in accordance with present views would be termed congestion; but it is precisely in those cases where the symptoms of irritation were most marked that severe and well-established flexions w'ere found to exist." It thus appears that in 60.8 per cent of these hospital out- patient cases which presented uterine symptoms of suffi- cient importance to suggest the necessity for making an examination, marked physical changes in the form, shape, or position of the uterus were detected. The total number of cases recorded was, as I have before stated, 1,205, '^^ which 714 are accounted for in the above * These data, the results of hospital experience, were first published in the last edition of this work, 1S72. DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 1 77 analysis. There remain 491 cases, which include many of syphilis or gonorrhoea, pregnane}', general debility, over- lactation, diseases of the bladder or external generative or- gans, phlegmasia dolens, tumors or inflammations of the ovaries, cases of doubtful diagnosis, cases of disease of other than the generative organs, etc. The foregoing statistics give the proportion in which dis- tortions and displacements are liable to be observed in the case of hospital patients, in London at least. Turning from these results of public hospital practice it is more difficult to arrive at results which will command attention as to the frequency of uterine distortions and displacements in the class of patients ordinarily denominated "private" patients and the majority of which belong to the better classes of society. I have, however, extracted the following particu- lars relating to six years of recent private practice with the view of arriving at some conclusion on the question as to tlie relative frequency of various forms of uterine disease. It must be premised that the six years' statistics given below are imperfect in one way, for they do not include a number of cases, particularly those seen in consultation practice away from my own residence, which have unavoid- ably escaped being recorded. The total recorded cases in six years (r,i4o) include — Cancer, uterine or vaginal 27 Fibroid tumor and polypus 60 Diagnosis of pregnancy 33 Flexions, and displacements of the uterus (see explana- tory statement below) 709 Miscellaneous, including a. Diseases of other than sexual organs b. Cases of disease of sexual organs, no physical 311 examination c. Various diseases of sexual organs not included in foregoing list 1 140 It is Stated in the foregoing list that 709 patients were affected with flexions or displacements of the uterus. This statement requires a more complete explanation. There were probably several other patients who would have been found to be suffering from these affections had an examina- tion been made. The 709 cases are put together because they evidently belonged to one class. The symptoms were so severe or troublesome that an examination was impera- 178 DISEASES OF WOMEN. tive, and the result of the investigation was to show that the symptoms were dependent on the uterus. In a few of the cases where it is expressly stated the uterus was found normal, the cases are still left in this categon.-, because the symptoms observed were such as are ordinarily present in cases of flexion or displacement, and no disease of any other organ was found to account for them. Flexions (ante- 4S8, retro- 180) 663 Uterus prolapsed without flexion 6 Uterus simply too large or too long 11 Hypertrophic cenrical elongation 3 Uterus normal 4 Cases of alternate ante- and retroflexion 2 Lateriflexion 3 Flexions combined with pregnancy 12 Total 709 Under the head " Miscellaneous" are included various slight cases of disorder of the sexual organs, in some of which examination was made, and in many not; it includes also cases diagnosticated to be disease of the ovaries by physical examination or otherwise. It also includes some few cases of patients who were not found to be affected with diseases of the sexual organs at all. The number of cases of the latter class is not, however, enough to vitiate any numerical conclusion to which the figures would appear to lead- Speaking generally of the foregoing statistics, they may be summed up as follows: Of 1 100 patients believing themselves to be affected with some disorder r'^erable to the sexual organs, or believed to be so affected by the practitioner under whose care they had been, after a careful investigation of the case and from the results of physical examination, about 700 were found to be suffering from well-marked flexion or displacement of the uterus; 87 were affected with cancer or fibroid tumor; there remain rather over 300 cases accounted for under va- rious heads in the foregoing list. The statistics of my own private practice thus show that in about 70 per cent of patients applying for advice, flexions and displacements existed, and, in my judgment, proved to be the essential cause of the sufferings of which the patients complained. When it is stated that flexions and displace- ments existed in this large percentage of cases, it is not to DISPLACEMENTS. DISTORTIONS OF THE UTERUS. I79 be inferred that these constituted the sole Tnalndies f-esent. Few of these cares were without . kinds. But almost the wh-^^e cf severe ones, none being :• ;ne patient was sunering or ; - . e in which the diagnosis was at ail doubtiiii. CHAPTER XV. Displacements axd Distortioxs or the Uterus (Flex- ions)— 3. Etiology. Etioi.^.-v — >-A:"i:'^ .-'^ rAi?< ■- ?'% A!r- P-Artice.i_- - --- o: >: Uterus ::..n: v —Physical P: a. Elxcilinj:: Ac .r .5 — (."> r:-r,\c-: s? — >y<:^. :_\;r; ^::i. Oxufviiions — Miiriogie. V General Causes. For some few years past II ^ to ascertain the cause of the ci-. . . in cases of this kind coming under rr In a consider- able number of the cases I found : . . -, .^, -^ ;., the previous history* particular causes t ; ur- rence. Due care has been taken iv. j^... .. ..> v,-. c.-..\ as possible against sources of fallacy in tracing the relation of he cause and effect. It is remark.ible how frequentir the narticutar cause of • "'. " "\ " , , - ^j. ^ — ta 1 > t i .1 i. \. I have selev : - f cr.sr? rrVrrtrd ;!::-:-:: six years 540 cases in wir.ch . ar- ried, was sterile, and in w th ante- or reirv>-rtexion. I have ed lor the moment cases of patients who . . .:. as in such cases child^i-th. or the sequelae of child-bed, introduce dis- turbing considerations. It thus appears that in ^*^. or 43 per cent, of cases of riexion in single women, or. if marrievi, sterile, the cause was distinctly traced to some one of the above-mentioned agencies. It is right to state that in three of the above cases the pa- l8o DISEASES OF WOMEN. tient had had a miscarriage, accident or strain having pro- duced apparently the miscarriage as well as the displace- ment, or, to speak more correctly, the accident or strain was responsible both for the displacement and the miscarriage. 340 Cases of Single or Sterile Patients Affected with Uterine Flexions. The flexion distinctly traced to Retro- Ante- flexions flexions Total. 13 49 62 II 18 29 6 9 15 8 7 15 I 3 4 I I 2 I I 2 I I I I I I 2 II 13 3 3 I I 44* lost 149 Strains, lifting, carrying, nursing, standing, danc- ing, gymnastics, croquet, swimming, etc.... Falls, or other accidents Horse exercise Over-walking Organ or harmonium-playing Long railway journey Retention of urine in railway journey Fright Sea-sickness (three months' voyage) Measles Scarlet fever or typhoid fever Menstruation checked by cold Menstruation checked by sea-bathing Strains resulting from efforts in lifting, nursing, etc.. con- stituted a very common cause — 62 out of 149 ca?es. They most commonly produce the effect in patients who under- take such exertions without proper training or strength. Nursing and lifting sick relatives appear to be very danger- ous. Lifting, or occupations involving much standing, were responsible in many cases. " Stretching up to a cord," "drawing the cork of a bottle," "carrying a child," "strain at archery," "moving furniture," " rowing," "use of sew- ing machine," "lifting a patient from the ground," "lifting w^ashstand," were the causes traced in other instances. Unnecessary gymnastic feats, excessive standing at croquet, one or two cases traceable to excessive swimming, may also be mentioned. " Falls," or other accidents, include many cases in the tabular list above given. " A complete somersault down a flight of steps," "thrown from a carriage," "fall from a * Selected from 83 cases ] _ t Selected from 257 cases [ ~ 34 DISPLACEMENTS, DISTORTIONS OF THE UTERUS. l8l carriage," " thrown from a horse," "fall from a horse," falls on the back, on the ground, down-stairs, etc. — under the foregoing heads I find cases of retroflexion recorded. "Jump from a carriage,'' "slipped down flight of stairs," "fall from back of dog-cart," "fall from horse," "slipped down-stairs," "fall down steps," "jump from a horse," "fall from a horse and horse rolled over her" — under these heads cases of anteflexion could be quoted. Horse exercise was clearly traced as a cause in several cases. In one case it indirectly led to displacement, owing to prolonged retention of urine. In weakly young women, imperfectly trained to it, horse exercise appears decidedly injurious. "Over-walking" includes several cases. "Long moun- tain walks," "daily long walks," and "long walks to catch a train," are causes traced in some retroflexion cases. " Long walks up-hill," "very fatiguing walk," " walk during menstrual period," etc., in certain cases of anteflexion. Organ or harmonium playing was found injurious in a few cases. Retention of urine during long railway journey, fright, etc. — these cases require no particular mention. There were fourteen cases in which the cause assigned above is measles, scarlet fever, or typhoid fever. The rea- son for introducing these cases is, that the details on inves- tigation proved that the uterine affection had occurred from ordinary walking during convalescence from the fever. The conclusion formed was that the uterus, enfee- bled in common with the other organs of the body, gave way under ordinary exertion, and the preceding fever was thus really responsible for the resulting uterine affec- tion. The causes of uterine distortions and displacements may be divided into three classes — predisposing, exciting, and general. PredispL "ising : — Undue softness of the uterus — From malnutrition (chronic starvation). From sub-involution following pregnancy. Physical general prostration and weakness, as from fever, etc. Rupture of perineum. Previous pregnancy. l82 DISEASES OF WOMEN. Exciting: — Accidents — ■ Strains. Falls. Railway and carriage accidents. Over-exercise — Long walks or drives. Excessive exercise during menstruation. " " " pregnancy. Exercise too soon after confinement. Special exercises — • Horse exercise. Gymnastics (inappropriate or injudiciously se- lected). Croquet, lawn-tennis, etc. (in excess). Special occupations — Requiring much standing, as counter work. Requiring carrying and lifting, as nursing. Washing. Use of sewing machine. Straining in defaecation, etc. Marriage. General. Se.& remarks later on. Of the predisposing causes, undue softness of the uterus is perhaps the most important. It may be due to malnutri- tion either in a single woman, or in one who has borne children. This condition of the uterus has been already described (p. 98). General prostration and weakness, as from the effects of fever, appear to be powerful predisposing causes (see list cf cases enumerated at p. 180). Clinical facts show that uterine flexions are liable to be initiated by exercise or movement taken shortly after prostration from fevers. Rupture cf the perineum is a special predisposing cause: the support of the lower part of the vaginal canal is taken away, and this is a powerful predisposition to dis- placement of the uterus and to flexion of the organ. Previous pregnancy predisposes to flexion in several ways. The influence of rupture of the perineum (if it exist) has already been alluded to. But in other ways a predisposi- tion may exist. Thus, if the uterus is left in a state of sub- involution, the mere weight of the organ tends to produce flexion. If the organ remains softer than usual, as well as in a state of sub-involution, the predisposition will be DISPLACEMENTS, DISTORTIONS OF THE UTERUS. I S3 greater. Again, the loosening of the attachments of the uterus is frequently great during pregnancy and labor, and even if no lesion is discoverable, the normal fixation of the uterus may have been lost and a predisposition to flexion created. Repeated pregnancies in women badly nourished has a tendency to weaken the uterus very much. The uterus has little rest — it has scarcely time to recover from the effect of one pregnancy before another occurs. In the end the uterus becomes flexed, the flexion is confirmed, and either abortions or sterility (secondary) result. Excidne; Causes of Flexions. — Accidents, including strains, fails, and rail way or carriage accidents, are very important. It has hardly as yet come to be recognized as a fact that the uterus may be very seriously displaced and injured by severe accidents. The number of cases of severe injury to the uterus from these causes recorded in my case-books is considerable. The nature of the injury is generally, as experience has informed me, not understood at the time of the accident: the patient feels ill, generally no bones are broken, there is a severe shock, the effects of which last a few hours or a few days or longer, and gradually the patient loses the pain and no further notice is taken of it. But later on it is discovered tliat the patient is more or less completely incapacitated, and careful examination reveals the fact that the uterus is displaced and distorted, investi- gation of the facts conclusively showing that the discom- fort or incapacity dates from a certain accident. One of the first cases of the kind which came under my notice was that of a young lady who, travelling by train, had been rolled down a railway embankment, and had become af- fected with acute retroflexion of the uterus as the result. The record of many cases of an analogous kind which is in my possession, gives unmistakable proof of the effect of accidents in producing such displacements and distortions. The effect of a severe concussion on the uterus varies in different cases, and it varies according as it is accompanied or not by a severe strain. It is not uncommon for the con- cussion and the strain to come together. There is the fall, and the muscular effort to avoid the fall or accident. In the latter case the displacement of the uterus is likely to be greater. The facts in my possession show that the uterus may be forcibly driven downward to the floor of the pelvis, or to the back part of the pelvis — into one corner of it as it l84 DISEASES OF WOMEN. were — or that it maybe actually driven out of the vagina— [at least I have known of one case of the latter kind in a patient who had had a child, and \vho, while in the standing position, slipped from the table on which she was standing to the floor]. More generally the uterus is not only driven downward to the floor of the pelvis, but it is bent backward or forward, very acutely, at the same time. It was believed by Dr. Squarey that rupture of the uterine fibres sometimes occurs in the suddenly occurring acute flexion cases, and I consider it quite possible that it is so. At all events, it is not uncommon for some blood to escape from the vagina after such accidents. The effect of the blow or concussion will vary probably according to the position of the patient at the time, and the condition of the uterus, but when the case is investigated it is found that the uterus remains on the floor of the pelvis, or in one corner of it, or that it is anteflexed or retroflexed. It is important to note that when bones are broken or other notable injuries received, tlie internal injury to the uterus may escape notice. Two cases of this kind occur to me to mention. One was that of a lady who fell and injured the sacrum, was laid up b}' that injury for some time, then went about and rode on horse- back much, subsequently becoming paraplegic. The para- plegia was naturally set down to the spinal injury, but it proved to be due to a retroflexion of the uterus, and the patient was completely cured by restoration of the uterus. Another was that of a young lady who fell and broke her arm: some months after that obstinate nausea attracted attention, and it was found that the uterus had been vio- lently displaced and pushed into one of the posterior cor- ners of the pelvis. Violent straining may produce severe flexion. Of this class of cases may be mentioned one in whicli the patient, quite unaccustomed to such an exertion, lifted a helpless invalid from the floor, who had suddenly rolled out of his chair, the result being severe flexion. Another, that of a young lady, who in a spirit of bravado carried a very heavy cheese across the room, and became forthwith an invalid from severe flexion of the uterus. Long walks may produce at once acute flexion, or, con- tinued from day to daj^ may slowly give rise to flexion. Very long walks are certainly dangerous to those unaccus- tomed to them. Young recently married women, untrained and unfit for such continuous exertion, often inflict very DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 1 85 serious injury upon themselves by walking about all day during the honeymoon. Long mountain walks should not be undertaken by young women unless trained for the pur- pose and in robust health; and if a predisposition to flexion exists, much harm may be done by them. "A long walk of ten miles to catch a train" produced severe retroflexion. Long walks often inflict serious injury on young women at school who do not happen to be "strong," and who are tlierefore predisposed to suffer from flexion. It appears that long walks are more dangerous if under- taken during the menstrual period, no doubt because the uterus is at that time heavier, larger, and more vascular, and therefore more liable to become displaced. Long walks are not uncomm(jnly the cause of abortion during the second or third month; the uterus becoming displaced or flexed, the abortion is thus produced. Another impor- tant class of cases is that in which walking in excess is undertaken too soon after labor, while the uterus is still heavy, and in a state of sub-involution. Horse exercise may cause flexion of the uterus. It may be produced suddenly and at once, or more gradually. It is not so liable to happen if the individual be strong and properly trained to it; but evidence that could be adduced seems to show that it is a kind of exercise not free from liability to produce serious uterine mischief, even when judiciously managed. The evidence shows that the uterus is liable to be pushed downward on the floor of the pelvis, and generally very decidedly flexed backward or forward. If there be no particular predisposition to flexion horse exercise may do no harm, but it is never certain that it will not. Some few cases of severe flexion were undoubtedly traced to too severe gymnastic exercises. In two cases severe flexions were produced by jumping down from a consider- able height; in one severe and most troublesome retro- flexion was produced by the feat of raising tlie body from tlie horizontal position without the use of the arms. In two cases rowing was distinctly traced as the cause. Dr. Aveling. who has published a valuable work " On the Influence of Posture on tlie Health of Women," considers that the erect posture has much influence in inducing dis- ease, gravitation giving rise to vascularity. He considers the sitting posture on a chair as unnatural and injurious, I 86 DISEASES OF WOMEN. and would prefer the sitting posture on the floor. It is in accordance also with my experience that the prolonged ordinary sitting posture is injurious, and I have seen many cases where this posture could not be borne at all. But I do not know whether sitting on the floor would or would not prove equally inconvenient. Lawn-tennis and croquet, when carried to exce6S, in the case of individuals predisposed to flexion, are not free from danger, though doubtless innocent enough under other cir- cumstances. The next class of cases includes special occupations re- quiring much standing. Young women standing for many hours consecutively at the counter become frequently af- fected with flexion of the uterus. In hospital practice sucli cases not uncommonly present themselves. Dr. Edis has lately done good service in calling public attention to tlie injurious effects resulting from such over-standing: the production of severe flexion of the uterus is certainly one of them. The occupation of nursing, involving, as it does, neces- sity for lifting invalids or for standing many hours togetiier, is liable to cause severe flexions in the case of young women who are not strong and properly trained to the work. Numerous instances have fallen under my notice in which permanent ill-health or incapacity, due to a severe uterine flexion produced while nursing a sick relative, has been observed. Laundry work is perhaps one of the most trying to the attachments and connections of the uterus. It is liable to produce severe flexion, though it is more commonly the case that actual prolapsus is produced by excessive labor of this kind. The use of the sewing machine, playing the harmonium, or organ, are other occupations requiring men- tion. Some severe uterine flexions have been produced by these occupations in cases which have come under my notice. Straining in defaecation is both a consequence and a cause of uterine flexion. Nothing is more common tlian to meet with cases in which uterine displacement and flexion give rise to constipation. The effort required to relieve the bowel increases the existing flexion. This is more particu- larly the case in retroflexion. I have seen a case of retro- flexion in which the fundus uteri was driven downward by DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 187 the straining effort against the sphincter ani, most effectively blocking up the canal like a ball-valve. Marriage must be mentioned among the causes of flexion. In cases where there is a predisposition to flexion, and where the uterus is soft and weak, intercourse has often a very prejudicial effect; and marriage in such cases may lead to troublesome disease of the uterus in consequence of the mechanical disturbing influence thereby brought to bear upon it. It seems probable that were the true history of every individual case known the cause would be evident enough. I have found it possible to assign a cause in a very large percentage of the cases which have come under my notice, and frequently the cause has been discovered some time after the patient has been under treatment. Slight acci- dents, even severe ones, are often passed unnoticed. In many cases, no doubt, the flexion occurs gradually. There is generally in such cases a slight predisposition to begin with; and although the exertion or exercise taken by the patient is nothing out of the ordinary, it is more than can be endured; and in the end, after many years perhaps, the uterus is found affected with a severe form of flexion. Young women, imperfectly fed, having no stamina to begin with, and called upon to undertake duties involving stand- ing or walking or other exertion — governesses, for instance, called upon to daily take long walks with their more robust pupils — offer numerous instances of the truth of these remarks. DISEASES OF WOMEN. CHAPTER XVI. Displacements and Distortions of the Uterus (Flex- ions) — 4. Classification and Pathological Effects. Classification of Flexions and consequent Displacements. — Patho- logical Effects. I. The Seat of the Flexion. 2. Variations in the Condition of the Tissues of the Uterus. 3. Various Kinds of Flexion or Version (Rotation). 4. Varieties in Position of Uterus as a whole. Pathological Effects of Flexions, Relation to Congestion, Relation to Hypertrophy of the Uterus — Contraction of the Cervical Canal — Changes in the Uterus, Atrophy, Compression at the Seat of the Bend, Sensitiveness at the latter Spot — Persistence of the Distorted Shape of the Uterus — Changes at the Os Uteri. One principal cause of disagreement in regard to flexion of the uterus is want of appreciation of the fact that flex- ions vary so much in character in different cases. To over- come this initial difficulty it is necessary to attempt some classification of the varieties observed. classification of flexions of the uterus and conse- quent DISPLACEMENTS. 1. The Seat of the Bend. — The most common situation is the position of the internal os uteri, or about midway be- tween the OS uteri externum and the top of the fundus. Dr. Emmet, speaking particularly of anteflexions, adopts a peculiar classification. He speaks of (i) flexions of the cervix below the vaginal junction, and of (2) flexion of the body of the uterus. He regards the first as congenital, the second as liable to occur after puberty. I do not share his view as to the congenital nature of the first variety, but it is the fact that the greater part of the bend is low down in many cases. In most cases the bend affects a consider- able part of the uterine canal, involving the upper part of the cervix as well as the lower part of the body of the uterus. 2. Variation in the Condition of the Tissues of the Uterus associated with the flexion. This variation is very impor- tant in the classification of flexions. a. The uterus may be excessively soft, hardly more re- sistant than wet brown paper. Reduction of the flexion DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 189 easy, but recurrence not observed perhaps until patient has moved about again. b. Moderately soft, hypertrophied as regards the fundus and cervix, congested and heavy. Reduction easy, recur- rence on withdrawal of sound not immediate. c. Normally hard, but hypertrophied as regards the fun- dus and cervix — one or both. Reduction difficult, recur- rence on withdrawal of sound immediate. d. Excessively hard, the os perhaps much hypertrophied, lips everted and congested; much hypertrophy of body of uterus also. Reduction very difficult, or only to be effected by sustained effort. e. Variations in the thickness of the uterine walls, espe- cially at the seat of the flexion. 3. Various Kinds of Flexion and Version. — a. Anteversion (anterior rotation) pure and simple. b. Anteflexion, first degree ) -.^i • j J, ' ,*, f with varymg degrees c. second degree \ . . ■ . .■ J ,( ♦111 (of anterior rotation. d. third degree ) e. Retroversion (posterior rotation) pure and simple. /. Retroflexion, first degree ) •., • j ■' u J *^ f with varving degrees p-. second degree \ e .'•..• *, ,j ^\ • A A (of posterior rotation. //. " third degree ) ^ j. Lateriflexion, right or left. k. Anteflexion with subsequent posterior rotation, the uterus yet preserving its anterior flexion. Oscillating, or alternate ante- and retroflexion. There are more minute shades of difference observable than those above indicated, and the differences existing between first, second, and third degrees of flexion may be not easy precisely to define, but in practice an approximate definition of the degree of flexion present is generally quite practicable. 4. Variation in Position of Uterus as a whole. — a. Uterus pushed backward on the floor of the pelvis, with or without flexion of the same. (Not common.) b. Uterus prolapsed, more or less completely in a retro- flexed state. (This condition more properly comes under the head of " Prolapsus.") c. Uterus higher than usual in the pelvis, but in a flexed condition. (Very rare.) d. Uterus flexed in various modes and degrees (see pre- ceding list), and lying lower than usual in the pelvis. (This is the most common condition.) 1 90 DISEASES OF WOMEN. t r^ I propose in the next place to call attention to some of the pathological effects of flexions of the uterus. Fig. 34 represents the comparative thickness of the walls of the Fig. 34. uterus, as shown by a section through it vertically and from be- fore backward. What would be the effect upon the uterus of a bending of the organ ? It would obviously be to produce a com- pression of the tissues of the organ at the seat of the bend (Fig. 35). Such compression is in the nature of things inevitable. The distance between the external and the in- ternal wall will, in process of time, though probably not imme- diately, be diminished. The dim- inution of the thickness of the walls of the uterus will take place to a greater extent on the concave side of the bend. There will be a diminution of the diameter at the position of the flexion {a,i>,c), and the general result will be that there is a compressing force exer- cised at the middle of the uterus upon the tissue of the organ (Fig. 35). The effects of this compression in retarding the circu- lation in the uterus, and in producing &cu\.e congtstion oi the organ, have already been discussed at p. 112 in connection with the subject cf congestion of the uterus. Its effects in producing a "strangulation" of the uterus have been also described in the same place. It is, I believe, an inevitable result that the circulation in the upper part of the uterus should be in a considerable degree interfered with when compression is thus exercised upon the uterus and its ves- sels, the result being that the upper part of the uterus comes in the end to contain a larger portion of blood than usual. It becomes unduly heavy and larger. It becomes not only congested, but likewise sensitive, to an extraordi- nary degree in some cases; and the congestion and sensi- tiveness constitute the most important of the phenomena, to a less degree in anteflexion than in retroflexion. This compression in the middle of the uterus produces variou? DISPLACEM'feNTS, DISTORTIONS OF THE UTERUS. I9I effects in different cases. After a time, if the flexion is not very acute in degree, the uterus may become habituated to it, and acquire a certain toleration of tliis condition. But wiien it does not acquire the toleration, or when, as fre- quently happens, the malady increases, we have an oppor- tunity of witnessing the following effects: the fundus uteri is found sensitive, swollen, and tender on pressure* the pa- tient is in a state of discomfort which hardly any physical condition of other organs of the body can exceed. The physical compression of the uterus is a phenomenon to which I attach great importance as a feature in the natural Fig. 35. history of these cases. An important effect of the mechan- ical interference with the circulation in the uterus occurring in connecticm with flexion, is that produced upon the men- strual functions. One effect of flexion is to narrow the uterine outlet so that the menstrual products do not so readily escape. But chronic congestion due to flexion alters the menstrual discharge in another way. Sometimes the quantity is enormously increased. In other cases it is as much diminished, is scanty and very trifling in amount. It is not uncommon to find cases in single women where menstruation has for some time been profuse, and then has become altogether too scanty. These results are due to mechanical interference with the general uterine circulation which severe flexion is capable of producing. The next effect to be mentioned is hypertrophy of the 192 DISEASES OF WOMEN. uterus^ general enlargement of the organ, the result of long- continued congestion. Dr. John Williams considers that the hypertrophy observed in cases of flexion is analogous to the hypertrophy of the heart due to stenosis of the ori- fices. In connection with the subject of hypertrophy of the uterus, it is necessary to consider the influence of defective involution after delivery. When we have the two things associated together — defective involution and flexion — we find hypertrophy of the whole organ. Flexion alone is sufficient, but, when co-t)perating with defective involution, the hypertrophy is most marked. Further, associated with tiiis hypertrophy of the cervix of the uterus, we generally meet with the following conditions: A very great increase of secretion from the cervical glands, and other changes in the mucous membrane which were formerly considered to be ulcerative in character. Descent of the Uterus as a Whole. — A common effect of flexion is descent of the uterus as a whole. This is one of tlie most important effects, clinically, and is the starting- point, in many cases, of prolapsus of the uterus. It is the first step in the process in a considerable number of cases. When the uterus is flexed, it becomes from that moment a source of irritation; the patient has difficulty in evacuating the contents of the rectum, and the functions of the bladder are interfered with, though in a somewhat different manner. The general result is, that the patient has frequently to use straining efforts either at stool or in micturition. The effect of this straining is to propel the uterus downward in the pelvis; and when this process has been going on for weeks and for months, or for 5'ears, the result is eventuall}'^ that the uterus, as a whole, comes to occupy a position in the pelvis which is much lower than it should be. In mak- ing an examination, we find the os uteri quite close to the vaginal ap:>erture in many instances; or, if we do not find it there, we find it dislocated in a corresponding manner back- ward, and very low down. I believe this is the mechanism of the first stage of prolapsus of the uterus in nine cases out of ten. The mechanical results observed are very interesting, and will be more particularly described in the chapter on Pro- lapsus. Compression and contraction of the cervical canal is another very important effect of flexion. It is necessary that this canal should be in a patent condition, in order that menstru- Displacements, distortions of the uterus. 193 ation may occur easily, and that impregnation may take place. Contraction of the cervical canal is one of the com- mon causes of dysmenorrhoea and of sterility, and is, ac- cording to my experience, a direct and almost necessary effect of fle.xion of the uterus (see chapters on Anteflexion and Dysmenorrhoea). Other conditions may produce contraction of the canal, but the percentage of cases of con- traction due to other causes is not more than from one to three or four per cent. The mechanism by which flexion obstructs is obvious. At the internal os uteri, the canal Fig. 36.* 'rTT:^iii;A''iy-/' has a diameter, under ordinary circumstances, of one eighth of an inch; tlie canal is larger below that point. But as the strength of a chain is that.of its weakest link, so the size of a canal is that of its smallest portion, when we come to consider how far it is available for the passage of fluid. Regarding the thickness of the walls, in proportion to the * Fig. 36 represents a case of long-standing retroflexion of the uterus. For purposes of illustration, I have, in teaching, used a model of the uterus on a large scale, constructed from sponge. When this model uterus is acutely bent, the compression thereby produced at the seat of the bend is very obvious. A marked condensation occurs at this spot. [The vagina is here represented by the artist as it should be in anteflexion. It should run in the opposite direction to make it a retroflexion.] 194^ • DISEASES OF WOMEN. size of the cervical canal, it may be conceived what must happen when that organ is bent at an acute angle; viz., a very considerable narrowing of the canal (Figs. 35 and 36). This is the explanation of dysmenorrhoea, and the reason wh}' it occurs so frequently in cases of flexion. In cases where the flexion takes place very gradually, where it has been advancing over a period of manyj'ears, the narrowing may be less obvious, owing to the gradual arching of the canal; but when the flexion is produced suddenly and acutely, it is often very decided. In some cases there is a real stricture at or near the in- ternal OS uteri, and the canal ^at the place in question is really narrow, and the sound only passes through the nar- rower part with a kind of jerk; but in many cases there is only what may be termed a potential stricture. The canal is narrowed and obstructed by the forcible coaptation of the opposite walls; thus the passage of fluids through it is obstructed, although the sound, if gently introduced, may be easily made to traverse the apparently narrowed part of the canal. There have been very great differences of opinion as to the frequency of stricture of the internal os, but, according to my experience, actual stricture of the in- ternal OS is not verj- common; while, on the other hand, apparent obstruction is frequently observed in cases of acute flexion. The condition of the uterus as regards hard- ness and softness is very important in the true estimation of these cases, for when the uterus is very soft the sound may pass in quite readily if held rather stiffly, and I have known cases where severe flexions have been overlooked, apparently from this circumstance of the sound encounter- ing no obstruction and thus entering in what seemed to be the normal manner. The fact is, that in such cases the sound straightened the uterus as it entered. The uterine canal being more or less impermeable in consequence of the flexion, various other effects result: such as the retention of fluid in utero, dysmenorrhoea from re- tention, leucorrhcea from retention, and sterility. Further remarks on these subjects will be found in the several chapters relating to them. The effect on the walls of the uterus at the seat of the flexion. — At the place where the flexion occurs, generally at the OS internum, certain effects and changes are produced. It appears that one of the first effects of the flexion is to give rise to a swelling of the tissues of the uterus on the concave DISPLACEMENTS, DISTORTIONS OF THE UTERUS. I95 side of the bend, this swelling affecting the uterine tissue and the plexus of vessels just outside the uterus. There is a specimen in the Middlesex Hospital Museum, in which a section shows an increase of the thickness of the wall of the uterus on the concave side of the flexion. In some cases of antefle.xion I have observed the presence of a sort of transverse ridge or elevation projecting on the concave aspect of the uterus, and felt by the finger through the roof of the vagina, due, no doubt, to the swelling of the tissues as above described. This is a condition of thinqs which is, however, not generally met with when the flexion has existed any considerable time. After two or three years (in cases of acute flexion) there always occurs an atrophy of the uterine wall on the concave side of the bend, and a consequent thinning of the wall at that spot. I have found it apparently hardly thicker than a piece of cartridge-paper at this spot. This condition of the uterine wall was some years ago described by Virchow. It appears to be a physical result of the compression or squeezing of the uterus itself at this situation. And it is not observed unless the flexion is severe enough in degree to cause such a compression. Accompanying irtrophy of the uterine wall as here described, there often occurs a considerable degree of hardening or condensation of the tissues. Probably the condensation is first in order of occurrence, the atrophy occurring later on. In cases where this hardening occurs, the uterine sound, on passing the narrowed part, encounters considerable resistance, and passes through and beyond it with a kind of jerk. In some cases the compressed tissues are actually softened. The compression to which the uterine tissues are sub- jected at the seat of the bend has the result, in many cases, of producing an extreme sensitiveness to the touch at the point in question. This is evident on using the sound. Thus, it will be found that the sound enters the cervical canal easily and gives no pain, but when it touches the uterine canal at about the internal os, severe pain is felt and evidence given of the existence of great sensitiveness. Passing beyond this point into the uterine cavity, it is found that the pain ceases. This observation I have made in several such cases. It is principally observ- able in those cases where the flexion is of long standing. The conclusion which I have formed as to such cases is, that the uterine nerves distributed to the tissues which are 196 DISEASES OE WOMEN. the seat of the compression are irritated by it, and that this is the explanation of the tenderness to the touch. The remarkable immunity from tenderness above and below the part affected, and its precise agreement in position with that of the bend, have led me to adopt the above explana- tion. This conclusion is of great interest in reference to various important questions as to the nervous and hysteri- cal affections to which women are liable. Slight bending of the uterus is not liable to produce atrophy of the walls at the seat of flexion. Atrophy occurs to the greatest degree in cases where the flexion is acute, and of long standing. Chronicity of severe flexion of the uterus appears to be mainly connected with alterations in the thickness of the w^all at the seat of flexion. This leads me to speak of the persistency of the distorted shape in cases of flexion. This persistency varies exceed- ingly in different cases, and appears to depend on the fol- lowing circumstances: If the flexion be severe, and nothing be done to relieve it the uterus becomes hardened, literally, in its distorted shape. This is observed when the flexion is the result of a severe accident, the individual being in a state of health at the time. Changes at the Os Uteri. — Another effect often observed in chronic flexion is eversion of the cervical canal, so that the OS uteri presents a raw, vascular surface. Such a condition is particularly met with (1) in cases of single women, where the uterus has become hypertrophied, softened, and the os considerably increased in size; or (2) in cases where the patient has borne children, and the aperture of the os is wide from side to side. The eversion most affects the pos- terior wall of the cervical canal in cases of retroflexion, and the anterior wall of the canal in cases of anteflexion. If the cervix has been lacerated bilaterally, the degree of eversion — ectropion — is very great. Such laceration of the cervix is not very uncommon, as has been pointed out by Dr. Emmet of New York. Eversion may, however, occur quite apart from laceration of the cervix. DISPLACEMENTS, DlStORTlONS OF THE UTERUS. I97 CHAPTER XVn. Displacements and Distortions of the Uterus (Flex- ions) — 5. Symptoms, Including Sterility and Abor- tions. Pain, Spontaneous — Pain on Locomotion (Uterine Dyskinesia) — Ex- planation of this Symptom: its great Importance — Undue Tenderness of the Uterus to Touch — The "Irritable Uterus" of Gooch shown to be Acute Flexion. Dysmenorrhoea, Leucorrhoea, Menorrhagia, Amenorrhoea — Sterility — Abortions — Statistics of Sterility and Abortions in Hospital and Pri- vate Practice. Disturbance of Functions of Bladder — of Rectum — Dyspareunia — Reflex Nervous Symptoms. There is abundant clinical evidence to show that of all the various derangements of function, observable in dis- eases of the uterus, by far the larger proportion are trace- able to the existence of flexions of the uterus or to tiie secondary effects of these flexions. In a former chapter (see p. 92) a list was given of the various symptoms ob- served in practice. It will now be necessary to take these symptoms one by one and point out how far they are con- nected with the existence of uterine flexions. Pain is either (i) spontaneous — occurring, that is to say, when the patient is at rest; or (2) // is produced by motion of the body or exertion; or (3) it is produced by touching the uterus itself — abnormal sensitiveness. Spontaneous Pain. — It is not common to meet with severe spontaneous pain in cases of flexion of the uterus when the patient is completely at rest. It is not uncommon to meet with a continuous slight aching. Spasmodic pain is not very uncommon. It has been described under the name uterine colic — a pain coming suddenly, lasting a short time, and disappearing for a distinct interval, resembling, in fact, very much a miniature labor pain. Such spasmodic pains are now and then met with in cases of uterine flexion. In a few cases a fixed pain is observable even when the patient is at rest. It varies also according to the nature of the flexi»n. As a rule, anteflexion is indicated by one kind of pain, and retroflexion by another. But these rules are open to ex- 19§ DISEASES OF WOMEN. ception. Most commonly the pain is felt in the back, in the sacral region. Another frequent position for pain is one of the groins, just above Poupart's ligament, on one or the other side. It is sometimes felt in the region of the uterus itself, but this is not so common. It is rather com- mon for it to be experienced down the back of the legs, down the back of the thighs, on one side or the other. With retroflexion the pain most commonh* occurs in the back, with anteflexion in the inguinal regions; in different cases, however, we find very remarkable variations in these rules. Some years ago I was requested to see a young lady who had been affected with pains in one spot in the abdomen, just on a level with the umbilicus, and on tlie left side of it; she had not been without that pain for a period of five or six months, and she had, previously to this time, for some years experienced other pains and serious discomforts. But the particular circumstance to which she called my attention was this pain in the abdominal region, in the position indi- cated. No tumor could be discovered in the abdomen, nor was there any apparent cause for this pain. But on investi- gating the condition of the uterus, it was found that the patient was the subject of acute retroflexion. The case was additionally interesting from the fact that after the intro- duction of the sound into the uterus, and turning the uterus into its proper position, there w^as no return of the pain whatever. Further treatment w^as necessary to rectify the state of the uterus; but, this particular pain, which was a source of so much annoyance, went away after the first use of the sound. Another case, equally interesting, was that of a lady who had had one child about five years previous to the time of my seeing her. She had been unable to walk about or to follow her ordinary avocations since the labor; but the inconvenience of which she chiefly complained was a pain on the right side of the abdomen, on a level with the umbilicus, and, in fact, in a corresponding position to the pain in the first case mentioned. This patient was found on investigation to have acute retroflexion of the uterus. I mention these exceptional cases, because they illustrate the fact that the pain which is produced by flexion of the uterus is not always in the same position. More generally, in 90 per cent of cases, the rule holds good that the pain is located in the back in cases of retroflexion, and in the ingu- inal regions in cases of anteflexion. As a rule, patients do DISPLACEMENTS, DISTORTIONS OF THE UTERUS. tQQ not complain of pains, in cases of flexion, so long as they remain quiet. If tlie\' remain in bed, or are content to lie on tlie sofa, there is usually but little pain. But any de- gree of motion is sufficient, or may be sufficient, to bring on pain, and the pain that is thus brouglit on may be either severe in degree or comparatively trifling; in some instances the discomfort produced can hardly be said to amount to pain. Pain on Locomotion ( Uterine Dyskinesia). — This is one of tlie very commonest of the symptoms observed in cases of uter- ine flexion. It is a symptom to which no sufficient amount of attention has as yet been paid, and it is so important in its effects, that careful consideration of the connection as effect and cause between it and uterine flexions is absolutely necessary. In patients suffering from flexions the pain produced by locomotion varies in degree very much. It varies from a slight pain in the back to a complete inability to walk or move without the extremest suffering. Questioning pa- tients as to their sensations, it will be found that they are almost invariably such as would come under the above heading — uterine dyskinesia. The pain produced by locomotion ma}' be slight or it may be violent in degree, but the characteristic of it is that it is brought on by motion. It may be so severe that the l^aiient is practically unable to move at all, or it may be so slight that she moves in spite of it, and continues to do so. There is no paralysis, in the ordinarj' sense of the word, but there is a strong disinclination to move. The degree of disability varies exceedingly in different cases. Some patients do not mention it unless they are asked whether they can take a moderate walk, without suffering pain; others can talk of nothing else — the inability to do this, that, or the other, to walk, or to ride, or to visit — these are to them ever-present evils from which they desire deliver- ance. The patient informs us that she is unable to stand fur more than two or three minutes at a time, after which she is obliged to sit down. Such patients cannot even bear to be kept waiting at the door while the bell is being an- swered. Others find that walking a short distance brings on so much pain and produces such discomfort that exer- cise is impossible. It is a remarkable feature that in all these cases motion produces pain. Such, for instance, as 206 DISEASES OF WOMEN. Stooping down to pick up any object from the floor, lean- ing forv\'ard, reaching upward, going upstairs, etc. The disability is sometimes so great that the patient is shut off from most of the enjoyments of life, for the simple reason that locomotion is impracticable. Patients consult us for a variety of reasons. In many cases undoubtedly the locomotive disability is not the reason they assign for ap- plying for relief. In a vast number of cases, however, this is the reason impelling them to seek aid, although they have not formulated their ideas on the subject with any de- gree of precision. The significance of this symptom has been overlooked, partly because it is so common, partly also because the idea has been too frequently entertained that this disinclination for walking, and other kinds of exertion, is a fanciful one — that it should not be treated seriously, being a whim or caprice of the patient, which should not be encouraged. In sixty-seven cases of uterine distortion or displacement, admitted during seven years into All Saints' Institution, re- ported by me in a paper read to the Obstetrical Society of London,* this symptom was so frequently observed that it may be said that almost all the sixty-seven patients pre- sented it in a marked form. The following are quotations from the paper in question: " The maladies with which these sixty-seven patients were affected existed in various degrees of intensity. In several cases the patients were actually bedridden, in others the capacity for locomotion was so materially diminished that the sufferers had to give up their emplo3'ment. In other cases, again, the malady, though not so severe, had proved intractable, and therefore relief was sought in the institution." " Outwardly, the condition of these patients was charac- terized by great weakness, more or less inability to walk (uterine dyskinesia), and a general condition of malnutri- tion. The principal organ aft'ected was the uterus; various degrees and forms of uterine distortion and displacement existed, causing painful symptoms of various kinds; pain on locomotion, nausea, and menstrual irregularities being those principally spoken of." "Almost all the sixty-seven patients admitted into the Institution and comprised in the foregoing remarks pre- * " Obst. Trans.," vol. xxii. for iSSo. DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 201 sented this symptom in a marked form. It may almost be said that this was indeed the principal symptom, and the one which had forced itself on their particular attention in the majority. This symptom I regard indeed as one de- serving of attentive notice in all cases of uterine distortion and displacement. The fact appears to be that physical exertion, of almost any kind, is, under such circumstances, uncomfortable in various ways, because it involves an ex- aggeration or temporary increase of the malady from which the patient suffers. An active life is necessarily abandoned after a time by the sufferer, and a helpless invalidism is the result in protracted cases. Some of the patients treated in All Saints' Institution had been bedridden for several years. With reference to such cases, it must be further remarked that the affection, which is indeed a very real one in these instances, is one which it was formerly the custom to re- gard as imaginary, fanciful, or hysterical, and such patients were consequently deprived not only of medical help, from the fact that their cases were misunderstood, but of tiie sympathy of their friends, who regarded them as capable of exertion if ' they only made an effort.' The fact is, that in these cases exertion only aggravates the mischief and perpetuates the malady." That uterine displacements are attended with discomforts is not a new idea. Because they are not absolutely univer- sally attended with discomforts, certain writers have thought themselves justified in saying that uterine displacements are in themselves of no particular importance. But, obvi- ously, the correct method of arriving at the truth on this subject would be to inquire how far and how frequently discomforts referable to the uterus, such as the particular one now under consideration — namely, impaired locomo- tion, or pain produced by locomotion — can be proved to be connected with uterine distortion and displacement. The two following propositions are essentially different, as will be readily admitted when they are concisely stated: i. Uterine distortions and displacement invariably give rise to pain on locomotion. 2. Pain on locomotion of such a kind as to be referable to the uterus is invariably associated with the presence of uterine distortion or displacement. These propositions are not identical, nor are they equally true. Tlie first proposition is more nearly true than is generally imagined. The second is, however, according to my ex- 202 DISEASES OF WOMEN. perlence, almost absolutely true, and this is the particular point to wliich attention is now directed. The connection between uterine distortion and pain on locomotion has attracted little attention at the hands of previous writers. To this statement a noteworth}'' excep- tion must be made. Chassaignac, in his work on " Clinical Operativ'e Surgery," published some years ago,* in speaking of the relation subsisting between certain morbid condi- tions of the uterus ("deviations") and the pains and dis- comforts with which these alterations are associated, thus expresses himself: Question: What is the cause (says Chassaignac) of the "accidents doloureux" observed in women the subjects of uterine deviation? Answer: The " ballottements" which the deformed or displaced uterus undergoes. Thus two conditions, the deviation and the movement impressed on the organ, must be conjoined in order that the pain may be produced. Further, this author goes on to state his opinion that the reason a particular deviation gives rise to pain in one patient and not in another is, that the baliottewent is in some wa}' prevented. Also that relief is to be given b}' curing the deviation or by prevent- ing the ballotteviefit. Hence, he says, the horizontal position is so frequently effective in abolishing the pain. Hence, also, the good effect of pessaries, the benefit derived in some cases from hypogastric bandages, etc. The uterus is thus brought to a state of rest. It is thus evident that Chassaignac recognized clinically the connection above in- sisted on; and not only so, he explained this connection by the concussion or jarring of the distorted or displaced uterus which motion of the body produces. Before going further, it is necessary to deal with the fact, or supposed fact, that in some cases uterine distortions do, and in others do not, give rise to painful sensations during locomotion — a circumstance which has had much to do in lending support to fallacious views on this subject. When flexions are apparently not causing particular inconven- ience to the patient, it has been argued that the}- are not in themselves of any great consequence. The facts of the case, according to my own experience, are as follows: Of the various forms of uterine deviation it appears that some are more liable to be attended with pain during locomotion * " Traite Clinique et Pratique des Operations Cbirurgicales," vol. ii, p. 926. Paris, 1863. DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 203 than others. Thus, take first descent of the uterus as a whole, unaccompanied by alteration of shape — cases of pro- lapsus, as they are termed. Now, it is the fact that such cases are really not attended with so much pain as others to be mentioned presently. It is quite true that when the uterus protrudes externally it is a serious evil, attended with grave inconveniences; but when it falls short of this, and does not protrude externally, the pain experienced may not be very noteworthy. And I have been surprised in some bad cases of external prolapse to find patients com- plaining comparatively little of difficulty in locomotion. Movement may of course produce in such cases friction, irritation, and ulceration of the exposed organ, but. apart from these effects, the movement itself may not be accom- panied with particular discomfort. The next form of uterine deviation is version of the uterus (rotation on the transverse axis), the organ preserv- ing its proper shape more or less perfectly, but being tilted backward, forward, or laterally, as the case may be. Slight version may be accompanied with comparatively little dis- comfort. In cases of severe version, forward or backward, the pain produced by locomotion is generally very distress- ing. Cases of version not accompanied with flexion are, as before stated, not in themselves very common, but it is not very uncommon to meet with cases of slight version together with slight flexion. And in these latter cases the discomforts now under consideration are undoubtedly less severe than in those next to be considered. The next category of cases is that in which there is de- cided distortion of the uterus, accompanied with a certain degree of version. It is in this class of cases that pain produced by locomotion is most severe. These cases furnish the instances of marked interference with locomotion, and, with few exceptions, this condition of the uterus is attended with the symptom in question in a more or less marked form. And I do not hesitate to state that I have found the condition and the symptoms associated so very constantly, that no room exists in my mind for doubt on the subject. Here we meet, as I have already remarked, with opposing statements as to the value and frequency of the association. Thus one statement is to the effect that.it is common enough to meet with cases of flexion in which there is no complaint and no inconvenience felt whatever. I can only say that such cases do not, at all events, present themselves 204 DISEASES OF WOMEN. in my practice. There are various ways of accounting for this discrepancy as to a matter of fact. Cases vary ver}' much in severity, and too much has been expected in regard to uniformity of symptoms when the conditions were not uniform. There is a great difference, for instance, between the degrees of flexion in the two cases of retroflexion represented in Figs. 37 and 38; and the degree of the flexion, the degree to which the uterus as a whole is sunk in the pelvis, produces necessary differ- ences in the severity of the symptoms. As regards this par- ticular symptom, pain on locomotion, it is one which I have hardly ever found absent when the uterus is actuall)' dis- torted. This symptom is plainly of importance, but it is not one which has usually been thought much of, and may have been present even to a marked degree in some of the cases, when flexion is said to have caused no complaint or inconvenience. Another circumstance is that, when the flexion is slight, and there is more version than flexion, the pain and inconvenience may be slight in degree. Further, it must be borne in mind that the flexed uterus is not always in the same textural condition. Sometimes it is much con- gested; at other times not particularly full of blood. Dr. Braxton Hicks has published * observations on retroflexion of the uterus, and, in accounting for differences of opinion on the treatment of this affection, he points out the differ- ences observable at different times in regard to the state of the uterus, as accounting for these diverse opinions. These remarks of Dr. Hicks meet, for the most part, with my concurrence. The congestion or engorgement is, no doubt, a condition which adds very much to the discomfort which a flexion produces; and in a case where it happened not to be present, the discomfort observed might be comparatively trilling. Then, again, the duration of the flexion is a mat- ter affecting painfulness. When the case is one of long standing, the uterus acquires in some cases a kind of tolera- tion of it, and locomotion perhaps ceases to be painful. But even in these cases it is enough to scrutinize the pre- vious history to become aware of facts which tell directly against the notion that flexions ever occur without giving rise to very decided discomfort and inconvenience. In the cases where pain is produced by locomotion, it is generally the fact that various positions of the body or * British Medical Journal, iSyy, DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 20S Fig. 37 * Fig. 38. Figs. 37 and 38 represent first and third degrees of retroflexion. 2o6 DISEASES OF WOMEN. certain exertions give rise also to pain. Thus, lifting a weight, carr)ang a weight, stooping to pick up objects from the floor, reaching to hang up an article of dress, riding in a carriage in an ordinary sitting position, riding on horse- back, even sitting up to dinner, — any one of these exertions, and a multitude of others that might be mentioned, pro- duce pain more or less severe. The horizontal position is in many cases the only one in which the patient is secure — and sometimes not even then — from pain. In short, the effect of movements of the body in cases where the uterus is distorted is almost invariably to pro- duce pain or inconvenience more or less marked. This is a striking fact, and has the greatest significance in estimat- ing the importance of uterine flexions. Why is it, we may ask, that this movement, these exertions, produce pain in cases of uterine flexion ? Chassaignac believed it to be on account of the jars or ballottcments the uterus receives. No doubt this is to some extent true. The flexed uterus is shaken, and the concussion is doubtless in part the cause of the painful sensation. But there is another and a far more important effect to which I would direct attention — viz., the temporary exaggeration produced by the exertion or mo- tion of the body. It is quite certain that this exaggeration and increase of the flexion do so occur. I have noted it in numberless cases; and it is, I feel convinced, the main cause of the pain. If corroborative evidence were required, it would be easily afforded by carefully investigating any marked case of this kind presenting itself, and inquiring into the effects of this, that, or the other motion in giving rise to pain; the very closest connection will then be shown to exist between the cause and effect in question. Given a certain kind of uterine flexion — determine what motion or exertion of the body would be likely to exaggerate that flexion: let the patient make that particular exertion, and it will be found to give rise to pain. Thus, in a case of severe retroflexion, such as that represented in Fig. 39, it is obvi- ous that motion in the vertical position, walking, for in- stance, will have a tendency to exaggerate the existing flex- ion by favoring the further descent backward of the fundus uteri, but if the patient be in the prone position, as shown in Fig. 40, it is evident that in the latter position (Fig. 40) the exaggeration of the flexion is not liable to occur. This prone position is ahva^'s found to be the most comfortable one in cases of retroflexion. In fact, investigation into the DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 20/ effects of certain exertions will often lead to the diagnosis of the nature and variety of the flexion, and actual exam- ination is afterward found to confirm the diagnosis so made. Further evidence in the same direction is afforded by placing the uterus, or even by placing the body, in such a position that exaggeration of the flexion cannot be produced by motion. It is observed under such circumstances that Fig. 39.* pain is no longer produced, or it is at ail events verv much diminished. By mechanically preventing further increase of the flexion it will be found that motion has no longer the same effect in regard to this particular symptom. A further question remains to be answered, and it is the most interesting of all — namely, why is it that flexion of the uterus gives rise to pain, and why does the temporary * Fig. 39 represents severe retroflexion of the uterus, the patient being in the vertical position. 2o8 DISEASES OK WOMEN. exaggeration of the flexion increase the pain ? We have carried the analysis to this point, tliat the pain and the flexion are associated, and the increase in the degree of the flexion is found to be answerable for increase in the amount of pain present. The clinical proofs of the accuracy of these statements which have presented themselves to me in the course of several years" observation are to my mind Fig 40 "* conclusive on these puinis. The answer to the further ques- tion, why a temporary increase of the flexion gives pain, in- volves the consideration of important pathological ques- tions. Hitherto we have dealt with the purely physical elements concerned — the shape, outline, variations of shape, * Fig. 40 represents severe retroflexion of the uterus, the patient being in the prone position. DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 209 etc., of the uteius. We now pass into a different territory, and enter on a ground which has been a field of contention and disagreement to an extreme degree. Pain necessarilv implies an affection of nerves. When any part of the body is the subject of physical alteration or change, pain is al- most universally present, this pain being directly trace- able, as a rule, to the physical impression of this alteration or to some change implicating the sensitive terminal fibres of the nerves themselves. One common cause of such effect is well known to be inflammation. Inflammation of an organ shut in by a tightly constricting membrane, such as the testis, for instance, how acute is the pain! this acute character being probably due to the great pressure on the nerves necessarily occurring under these circumstances. The more closely tlie phenomena of pain are examined, the more evident does it seem that pressure upon, or undue tension of, the ultimate sensory portions of the nerves is the cause of the pain. Pains referable to the uterus have had various explanations. By many they are regarded as fanciful or imjiginary. or due to inflammation or to neural- gia. But no intelligible and consistent explanation has, so far as I am aware, been given of the tnodus operandi of the production of these pains. The explanation which I have to give is sufficiently sim- ple; my only fear is that its very simplicity may prove a bar to its being accepted to the extent which is desirable in the interests of truth and progress. It is that the pain is produced by the actual compression of the nerves at the seat of the flexion. My observations have led me to con- clude that the compression and condensation of the tissues of the uterus which occur at the seat of the bend is the im- mediate cause of this pain. This pain is increased for the moment, and it is very frequently actually brought on, by any circumstance tending to condense and compress these tissues still more. Such an event happens when, from any physical cause whatever, the uterus becomes more flexed. It is my belief that the circumstance of the additional com- pression is responsible for the pain. But it is to me quite conceivable that this may not be the whole of the explana- tion. Another theory might be well set up, and perliaps ably sustained. It might be urged that the congestion, engorgement, fulness, or whatever you please to term it, of the body of the uterus and of the cervix and os uteri, which are so frequently present in cases of flexion, are concerned 2IO DISEASES OF WOMEN. in the production of the pain. As I shall hereafter show, congestion of the two extremities of the uterus, the fundus and OS, are almost constant accompaniments of decided uterine flexions, and it is susceptible of absolute proof that the more acute is the flexion the greater is the congestion and engorgement. Plainly, therefore, it may be said, Why do you not attribute the increased pain during locomotion in cases of flexion to temporary increase of the congestion? For, it might be added, this increase of congestion would produce further compression of the nerves of the body of the uterus. In fact, according to this mode of reasoning, it might be made to appear probable that the pain in question is due to increased tension of the nerves of the body of the uterus set up by temporary increase of the con- gestion of the part in question. Admitting, however, that much may be said in favor of this latter view, observation has induced the adoption on my part of the former idea as to the mechanism of the production of the pain. The con- comitant congestion of the other parts of the uterus doubt- less contributes to the pain, but it would seem to me prob- able that it does so mainly because it has a tendency to increase the compression of the tissues at the seat of the flexion. The presence of nervous filaments throughout the uterine tissues is generally admitted, though there are dif- ferences of opinion as to their actual size. At its central portion around the internal os uteri there are nervous fila- ments forming part of those tissues. When compression of the uterine tissues at this situation occurs, these filaments participate in that compression: hence the sensation of pain. There are still other views as to the etiology of the pain in question to be considered. It seems probable that some part of the discomfort felt by the subjects of uterine flexion during locomotion is due to the stretching and tension of the ligaments or attachments of the uterus. Thus the feelings described as "sinking" and "bearing down," wliich are often complained of, seem due to this tension of the uterine attachments. The round ligament, the broad ligaments, and the utero-ovarian ligament are the ligaments principally affected — some more, some less. The so-called ovarian pain, which has for a long time been considered evidence of ovarian inflammation, is generally traceable, according to my experience, to uterine flexion, and to be produced by the traction of the connection between the ovary and the uterus caused by the flexion. In cases of DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 211 retroflexion a severe pain, situated near the groin on one or other side, is in rare cases observed, and has appeared to ine to arise from tension and stretching of the round liga- ment. In this place also it is proper to direct attention to the fact that when the ovary is actually displaced down- ward, as is sometimes the case in flexion of the uterus back- v.'ard, the pain produced by locomotion is very acute and severe. This displacement of the ovarj' is, however, by no means a common complication of uterine flexion. 3. Uiidite Tciukrness of the Uterus to the Touch. — In the next place, we have to consider tenderness, or undue sensitive- ness, of the uterus to the touch, and the relation of this symptom to flexions of the uterus. In a state of health the uterus is not highly sensitive to the touch. And even the passage of the uterine sound, if carefully performed, hardly gives rise to a painful sensation until it touches the fundus uteri, when there is generally evidence of slight pain. But, under certain conditions, we find the uterus extremely sensitive and painful, so much so that the slightest touch gives rise to acute pain. I need hardly say that those cases where the entrance of the vagina is acutely sensitive to the touch — hyperaesthesia of the vagina as they are termed — are not included in the present discussion. Undue tender- ness of the uterus may be present in all degrees; the os uteri alone may be affected, or the posterior or anterior as- pects of the uterus. In severe cases the whole uterus ap- pears sensitive to the touch. Respecting the connection existing between tenderness of the uterus and alteration of its shape, I claim to have es- tablished a most important generalization and conclusion, which is to the effect that tenderness of the uterus to the touch is rarely observed except in cases where flexions are present. The more acute the flexion, the more acute, as a rule, is the tenderness. Tenderness is not invariably present in cases of acute flexion, and, indeed, when cases have become quite chronic, there may be little or no ten- derness. My proposition, therefore, is not that cases of flexion of the uterus are always attended with tenderness, but that, when tenderness is present, it is in all but a very few cases (I have not myself met with more than one really exceptional case) associated with the presence of uterine distortion. Possibly this may be considered a bold asser- tion, but I confidently make myself answerable for its sub- stantial accuracy. 212 DISEASES OF ^YOMEN. As long ago as the year x868, I published in the Prac- titioner a paper, having for its object to show that the " irritable uterus" of Dr. Gooch is nothing more than chronic severe retroflexion of the uterus. Dr. Gooch's description of these cases is well known: "A young or middle-aged woman, somewhat reduced in flesh and health, almost living on her sofa for months, or even years, from a constant pain in the uterus, which renders her unable to sit up and take exercise. The uterus, on examination, unchanged in structure, but exquisitely ten- FiG. 41.* der; even in the recumbent position always in pain, but subject to great aggravations more or less frequently." Dr. Fergusson, who edited Gooch's writings some few vears since, speaks of a congested condition of the uterus' "al- tering its shape into that of a retort," as having existed in some instances, though he does not appear either to have connected the retort shape with the congestion, or to have considered it as in any way concerned in the pro- duction of the pain. In my paper I proceeded to show that this retort shape of the uterus was a necessary part and parcel of the affection, and expressed my opinion that these so-called cases of " irritable uterus" were actuallv * Severe rciroflexion of ilic uterus. DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 213 cases of chronic retroflexion. Since this paper was writ- ten I am not aware that any refutation of this view has been published; and the only further observation I have to make on the subject of Gooch's irritable uterus is, that I have since seen many cases of this kind in which the condition of the uterus amply sustained the view in ques- tion. But there is a slight qualification to make — viz., that the same symptoms may be observed in connection with anteflexion of the uterus as with retroflexion. The typical and most severe cases are those of retroflexion, but in severe cases of anteflexion the symptoms may be very much the same. Further inquiries and observations have made me acquainted with the close connection ex- isting between distortion of shape and tenderness of the uterus, of which Gooch's cases of irritable uterus constitute well-marked and extreme instances. A very acute flexion is usually attended with great con- gestion. The conjunction of the two gives rise to the great- est degree of tenderness. And, inasmuch as the uterus may become more bent when the fundus is turned backward than when turned forward, the retroflexion cases are, as a rule, the most severe, and accompanied with the greatest tenderness. In cases where there is much congestion the tenderness is more evident when the body of the uterus than when the cervix is touched. In backward flexions the fun- dus is often found so tender that the merest touch gives acute agony, and the act of def^ecation is attended with great suffering. In acute anteflexions the fundus is gener- ally less easily felt, owing to the intervening bladder, but the presence of acute sensitiveness of the fundus can often be substantiated in these cases. It is worthy of mention that considerable sensitiveness to touch is sometimes found on examination in cases where other symptoms — pain on locomotion, etc., — have been slight in degree; and under these circumstances the exam- ination reveals the grave nature of the case. The sensitiveness of the uterus in cases of flexion may be associated with slighter degrees of congestion. It may be l)resent also in cases where the congestive stage has passed away, leaving the uterine tissues hard and hypertrophied. In these latter cases the tenderness is less universally spread over the uterus. Extreme sensitiveness is met with in many quite chronic cases of flexion at the internal os uteri or its neighborhood. 214 DISEASES OF WOMEN. The existence of this sensitiveness is, of course, only ascer- tained by the use of the sound. This, however, seems the place to mention it. Under these circumstances there ex- ists a severe chronic neuralgia at the internal os. The subjects of this affection have well-marked pain on locomo- tion, always situated in some one spot. Thus, in two very chronic anteflexion cases where this severe internal sensi- tiveness existed, walking always occasioned so severe a pain in the inguinal region that it had to be given up, and the sofa had become always necessary. Dystnenorrhoea. — Uterine flexions are not the sole cause of dysmenorrhcea. Again, flexions of the uterus are not al- ways attended with dysmenorrhcea. One of the most fre- quent effects of flexion of the uterus is, however, to produce impediment to the escape of the menstrual fluid — an effect generally due to compression of the uterine canal at its narrowest part, viz., the internal os uteri. The compression has the same effect as if there were an actual stricture of the part. Flexions of the uterus are in practice found to be the principal cause of the severe pain felt during men- struation as well as of the extreme difficulty with which the exit of the menstrual products may be attended. Dysmen- orrhcea is often the first symptom observed in cases of flexion, and although slight dysmenorrhcea is no proof of the existence of severe flexion of the uterus, it may be stated that when the dysmenorrhcea is chronic it may be assumed that there is an impediment to the escape of the menstrual fluid, which impediment is in all probability due to the exist- ence of uterine flexion. In the chapter on Dysmenorrhcea further remarks on this subject will be found. Leucorrhcca. — Flexions are a very common cause of leu- corrhoea, and there are few cases of flexion in which leu- corrhoea, to a greater or less degree, does not occur. In the chapter on Leucorrhoea further remarks on the subject will be found. Here, however, it is necessary to point out the particular relation which subsists between flexions of the uterus and "leucorrhoea from retention," as it may be appropriately termed. One of the effects of flexion not rarely observed is retention of the secretions of the uterine cavity within it, owing to the retort shape of the uterus, and the (virtual) closure of the internal os uteri. There are a certain number of cases occurring not very rarely in which, during the inter-catamenial intervals, there are observed from time to time — perhaps once in two or DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 21$ three days, and generally particularly during the week or ten days immediately following catamenial cessation — dis- charges of a puriform character, coming on suddenly, last- ing for a brief period only, and then ceasing. There is a Fig. 42.* puriform leucorrhoea occurring in gushes. This occurrence is due to the existence of chronic flexion and arises from imperfect emptying of the uterus. At the close of the or- dinary menstrual period something is still left in the uter- us. This unevacuated fluid undergoes changes resulting *Fig. 42 shows the third stage of anteflexion with distension of cavity and thickness of uterine walls, such as may be found in cases of chronic nienorrhagia and leucorrhoea occuriing in gushes. 2l6 DISEASES OF WOMEN. in its conversion into puriform fluid. - The uterus becomes distended with this accumulation. It is increased by the addition of further fluid of a watery character, poured out by the lining of the uterus, and when distension reaches a certain point, it is expelled. That is to sa}', it is partly ex- pelled, but after a time further distension occurs, followed by fresh expulsion. I have observed many cases of this kind — in fact, the occurrence of puriform leucorrhaea com- ing away in gushes is by itself almost diagnostic of the ex- istence of a chronic flexion of the uterus, and, during an experience of some years, this sign has proved of great value. Patients suffering from this affection sometimes describe what they term " little abscesses" bursting from time to time. In certain rare cases the retained uterine con- tents are actually offensive to the smell, the fluid having become putrescent before it is discharged. The uterus be- comes irritated, and the lining membrane secretes more fluid than usual; there is, in short, w^hat is termed endometritis. Mefiorrhagia. — The menstrual periodic discharge is fre- quently increased inquantit}' in cases of flexion, though by no means constantly so — for the quite opposite effect may be noted. Nevertheless, taking all cases of menorrhagia, one with another, the commonest cause is found to be either uterine flexion, or some of the secondary effects re- sulting from uterine flexion. Menorrhagia occurs often in consequence of the impedi- ment to escape of blood; the blood accumulates in the uterus, distends it, and is from time to time expelled in gushes. The process observed is sometimes like that of labor on a small scale, the patient experiencing severe recurrent pains; and after a time these pains result in expulsion of blood in considerable quantity: here we have dysmenorrhcea and menorrhagia combined. After a time the uterus becomes hypertrophied, its cavity permanently dilated, and the area of its internal surface proportionately extended. Then the patient becomes subject to perma- nent menorrhagia, and the quantity lost at each period may be exceedingly great. Examination reveals probably the existence of long-standing flexion, with considerable hyper- trophy of the whole uterus; or the whole organ may be found in a loose, soft, congested, sponge-like condition, the blood poor and watery in character from long-continued losses, and the large retort-shaped uterus pouring out much blood for many days together. DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 217 Tlie presence of clots in cases of menorrhagia is some- times noticed. Sometimes such clots are formed in the va- gina, but more generally they originate in the cavity of the uterus. Retention of blood is, probably, the first event in such cases; the blood so retained becomes clotted, and Fig. 43.* lias hnaily lu be expelled. The passage of the clot through this narrow internal os uteri necessarily occasions much pain. The dysmenorrhoea is most severe in cases where clots have to be got rid of, and the pain is sometimes of a most agonizing character. In some cases the clot never is * Fig. 43 represents severe antefle.xion with enlarjjed uterine cavity, as in Fig. 42, but the position of the pelvis is here altered, as if the pa- tient were recumbent on the ba'-k. The tendency of this position is ob- viously to throw the fundus upward and backward. 21 8 DISEASES OF WOMEN. expelled as such, but becomes broken up. No doubt some of the cases where a sanious leucorrhoea is observed for a few days after the regular period is over are cases of this kind; the clots retained break down, and the debris are gradually, but slowly, expelled. It must be further remarked that the difficulty experi- enced by the uterus in relieving itself of the retained pro- ducts in cases such as above described is materially in- creased by the dependent position of the pouch containing the fluid. When the patient is upright, and the body of the uterus strongly bent forward or backward, the action of gravity is opposed to the evacuation of the uterine contents (see Figs. 23 and 18). Thus, in the retort-shaped uterus, the enlarged pouch hangs downward, forward, or back- ward, as the case may be, and the fluid must move really upward, in order to pass through the internal os viteri, where the obstruction which exists further adds to the dif- ficulty. The double difficulty of moving upward in a direc- tion opposed to the action of gravity and moving round a corner presents itself under such circumstances. Clinical observation offers convincing proofs of the operation of these natural laws. Thus it may be found that in a case of anteflexion, with purulent retention, the discharge is free and continuous so long as the patient remains in bed, but on rising in the morning it suddenly ceases, appearing only in gushes at intervals during the day, and on lying down again at night a further comparatively free and continuous escape of fluid occurs. Affienorr/uva. — The effect of uterine flexion in arresting the discharge for a time has been mentioned, but in connec- tion with menstrual retention only. In a certain number of cases, however, the discharge becomes gradually less and less, the periods become habitually "scanty," and in a few the discharge ceases. Actual suppression of menstruation for some months, or its premature termination at a com- paratively earl)' age, is now and then observed, in cases of acute flexion. Probabh' the compression of the organ which is the effect of the flexion has much to do with it. The uterus having its circulation interfered with is no longer capable of carrj'ing on its function properly. The whole process is occasionally witnessed. In a known case of flexion, menstruation is for a time scanty. Each month it is less in quantity. By and by a month is passed over without discharge. After a time the interval is longer. DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 219 And, concurrently with these effects, other symptoms are noticed, which _e;ive evidence that the flexion lias become aggravated. The flexion is now dealt with and treated, and the amenorrhoea ceases. Cases of this kind are inier- fsting and convey important clinical lessons (see chapter on Amenorrhcea). Steiility. — Any circumstance producing imperviousness of the external or internal os uteri must necessarily produce sterility, and flexions are responsible for this result in very many cases, the narrowed condition of the internal os ob- structing the passage of fluid upward. But in very many cases the mere obstruction is not the sole cause of the ster- ility. Another circumstance is to be taken into considera- tion — viz., the altered condition of ihelining of the body of the uterus, which, as previously pointed out, is liable to be produced by retention of secretions within the uterine cav- ity. These retained secretions have doubtless a powerful influence in deranging the physiological process and dam- aging the products of conception. Further, an irritated al- tered mucous membrane, such as must be present in such cases, cannot ot'fer a proper surface for the attachment and growth of the ovum, even supposing it has been impreg- nated and has descended into the uterine cavitv. Abortions. — Hy far the most common cause (jf abortions is the existence of flexion of the uterus. The almost in- cessantly observed conjunction of the two elements — exist- ence of a known flexion of the uterus and liability to abor- tion in the same individual — has led me to this conclusion. There are undoubtedly other causes of abortion — syphilis, lead poison, accidents, falls, blows, mental emotions, etc. But, after all, cases referable to these heads coUectivelv form a very small percentage of the number of cases of abortion actually observed. The connection between retroflexion of the uterus anrl liability to abortion is tolerably well recognized. But it is not so well known that anteflexion is a rather common cause of abortion. The proof of the truth of the statement that abortion is often due to uterine flexion is necessarily to be obtained only from careful clinical observations. Such observations only require to be made in order that the proofs may be obtained necessary to convince others as they have con- vinced me. Clinical histories, such as the fr)llo\ving. consti- tute important evidence. In a case of known anteflexion, 220 DISEASES OF WOMEN. pregnancy occurs, and is shortly followed by an abortion. In another case, a flexion is undergoing treatment; becomes relieved up to a certain point; pregnancy occurs, and abor- tion happens. In another case also where flexion is known to exist, pregnancy happens, and the patient goes to full term; recovers from her confinement; becomes again preg- nant, and is threatened with an abortion. On examination it is found that the old evil has recurred; the uterus is in a state of flexion. Take another class of cases. In a certain case abortion happens, the ovum partly escapes; the thick- ened decidua and commencing placenta are retained in utero. Examination is made, and the uterus is found acutely anteflexed or retroflexed. A succession of such cases present themselves, the circumstances being a little varied. What other opinion can be arrived at than that the abortion is due to the flexion ? I assume, of course, that the operation of other possible causes of abortion is duly regarded, and the particular case excluded from these categories. Complete the proof : trace the further history of these very cases, and suppose it to be found that the phenomena described have a great tendency to recur. Let this kind of observation be made over and over again, and conviction naturally follows. The following table contains a statistical account of cases in hospital and private practice, with interesting particulars in reference to the question as to the influence of flexion of the uterus in producing sterility and in inducing a liability to abortion. Some of the facts were observed in hospital practice two 3'ears ago. A second series of facts are the results observed in private practice. And the two series of facts are so arranged that they can be compared. The general conclusion to be drawn is that, taking 100 patients affected with flexion of the uterus, it may be expected that in about one half of them sterility or abortions will occur. There is a remarkable coincidence in regard to the two classes of cases, hospital and private, there being sterility or only abortions in 34 per cent in both series. So also in regard to fecundity, for, in the hospital series, 65 per cent bore children (including 11 per cent who also had abor- tions), and in the private practice series 67 per cent had had children (including 17 who had also had abortions). Of those absolutely sterile — that is, who had never had a pregnancy at all — there were 24 per cent of the hospital cases, and 28 per cent in the private cases. DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 221 Abortions occur very frequently, as evidenced in the statistics below. There w^ere some few cases (lo per cent in the hospital series and 5 per cent in the private series) who had never had a child, but had had abortions, and in addition to these there were cases in which, although the patient had had children, there had been noticed abortions also — II per cent in the hospital series, and 17 per cent in the private series. The total percentage of cases of flexion Frequency of Sterility and Abortions in Cases of Flexions. Sterile or only abor- tions. Absolute- ly sterile : no preg- nancy. Abor- tions only. Chil- dren & abor- tions. No abortion. Facts as to number of children. Hosf>ital Practice. Cases of uterine flexion, 1865-1869: I 135 anteflexion 1 81 57 3 27 127 " 1 100 retroflexion 1 (34-4 p. c.) (241P.C.) (10 p. c.) ("•4 p.c.) (54 P- c.) Private Practice. Cases of uterine flexion, 1873-1879: 668 cases. (499 married, 169 single) ["360 anteflexion 129 ■] 107 1 22I 67I '^*1 V47"8 51 patients l34'2 128-4 1 5 I »7-8 had only 499] fp.c. fp.c. P.O. p.c. p.c. I child. 1,139 retroflexion 42 J 35 J 7J 22 J 75 J 21 had only I child. in which abortion was noted was, for hospital cases 21 per cent, for private cases 22 per cent — figures which are almost identical. The above figures have been extracted with great care from records of cases in my possession. It may be well in the next place to speak of what may be termed "secondary" sterility in connection with flexions of the uterus. There is abundant evidence that flexions arising after labor give rise not seldom to sterility. The patient has had one or two children but has become after- ward sterile. The following table gives, from records in my possession, statistics in regard to the influence of flexions in producing sterility in women who have had children : 122 DISEASES OF WOMEN. Cases of Fertility with Subsequent Sterility. (Private Practice.) Number of cases. Average number of years elapsed since. Variation in number of yrs. expired since. One child only) (over I year V expired since) . . . ) Two children 1 only (over i year >■ expired since) . . . ) I Anteflexion 51 ( Retroflexion 21 ( Anteflexion 38 ( Retroflexion 12 Anteflexion 6'4 years. Retroflexion 8 years. Anteflexion 4' 4 years. Retroflexion 5 ' i years. Anteflexion i to 22 years. Retroflexion i to 24 years. Anteflexion i to 16 years. Retroflexion i to 14 years. Disturbance of Functions of the Bladder. — These constitute a class of symptoms rather common in cases of uterine flexion. Great frequency of micturition is often observed in anteflexion cases. This symptom is sometimes very dis- tressing, there being a perpetual necessity for evacuating the bladder, as often, in one case, as every five or ten min- utes. Retention of urine sometimes occurs as a consequence of flexion — more often from retroflexion. Incontinence of urine is occasionally observed as a result of retroflexion. Extreme pain in the bladder after evacuation of its contents is sometimes noticed in cases of anteflexion, apparently due to pressure of one wall of the empty bladder on the other. Taken as a whole, the bladder symptoms are not always observed in cases of flexion, but they sometimes constitute the chief or most distressing of the symptoms of which the patient complains. Disturbance of Functions of Rectum. — In cases of uterine flexion the function of defaecation is often interfered with in various ways, the patient finding often a difficulty in evacuating the contents of the rectum, in consequence of the pressure of the uterus upon it. The pressure of the uterus acts in a kind of valvular manner, and, the more the patient strains, the more complete is the closure. In other cases, defaecation is attended with considerable pain. The most aggraviited cases, and they are not very commonly met with, are those in which there is retroflexion, accom- panied by rectocele. The perineum is partly destroyed, and the rectum protrudes a little through the vaginal aperture. The uterus is retroflexed, and presses down the rectum, and it thus obstructs the canal; a state of things may then arise which produces intolerable anguish to the patient. The DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 223 rectum may become ulcerated. At the part where the rectum projects into the vagina there is a bend, and in this position ulcers are liable to form. This is an extreme case, but the right explanation of such a case is of some moment. Retroflexion may thus, sometimes, produce what appears to be a serious disease of the rectum. In some cases, ante- version leads to very serious interference witli defaecation. Clironic and troublesome diarrhoea is sometimes caused by retroflexion of the uterus. Pain on Intercourse — Dyspareunia. — This is a symptom and effect of the presence of flexions of the uterus which deserves attention. There are of course other conditions of the generative organs capable of giving rise to the symp- tom in question, but, certainly, flexions of the organ are most common causes. Reflex Nervous Symptoms. — The symptoms included under this heading constitute a most interesting class. The exist- ence of a relationship between these symptoms and the presence of uterine flexion is only now beginning to be known and admitted by uterine pathologists. " Nausea and vomiting," "hysteria," "convulsions," "mental de- rangements," are the more important of these reflex symp- toms. It is impossible to discuss the whole question in this place; the reader is referred to the separate chapters which will be found devoted to these subjects. Here it is necessary, however, to say that the clinical evidence of the very close connection as cause and effect between uterine flexion and these reflex nervous symptoms is most distinct and clear. There cannot be a question that, in the future, as observations are increased in number the truth of this statement will come to be universally admitted. Reflex nervous sj^mptoms are, however, by no means always present in every case of uterine flexion. 224 DISEASES OF WOMEN. CHAPTER XVIII. Displacements and Distortions of the Uterus (Flex- ions) — 6. General Principles of Treatment. Principles of Treatment. — Indications i. — Restoration of General Strength. 2. Restoration of Uterus to Proper Shape and Position. Difficulties Encountered. — Question of Necessity for Examination — Definition of General and Local Treatment — Curability of Flexions — Various Causes of Difficulty. General Treatment. — Restoration of Nutritional Power and Activity — Rest, how to be carried out — Utilization of Influence of Gravity — At- tention to Condition of Bowels. Local Treatment. — Positional or Postural Treatment — Prone Kneel- ing Position — Horizontal Position. Use of the Sound repeatedly — Cases adapted for it. Use of Sound combined with Dilatation of Canal by means of a Dilating Sound. Treatment by means of Stems: Cases requiring it — its Value and Applicability. Use of Tents. Incision of the Uterine Canal. Vaginal Pessaries — General Method of Action — Cases suitable for. Necessit}^ for conjoint Postural Treatment and use of Sound. Other Requirements when Vaginal Pessaries are em- ployed. Material of Vaginal Pessaries. General Summary. Palli- ative Treatment. Use of Hot-water Injections. Opiates. Treatment of the accompanying Congestion. Various modifications in regard to detail and mechanical procedure are required in different cases of uterine flexion. Here, however, it is intended to describe the general prin- ciples of treatment of these affections. The principal indications are: 1. To restore or improve the general strength and vital- ity of the patient, almost always in a state of deterioration more or less pronounced. 2. To restore the uterus to its proper shape and position. The above indications are formulated in conformity with the general views which have been set forth in previous pages in reference to the nature and cause of flexions of the uterus. It will be found in practice impossible satis- factorily to treat cases unless both of the indications al- luded to receive due attention. Whether the first or the second indication is the more important will depend on the nature of the particular case. In cases where the flexion is slight in degree and recent in occurrence, general measures may prove entirely effectual, the uterus participating in the general improvement pro- duced by the treatment in question. DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 22$ When, however, the flexion is severe and of long stand- ing, no amount of attention to the general treatment will prove efficacious in curing the flexion, local treatment be- ing necessary before real improvement can be expected. In severe and long-standing cases local treatment alone is insufficient. General treatment must be associated with it or disappointment will be experienced. At the outset the question arises as to the employment of local treatment of the uterus in cases of unmarried women affected with the disorders now under considera- tion. It may be well to consider how best to obviate these difficulties. The first difficulty is as regards the diagnosis. In young unmarried women the diagnosis is at first of course only pre- sumptive. Persistence of particular symptoms for many months in succession, such as marked deterioration of healtli, obstinate nausea, dysmenorrhoea, continued diffi- culty in locomotion, continued suffering of some kind refer- able to the uterus; under these circumstances a com|)lete diagnosis of the case should be made, instead of waiting, as is sometimes done, two or three years before any reliable information is attempted to be gained. In many cases a tolerably exact notion of the case can be obtained by an examination per rectum, or it can be thus ascertained if a further and more exact investigation is required. The diagnosis made even in this imperfect way is of service in pointing out what general metliod of treatment is likely to be of use (decision, for instance, between anteflexion and retroflexion), or whether the affection is so severe as to make a vaginal examination imperative. In young unmar- ried women an anaesthetic is frequently advisable in cases where it is decided to make a vaginal examination. It is impossible to lay down a strict line of conduct for all cases. On the one hand, it is improper to subject young women to vaginal examinations unless they are considered neces- sary after proper consultation on the subject. On the other hand, it must be borne in mind that the foundation of a life-long condition of invalidism and general inefficiency may be laid by two, three, or four years' neglect of a severe uterine flexion, and consequently that delay in making a necessary examination may be most injurious to the patient. In cases where the symptoms have existed for some years tliere should be no scruple in insisting on the necessity for 9. proper examination. 226 DISEASES OF WOMEN. Some explanatory remarks are here required respecting what is meant by general and local treatment. It has already been stated that general treatment has often a local effect. As regards local treatment, the most efficacious is mechanical. By mechanical treatment is not meant, how- ever, the use of instruments or necessarily of instrumental procedures. There are methods which are in their mode of action strictly mechanical — utilizing the force of gravity, rest, and the like — although not including surgical procedure in the ordinai'y sense of the word. Cii?-ability of Uterine Flexions. — The apparently intractable character of certain forms of the affection has led some authorities to conclude that flexions are incurable. As a general statement this is undoubtedly a mistake, although in some cases a complete cure is no doubt very difficult to obtain. a. One source of difficulty is weakness of the uterus from malnutrition. So long as the tissues of the organ remain soft and give way to pressure, the cure of the flexion is a matter of impossibilit)^ b. Another is the atrophy often present in long-standing flexions at the seat of the bend, which has this effect, that while it ma)^ be easy to maintain the organ artificially in its normal shape, the moment the assistance ceases the flexion recurs. The uterus has virtually lost its stem. c. Another is the rigidity of the uterus. It has become set in a certain abnormal shape, and though it may be un- bent by means of the sound, the flexion recurs directly it is withdrawn. This rigidity may be accompanied with atrophy around the internal os, or not. d. Another diff.culty is the presence of adhesions tying the fundus down in its abnormal position. e. The most common difficult}', however, is the absence of an accurate diagnosis of the physical condition of the uterus in the particular case. The use of the sound is an important aid in determining the curability of a given case of flexion. At all events, it is possible by its means to measure the rigidity of the uterus. By gently unbending the uterus by the sound, and then withdrawing it and observing how quickly it returns to the flexed state, the degree of rigidity is indicated. In a long- standing severe retroflexion we suppose, for instance, that the sound raises the fundus up to its proper position, but immediately it is withdrawn the fundus is felt by the finger DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 22/ to resume its old position. This indicates considerable rigidity; but the fact that the uterus can be raised by the sound shows that a cure is possible. The degree of resist- ance encountered in changing the form of the uterus by the sound is in some degree a measure of the difficulty of the cure. The presence of atrophy in the uterine wall is indicated by the touch; the sound having been previously introduced, the thickness of the uterine wall at the flexion can be esti- mated by the pressure of the finger opposite this situation. Some general statements may be made as to the curabil- ity of different cases. The cases are most amenable to treatment in which the affection is of not over two years' standing, and the uterus not very resistant to the restitution of proper shape by the aid of the sound. Cases are tolerably amenable to treatment up to the age of thirty, even when the affection has lasted some years, provided that there is no considerable parietal atrophy, that the reposition by the sound is not very difficult, and that tliere are no other complications. After the age of thirty the cure of long-standing flexions becomes more and more difficult, and cure at the age of forty, for instance, of a severe retroflexion of ten years' standing would be very difficult. As a rule it may be stated that the time required to effect a cure is indirect proportion to the duration of the disease. Recent cases are cured most readily. Recent cases, too, are cured most completely, for long-standing flexions, even when cured, have a great tendency to recur. Thus, I could give particulars of cases both of anteflexion and retroflexion cured so that the patients conceived and had children, and the flexion recurred intermediately three or four times — i.e., once after each labor was over — requiring treatment, which was again and again successful. It is probable that when proper attention is paid to the general treatment, the cure of uterine flexions will become more complete. My own experience gives reason for this conclusion. Lastly, it is to be stated that particular kinds of flexion are more difficult to cure than others, as will be more par- ticularly described later on (see chapters on Anteflexion and Retroflexion). Dr. Paul F. Munde * says, " Permanent relief, cure, can * Amer. Jour, of Obstet., Oct., i88i. 228 DISEASES OF WOMEN. be expected and will be obtained only when the displace- ment is of recent origin, especially when it has been produced by some sudden physical shock, or when the complete tissue-metamorphosis accompanying puerperal involution aids in restoring to the uterine supports and to the uterus itself their original and healthy tone." Pessaries, according to Dr. Munde, give temporary re- lief, but cure only in a few cases. He prefers the wearing of astringent vaginal, tampons introduced daily, for some cases of ante- and retro-displacement, and considers this method the only efficient and safe remedy for most cases of procidentia. He contends that this treatment is preferable to the use of hard or soft pessaries. Dr. Munde's views as to the difficulty of cure are to a certain extent correct, but I think the difficulty is over- stated. The importance of seizing the time of puerperal involution for remedying the shape of the uterus is cer- tainly great, as Dr. Munde points out; but, unfortunately, in many cases there is no pregnancy to help us. General Treatment. — The first object is to maintain the nutrition of the body in a state of activity. Attention to this is specially required in cases where there is much gen- eral debility, and where it is known or suspected that the uterus is in a condition of undue softness. Many months may elapse before much improvement is observed in regard to this special point. In a case of chronic starvation of some years' duration the nutritional activity takes long to restore. How this is best to be effected has been already described (see p. 128). But it must here be stated that experience renders it evident that the secret of success in the treatment of chronic flexions with the uterus in a weak, atonic, soft condition is perseverance in careful feeding. There are not a great number of cases in which care in the matter of nutrition can be dispensed with. It is not rare to see cases of chronic flexion in which the prostration is so severe from long-continued semi-starvation that it de- mands at first almost exclusive attention. The principal malady for the moment is in fact the starvation, and great care is required even to save the patient from perishing from its effects. Such extreme cases are chiefly noticed where the flexion has set up a chronic obstinate vomiting, and the patient has been thus effectually deprived of nour- ishment for a long time. Rest is a most important part of the general treatment, DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 229 The indication is to take off all pressure from the uterus. The horizontal position, modified in various ways, best effects this. The extent to which rest must be insisted on depends on the severity of the case. In some cases it is merely neces- sary to order the patient to abstain from certain exertions and to walk little; in others, on the contrary, no good can be done without insisting on the most absolute rest, and that to be maintained for some time. Certain errors are prevalent in regard to what constitutes rest. Sitting in the ordinary position in a chair with a ver- tical back is not rest for cases of flexion of the uterus; nor is riding in a carriage rest under these circumstances. Rest is more particularly necessary at the menstrual pe- riods, for the troublesome symptoms are then likely to be aggravated. There are various other precautions to take which will be suggested by reading over the list of causes of uterine flexion given at page 180. Experience has convinced me that in chronic cases the persistent action of the force of gravity can be utilized very largely by a well-adjusted system of rest. In cases where mechanical internal appliances are employed this agent should be carefully brought in as an ally in the treatment. In this way only can some of the difficulties of chronic cases be overcome. The scientific employment of rest in association with feeding, massage, etc., which has been largely employed by Dr. Weir Mitchell in America, and which has been alluded to in a former chapter, is precisely the treatment adapted to the cases now under consideration. The condition of the bowels is always a matter demand- ing attention. The bowels should be opened daily, either by means of an enema, of half a pint of tepid water or a minute dose of some aperient found to suit. It is most important to prevent the straining and forcing liable to occur when the bowels become constipated; and it may be assumed that such precautions will always be required in patients who do not take regular exercise. Local Treatment. — The first procedure to be adopted in regard to the local treatment is what may be termed " pos- tural " treatment. Of late years I have employed it with great advantage, either by itself or as an assistance to other local measures. In the United States, Dr. Campbell, of Georgia, has particularly advocated the knee-and-breast 230 DISEASES OF WOMEN. position in the treatment of retroflexions of the non-gravid uterus. The accompanying figures illustrate this principle Fig, 44. IV *o of treatment. Fig. 44 is an outline of the position taken by the patient. Fig. 45 shows the uterus in a retroverted Fig. 45. position; the patient being in the knee-breast position it is evident that the weight of the uterus will tend to throw Fig. 46. the body of the organ forward. Fig. 46 shows the patient in the same position with the uterus turned forward as just DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 23 1 described. Fig. 47 represents an air-tube which Dr. Camp- bell recommends to be inserted in the vagina so as to allow the air to enter it, the object being to facilitate the move- ment of the body of the uterus into its normal position. The necessity for the use of the air-tube has been disputed. I have largely employed the postural treatment as de- scribed, but without the air-tube, and the effects have appeared to be satisfactory. I have found the knee-and- breast posture very serviceable in cases of uterine fle.xion, whether backward or forward. The patient must be di- rected to maintain this position from two to four or five minutes several times in the day, or whenever it is con- venient to do so; and this is to be kept up for some weeks. Postural treatment can of course be carried out by the patient herself, which is an advantage in many cases where Fig. 47. otlier methods of local treatment are inapplicable. Postural treatment is not sufficient by itself in severe cases, but it is always available as an adjuvant to other procedures. In cases of forward displacement of the uterus the hori- zontal position on the back is the best, the effect being increased by placing a pillow under the sacrum. This position is the worst possible for cases of backward dis- placement, and it is not rare to meet with cases of retro- flexion rendered chronic by the patient having been kept lying on the back for a considerable time. In cases of backward flexion the patient must be made as a rule to lie on the side, or at all events not on the back. These points will have to be further discussed later on. We now come to special methods of internal local treat- ment. The sound is an instrument by which the shape of the uterus can be rectified. A repetition of this rectification at intervals is a method of internal treatment of great value. The operation consists in carefully introducing the sound beyond the seat of the flexion, and then gently turning it 232 DISEASES OF WOMEN. round so that the concavity is turned the opposite way. The sound should be very slightly curved, should be gently inserted, and no force whatever mployed. By holding the sound in the uterus for a few minutes after the flexion has been reduced by its means, a greater effect is produced. This method of reduction may, if carefully done, be re- peated every two or three days if necessary: the plan offers a means of gradually reducing an obstinate flexion. It is frequently found advisable to conjoin the use of a pessary with treatment by the sound, but the double treatment is more likely to produce irritative symptoms, and if a vaginal pessary be at the same time worn, the frequent repetition of the use of the sound is not so well borne. In unbending the uterus by means of the sound, great gentleness should be employed, and it should be done slowly. It is advantageous to use a nearly straight sound, because the torsion of the uterus effected by it is less. It is more difficult, of course, to introduce a nearly straight sound, but this method of treatment should never be em- ployed by any one unable to thread an acute flexion with a nearly straight sound. The dangers attendant on the above treatment are irrita- tion and abrasion of the lining of the uterus and production of a quasi-pyaemic or actually pyaemic process; great care is therefore required to avoid abrasion or injury of the uterine lining. The " sound "treatment is not adapted for cases in which the uterus is very soft. It should not be employed too near to the time of the menstrual period, either before or after, and it is better that the patient remain recumbent for half an hour or so after use of the sound. Sound combined with Dilatation. — A method of treatment consisting of use of a dilating sound is sometimes very effec- tual. It is not adapted for cases where the uterine canal is very tortuous, but when it has become tolerably easy to introduce a nearl)^ straight ordinary sound, the process now to be described can be adopted. The instrument I employ for the purpose is one which has been copied from a larger-sized one, used by the late Dr. Rigby, and made for me by Coxeter. The principle is not new, being that of the glove-stretcher, but the dilating blades are small and can be introduced easily. After intro- duction they are separated by a screw action, and very great force can be made to bear at the point where dilatation DISPLACEMENTS, DISIUKTIONS OF THE UTERUS. 233 Fig. 48.* Fig. 49.* * Figs. 48 and 49 represent Graily Hewitt's Uterine Dilator. Fig. 48 is a reduced drawing. In Fig. 49 the blades are shown the actual size, 234 . DISEASES OF WOMEN. is most required, viz., the internal os. This instrument must be used with great caution and care. The object is to gradually open out the uterine canal. This dilatation should be effected at intervals of two or more days, and should be slight. It is not safe to effect dilatation by this means unless the instrument can be introduced without abrading the uterine canal. On the whole it is safer also to avoid using the dilator when vaginal pessaries are being employed. The metallic dilator above described should have a slight groove cut on the side opposite the small projection indi- cating the depth of the uterine canal. By this means the operator is able to tell when the instrument is properly and sufficiently inserted. The system of dilatation alDOve described is in principle identical with the gradual dilatation by a succession of bougies employed some 3'ears ago by Dr. Mackintosh for the relief of dysmenorrhoea. A more rapid and extensive dilatation of the uterine canal has been employed by Schultze, the object being at one operation to produce considerable enlargement of the uterine canal. The procedure consists first in dilating the canal by tents, and then forcible dilatation is effected, by means of a two-bladed instrument, in such a way that the structures of the cervix are made to give way, and a large- sized canal at once procured. The treatment of flexions by means of the Uterine Stem must be next considered. The object of the use of the stem is to maintain a continuous reduction of the flexion, and to keep the uterine canal straight, with the notion that after employment of this treatment for some weeks, or months, or longer, the uterus will be made to assume per- manently a normal shape, and the uterine canal cease to offer obstruction to menstruation and to interfere with other of the uterine functions. With certain reservations, which will be presently pointed out, there is no doubt that the uterine stem treatment offers one of the best methods of dealing with cases of chronic flexion of the uterus. Many condemn the practice, and some consider it justifiable, and reserve it for exceptional cases. There are various methods of using an intra-uterine stem, some of which are much better and safer than others. The requirements, according to my own judgment, are — I. The stem should be smooth, rounded at the extremity, DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 235 of an incorrodible material, and should not project more than one third of an inch into the cavity of the bod\' of the uterus — i.e., the whole length of the stem should not exceed if or 2 inches. 2. It should be attached to or connected with a vaginal portion, so that the uterus as a whole shall have its motions controlled within certain limits. Some are in the habit of employing a simple uterine stem, the objection to which is that it only keeps the uterine canal straight, and does not prevent the uterus from falling into a state of anteversion or retroversion. 3. The uterine canal must be previously sufficiently dilated to allow of the easy introduction of the stem. 4. The uterus must be in a non-irritated condition. Cases of retroflexion are, as a rule, not suitable for the stem treatment. There can be no question that the uterine stem can be quite safely employed by an expert fully alive to the nature of the accidents which may occur, and who properly selects the cases in which to employ it; and it is equally certain that the treatment is a great help in the cure of certain dif- ficult cases. On the other hand, it must be admitted that, owing to the impossibility always of exercising the needful supervision, other methods of treatment will very frequently be preferred. When the uterus has attained to the condition of toleration of the stem, and it is well fitted, it may be worn without trouble of any kind often for months to- gether. According to my own experience it is best borne in cases where the flexion is least severe; and this is to be remembered in considering the question as to the general applicability, or rather as to the general superiority of the stem method of treatment. Again, when there is great parietal atrophy as a consequence of the long-standing flexion, the stem treatment must be continued for a long time; even after it has been in operation for a year or so, on removal of the stem the flexion may be found to return almost as badly as before. In some such cases I have found vaginal or extra-uterine pessaries to be the only practical method of preventing the recurrence of the flexion. Various details as to the application of stems will be found in the chapters on Anteflexion of the Uterus. Use of Tents. — Tents are sometimes employed as a method of curing flexions of the uterus. They offer a means of di- lating the uterine canal and temporarily abolish the flexion. 236 DISEASES OF WOMEN. Tents have been used both for the purpose of procuring room for the insertion of a stem, and also for the purpose of straightening the canal. Tents have a temporary effect only on the uterus. They might probably be used at intervals for the purpose of straightening the canal by repetitions of the process, but it does not appear that one operation is by itself of much service in the case of a chronic flexion, though it may be of the greatest assistance to the carrying out of other methods. Tents require great care and caution in their use. Details respecting their employment will be given later on. Incisions of the Uterine Caiial. — For the cure of sterility, or for the cure of dysmenorrhoea, the operation of incision of the uterine canal has been largely employed. This oper- ation is not so largely in favor now it is coming to be better understood that the supposed stricture of the cervical canal is in most cases due to the uterus being flexed. But it has also been practiced with the express object of facilitating the cure of flexion of the uterus, the latter condition being at the time recognized and duly appreciated. The method adopted is to make longitudinal incisions to a considerable depth in the cervical canal, to fill the en- larged canal at first with a plug of lint, and afterward by a stem. This operation will be described more in detail later on. Vaginal Pessaries. — Formerly vaginal pessaries were em- ployed simply to prevent prolapse of the uterus. They are now also employed with great success in the treatment of uterine flexions. It is a very great mistake to suppose that any pessary will suit any case. If employed with the view of curing or relieving a case of uterine flexion the vaginal pessary must be very carefully adjusted to the necessities of the case, or it will do more harm than good. Dr. T. Gaillard Thomas says on this subject: "A great deal of experience is neces- sary before any one can use them with certainty of accom- plishing good results. A large and varied assortment is necessary, and sufficient mechanical ingenuity to mould and adapt to special requirements of cases." The secret of success in adjustment of a vaginal pessary, in the treatment of uterine flexions is — (i) A right appre- ciation of the shape, size, and position of the vaginal canal. (2) The use of an instrument which shall not unduly dis- DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 237 tend the vaginal canal, but which shall exercise a constant controlling action on the movements of the body of the uterus. No better notion can be given of the kind of effect neces- sary to be produced than by pressing the fundus upward by means of the finger. Let us suppose the uterine body can be felt behind the cervix (in position of retroflexion). By pushing against this with the finger it can be made to ascend. Now this is the kind of action required to be effected by the vaginal pessary, and it has the advantage of being in constant operation. In the case of anteflexion the pressure is required in front of the cervix. It generally happens that pressure is required either in front of or behind the cervix. This pressure must have a point d'appui, or basis, from which to start. This is the vaginal canal, in which the supporting agent must be placed. Some vaginal pessaries give pressure in a circular manner all round the uterus, and where the diagnosis is not very exact such pessaries are better, or at all events safer, than others more specially designed to give pressure in one determinate direction. Vaginal pessaries giving distinct pressure (forward or backward, as the case may be) operate on the flexion — (i) By pushing up the fundus; and (2) By exercising traction on the cervix uteri. Thus in a case of retroflexion the Hodge-shaped pessary both pushes up the fundus and draws the cervix backward. It is a joint action, and sometimes the effect is not what is intended, because the traction on the cervix is too great and the uterus is turned on its trans- verse axis without being unbent. There are man}' details connected with this subject which will be found later on. By a proper system of graduation in regard to size the effect of the vaginal pessary can be increased, if required, from time to time. Vaginal pessaries with special pressure action require supervision; otherwise it may happen that the uterus gives way and becomes flexed in the opposite direction. This can only happen when the uterus is rather soft in texture. It thus follows that a vaginal pessary may work well for three months, but after that time it may require to be readjusted. In flexions slight in degree and recent, a vaginal pessary alone is often the only treatment required. If chronic, a preliminary treatment is necessary, or (and this is a point to which attention is particularly directed) it will be neces- 238 DISEASES OF WOMEN. sary to keep the patient in a state of great quietude, in the horizontal position, until the pressure of the support is well tolerated. It is a great mistake to apply a support giving considerable pressure and at the same time to allow the patient to go about as usual. Postural treatment should be always used conjointly with the vaginal pessary in severe cases. In most of the difficult long-standing chronic cases no method has seemed to me better than conjoint treatment, consisting of — (i) postural treatment, (2) use of vaginal pessary, (3) use of uterine sound, or uterine dilator. This process of cure, though tedious, seems the most effectual. A point worthy of attention is the necessity for aperient medicine or daily enemata in cases where vaginal pessaries are worn. It is frequently observed that the natural action of the bowels is a little interfered with, and medicine or enemata will then be required. Another point is the necessity for use of vaginal injections in most cases where vaginal pessaries are worn; especially should such injections be used as the menstrual period is coming to an end. Half a pint of rather warm water mixed with a teaspoonful of Condy's fluid is the best injection to employ. As regards the material of which vaginal pessaries are constructed something has to be said. When the pessary Fig. 50.* has to be worn some time, and no further change of shape is required, ebonite is the best material. Cop- per wire covered with india-rubber is a good material because of its softness and pliability. Cleansing injections are, however, more often required. Metallic pessaries are sometimes very convenient. Block tin is a good material, though heavier than ebonite. Aluminium is an excellent material, owing to its lightness. Vaginal tampons have been rather largely used by practitioners in America and elsewhere in the treatment of flexions. Thus Dr. Paul F. Munde, of * Fig. 50 shows (after Thomas) the position of the tampon in the vag- inal canal. DI^LACEMENTS, DISTORTIONS OF THE UTERUS. 239 New York, says: "The protracted wearing of astringent vaginal tampons introduced daily offers for some cases of ante- and retro-displacement an excellent and, for some cases of procidentia, almost the only efficient and safe remedy for the displacement — far superior to all steadily worn hard or soft pessaries."* For my own part I have little experience of the use of tampons, but it is easy to see that they might be of great service, though the necessity for daily attendance on the patient which their employment involves is a very great drawback. Electricity has been employed in Paris for the cure of uterine flexions, with some success, and it appears to me likely that it might be found of great service if persever- ingly and skilfully employed. But it could not be expected to do ver}'^ much in long-standing chronic cases, while in the more recent ones simpler methods of treatment are found successful. General Sutninary. — A restoration of the firmness and natural resistance of the tissues of the uterus is required in the majority of cases where the affection is recent, and in many also where it is of long standing. So long as the uterus is deficient in these qualities it is necessary to enforce a system of rest, or else to provide means — e.g., internal appliances — for preventing the action of gravity from reproducing the flexion. When the flexion is confirmed and the uterus hard, con- siderable time is required to be spent in straightening it, and prolonged assistance by means of internal appliances is required after the cure of the flexion, in order to prevent the action of gravity from reproducing it. Dilatation of the uterine canal is frequently required in the latter class of cases. And in some cases incision of the cervix is required in order to facilitate the restoration of the proper shape. Palliative Treatment. — In many cases it is necessary to institute treatment for the relief of the pain, irritation, and discomfort the patient is suffering from, irrespective of, or in addition to, the measures required for the cure of the affection. Thus, when there is acute congestion of the uterus the pain may be very great. In relieving this pain vaginal injections of hot water (temperature 100° to 110°) * "On the Curability of Uterine Displacements," p. 24. 240 DISEASES OF WOMEN. are of great service. Dr. Emmet strongly recommends fre- quent use of hot-water injections in cases where the uterus is in a state of irritation, and I have also observed very- great benefit from their employment. Opiates are most readily employed to relieve pain in form of suppository, or laudanum with water injected per rec- tum. The congestion so frequently coupled with flexion is treated by some practitioners by leeches or scarifications of the OS uteri. And there can be no question as to the utility of such local depletion in such cases. I confess, however, that in practice I find these measures very rarely required, for it is found that when steps are taken to relieve the em- barrassed uterine circulation by elevating the fundus of the uterus, the congestion disappears. There are cases where this procedure cannot be at once effected, and in such it may be expedient to use leeches. But here comes the ques- tion. Are we to wait for subsidence of congestion before employing mechanical resources? The reply to this ques- tion is, that a well-adjusted pessary, together with observ- ance of complete rest and a suitable postural treatment, will be found not only a possible, but a most efficacious method in all but a very few cases. It is only necessary to carry out this plan of procedure to become convinced of its pro- priety and suitability. In cases where the use of a pessary is postponed, the vaginal tampon would be found tempo- rarily a suitable method of treatment. Counter-irritation may be employed in a variety of ways, the plan selected being in accordance with the peculiar re- quirements of tlie case. A severe, sharp, acute pain is best met by application of a strong mustard poultice over the hypogastric region, or round the loins; this is to be re- peated at intervals. Turpentine dropped on a piece of flannel wrung out of boiling water, and applied to the skin, is another counter-irritant, even quicker in its action than the mustard poultice. Warmth. — Hot poultices of linseed-meal or bran are most valuable for the relief of pain in all kinds of inflammatory affections. They should be large, quite a third of an inch in thickness, and applied very hot. Several layers of flan- nel wrung out of boiling water, and rolled round the pel- vis, offer a ready means of applying warmth. The warm hip-bath may be used for like purpose. Bottles of hot water, or hot bricks wrapped up in flannel, are household DISPLACEMENTS, DISTORTIONS OF THE UTERUS. 24I remedies of every-day use. A warm decoction of poppies is often advantageously substituted for simply hot water for fomentations. The application of cold is not without its uses; but, as an anodyne, warmth is generally far more ser- viceable. Anodynes. — The internal anodyne most ordinarily availa- ble is opium. The " liquor opii sedativus," of Battlcy, is one of the best forms in which to use the medicine in ques- tion. Opium is often combined advantageously with some of the ethereal preparations. A draught containing " Bat- tiey" and the compound spirit of sulphuric ether is one of tiie best remedies for the relief of severe non-inflammatory ])ain referable to the uterus or ovaries which can be em- ployed. In chloroform we have an agent often of great service. Complete anaesthesia by means of inhalation of chloroform is not often required, except in cases where pain is very severe, or in order to facilitate operative manoeuvres of va- rious kinds. Taken internally, in the form of chloric ether, it is very useful as an adjunct to opium. Belladonna, hyoscyamus, and conium are uncertain, and therefore very unsatisfactory, remedies, for the relief of pain, compared with those just mentioned. The Indian hemp is, however, better entitled to consideration, and in many cases undoubtedly exercises a marked influence in allaying or preventing pain. Camphor and Indian hemp combined I have often found of great service. Indian hemp is a medicine which, so far as my experience goes, appears to effect different individuals very unequally. Camphor, alone or combined with opium, is of service when pain is spasmodic. The various remedies known as "antispasmodic" fulfil a like indication, and, as already ob- served, the ethereal preparations are most important for the relief of certain kinds of pain. The pain associated with uterine contractions, in cases of difficult menstruation, is best influenced by the use of antispasmodics. The com- pound tincture of lavender, chloric ether, and the compound spirit of sulphuric etiier, may be often very usefull}^ asso- ciated (twenty drops of each for a dose), opium being added or not, as may be judged necessary; this forms a combina- tion adapted for all cases where there is pain of a spas- modic character, whether at the menstrual period or at other times; this "red" mixture is one which is very highly ap- proved of by patients. 242 DISEASES OF WOMEN. Local application of anodynes is often attended with good effect. The hypodermic application of one of the salts of morphia is tlie' most potent of these. Chloroform dropped on a piece of lint, and applied over the uterine or ovarian regions, is a remedy now and then very useful for the relief of temporary pains in these regions. Tincture of aconite may be rubbed in with a like object. Suppositories or enemas, which are in a manner local remedies, offer fre- quently a ready means of relieving pain in the pelvic or- gans. Solid opium may be employed for this purpose, or the tincture of opium suspended in water-gruel, or mixed with tincture of valerian or assafoetida; the latter combina- tion is particularly useful in hysterical cases. Opiates and sedative remedies may be also used locally, by making them up into the form of pessaries, which are inserted in the vaffina. CHAPTER XIX. Retroflexion and Retroversion of the Uterus. Severity of the Affection — Curability. Frequency — In Hospital and Private Practice — Compared with Anteflex- ion — Single or Married. Special Causes— Traumatic Influences — Dr. Squarey's Views — Influence of Bladder — Pregnancy — Straining Efforts in Defsecation. Varieties — Basis for Classification, i. Degree of the Flexion, first, second, third. 2. The Degree of Version (Rotation) — Substitution of Word " Rotation" for Version — Degrees, one, two and three. 3. De- gree of Descent of Uterus as a Whole. 4. Degree of Resistance to Replacement and Unbending. 5. Degree of Congestion and Enlarge- ment. Progress. Cornplications — Adhesions — Congestion — Not to be confounded with Rigidity — Prolapse of Ovary — Rupture of Perineum — Fibroid Tumor — Prolapsus of Rectum. Symptoms — Pain, Dysmenorrhoea, Menorrhagia, Leucorrhoea, Amenor- rhoea — Sterility — Abortions — Derangements of Bladder, of Rectum — Reflex Disturbances. Diagnosis. The backward displacements and flexions of the uterus — retroversion and retroflexion — constitute a class by them- selves, and may be conveniently considered together. Retroflexion of the uterus is one of the most painful and troublesome of the affections to which women are liable. RETROFLEXION AND RETROVERSION OF UTERUS. 243 The affection is not always severe, it may be a very slight one — so much so as to give rise to no symptoms calling for particular attention; but it is not uncommon to see patients who have been for years tortured and incapacitated by it to an extreme degree, and reduced to a helpless condition of invalidism. The obscurity which has surrounded it has not even yet been completely dissipated, there being still some who deny the importance and seriousness of the affection; so strong is the effect of past teaching in perpetuating im- perfect and erroneous views in this as well as in other de- partments of medicine. Curability. — It is well known to those who have paid at- tention to the subject that retroflexion of the uterus is some- times so troublesome and severe in character that it can only be cured by the greatest patience and care. Not only so, but cases are not rare in which the affection has been pronounced incurable. And more recently some such cases, considered otherwise incurable, have been submitted to the operation now known as Battley'g operation, in order to relieve the patient of her sufferings. According to my experience, however, the very worst cases are generally amenable to a judicious and patient course of treatment. When the disease has existed in a severe form for several years nothing can be done in the way of permanent rectification in less than a year or a year and a half; and in such cases, when the rectification is ac- complished the uterus will require artificial assistance for a still longer time. I have succeeded in completely curing many very chronic cases, the success obtained being largely attributable, as I believe, to the great attention paid not unly to the perfect maintenance of the uterus in its proper shape, but to the restoration of the general strength by adequate nutritional treatment. I have known cases where success has not resulted from mechanical treatment owing to neglect of the latter element in the treatment, and, under such circumstances, it is no wonder to me that they should be found " incurable." Frequency. — The following figures convey the results of my own observations: During four and a half years (1865-1869) at University College Hospital,* out of about 1200 cases prescribed for in the department for diseases of women, 112 were found to * These cases were given in detail in the 3d edition of this work. HA DISEASES OF WOMEN. be affected with retroflexion and retroversion. [Cases of anteflexion or -version, 184.] During a period of six years of private practice (April 1873-1879), out of 1 140 cases, 180 were found to be affected with this distortion of the uterus. [During the same period 488 cases of anteversion and -flexion were recorded.] Thus 1 140 private patients afforded 488 cases of anteflexion as against 180 retroflexion, and hospital practice afforded out of a total of 1200 patients, 184 cases of anteflexion com- pared with 112 of retroflexion. (For further remarks on this point see chapters on Anteflexion.) Single or Man-ied. — Retroflexion of the uterus is frequently observed in single women, though the greater number ap- plying for relief are found to be married. Out of 180 ret- roflexion cases in private practice 41 patients were un- married (227 per cent.). The following Particulars refer to 180 Cases in Private Practice. Age. Unmarried. Married: fertile. Married: sterile. 18 2 cases 19 3 ' I 20 ' I 20-25 9 ' 14 6 25-30 12 ' 21 19 30-35 6 ' 19 4 35-40 3 ' II 5 40-45 4 ' 15 I 45-50 2 ' 7 over 50 ' 3 2 age not stated. Total. — 7 3 41 97 42 180 Special Causes of Retroflexion. — The general question as to the causes of uterine flexions has been already discussed (see p. 179). The remarks there made apply for the most part equally to cases of retroflexion and anteflexion. Attention may, however, again be drawn to the great fre- quency with wiiich what may be termed traumatic influ- ences can be shown to give rise to this form of displace- ment. In a table given at p. 180, particulars of 44 cases of RETROFLEXION AND RETROVERSION OF UTERUS. 245 retroflexion in single or sterile women are given. The table is to be read in this manner: There were 41 sinerle patients ) a • t ^ ^ • J . -1 .• ^ f suiierms: from ret- 42 married sterile patients V a ■ . , , ., ^ . ^ I roflexion: 97 married fertile patients ) 41 -{- 42 = 83 cases in whom child-bearing had no part in the production of the malady (7 of them, however, had had abortions). Now out of these 83 cases it was found easy to trace a traumatic origin for the retroflexion in 44 instances. In the remainder a traumatic influence was not proved to exist, or at all events it was not detected. This is an ex- ceedingly important fact as showing the frequent traumatic origin of the affection. And in other cases where no par- ticular accident or special exertion could be traced a me- chanical cause had evidenth' been in operation, acting more continuously and slowly, but gradually bringing about the change of shape and position. It ma}' be inquired. Are there any special mechanical causes for retroflexion ? — that is to say, is any particular force more likely to produce a retroflexion rather than an anteflexion? In a very interesting paper bj' the late Dr. Squarey "On the Causation of Acquired Flexions of the Uterus,"* the attempt is made to explain why in some cases flexion backward occurs and in others flexion forward. Dr. Squarey suggests that it is due to the position of the uterus at the time of the blow or shock or fall which occa- sions the flexion, and that if the uterus be high in the pelvis it is more likely to be pushed forward, having a natural in- clination in that direction when high in the pelvis; whereas, if it be low down in the pelvis, it has a natural inclination backward, and the force will have the effect of producing in the latter case retroflexion. There is much to be said in favor of this view. On looking at the list of causes given at page 180, where the results of observations and of in- quiries in 340 cases are tabulated, it will be seen that vari- ous " traumatic" influences (as Dr. Meadows would term them) were shown to have produced in some cases one form of flexion, in others another. And particular accidents or exertions seem to have been tolerably impartial in regard to the effect produced. It must be recollected that the uterus in a state of health is well balanced, and a very trif- ling thing, the fulness or emptiness of the bladder, of the *"Obst. Trans.," vol. xiv., 1873. 246 DISEASES OF WOMEN. rectum — the position of the body at the moment — or other circumstances, may determine whether the fundus is to go backward or forward. It has been shown (see p. 167) that the uterus has nat- urally a certain degree of what may be termed " play" for- ward and backward, in order to allow of due action to the neighboring viscera. The extent of this play is not, prob- ably, in a state of health very great. The bladder is no doubt capable of producing a considerable exaggeration of the natural movement of the uterine fundus backward, and it is quite possible that the fulness or emptiress of the bladder at the moment when a particular accident or shock is sustained may be the reason why the fundus is driven violently downward and backward in a state of acute flex- ion, whereas if the bladder had been empty the result of the accident might have been quite different. It is a fact that undue distension of the bladder may actually produce ret- roflexion. In the etiological list (p. 180) mention is made of one case of this kind. In this instance, retention of urine during a railway journey produced retroflexion of a very marked character. This effect of bladder distension in causing (or rather predisposing to) retroflexion must not be confounded with bladder distension the effect of retroflexion, for, as is well known, retroflexion of a large uterus may give rise to dis- tension of the bladder and actual retention. One important factor in the etiology of retroflexion ap- pears to be the circumstance that when the uterus happens to be bent backward there is less power of self-rectification than when it is bent in the opposite direction. In the case of antefl.exion the filling of the bladder may again lift the fundus upward, but in the case of the retroflected fundus there is nothing to lift it out of the Douglas pouch, or at all events to push it upward. The action of the distended rectum is not analogous to that of the distended bladder. The restorative influences in the case of retroflexion are only the natural erectile resiliency and elasticity of the uterus, and possibly in some degree the action of the round ligaments. There is also a possibility of a greater amount of flexion in the posterior than in the anterior direction, owing to the depth of the Douglas pouch behind the uterus. I should be inclined to think, judging from actual experi- ence, that in cases where accidents have produced severe displacements the uterus must have had an inclination for- RETROFLEXION AND RETROVERSION OF UTERUS. 247 ward or backward at the time, and that the result of this accident was a great exaggeration of the previously exist- ing inclination. There can be no question that traumatic influences are capable of producing severe retroflexion in individuals pre- viously in a state of good health; but it is also certain that general malnutrition provides a predisposition of a power- ful character, tlie practical effect of which is that a weakly patient will be more likely to be injured by a severe exer- tion or accident than one who is strong. Put in this way it is a truism. Another important class of influences capable of produc- ing retroflexion of the uterus is pregnancy and its effects. In some few cases retroflexion occurs for the first time soon after pregnancy has begun; this appears, however, to be a rather rare event. Many women become subjects of retro- flexion after pregnancy is over who were not affected with it before. It does not appear, however, that pregnancy has any special effect in subsequently causing retroflexion rather than anteflexion. A pregnancy is not necessarily followed by a flexion at all. It is not, I believe, so often followed by retroflexion as by anteflexion. Still the fact remains that we meet with retroflexion in women who have borne children and in whom the retroflexion is indubitably connected with the previous occurrence of pregnancy. Pregnancy leaves the uterus soft, large, heavy, and more liable to be acted on by the force of gravity. It sometimes leaves behind a special predisposition, viz., rupture of the perineum. I find that of 180 cases of retroflexion in pri- vate practice 97 were observed in married women who had had children. In these 97 cases traumatic influences were found to have produced the retroflexion in a considerable number of cases. The undue weight of the uterus, defi- ciency of the perineum — are two predispositions, and a walk, or strain, even the act of straining at stool, may under such circumstances produce suddenly the backward dis- placement. Protraction of the period of involution of the uterus, which means generally extreme weakness and mal- nutrition, is the precursor of retroflexion in many cases. One very common cause of severe exaggeration of retro- flexion is straining in the process of defaecation. It is prol)- able that such straining is the primary cause in a consider- able number of cases. Is retroflexion of the uterus ever congenital 1 My own 248 DISEASES OF WOMEN. Fig. 51. Fig. 52. RETROFLEXION AND RETROVERSION OF UTERUS. 249 observations have not furnished me with a single case. Schroeder gives the opinion that it never occurs. Grenser, in an interesting paper on " Retroflexion,"* says, however, that Ruge in 1875 described a case of retroflexion in a new- ly-born child. Varieties of Retroflexion. — Four principal conditions offer a basis for classification. One is tlie degree of the bend, another the amount of version (or rotation), a third the descent of the uterus as a whole, and fourth, the degree of resistance which is offered to the replacement of the uterus in its proper position and shape. Fir.. ;r The Degree of the FIexio?i. — Flexion may be conveniently spoken of as existing in three degrees — the first degree when the axis of the body of the uterus has a relation to the axis of the cervix of about 45°; the second degree when the angle is 90°; and the third when the angle is be- tween 90° and 135° or greater than 135° — the uterus in the latter case being doubled upon itself. The accompanying figures represent the outline of the uterus in these three degrees of flexion. Fig. 51 shows the first degree of retroflexion. Fig. 52 shows the second. "Arch, f, Gynak." ii. p. 145. 250 DISEASES OF WOMEN. The body of the uterus is heavier, and its walls are shown to be thicker than normal. There is considerable conges- tion of all parts of the uterus, both fundus and cervix being larger than usual. The os uteri externum is widely open and the lining of the cervical canal partly everted. Fig. 53 exhibits the third stage of retroflexion of the Fig. 54.* ^1 uterus with much contraction and compressiort of the canal at and near the internal os uteri. There is a very depend- ent position of the fundus uteri; there is also considerable distension of the cavity of the body of the uterus, niucli swelling of the lips of the os uteri, especially the posterior lip, and much eversion of the cervical canal at the os uteri. * Fig. 54 shows the second stage of retroflexion, together with the second degree of rotation; the rectum and bladder are also shown. RETROFLEXION AND RETROVERSION OF UTERUS. 25 1 There are other intermediate desjrces of flexion possible, but for practical purposes this subdivision will be sufficient. It is not intended to imply that the angle formed is repre- sented by straight lines; the uterine canal as a rule forms a curve, no part of it being a straight line. The Degree of Version {Rotation). — If the uterus were per- fectly rigid, and if its axis of suspension (a horizontal line Fig. 55.* drawn transversely across the pelvis at the centre of the uterus) were also fixed, the descent of the fundus back- ward would imply necessarily a corresponding elevation of the OS uteri. The motion would be a see-saw motion — as the fundus descended the os uteri would be elevated — there would be true retroversion. But the uterus is not abso- * f 'g- 55 represents a third stage of retroflexion of the uterus, with third degree of posterior rotation; the pressure on the rectum and drag- ging on the urethra are also represented. 252 DISEASES OF WOMEN. lutely rigid, and when the fundus descends backward it usually becomes bent above the axis of suspension, and below it also. The attachments of the cervix uteri prevent the elevation of the os, so the whole canal becomes fiexed. The OS uteri has different degrees of elevation in different cases. Three factors regulate this — (i) The general rigidity of the uterus; (2) The degree of fixation of the cervix uteri; (3) The mobility (which varies) of the axis of sus- pension of the uterus as a whole. A true notion of what really happens to the uterus in cases of flexion cannot be conveyed by using the words " version" and " flexion" only, for there is another motion to be considered — viz., the rotation of the uterus on its axis of suspension when in a flexed condition. Let us suppose the uterus to be flexed backward in the first degree and incapable of flexion beyond that degree. If an imaginary fixed rod be passed transversely through it at its middle, and pressure be made upon the fundus, the uterus will have a rotary motion imparted to it. The flexion will not be increased, but the fundus will descend lower while the os uteri will be elevated. It is possible to have this rotatory motion with any degree of flexion, and as a matter of fact the rotatory movement in question is one of the most important of the clinical features of retro- flexion. Rotation may, and generally does, increase the degree of the flexion, but it is not rare to meet with cases in which the uterus has become so hard in its flexed state, that al- though considerable rotatory motion often occurs, the de- gree of the flexion is not much increased thereby. In view of the foregoing considerations it appears to me desirable to substitute the word "rotation" for "version" in speaking of retroflexions, more particularly as it will then be more easy to give a practical and clinical classifica- tion of cases. There are three degrees of rotation. Thus, when the uterus is slightly turned backward on its central transverse suspensory axis, that will constitute the first degree of rotation; when the rotation is greater, the second degree; and when the rotation is extreme, the third degree. Rotation may be great while flexion is very slight. Thus we may have i^otation in third degree with flexion in first degree. Such a case as this would be what is usually RETROFLEXION AND RETROVERSION OF UTERUS. 253 termed pure and simple retroversion of the uterus, and it is a condition very rarely met with. On the other hand, rotation may be slight (first degree) Fig. 56. while flexion is great (third degree). But neither is this a very common combination. It is more common to meet with the conjunction of rotation in the second degree, and flexion in the second or third degree. Increase of rotation has a tendency to increase the de- gree of flexion, and indirectly, sdso,vue versd. 254 DISEASES OF WOMEN. In cases of retroflexion, the degree of rotation is ever liable to change. Exertions of various kinds increase the degree of rotation for the time being. The degree of flexion is generally increased at the same time, so that the displacement diS well as the distortion of the uterus is conjointly intensified. When, however, the exertion is at an end, there is a more or less complete return to the previous condition. As, however, the return is hardly ever equal to the disturbance, the tendency is to a gradual intensification of both rotation and flexion. The drawing (Fig. 56) shows three degrees of retroflexion — first, second, and third. After what has been said, it is hardly necessary to point out that ascent of the fundus from a low position in the Douglas pouch does not necessarily imply a lessening of the flexion; it may mean simply reduction in the degree of rotation. The application of this remark to treatment is obvious. The Degree of Descent of the Uterus as a Whole. — Men- tion has been made of the axis of suspension. This axis is not fixed, and it is sometimes so little fixed, that the uterus is allowed to fall very low — even to protrude from the vulva. When the uterus is very low in the pelvis its shape is more readily made out, but the uterus may be much dis- torted without falling very low. Asa rule, however, when the distortion is great, the uterus is low. In a very severe case we may have third degree of flexion, third degree of rotation, and descent of the uterus to the perineum, all conjoined. And in some instances the whole uterus so retroflexed escapes at the vulva (see Prolapsus). Degree of Resistance to Replacement and Unbending. — Cases differ much in this respect. The unbending and replace- ment may be easy, difficult, or very difficult. The sound is used to determine the degree of difficulty. When replacement is very easy, the uterus is usually ab- normally soft. When difficult or very difficult, the flexion is usually of duration in proportion to the degree of diffi- culty. The resistance encountered arises, I believe, gen- erally from the acquired rigidity of the uterus as a whole, and only very rarely from peritoneal adhesions. The uter- us in chronic cases of retroflexion is almost always hyper- trophied, and frequently becomes in time hard and resistant, so that it becomes more and more difficult to straighten it RETROFLEXION AND RETROVERSION OF UTERUS. 255 as years go on. But this is by no means constantly the case; for I have met with very long-standing retroflexions in single patients in whom the uterus was found exceed- ingly soft and pliable. Extreme and long-continued mal- nutrition has always been a feature in such cases. The utero-sacral ligaments have, perhaps, been occasionally taken for adhesions. In some few cases the uterus is readily straightened owing to atrophy at the seat of the bend. Long duration of the malady does not therefore necessarily produce difficulty of restitution. Degree of Congestion or Enlargement. — Retroflexion of the uterus is remarkable for the extreme degree of acute con- gestion which may be associated with it. The cases which used to be recorded as cases of acute inflammation of the uterus were unquestionably most of them cases of severe retroflexion coupled with very acute congestion; and when the acnte stage had passed away the uterus was left in a state of chronic irritability. Some of these latter were en- countered by Gooch, and described by him as cases of " irritable uterus." Congestion may exist in all degrees in different cases. It is most severe when the flexion is greatest, and its access in great severity marks almost com- plete arrest of the circulation in the organ. The uterus swells, is acutely sensitive, and all motion is painful. In other cases it is less severe, and in a few it does not form a noted feature of the case. In cases where the flexion is only in the first degree, but where the rotation is not great — such as approach to version pure and simple — the con- gestion may not at any period be very intense. In some such cases the symptoms, being slight in degree, have given apparent foundation for the notion entertained by some that retroflexion is an affection of no clinical impor- tance. One effect of persistent congestion is great enlarge- ment of the uterus as a whole, and specially of the fundus. I have found the body of the uterus four or five times its natural size in cases of severe flexion, and if allowed to re- main in its flexed condition the enlargement is persistent. The enlargement due to congestion of the retroflexed fun- dus is sometimes so great that there seems to be a large tumor behind the uterus, and I have more than once been misled by this, on making a first examination. The congestion affects the os uteri also, rendering it swollen, tumid: and as it is engorged with blood, the mucous membrane of the partially everted cervix presents 256 DISEASES OF WOMEN. a highly vascular appearance. Other important secondar)' changes occur (see Congestion of the Uterus, p. no). Later on the uterus is less congested, but in a state of chronic in- duration, liable to attacks of congestion on slight provoca- tion. Progress. — It seems very possible that the first step in the production of retroflexion is often a slight exaggeration of the natural rotatory motion in the backward direction; next slight flexion; then increased rotation and increased flexion; and so on. From time to time the flexion and rotation are increased, a daily oscillation at the same time occurring in degree. During the day it is increased, at night diminished. The affection remains a slight one, but usually tends to become severe. It may occur acutely, rapidh', even instantly, at- taining a high degree of intensity (as from a sudden acci- dent), or in the course of months may gradually become worse and worse. Having become very severe, and the patient being quite laid up for some time with it, a certain degree of improve- ment may occur, the uterus acquires some tolerance of its distorted condition, and an incomplete recovery follows. Slowly there is a return to efficiency, but suddenly, after a few weeks or so, a slight exertion brings back all the symp- toms with redoubled force, the flexion and rotation having become suddenly intensified. Again a rest; and again an ill- ness. In course of longer or shorter time tolerance may be es- tablished, the uterus has become harder, it bends less on motion, and a tolerable recovery is effected. It is not com- mon to meet with this latter result where the flexion passes the second degree, or where the rotation exceeds the sec- ond degree. In the latter class of cases recovery of efficiency (by which is meant ordinary capability for the duties of life) is very rare, and chronic invalidism is the rule. The above statements apply to the malady as observed in cases where no particular attempt has been made to remedy the retroflexion, and where the disease has taken its own course. Marriage usually makes things worse for a time. Preg- nancy may occur; more often, perhaps, does not. If preg- nancy occurs abortion may, and most frequently does, follow. If abortion does not occur, a cure is for the time effected. The further history in such a case varies; either RETROFLEXION AND RETROVERSION OF UTERUS. 257 the retroflexion recurs, becomes worse, and remains worse, or there is a succession of abortions, or a succession of pregnancies with occasional abortions, or a complete cure. Co plications. — Congestion of the uterus in a most intense form is almost a part and parcel of severe degrees of retro- flexion. The congestion is the mechanical result of the flexion (see p. 112); it usually becomes increased in direct proportion to the degree of the flexion and rotation. It is most intense in cases where the flexion is in the third de- gree, but the rotation in the second. It is certainly less severe in proportion as the flexion approaches the first de- gree; and after some years it sometimes happens that con- gestion ceases to occur. Congestion is so common that it can hardly be considered as a "complication." Presence of adhesions is a real complication. It appears to be rare, but certain cases of its occurrence are well authenticated. The fundus in such cases is bound down by peritoneal bands in its unnatural position. The elevation of the uterus by the sound, conjointly with the use of the finger in the rectum, is the best method of diagnosing them, for mere difficulty in raising the fundus does not prove presence of adhesions, as already stated (see p. 254). In a paper by Dr. Erich are described " Seven Cases of Retroflexion with peritoneal adhesions of the fundus in the hollow of the sacrum, treated by forcible separation of the adhesions;" * but on reading the reports of these cases, evidence of a satisfactory nature as to actual adhesions is wanting. The reports give the notion that they were cases of rigidity of flexion, rather than cases of peritoneal adhe- sions. I have repeatedh' found the same difficulty of re- positing the uterus which Dr. Erich describes; but, except in a few cases, I have not had reason to suspect peritoneal adhesions. The fact is, that after a time the uterus often becomes very firmly set in its abnormal shape. Forcible action of the sound straightens it for the moment, but the flexion returns directly. This return of the flexion is cer- tainly not a proof of adhesions. The utero-sacral ligaments sometimes catch the fundus, as it were, between them in its retroflexed position (as Dr. John Williams has pointed out) and occasion an intensifica- tion of the congestion. It is evident that this kind of in- carceration might give rise to a suspicion of adhesions. * Amer. Journ. Obst., Oct., l88o. 2S8 DISEASES OF WOMEN. These bands would be felt tightly on each side, and, as a matter of fact, these utero-sacral ligaments vary much in distinctness in different individuals, and it is only in excep- tional cases that they are verj' strong and well marked. Prolapse of the ovarj' on one or both sides is a compli- cation of a very troublesome character. It does not occur very often, but when the ovary falls down along with the fundus uteri into the Douglas pouch, and becomes adherent in that position — a condition sometimes met with — the case becomes a very difficult one to deal with in the ordinary manner. If the ovary be not adherent the complication is not so troublesome, and when the fundus is replaced and kept so, the ovary goes back into its place also. Rupture of the perineum is a complication, grave or not according to the degree of the rupture. The retroflexion is sometimes entirely due to the deficiency of the perinaeal support, and the one cannot be cured without remedying the other. Fibroid tumor sometimes complicates retroflexion: a tu- mor growing at the back of the uterus tilts the uterus back- ward, and constitutes a very grave complication. The tumor occasions most trouble perhaps where it is not big- ger than an orange. Prolapsus of the rectum is sometimes due to the fundus being pushed down into the rectum, partially inverting it and forced partly out at the anal aperture during attempted defaecation. Here the fundus uteri acts as a complete ball- valve in the rectum, and seriously interferes with its due action. SYMPTOMS. A general account of the symptoms observed in cases of flexions has been already given (see p. 163). These symp- toms are observed in an intense degree — some more, some less — in different cases of retroflexion. Some of these symptoms present peculiarities in cases of retroflexion which require to be noted. The degree of pain (spontaneous) is as a rule greater in retroflexion than in anteflexion, probably because the de- gree of flexion is greater in the former than in the latter. The pain is generallj' in the sacral region, but it may be a fixed pain on one side of the umbilicus, or even higher, or it maj- be in the groin. I have met with a few cases in which the pain has been so situated as to entirely attract RETROFLEXION AND RETROVERSION OF UTERUS. 259 attention away from the uterus as the cause. I have known it to be so persistent in this situation as to have been diag- nosed to indicate cancer of the pylorus. The pain on loco- motion or movement (uterine dyskinesia) is often most intense. This symptom is one almost always very decid- edly and painfully well-marked in retroflexion cases. Any- tliing whicli gives the action of gravity an opportunity for still further rotating and bending the uterus — as standing, walking, stooping, even sitting — may give rise to extreme torture. This symptom may be absent, or not noticed, when the disease is of slow growth, but in the end it shows itself in a marked form. A not uncommon circumstance is to find that a patient is what is called "very weak." This may turn out on inquiry to mean that she can walk but little; and investigation shows perhaps that she does not walk, because of the discomfort produced by it. This discomfort finally is discovered to be due to an unsuspected retroflexion. The sensitiveness of the uterus to touch is in very severe cases most extravagantly great. These are the typical cases of what has been known as " Gooch's irritable uterus," the pathology of which has been explained at p. 212. Chronic severe cases of retroflexion are cases of this kind. This degree of sensitiveness is not so often found in ante- flexion cases, though it is sometimes met with. The sensi- tiveness is accompanied with congestion. The part most sensitive is the fundus; the os uteri is not generally so sensitive to the touch as the fundus. Any attempt to ex- amine the uterus with the finger, unless done with the greatest care, causes the patient to shriek out; and it is at first rather surprising to find the uterus so sensitive when tlie amount of spontaneous pain felt may not be very great. There is, I believe, always in such cases considerable me- chanical pressure on uterine nerves, due to the squeezing of the tissues of the organ. Dyspareunia is almost always well marked in severe cases of retroflexion. Dysmenorrhoea is often severe, but as a rule not so com- mon as in anteflexion. Leucorrhoea, appearing in the form of gushes, is not un- common. A more or less copious puriform discharge is rather frequently observed. Menorrhagia is common. Patients with retroflexion often lose largely at the periods, and there are losses often at in- tervals besides. Large clots often form in the dilated 26o DISEASES OF WOMEN. Uterine pouch, and are expelled with great pain and further loss of blood. Amenorrhoea is the result in some few cases. Chronic retroflexion at first has a tendency to increase the quantity of menstrual fluid, but after a time in some few cases it ma}' even bring it to a premature end. This latter result is due to the compression and hardening and contraction the retroflexed uterus in some cases finally undergoes. Its circulating apparatus becomes in fact less and less efficient, and menstruation ceases. Sterility is a common symptom (see p 219). Abortions also are common (see p. 219). The distiirbajices of the fu fictions of the bladder due to retro- flexion are various. In slight cases no disturbance may be noticed. In severe cases micturition is sometimes entirely impossible for a time, owing to the dragging upward of the meatus by the elevation of the cervix, or by the actual com- pression of the meatus against the pubic symphysis by the OS uteri. Then we have retention of urine. Sometimes micturition is more frequent than usual. The rectum lies close to the uterus and suffers frequently in cases of retroflexion. The commonest symptom is con- stipation, result of actual compression of the rectum by the fundus uteri. The more the patient strains the greater the difficulty, because flexion is increased. Defaecation be- comes also extremely painful — it is positive torture in bad cases. The bowel is sometimes in such cases thought to be diseased when it is really quite sound. Haemorrhoids are unquestionably rather commonly produced by retroflexion. A raw bleeding ulcerated surface is sometimes found pro- duced by prolapsus of the bowel, result of the continuous straining efforts in the process of defaecation (see Com- plications, p. 221). The reflex nervous symptoms due to retroflexion are numer- ous, and they are of the greatest importance. Severe nau- sea, severe hysterical symptoms, are the most marked of these, but these and other reflex sj'mptoms are not peculiar to retroflexion, and are not therefore specially indicative of its presence. These symptoms are, on account of their great interest, reserved for consideration in a separate chapter. DIAGNOSIS. Diagnosis is generally eas}^ but in a few cases difficult. It is absolutely impossible to certainly diagnosticate retro- RETROFLEXION AND RETROVERSION OF UTERUS. 26 1 flexion without a physical examination, many of the symp- toms observed being liable to occur also in anteflexion cases. The uterine fundus is readily felt from the vagina by the finger: also from the rectum. I have known cases where it has been overlooked, apparently from want of due care in placing the patient in a favorable position for examination. The lateral position, with the knees well drawn up, is re- quired; this position allows the finger to pass higher than an)^ other. When the flexion and rotation are only in first degree, the fundus might not be reached even then by the finger. When in second or tliird degree it could hardly be missed. The lower down the uterus is as a whole, the easier becomes the exploration. The tumor felt behind has the shape of the fundus. But not always so: it may be much swollen. In some rare cases it is pyriform, from the fundus having been repeatedly and forcibly propelled down into the rectal aperture. It is generally sensitive to the touch. It is of course continuous with the uterine cervix. It can only certainly be diagnos- ticated to be the uterine fundus — unless by an experienced observer — by using the uterine sound. Very gently and carefully the sound, only slightly curved, is passed, with the point directed backward, and if it passes to the full extent the diagnosis is established. In flexions of third degree, especially with rotation to second or third degrees, the sound must be more decidedly bent in order that it may enter. Further the diagnosis can be carried by gently turn- ing the sound round after so introducing it, when the tumor generally can be made to disappear and can no longer be felt by the finger. On withdrawing the sound the fundus again descends unless the flexion be very recent. The sound enables us to distinguish retroflexion from fibroid tumor growing at the back of tlie uterus — a condi- tion which sometimes very closely simulates it; also from a small ovarian tumor which might be felt in the same po- sition (very rare); also from tumor produced by haematocele, and from tumor due to pelvic cellulitis; though the two latter conditions could hardly be confounded with retro- flexion (of the non-gravid uterus at all events); also from carcinomatous infiltration between the uterus and the rec- tum. The shape of the os is peculiar (as a rule) in retroflexion. It is crescentic, the posterior lip is longest; and it is everted, 262 DISEASES OF WOMEN. and often very much swollen. In the nulliparous uterus this characteristic shape of the os is not usually observed. The position of the cervix is abnormal. It is more or less tilted upward; sometimes it is quite high up behind the symphysis and very close to the pubic bones. The vaginal pouch behind the cervix is lost, owing to the fundus pressing it downward and obliterating it. And there is an. unnatural pouch up behind the symphysis pubis in front of the cervix. Moreover, by the double touch the fundus is found absent from its normal position. CHAPTER XX. Retroflexion and Retroversion of the Uterus — {Continued?). Treatment. — General — Local — Plan recommended — Outline and De- tails — Postural Treatment — Mechanical Direct Reposition — Mainte- nance of Proper Position by Vaginal Pessary — Form of Pessary recom- mended — Various Sizes required. Position of Patient — Use of the Sound — Conjoint use of Sound and Pessary — Difficulties encountered in Treatment of Cases — Adjustment of Size of Pessary — How far Vaginal Pessaries are reliable — Action of the A. Smith Modification of Hodge Pessary — Necessity for Rest, and gradual Elevation of Fundus in some Cases — Occasional Over-action of the Retroflexion Pessary — How long to be continued — Method of Introduction — Change of Pessary — Various Modifications of Retro- flexion Pessary — Dilatation and Moulding for Cure of Retroflexion — Stem Pessary — Incision and Immediate Rectification — Radical Opera- tion (Koeberle) — Oophorectomy. TREATiMENT, The general principles of treatment of flexions laid down at p. 224 apply and should be applied to the treatment of this particular variety — retroflexion. It is most iinportant at the outset of the treatment that the view taken of the case be as complete as possible, and that l\\& general 2iX\<\ tlie local receive each their proper and due share of atten- tion. Premising that this has been done, we proceed to con- sider the various details of the treatment of retroflexion. The Local Treatment. — There are various plans adopted for the treatment of cases of retroflexion. The plan which I have found satisfactory in the large majority of cases I pro- pose to mention first. It may be described as follows: RETROFLEXION AND RETROVERSION OF UTERUS. iG- The fundus uteri is pushed upward from behind, rapidly or slowly according to circumstances, by means of a pessary constructed on the Hodge principle; the pessary is kept in situ persistently and the size altered as circumstances re- quire. The sound is employed from time to time to aid in the elevation if it be at all difficult. The patient is kept more or less completely at rest until the uterus is well in its place, and suitably maintained there. Every advantage is taken of the assistance of gravity in righting the fundus, by the prone position, by the knee-and-elbovv position, by Fig. 57.* avoidance of the recumbent-dorsal position, by avoidance of the sitting posture, etc. The bowels are kept in order by daily injections, or otherwise. Pain is relieved by opi- ates or by vaginal injections of hot water. Careful general appropriate treatment. The above is an outline. The details require further specification. * Fig. 57 represents a medium-sized pessary of this kind, plan and the sectional lateral view are given together. The ground 264 DISEASES OF WOMEN. Direct Mechanical Reposiiion. — Regarding the condition as entirely a mechanical one, the resort to mechanical treat- ment is only natural. There is no necessity to be afraid of restoring an acutely congested retroflexion, or of beginning the attempt at all events, simply because the uterus is acutely sensitive and in a state of intense congestion. Nor is there any necessity for depleting the uterus by leeches Fig, .58. ....?i. iri'.. 3. m. — ••"».... Zl IN. ,- 2i IN. ,*"'' ■""'-.^ 2i-_ IN. ,,.- ' ' -^-^^^ 2 !H. \ N \ *• before commencing the mechanical restoration, seeing that this restoration will pretty certainly remove the congestion (see p. 137) as I have observed over and over again in prac- tice. The uterine fundus may, if very sensitive, be gently pushed upward by the fingers at first, the postural treat- ment following it; or it may often be replaced wholly or in part by the sound at once if the practitioner is gentle and skilful in its use. A day or two of postural treatment is a good preparation for the above measures. Surprising re- RETROFLEXION AND RETROVERSION OF UTERUS. 26: lief often follows the elevation of the fundus in tlie acutely suffering cases. The pessary may be often used at once, pressure being made slight at first and gradually increased. It is absolutely necessary at first to maintain the recumbent Fig. 59.* position if a pessary be employed and the case at all a difficult one, or one of long standing. The pessary I have for some time employed is a vaginal pessary on the Hodge principle. I have for the last three or four years, in the * Fig 59 shows the action of the pessary described in the text. The dotted line represents the position of the uterus prior to the insertion of the pessary. 266 DISEASES OF WOMEN. majority of cases at least, used a sliape nearly identical with that known as thq "Albert Smith" shape — broad above and narrow below. From a copper ring covered with india-rubber an admira- ble instrument can be made. The type of the instrument is that shown in Figs. 57 and 60. It requires various modi- fications in different cases. Therefore, various-sized rings are required. A series of rings ranging in outside diameter from two inches to about three and a quarter inches are required (see Fig. 58): the first measuring two inches, the second two and a quarter, the third two and a half, the fourth two and three quarters, and so on up to three and a quarter inches. The thickness here shown is five sixteenths Fig. 60.* of an inch; other degrees of thickness are required or may be used at the discretion of the practitioner. The copper wire used should be rather stout for the large-sized rings — rather thicker than for the smaller ones. The thickness of ^he ring when covered with india-rubber may with advantage be a quarter of an inch for the very small rings (instead of that shown in the figure, which is five sixteenths), but about five sixteenths is a good thick- ness for the sizes ordinarily required. For larger sizes the thickness may be increased to six sixteenths with advan- tage. The accompanying drawing (Fig. 59) shows the retro- flexion pessary of the A. Smith type in situ; the drawing is life-size, the pessary shown in situ is constructed from a * Fig. 60 shows an oblique view of a medium-sized A. Smith type Hodge pessary. RETROFLEXION AND RETROVERSION OF UTERUS. 267 ring two and three quarters inches in diameter. The upper curve of the instrument may be modified. The curve I generally employ is less sharp than that depicted in some American works, but this is liable to modification according to the particular case. In the last edition of this work are represented figures of an oval-shaped pessary rather larger at one end than the Fig. 6i. other, the smaller end being behind the cervix uteri. But I have found the shape originally introduced by Dr. A. Smith to work so satisfactorily that I prefer it to all others. His modification of the Hodge pessary for retroflexion is broad above, narrow below; it has a rather sharply double bent outline looked at from the side, and it is this outline which preserves it from slipping downward. Roughly speaking, the instrument is a triangle: the base above be- hind the cervix supports the fundus, the apex below should 268 DISEASES OF WOMEN. be so curved that it lies on the vaginal floor, and does not press on the urethra. In considering the Albert Smith type of the Hodge pes- sary as the best, I am in agreement with several distin- guished gynaecologists, both American and European. Fig. 62. 876 Various sizes are required to be used in different cases. In Figs. 61 and 62 are represented eight different sizes. The extremely small and extremely large sizes are rarely required. In single women a narrower pessary is required than in other cases. The size will generally require to be altered as the cure advances, and as the fundus rises up RETROFLEXION AND RETROVERSION OF UTERUS. 269 to near its proper position, for if the case is a chronic one it is quite certain that only a small-sized pessary will be borne at first; the pessaries constructed from rings of two and three quarters to three or three and a quarter inches in diameter are most often required for married pa- tients. The very large sizes, marked 6, 7, 8, in Fig. 62 are rarely required, but they are sometimes necessary when the uterus is exceptionally hypertrophied as well as retroflexed. When the swelling of the uterus has gone down, as it may do after a few weeks, a smaller pessary can be employed. Position of the Patient. — The patient should lie not upon the back, but upon the side, or, still better, upon the face. This is effected by making a kind of inclined plane with pillows placed under the chest and abdomen, one arm being placed quite behind the patient's back. By a little manage- ment a very comfortable position is thus attained. The result is, that the weight of the fundus uteri is in a great degree thrown forward instead of backward, and great as- sistance in the mechanical treatment is thus afforded. In severe cases this position of the bod}'' is in fact absolutely necessary, and I have seen patients who before had been in a state of absolute torture while lying flat on the back re- stored to comparative comfort by the simple procedure of enforcing the position on the face. The length of time during which it is necessary to maintain this position of the body depends upon the acuteness of the case. But when there is much irritation about the uterus it is absolutely necessary for the patient to remain in this position for some weeks. The upright position is destructive of progress in the right direction. The knee-and-breast position should be used several times a day for three or four minutes at a time. All exertion must be absolutely interdicted for a time, varying according to circumstances. In this manner we carry out as far as possible what may be termed the treatment of rest., a most important element in the treat- ment of these cases. The Use of the Sound. — The method which I recommend in the treatment of a recent case of retroflexion is that the sound, very slightly curved indeed, should be introduced gently and gradually into the uterus, and then gently turned round, so that the concavity looks forward, and the uterus thus restored to its proper shape; that the sound should be used once in two or three days, perhaps at inter- vals of a week; and that this treatment should be com- 270 DISEASES OF WOMEN. bined with the continuous use of the vaginal pessary. In a recent case, the use of the sound is generally unnecessary for more than a limited time, perhaps for a week or two. In a chronic case, where disease has existed perhaps for some years, the use of the sound is necessary at intervals of a few days, employed with great care, extending over a period of possibly tw^o or three months, and we may be obliged to intermit the use of it occasionally. Some cases do not toler- ate the repeated use of the sound, owing to occurrence of irritative symptoms; and these are more likely to occur if the vaginal pessary is at the same time continued to be worn. When the sound is used for altering the shape of the uterus it should be bent very slightly; indeed it should be very nearly straight. The difficulty of introducing the sound is got over by pushing up the fundus uteri by the finger at the same time that the sound is gently passed inward wath the concavity backward. Even in cases where the flexion is very acute the bend of the sound need not be great if the procedure be simultaneously adopted of pushing up the fundus. The use of the sound alone is rarely attended with any permanent benefit. The uterus almost invariably returns to a flexed condition a few moments after the sound is withdrawn. The rapidity wuth which the flexion returns on withdrawal of the sound is a useful indication as to the difficulty or not of the cure. The sound should always be used gently and held lightly. Force must not be employed, for the process of unbending the uterus in a chronic case is necessarily a long one, and involves considerable change and stretching of the tissues. It is very advantageous in many cases to hold the uterus in its proper shape by means of the sound for half an hour or an hour at a time. Difficulties in Regai'd to Treatment. — There is a very striking difference in regard to curability under different circum- stances. A case of retroflexion which has only existed for two or three months, and which is not very acute in regard to the degree of flexion, may be cured in a few weeks. If the flexion has existed for two or three years it may be ex- pected that the treatment v/ill not be completely successful under, perhaps, six or eight months. And in cases where the malady has existed for nine or ten years the treatment may not be successful even in a much longer time, in re- moving absolutely all effects of the disease. The changes ip the texture of the uterus itself are sometimes so great RETROFLEXION AND RETROVERSION OF UTERUS. 2/1 that it is difficult to restore the organ to its natural size and position, and its walls to their natural tliickness. And I have known cases in which the long continuance of the com- pression process on the tissues in the posterior wall of the uterus has left behind it a neuralgia of troublesome charac- ter, even after the shape of the uterus had been restored. This is what might be expected, and it is analogous to those cases where inflammatory processes, resulting in com- pression of nerve trunks in other parts of the body, leave beliind them a persistent and intractable neuralgia. The first difficulty is the selection of the method of treat- ment appropriate to the case. And it is not easy to lay down precise rules on the subject. Some generalizations may, however, be offered as an attempt to smooth the way for those who have not had much experience in the matter. The resistance offered to straightening the uterus is of great value as an indication. If the directions previously given be attended to, and the sound lightly and carefully used, the necessary information can be obtained. If there is any resistance to straightening, or if the uterus returns to a state of flexion immediately on withdrawal of the sound, it is certain that treatment b}' a vaginal pessary alone will not be likely to succeed, and repeated use of sound (or other like methods) will be also required. A well-fitted vaginal pessary will do much; but if the uterus be set and firm in its flexed condition, the only effect of its use will be to prevent increase of rotation of the uterus, but the flexion may remain unaffected. And in such cases the patient remains imperfectly relieved, or if relieved, it is found, on taking out the pessary later on, that the flexion is as bad as ever. On the other hand, if the uterus be soft and pliable, easily replaced and remaining replaced after withdrawal of sound for two or three minutes, it may be assumed that the case maj' be safely treated by vaginal pessaries and postural treatment or without necessity for repeated straightening. Then it may be asked, Cannot some cases be treated without a vaginal pessary at all, and by postural treatment alone ? No doubt if we saw the case in its earliest inception the thing might be done; but I have, myself, never seen a case at a sufficiently early stage to allow of this. On the other hand, I have known of retroflexion cases which have been treated by posture (lying on a prone couch at all 2/2 DISEASES OF WOMEN. events) for a year, or upward, and which have not been cured thereby. The adjustment of vagnial pessaries is a matter of no little difficulty. I do not mean the actual operation or in- sertion, but the selection of the instrument to be used. This seems the place for the discussion of the question as to the efficacy of vaginal pessaries in treatment of retro- flexion. 1 have had the greatest success with them, and have cured many very severe cases by their aid, assisted, as above described, by use of the sound. Their action requires to be carefully watched and adjusted until the uterus is secured in a good shape and position, after which they give little trouble. The upper extremity of the pessary must carry the fundus up to its proper place. In order to do this it must be sufficiently long. The vaginal pouch behind the cervix is of course pushed up in accomplishing this, and I have hardly ever met with a case where a sufficiently long pessary could not be inserted. The process often requires a little patience, and the pessary requires to be exchanged for a longer one from time to time until the object is attained. The pessary must be carefully examined when in situ to ascertain if the work required is actually done, for sometimes it will be found that the pessary is simply imbedded in the concavity of the flexion, and is doing not only no good, but actual harm. One practical direction may here be given. Sufficient care is often not given to the method of malcing the digital examination. If the patient be properly placed with the knees well drawn up, the finger can be made to reach nearly an inch higher in the vagina than would otherwise be the case, and thus the displaced fundus can be felt more readily. This is important in testing the action of the pessary. The sound can of course be used to test the position of the fun- dus; this requires to be done carefully, and the sound should be used nearly straight. In some cases it is found that the pessary requires to be carried so high up behind the uterus that it is difficult to reach the upper end with the point of the finger. It is impossible to do more than give the possible range of length and size of instruments, for each case has a law for itself as regards size and shape. The pessary which I have above mentioned (the Albert Smith variety of the Hodge pessary) is very successful in getting over a difficulty I had frequenth^ experienced before employing it. Retroflexion of the uterus is rarely exactly RETROFLEXION AND RETROVERSION OF UTERUS. 273 median, the fundus having generally an inclination to one side. Hence, the fundus is found often to slip to one side of the ordinary-shaped instrument. But when the instru- ment is made wide above, as in the Albert Smith pessary, this slipping of the fundus is prevented. Sometimes the width required to prevent such lateral deviation is consid- erable. It is difficult to introduce a wide instrument when the vaginal entrance is narrow, but in women who have borne children it is quite practicable. It is sometimes ad- visable to give the upper limb a slight extra projection to one side or the other. Fig. 63. A valuable modification of the retroflexion pessary is described by Dr. Gehrung,* consisting in giving the upper part of the pessary a central depression, so as to prevent the fundus slipping to one side of the pessary. The same idea is carried out in Dr. Gervis' pessary. Gehrung's pessary is shown in the accompanying figure (Fig. 6;^) and is peculiarly useful in cases where the uterus is really retro- flexed a little to one side. The principle of this modifica- tion is excellent, and I have repeatedly employed it. The pessary above recommended has a double action: it draws the cervix backward and thus reduces the rotation, and it appears to be considered by some writers that the * St. Louis Med. and Surg. Join:, August, 1878. 2/4 "DISEASES OF WOMEN. action of the Hodge pessary is limited to this. But it is not so, and I know from practical experience that by the direct pressure and lifting action of the upper limb of the pessary the fundus can be carried to the necessary height, though to accomplish this a rather long pessary may be needed. In some cases where the uterus is very large, a pessary of considerable size is needed (see p. 269), and unless one of sufficient size be used the uterus cannot be kept in place. Fig. 64. Other Modifications of the Retroflexion Pessary. — There is no doubt that in some cases it is an advantage to have the upper part of the pessary of considerable thickness, as the pressure is better borne, and it acts mechanically better; say, the size of the little finger (about half an inch). An expedient which has been frequently had recourse to in cases where the pressure of the instrument against the fun- dus is badly borne, is to cover the upper end with a cushion RETROFLEXION AND RETROVERSION OF UTERUS. 27^^ / J containing water or air. Dr. Priestley's pessary (which is a stem acting from without) is arranged in this manner. I have occasionally had pessaries on the Hodge principle covered with such a cushion at the upper end. In Dr. Greenhalgh's pessary (see Fig. 64, representing a medium- sized instrument) a similar object is effected by an air-pad, or by use of the soft elastic material known as moc-main covered with india-rubber. In a really troublesome case it would be best to have an instrument so padded, which would admit of being moulded into the exact shape required. Practically I find that, generally, direct pressure on the fundus can be prevented; and when it cannot, by proper positional treatment and other adjuvants, the necessity for a padded pessary can be often avoided, even when the fun- dus is very tender to the touch. Cutter's pessary for retroflexion is one well worthy of trial in cases where continuous pressure cannot be borne. It is an ebonite pessary, shaped something p,^ ^. like the upper part of a Hodge pessary, wliich in Dr. Thomas's modification of it is made rather thick; but the lower part is prolonged, in a sigmoid shape, and projects at the vulva. At this latter point it is curved a little back over the perineum, and a tape is thereto affixed, curved upward over the sacrum, and tied to a circular waist-belt. The pressure made on the fundus is thus capable of regulation from the outside. The advantages and the disadvantages of tins treatment are obvious enough. I have seen cases where the instrument would have been applicable with advantage, but personally I prefer other methods of treat- ment. In Fig. 65 is shown Dr. Thomas's modification of the instrument. General Remarks on the Employment of the Retroflexion Pes- sary. — It is sometimes the case that the pessary, though well fitted, can be tolerated for not more than a few hours. The uterus will not always bear to be carried at once to its proper position. Two courses are open: to lessen the pres- sure by using a smaller pessary, or to rigidly enforce the prone position; and both these courses may have to be taken at the same time. The pessary should be made to act as little by direct pressure on the fundus as may be, 276 DISEASES OF WOMEN. and the use of the sound takes it away from the pessary. The prone position and the knee-and-elbow position have the same result in a more or less complete degree according to circumstances. For these reasons if the uterus be tender to the touch, a pessary should not be employed unless care be taken by rest and suitable position to lessen as much as possible the direct pressure of the pessary on the fundus; and this is a great part of the secret of success in difficult cases. It does not at all follow because the pessary does well for a considerable time that it will do so indefinitely. In fact, there comes a period in some cases when, the condi- tion of retroflexion having been cured, the uterus is rotated forxvard by the action of the pessary, and the retroflexion is changed to an anteversion or flexion. I have seen cases where much disappointment had been experienced in con- sequence of an apparent recurrence of symptoms, and where, on examination, this result was found to have occurred. It is more likely to happen in cases where the uterus is rather soft than under other circumstances. There are a few cases where the uterus is very soft, and where the change from retroflexion to anteflexion occurs almost at once on application of a retroflexion pessary; but they are very rare. It is difficult in some cases to say when the pessary can be safely left off. This involves the question as to the complete curability of retroflexion of the uterus. When pregnancy occurs, the pessary can be removed at four months, after which time there is little danger of recur- rence. After pregnancy is over, the pessary will probabl}'' be again required (in about three weeks), if the distortion is of long standing. On the whole, it may be said that if the retroflexion has existed for two years it will probably be necessary to employ the pessary for nearly an equal time. And, speaking generally, it would seem that the duration of the disease regulates pretty directly the dura- tion of the mechanical assistance the uterus requires. There are cases which are more speedily cured, but they are exceptional. Pregnancy certainly aids in the cure, but does not absolutely effect it. After long years' duration, a complete cure is almost impossible; though, by the ex- penditure of much time and patience, the uterus may ulti- mately be made to assume a correct form, even after six, RETROFLEXION AND RETROVERSION OF UTERUS. 2;/ eight, or ten years; but in such cases the very prolonged use of a vaginal pessary will be required. It must be understood that the pessary above recom- mended has no fixed bearing against any part of the bony framework of the pelvis. Any pessary pressing against the pubic bones is badly adjusted, and will be likely to be mischievous. The pessary must be so fitted that it is em- braced and kept in place by the vaginal canal itself, which embraces it and surrounds it. Ordinarily it is not neces- sary to have a broad base for the instrument, for the sig- moid curve which it possesses seems admirably to insure its retention in the vaginal canal. The lower extremity of the pessary should therefore be just within the vulva at the centre of the aperture, and should not press against the rami of the pubes. Introduction of the Retroflexion Pessary. — The patient must be well placed on the side, with the knees drawn high up. The instrument should be well covered at one end with cold cream or fresh lard. It should be held a little obliquely at the vaginal aperture, as it then passes in more readih\ It is then gently inserted about half way into the canal. When arrived at this point the finger should be passed in behind it, and the upper extremity pushed sliarply back- ward behind the cervix. It then shoots rapidly into its proper position. It almost invariably happens that the instrument passes in front of the cervix uteri instead of behind it if these precautions be not attended to, and it is hardly necessary to state that in such a position the instru- ment will do considerably more harm than good. After it is in its place it may be pressed firmly to make sure its pressure can be borne; and it is a good plan to make the patient cough or to strain downward in order to test the question as to whether the pessary is so well adjusted that it will not escape. It is sometimes difficult to insert a pes- sary owing to tenderness or spasmodic resistance of the patient, without anaesthetic aid. When the entrance of the vagina is narrow care is requi- site to avoid bending the pessary, if made of copper and india-rubber, in the process of introducing it. A solid ebonite pessary is in such a case better, unless the operator is well skilled. It may be well to mention that the pessary is worse than useless if it be inserted with the concavity downward instead of upward. No one who has not studied 2/8 DISEASES OF WOMEN. the construction and objects of the instrument should attempt to insert it. Necessity for changing the Pessary. — A well-fitted pessary should require to be changed very rarely. The object of the pessary is to maintain the fundus in its proper place, and if it be taken away for purposes of cleanliness it should be again at once inserted, otherwise ground gained is un- necessarily lost. The pessary should be considered in the light of a splint, the action of which should be continuous. On no account should it be removed at the catamenial period. If well-fitted its presence will at that time be very necessary and useful. If it is thought serviceable to re- move the pessary for a few days the patient should not be allowed to move out of the horizontal position. For pur- poses of cleanliness it is sometimes desirable to employ daily injections of warm water with a little disinfecting fluid when the pessary is constructed of india-rubber; but when of ebonite, injections are generally only required just after the monthly period is over. Change of the instru- ment is of course required if it does not fit, or when cir- cumstances require an instrument of a different size. In practice I have found that patients go on comfortably wear- ing the same instrument sometimes for years together. While writing this I receive a letter from a patient whom I have not seen or heard of for three years, and who writes to say that she has been perfectly well all the time, and wishes to know what to do, as pregnancy has now occurred. .It should be the rule to take note of the condition of things at stated intervals; not more than a year certainly should elapse without proper examination and removal of the pes- sary; though in my experience I have not met with any in- convenience resulting from uninspected long protraction of the use of vaginal pessaries. The Simple Ring Pessary for the Treatment of Retroflexion. — Some years ago Dr. Meigs introduced the " ring" pessary for treatment of retroflexion, and it has been largely em- ployed for the purpose. The basis is a piece of watch- spring. The instrument, as now a good deal employed by Dr. John Williams and others, is made in various sizes and covered thickly with india-rubber. This pessary admits of easy introduction. Its merits are that it is readily intro- duced, that it acts fairly well, and is borne with less diffi- culty, owing to its elasticity, than a more rigid instrument. Its defects are, that it is incapable of carrying the fundus RETROFLEXION AND RETROVERSION OF UTERUS. 27c Up beyond a certain limited distance, and that the ring must be a large one to do very much in this direction; in- volving thereby undue stretching of the vagina transversely. It is, I have found, most useful as a temporary expedient in cases when a more thorough treatment has to be post- poned, and in a few instances it is superior to other pes- FiG. 66.* saries. When thickly covered with india-rubber, this pes- sary acts somewhat after the method of the old-fashioned disk pessary. Dilatation and Moulding of the Ute?-us as a Cure for Retroflex- ion. — Some years ago Dr. Moir of Edinburgh suggested and practiced a method consisting of dilating the uterine canal by tents and the subsequent wearing of a stem-pessary; the * Fig. 66 shows a combined stem and Hodge pessary. The shape of the Hodge pessary in the above figure is not the best that could be de- vised; the Albert Smith type is best modified according to the require- ments of the case. 250 t)lSEASES OF WOMEN. object being to overcome the resistance and flexion by full dilatation in the first place, and use of the stem afterward to maintain tlie straightness. The method is undoubtedly sound in principle, and could be employed in chronic ob- stinate cases with advantage (see later chapter on Methods of Dilating Cervix Uteri). Schultze * has more recently adopted the plan of dilating first by means of tangle tents, and afterward injecting carbolic acid or dilute iron solu- tion to promote contraction. He uses also a vaginal pes- sary of figure-of-eight shape to help in restoration. It ap- pears that he has employed the method in a large number of cases without bad result. The Stem Treat77ient in Cases of Retroflexion. — It has already been stated (p. 234) that as a rule the stem treatment is best adapted for anteflexion cases. I have occasionally treated cases of retroflexion with the aid of stems, and suc- cessfully; but in the large majority of cases I have found the ordinary plan the best. In the last edition of this work was figured an instrument I have used for the purpose. It consists of an ebonite stem fitting into a vaginal pessary on the Hodge principle, so that it has a double action. My own impression is that the stem pessary should, if adopted, be used in conjunction with the vaginal pessary, as shown in the annexed figure. It is essential that the stem be kept thoroughly in the canal of the uterus and not allowed partly to escape, also that it should not touch the top of the fundus, and it is certainly less likely to wound the uterus if the fundus be at the same time supported from behind by the aid of the vaginal pessary. Incision and Immediate Rectification. — It has been proposed to incise the uterus from within in order to relieve the flex- ion by an operation which is a modification of one which has been largely practiced by Dr. Marion Sims for stricture of the uterine canal. The latest phase of this procedure is an operation de- scribed in the '■'Americati Jou?-nal of Obstetrics'' June, 1876, by Dr. Lennecker of Chicago, on " The Surgical Treatment of Primary Retroflexion of the Uterus." He appears to speak only of retroflexion occurring before marriage. The patient is placed in lithotomy position; he then incises the cervix with scissors, front and back; then with narrow knives incises the uterus up to fundus latterly * Centralblatt f. Gyn., No. 3, 1879. RETROFLEXION AND RETROVERSION OF UTERUS. 28 1 and anteriorly (three incisions), the knives, three in number, being of peculiar shape, the handles bent and adapted to curve of canal. After sponging with iced water, cotton is inserted soaked in carbolic acid to cauterize the incision. This cautery is repeated in 48 hours after use of a two- bladed dilator; then repeated every third day till twelfth; then once a week for six weeks. Ten days after operation a modified Hodge used for eight to ten weeks. He has operated in thirteen cases; in all complete cure; in three cases pregnancy speedily followed. Of latter: case 6, set. 19, married i year; case 10, set. 22, married 2 years; case II, aet. 22, married 6 months. It is stated that all the cases were cured, and that in three pregnancy speedily followed, but as the ages of the three latter were respectively 19, 22, and 22, the inference is that the retroflexion was not of long standing, and could have been readily cured by less severe procedures. I have now entirely relinquished the use of the air-ball and stem-pessary described in the last edition of this work. Radical Operation. — Here may be mentioned an operation performed by Koeberle of Strasburg, March 27, 1869, for the radical cure of retroflexion by gastrotomj^ and fixation of the uterus to the anterior abdominal wall by means of the broad ligament, which, being brought forward, was fastened to the edge of the abdominal wound. Dr. Sche- telig, who describes the operation.* states that the patient recovered, and the displacement of the uterus was cured. Ttie patient's age was twenty-five. The duration of the malady was 2\ years. The operation is a curiosity and the procedure ingenious, but it obviously involves a confession of deficient mechanical resource of the less dangerous kind. Oophorectomy (Battey's operation). — In cases deemed other- wise incurable, the operation known as Battey's operation lias been in some instances practiced. Such an operation can only be required or considered justifiable in very ex- treme cases. My own experience is that with time and pa- tience even the worst cases are curable. It is possible that there may be cases in which a long course of treatment would not succeed, but I have not as yet met with sucli cases. This subject will be again referred to in the chapter * Dr. Schetelig, Ueber eine Radicaloperation zur Beseitigung der Ret- roflexio und Retroversio Uteri; Sep. Abdr. a. d. Centralblatt f. d. med. Wissemch. 1869. No. 27. 282 DISEASES OF WOMEN. on"Diseases of the Ovaries." Here I may say, however, that some of the published records of cases of oophorec- tomy in which chronic retroflexion existed appear to me to offer conclusive evidence tliat the uterine displacement might have been cured, and the operation thus rendered unnecessary, by further and more patient efforts to cure the retroflexion of the uterus. [Dr. Simpson was the first to teach us how to diagnose, and how to rectify a retroversion. He passes his uterine sound to diagnose the position, and then turning it half a circle, the retroverted fundus is nec- FiG. 67. essarily elevated toward the promontory of the sacrum. But this operation often produces great suffering and sometimes haemorrhage, and I have not for many years used Simpson's sound as a redresser. I have not seen any more serious accident from it. Some object to the instru- ment and ostracize it altogether, because perforation of the fundus and death have followed its injudicious use. I ob- ject to it only as a redresser. Its principle of action is wrong, and hence the pain and suffering it produces. I only wonder it has not done greater mischief. Let us for a moment look at its modus operandi. Fig. 67 represents a retroverted uterus with Simpson's sound introduced as a redresser. Now if we turn the handle of the instrument (a) on its own axis half a circle, the distal end will elevate the uterus RETROFLEXION AND RETROVERSION OF UTERUS. 283 from its abnormal position to that shown b}' the dotted figure {c); but in doing this it will describe a semicircle of but little less than two inches and a half radius, sweeping the fundus around with the whole weight of the organ, supported principally on the very end of the instrument which, in its gyration, changes its point of pressure from the posterior to the anterior face of the uterine cavity. To Fig. 68. elevate the fundus still more we push the handle (^) back toward the perineum, which thrusts the uterine end up- ward. Is it to be wondered at, then, that we occasionally meet with patients who look upon the uterine sound with the most painful recollections.'' Seeing that an intra-uterine force was occasionally necessary for the rectification of this malposition, my father devised the following instrument in 1856 and has used it ever since. Its principle of action is that of elevating the fundus ir^ 284 DISEASES OF WOMEN. a straight line instead of a circle, and of supporting the weight of the organ on a disk at the os tincae instead of the distal end of the instrument at the fundus. For this it is onh' necessar}' to make a joint or hinge in the sound, about two inches from its uterine extremity, and fix a disk or plate there, as a point of support for the weight of the uterus. For instance, let Fig. 68 represent a retroverted uterus, with a jointed sound (a) introduced, the joint being at the OS. Now all that we have to do is to push the mouth of the womb downward and backward in the posterior cu/ de sac in the direction of the place which was at the inception of this movement occupied by the fundus. By this manoeu- vre the OS tincae describes the small arc of a circle repre- sented by the dotted line (^/), while the fundus being ele- vated in a right line describes a larger one and takes the position {l>)y the handle or shaft of the instrument being represented by the dotted line {c). If the instrument be properly adjusted this operation is effected without suffer- ing to the patient or injury to the uterus. If there are ad- hesions we can measure very accurately their resistance and extensibility. This instrument is simply Simpson's sound with a joint or hinge two inches from its uterine extremity, but its modus operandi is very different. One elevates the uterus in a right line, the other in a circle to the right or left; one supports the weight of the organ on a ball or disk at the os, the other principally on the point of the sound in the uterine cavity; one elevates the uterus by a power exerted on the cervix, the other by a like power on the fundus; one seldom produces pain, the other often does. This instrument is sometimes valuable in assisting us to diagnose the relative position of small tumors on or near the uterus. Thus, suppose we have the uterus impaled with a stem {a) at right angles with the shaft, its body being thus held firmly in the centre of the pelvis with the fundus pointing to the umbilicus — by pulling the handle of the instrument forward while it is thus rigidly fixed, we can draw the body of the uterus toward and very near the inner face of the symphysis pubis; by pushing it back, we can carry it directly backward as far as the depth of the vagina and the sacral promontory will allow it to go; by turning the handle from side to side, we can at will throw the fundus RETROFLEXION AND RETROVERSION OF UTERUS. 2^5 to the right or left as we please, and all this without in- jury to the organ itself, for its whole weight is supported, as before said, not on the point of the instrument, as when we execute any of these movements with Simpson's sound, but on the disk at the os tincae; and while we are thus changing the position of the uterus we can, by a finger in the vagina or rectum, and by palpation externally, deter- mine whether any suspected tumor be attached to the uterus by sessile adhesions or by ligament only; or whether the two be entirely separate and independent of each other. The intra-uterine portion of the elevator is malleable, be- cause we may sometimes wish to curve it a little to suit the peculiarities of some special case. Ordinarily this stem should not be more than two inches long. It should never be long enough to touch the fundus uteri by any possibility. In its use we should be careful to keep the ball or disk always pressed well up against the os tincae, for if it should slip down half an inch or more we shall fail to elevate the fundus, as the whole power of the instrument will tlien be expended only in pushing the os tincae backward and doub- ling the cervix on itself. Almost every day we have need of the uterine redresser. Where we have a chronic reflexion with enormous hyper- trophy of the posterior wall it is almost impossible to re- place it merely by manipulation alone. In England it is the habit with best practitioners to push the uterus back as far as possible with the finger and then introduce a Hodge pessary or some modification of it to complete the replacement of the organ. This is bad practice and is often attended with mischievous results. We should never apply a pessary in cases of retroversion till we have placed the uterus in a complete state of anteversion, whether by manipulation or by the redresser. Where the displacement is of long standing the uterus should be replaced by the redresser every day for two or three days, after which we may insert a pessary of the Hodge order. The pessary must be moulded and fitted to the peculiari- ties of the individual case. It must not be too large or too small, too long or too short, too wide or too narrow, too curved or too straight. It must hold the womb in its proper position, rather anteverted than retroverted. It must not produce the least feeling of discomfort or pain. It must not press anteriorly on the neck of the bladder, nor pos- 286 DISEASES OF WOMEN. • teriorly on the cervix. In short, if the patient is conscious of its presence, except in the relief it gives, it must be promptly removed. It is dangerous to leave an instrument in the vagina even for an hour if it produce pain. Nothing requires more care than the adjustment of a pessary for the treat- ment of uterine displacements. The whole art of it is: first, in replacing the uterus per- fectly; and second, in adjusting an instrument to hold it perfectly and comfortably in position. The pessaries should be made of some malleable ma- terial, so as to mould it to fit the case. Our author uses india-rubber on a malleable copper wire. This is objec- tionable on account of the disgusting odor of the rubber. Dr. J. Marion Sims has used block tin for this purpose for twenty-five years or more. Otto makes a very cleanly instrument of celluloid on copper wire. The camphor odor is not objectionable. The ordinary hard-rubber pessary can be bent in the desired shape by greasing it and passing it rapidh' to and fro through the fiame of a spirit lamp till it is soft enough to be curved or moulded as we wish. The patient should return from time to time to see if the instrument is answering its purpose. Or she should be taught how to remove and replace the instrument.] CHAPTER XXI. Anteflexion and Anteversion of the Uterus. Importance of Anterior Displacements and Flexions Considered. — Frequency with which these Conditions give rise to Uterine Dyski- nesia — Great Frequency of this latter Symptom as observed in Practice. Definition. — Difficulty hitherto Experienced in Definition — Owing to Existence of slight Anteflexion in normal Uterus — Owing also to Mis- apprehension of true nature of Congestion of Uterus associated with Anteflexion — Author's Definition: Exceptional Cases when the Defini- tion does not apply — Use of the Finger in making the necessary Ex- ploration — Precautions to take. Etiology. — Predisposing Causes — Discussion of Schultze's views as to Movement of Uterus when Bladder is Emptied — Author's Dissent from Schultze's Conclusions — Importance of Softness of Uterine Tissues and want of Rigidity as Causing Anteflexion — Previous Pregnancy — Rup- . ture of Perineum — General Physical Weakness and Prostration — Spe- ANTEFLEXION AND ANTEVERSION OF UTERUS. 28/ cial or Exciting Causes: Traumatic Causes, their great Frequency — Previous Attacks of Parametritis — Schultze's " Pathological Anteflex- ion" — General Perimetric Fixation result of Anteflexion of long standing. The anterior displacements and flexions of the uterus are real and serious ailments, although there are not wanting authorities who dispute this view. At the present day, however, many gynaecologists of re- pute recognize the importance of anterior displacements of the uterus. The growing feeling of the importance of these maladies is shown in the fact that very numerous mechan- ical appliances have been recommended for their relief. In reference to the question as to the " importance" of Fig. 69.* these affections it will be found on considering the matter that the question really at issue, but which many who have discussed it have not thought it worth while even to allude to, is this: Taking the case of a patient who is suffering from symptoms referable to the uterus, what is the actual explanation of the pain or discomfort, or particular symp- tom, which induces the patient to seek medical advice in such cases ? Having for many years systematically en- deavored to procure an answer to this question in every in- dividual case which has come before me, I have arrived at the conclusion that anteversion and anteflexion are maladies having a very high degree of "importance." The general * Fig, 69 shows a very marked case of anteflexion. The drawing represents a specitpen from University College Museum. 2855 DISEASES OF WOMEN. considerations which have led me to arrive at this conclu- sion may be stated as follows: In the first place, attention must be directed to the great frequency with which patients coming to consult us com- plain of pain or discomfort of various kinds 07i motw?i. In the chapter on Symptomatology this subject has been fully discussed. The analysis of this symptom, which I have designated "uterine dj'skinesia" shows clinically in the most conclusive manner its dependence on an exagger- ated motion or mobility of the uterus in one direction or another; and a multitude of observations extending now over many years has proved to me that the generalization Fig. 70.* is a sound and a true one. Further, it can be abundantly shown from clinical evidence that sufferings coming under this head constitute the large proportion of the complaints of patients seeking advice. Here we have therefore two points of importance: (i) That certain mechanical motions of the uterus give rise to pain and suffering; and (2) that such mechanically produced pains constitute the greater part of the affection present. For, in the patient's estima- tion at all events, what she feels is to her the disease. In the next place, an extended observation has shown that there is a very close connection between certain de- grees of anteversion or flexion, and marked uterine dys- * Fig. 70 exhibits acute anteflexion of the uterus in profile, sectional view, become chronic. ANTEFLEXION AND ANTEVERSION OF UTERUS. 289 kinesia, and that the latter is almost invariably associated with the former (unless in cases where the flexion or dis- placement is in the backward direction). A definite symp- tom is thus found to indicate so generally a definite condi- tion of the uterus that it is obviously a relation of cause and effect. A further set of proofs consisted in observation of the effects of rest, maintenance of the uterus in its proper shape and position, etc., in removing or alleviating this particular set of symptoms. This effect is most marked, and here again observation, repeated over and over again, has shown that these symptoms of which the patient complains so much give way to a treatment which is essentially a me- chanical one; and cease in direct proportion to the success of the measures taken for preventing and restraining the abnormal movements of the uterus, and for restoring the organ to its proper shape. It is thus by observations, repeated day after day, for some years past, and which may in one sense of the word be termed "experimental," that conviction has followed as to the real and substantial influence exercised by antever- sion and flexion of the uterus in the production of the pain, suffering, and discomfort of various kinds of which patients so commonly complain. The same reasoning and the same conclusions apply to retroversion and retroflexion, and the foregoing statement concerns the posterior equally with the anterior displace- ments of the uterus. The reason for making the state- ment, in this place, is that while retroflexion and retrover- sion are admitted, with very few exceptions, to be maladies, it is not so in regard to anteversion and anteflexion: and I desire to point out how and why it is that I have been led to regard the latter as substantial and important affections. It is not intended, in the foregoing remarks, to imply that "uterine dyskinesia" is the only severe symptom in cases of anterior flexion. Other symptoms are important also, but they are better known, and duly recognized as such, by those who have given attention to the subject. Definition. — It is now necessary to give a definition of anteflexion and anteversion. The question resolves itself into this: What degree of anterior flexion or anterior version is to be considered abnormal ? The particular point at which I find myself at issue with 29b DISEASES OF WOMEN^ some writers and practitioners of repute is in regard to the importance of the lesser degrees of anterior flexion and version, and their capability of producing symptoms of a troublesome character. The basis of my conclusion is, as already stated, a prolonged series of clinical observations on tliis subject. With reference to the more severe degrees of anteflexion and version the number of scientific observers who recognize their importance is very considerable. There are onh' a few left who still deny the practical significance as diseases of the more severe cases of anterior displacement. As re- gards the importance of the less severe degrees of anterior flexion and version the number of converts still to be made is more considerable. There can be no doubt that the principal cause of the reluctance to recognize the anterior displacements as dis- eases, is the notion that inasmuch as the uterus has a slight normal curvature and inclination forward, further degrees of that curvature and inclination forward cannot have any practical importance. The prevalence of this notion is and has been so great that few have taken the trouble to differ- entiate the various degrees of anteflexion and anteversion. This is not the only reason for the neglect which the sub- ject has received. Another reason has been the complica- tion of congestion of the uterus so frequently met with in these cases, which complication has received exclusive at- tention, while the displacement has been either not recog- nized at all (as is most commonly the case), or, if recog- nized, has been regarded as an affair of quite secondary importance. Having had frequent opportunities of meet- ing practitioners in consultation in cases of this kind, I have formed the conclusion that one reason why so little is known as to the frequency and effects of anterior displace- ments is that the very simple and easy exploration of the condition of the uterus, by means of a digital examination, is little practiced. Over and over again it has happened in cases brought to me for consultation that marked antever- sion or flexion has existed and remained undetected for this reason and this reason alone: the condition has been unrecognized simply because it has not been looked for. The too exclusive use of the speculum and the too general concentration of attention to the condition of the os uteri is responsible for this too common omission of the digital examination. ANTEFLEXION AND ANTEVERSION OF UTERUS. 29 1 Thus it happens that these affections have been compara- tively neglected, sometimes because they have not been looked for, sometimes because, when known to exist, they have been misinterpreted. We may now proceed to the definition, which I would give as follows: Abnormal atiteflexioti or version exists when the fundus of the uterus can be felt by means of the finger introduced as far as the middle of the proximal phalanx^ the patient lying on the side and the knees drawn up in a favorable position for such exa?nina- tion. For the application of this definition it is to be as- sumed that there is no tumor or considerable enlargement of the uterus. The above definition covers by far the majority of cases, but not all. For in some exceptional instances the uterus lies rather high and yet it is much and abnormally antefiexed. Neither does it cover those cases where the uterus is ex- cessively mobile and the fundus retreats before the point of the finger, for in such cases the condition might be over- looked. Neither does it provide certainly for the recognition of anteflexion in cases where the uterus is excessively soft, for the uterine fundus under such circumstances may not be easily felt by the finger, though the uterus is undoubtedly in a state of anteflexion. Neither does it provide for recognition of cases of ante- flexion with retroversion, to be explained further on. It will be found on practicing the investigation above de- scribed that the lower border of the triangular ligament corresponds to the joint between the proximal and second phalanx of the finger. It is generally easy to introduce the finger as far as this by placing the patient in a proper posi- tion. I consider it necessary to insist on the observance of this latter condition, because the drawing up of the knees enables the observer to introduce this finger nearly an inch farther than can be done when the patient is in any other position. Theoretically the condition of the bladder might be sup- posed to modify the results of the examination. But prac- tically it is found not to be the case, for if abnormal ante- flexion or -version be present the fundus of the uterus is generally, though not invariably, always within reach as above described. To come within the above definition the uterine body ^92 DISEASES OF WOMEN. must have become materially flexed or rotated forward from what has been described in some of the former pages (see page 164) as the normal position of the uterus, or the uterus must have as a whole descended much lower in the pelvis than usual. It will be found that, without using any force, it is gen- erally possible easily to introduce the finger to the extent of three inches, and when the fundus is easily reached, and its outline definable within this distance of the ostium vagina, a displacement exists. The question as to the normal position and normal mo- tion of the uterus has been already fully discussed at page 167. The range of normal anterior motion which I would as- sign to the uterus is represented in the accompanying draw- ing (Fig. 71). The labia majora offer a projection externally, and a portion of the three inches constituting the available length of the finger is occupied in traversing the vulva, generally as much as one inch (in cases of obesity more than this), so that only two inches are left for the explora- tion of the vagina proper. It is possible to introduce the finger farther than this by exercising some degree of pres- sure, but the above definition applies to ordinary explora- tion, without exercise of undue pressure. (See Fig. 8, showing the line of direction of a digital examination.) When the motion of the uterus does not exceed what has been above laid down as the normal limit, the space left between the uterine fundus and the pubic symphysis is as nearly as possible one inch and a half. When the fundus encroaches on this space, therefore, the position is abnormal, unless it can be accounted for by increased size of the whole organ. This latter condition would obviously have to be eliminated. Anterior displacement beyond the limit mentioned would bring the fundus within the reach of the finger, introduced to the medium degree, as above described. There are cases in which circumstances prevent the recognition of the fundus by the digital examination, some of which have been mentioned. It must not, therefore, be concluded absolutely, because the fundus cannot be detected by the touch in the manner directed, that no anterior dis- placement exists. It is to be remarked that the directions given suppose the patient to be lying on the side. It is obvious that this is ANTEFLEXION AND ANTEVERSION OF UTERUS. 293 not the most favorable position for the detection of a slight anterior displacement. A slight anterior displacement would no doubt be more readily detected by the touch in Fig. 71. the upright position. But tliis consideration is in favor of the definition as above given, for the patient being in the lateral position, a too unfavorable view of the case would not be so likely to be given by the digital examination. In severe cases of anteflexion and -version, the uterine fundus is very readily reached, whether the patient be standing or lying on the side. 294 DISEASES OF WOMEN. ETIOLOGY. Predisposition. — There can be no doubt that there is what may be termed a special predisposition to anteflexion and -version in the natural slight inclination of the uterus forward, and in the fact that there is normally a very slight anterior curvature of the uterine canal. Aided by its own natural firmness and rigidity, and supported to a certain extent by Fig. 72.* the moderately distended bladder, the position and shape of the uterus are in a state of health preserved. The relations of varying conditions of the bladder to the nor- mal movements of the uterus have been considered at p. 173. Here it is necessary, however, to discuss the matter further, * The above drawing is Schultze's representation of what he considers to be the normal outline of the uterus (nulliparous), after emptying of the bladder and rectum. {Arch. f. Gyn., S. 142.) ANTEFLEXION AND ANTEVERSION OF UTERUS. 295 as it lias a considerable bearing on the subject now under deliberation. In opposition to the views of Schultze * I would repeat that the results of my observations do not sus- tain his view that the healthy uterus becomes decidedly anteverted and slightly flexed when the bladder is empty. I believe, on the contrary, that the space in the pelvis de- rived from the emptying of the bladder is ordinarily filled by the descent of the intestines, and that the uterus retains its normal (slightly curved forward) shape under such cir- cumstances. I therefore dispute the occurrence of what Schultze terms normal anteflexion and -version, at all events to the degree described by him. It seems probable that the case or cases from which Schultze took his drawings of so-called normal anteflexion would only truly represent what may be observed in cases where the uterus is soft and unduly pliable, but then I should deny the applicability of the term " normal " to such cases. This author, whose able memoirs on the subject may be consulted with advan- tage, appears not to have noticed what I consider to be a most important factor — namely, the softness or hardness of the uterus. Assuredly this must be taken into account in any attempt to lay down a law as to the definition of nor- mal and abnormal anteflexion. In the chapter on Etiology of Flexions softness of the uterus is mentioned as a powerfully predisposing condition. Here these observations apply with peculiar force. A very extensive observation has convinced me that it is a factor of the extremes! importance in bringing about anteflexion and -version. What this undue softness of the uterus means has been discussed in a former chapter (see p. 98). This want of tone, want of rigidity and resistance, on the part of the uterus, places it at the mercy of external influ- ences of a mechanically disturbing character. A year or two of deficient or insufficient feeding suffices to produce decided uterine softness, and ordinary exertions may then prove too much for the stability of the uterus. The ac- quired softness, the natural inclination of the uterus for- ward, a slight exertion, all coming together, have then the result of bringing about mischief of a decided character. My knowledge of softness of the uterus as a predisposition to flexion was the result of observation of cases of ante- flexion, and I have been familiar with this softness as a * Arch. f. Gyn. 8. 134. 2(p DISEASES OF WOMEN. frequent condition long before it occurred to me to give a satisfactory explanation of it. Previous pregnancy is responsible for innumerable cases of anterior displacement. It acts as a predisposition by loosening the attachments of the uterus, leaving it in a soft bulky condition; and under these circumstances it readily gives way when the patient begins to move about, espe- cially if there be added the debilitating influences of a defi- cient dietary during child-bed. In some cases of abortion the malady begins with the abortion and becomes firmly established when the uterus is allowed to set and become contracted in its distorted condition. Rupture of the perineum in some cases favors the oc- currence of anteflexion and -version. I have seen several cases in which the perineal injury seemed to have been the starting-point of the displacement. Lastlv, one of the most common of the predisposing causes of anteflexion and -version is general physical weak- ness and prostration. Of such typical instances are the weakness produced hy typhoid fever, measles, scarlet fever, and the like. I have seen several cases where the malady began unmistakably on getting up from a severe attack of fever, and some of the most severe cases of anterior dis- placement I have witnessed have been of this kind. It is not, however, necessar)^ that the physical exhaustion should proceed from fever. There are many other depress- ing influences which might be mentioned. They mostly act by reducing the tone of the uterus, softening its tissues, and by virtue of that alteration, predisposing to distortion of the organ. Special or Exciting Causes of Anteflexion. — The evidence af- forded by the critical investigation of cases is most remark- able in showing the very great influence of mechanical disturbing agencies in the production of anteflexion or -ver- sion. It is to be remembered that while a single accident or se- vere strain has evidently been the cause in a number of cases, there are many others in which the application of the cause has been spread over a considerable time, the uterus having been displaced by the continued — i.e., daily — operation of a particular exciting cause. Daily severe walks, daily standing for many hours in succession, as in the case of shop-women, severe and long-continued standing while nursing a sick relative — these are instances of the kind al- ANTEFLEXION AND ANTEVERSION OF UTERUS. 297 luded to. Riding on horseback, use of a sewing machine, are other causes of a like character — the mischief being done not necessarily at once, but by slow degrees. There is no doubt that marriage is the cause of anteflex- ion in some instances: the uterus becomes displaced as a result of the act of intercourse in some except'onal cases. Some few cases of severe anteflexion and -version arise from exertion, combined with a chill received during men- struation, which I attribute to the occurrence of exudation or thickening around the uterus, result of the menstrual suppression, whereby the uterus becomes more or less fixed in a distorted shape. The relation of inflammatory exudations, effusions around the uterus, parametritis, etc., to anteversion and -flexion, has been the subject of a paper by Schultze.* This author believes that a principal cause of what he terms " pathological anteflexion" of the uterus is rigidity and shortening of the Douglas folds behind the uterus, which rigidity is the result of chronic atrophic parametri- tis affecting the connective tissue in the Douglas pouch. Schultze states that he has very frequently found this pos- terior fixation along with anteflexion. There is no doubt that undue shortness of the Douglas folds might produce such an effect, but it is another question whether the occur- rence is at all common. Here, again, it may be suggested that in the cases alluded to by Schultze, the really abnormal condition may have been a very soft anteflexed uterus, and that the supposed posterior fixation was only normal. Schroeder and Miiller (of Berne) contest the accuracy of these views of Schultze. I have in some few instances met with a condensed resisting condition of the connective tis- sue around the Douglas pouch, in cases of anteflexion, where there had been pelvic cellulitis. Abnormal shortening and rigidity of the Douglas fold is, according to my experi- ence, very rare. It is, however, not uncommon to meet with what may be termed parametric exudation and hardening around the uterus, so far as can be explored by the finger, in cases of anteflexion and -version of a chronic character. Such hardening and contraction of the cellular tissue acts as a fixation of the uterus, and indeed offers difficulty in elevat- ing and straightening it. The exudation in question is not, * Archiv. f. Gyn., 8. i. 29» DISEASES OF WOMEN. however, the cause of the flexion and displacement, but precisely the opposite — it is the result of it. Pelvic celluli- tis may give rise to a localized effusion which may push the uterus quite away from its proper position to one side or the other, or backward or forward, and the organ may be thus pinned down as it were by such exudation, though in- stances of this kind are not common. This subject will be again considered in describing the complications of ante- flexion and -version. CHAPTER XXII. Anteflexion and Anteversion of the Uterus — {Continued^ Varieties. — i. In Degree of Flexion; 2. Degree of Rotation of Uterus; 3. Degree of Descent of Uterus as a Whole; 4. Rigidity of Uterine Tissues — Various Combinations of these possible, hence Infinite Dif- ferences of Cases — Three Principal Degrees of Flexion — Some Leading Types Described — Various Conditions of Cervix — Anteflexion with Posterior Rotation — Severe Cases in which the Uterus is very low down, compressing the Rectum — \'ariations in Rigidity of Uterine Tis- sue and Connections — Clinical Features of Different Cases — Illustra- tive Cases given — Degree of Congestion. Complications. — Congestion, Accessions of Acute Congestion — Disten- sion of Cavity — Adhesions — Cystocele — Cystitis — Constipation. Symptoms. — Uterine Dyskinesia — Illustrative Facts in regard to this ob- served in Thirty-three " Fertile" Women and in Thirty five Single Cases — Spontaneous Pain — Tenderness of Uterus to Touch — Other Abnor- mal Sensations — Dysmenorrhoea, Menorrhagia, Leucorrhoea, Amenorr- hoea — Sterility — Abortions — Dyspareunia — Reflex Nervous Symp- toms — Symptoms referable to Bladder; to Rectum. Diagnosis. — Various Difficulties — Method — Use of Sound — Precautions and Difficulties in Introducing it in Different Cases. varieties. In the chapter on Retroflexion and -version a certain method of classification has been adopted which may with advantage be followed so far as the circumstances admit in regard to anteflexion- and -version. Reasons have been there (see p. 252) given for using the word " rotation" in- stead of " version," and the same reasons render it conven- ient to employ this term in describing the varieties of an- teflexion and -version. Cases may be classified according to I. Degree of flexion — first, second, or third, as the case may be; also the variations in the position of the flexion. ANTEFLEXION AND ANTEVERSION OF UTERUS. 299 2. Degree of rotation. 3. Degree of descent of uterus as a whole. 4. Degree of resistance offered by the uterus itself to un- bending or replacement. 5. Presence or absence of (a) congestion, (^) enlarge- ment. Seeing that in practice the several factors above detailed are combined in different ways in different cases, it becomes Fig. 73. evident that infinite varieties may be observed. It is a conclusion to which all who study the subject practically will come, that hardly two cases are found exactly alike. The appreciation of this fact is necessary for success in treatment, every case having peculiarities of its own. The above classification will serve to indicate the points to which attention must be directed in obtaining a definite and broad view of the particular case before us. Anteflexion of the uterus, according to Dr. Emmet, affects generally the cervix of the uterus, rarely the body. My own idea on the subject is not in agreement with this view, although it is no doubt the fact that many cases are observed in which the flexion is below the internal os uteri, 300 DISEASES OF WOMEN. What may be termed the typical varieties of anteflexion and -version will now be described. Fig. 74. The most simple case is that in which the uterus is flexed to first degree, the fundus too far forward, and the os uteri Fig. a little nearer the sacrum than natural (Fig. 73). With this is frequently associated the ftrst degree of rotation forward ANTEFLEXION AND ANTEVERSION OF UTERUS. 30I (the latter not shown in accompanying drawing); a second degree of anteflexion is shown in Fig. 74, together with a slight amount of rotation. This may be associated with a much more severe degree of rotation tlian that shown in the drawing. A third and very severe form of anteflexion is shown in Fig. 75, together with some degree of rotation. The curve offered by tlie uterine canal in cases of ante- flexion is, according to my experience, a gradual one; there is no sudden alteration in the direction of the canal: such a sudden change in direction is not possible under ordinary circumstances, the bend offers degrees as above stated — FiG. 76. first, second, and third — but the bending is distributed over three quarters of an inch of the canal, more or less, in ordinary cases. The Figs. 74 and 75 represent this. The actual centre of the bend may be higher or lower than the internal os uteri. Rotation is found in very different degrees in different cases. Thus we may have an extreme degree of rotation with little or no anteflexion. Such cases have been termed anteversion pure and simple. They are by no means com- mon; the uterus lies almost parallel to the vaginal canal; the fundus is very near to the symphysis pubis, and the posterior wall of the bladder lies in close coaptation to the base of the bladder, with no appreciable interval. Such a case 15 shgwn in Fig. 76, The os uteri is reached by the 302 DISEASES OF WOMEN. finger with great difficulty, as it lies so far back in the hol- low of the sacrum. As a rule rotation is not very great when the degree of flexion is considerable, and in this respect there is a differ- ence between cases of anteflexion and retroflexion ; the Fig. 77. 4 \ bladder offers an obstacle to very considerable anterior rotation. Fig. 77 shows three degrees — (1) first degree of anteflexion, (2) second degree, (3) third degree — of flexion, together with the more usual accompanying degrees of rotation. The condition of the vaginal part of the cervix differs ANTEFLEXION AND ANTEVERSION OF UTERUS. 303 very much. In some cases it is nearly straight with the os directed distinctly backward; but in many instances it is bent forward, so much so indeed that the opening of the os uteri does not look toward the vaginal outlet but upward and forward. Thus we sometimes meet with anteflexion in the third degree with the whole uterine canal having the form of a parabolic curve, the flexion as great as it can be. This kind of case is more often met with in young women who have had no children; the cervix has a conical shape and is frequently unduly elongated. This considerable bending of the vaginal part of the cervix is, I believe, due Fin. 78.* (as Dr. Emmet remarks) to the repeated forcing down of the uterus against the vaginal floor, whereby the cervix be- comes bent and turned upward. It constitutes a condition very troublesome from the severity of the symptoms, and difficult of cure. (See Figs. 78, 79, and 80.) Some observers regard cases similar to those just described as "congeni- tal." Thus Dr. Roper f says: I. A certain class of cases of anteflexion "are congenital and are not the result of any pathological change in the * Fig. 78 is Dr. Emmet's drawing of a severe case of anteflexion, the dark line A B C D showing the extent of incisions made in his operation for the cure of this affection. f " Obst, Trans.," vol, xx., p. 304. 304 DISEASES OF WOMEN. uterine texture, but are malformations of the whole or part of the organ." 2. "Acquired flexions generally are associated with some pathological change in the uterine tissue, whether it be one of hypertrophy, atrophy, or degeneration." He proceeds to explain that in the first class of cases ''there is an antecurvature of the uterus running from the top of the fundus to the point of the cervix, extending the whole length of the organ. There is no point on either the cervix or body at which a flexion exists as in the pathologi- cally flexed organ" {loc. cit., p. 305). Fig. 79. The context shows that Dr. Roper only admits existence of "flexion" when the cervix and the body of the uterus are separated by "an intervening portion of softened tissue." And when he finds that the uterus is uniformly solid and rigid, mere curvature does not for him constitute flexion. But it is to be remarked that the consistence of the uterine tissues varies: the uterus is generally in a soft condition when the flexion occurs, but it may and frequently does subsequently become firm and hard, although still preserv- ing the flexed condition. Dr. Roper's definition of flexion therefore cannot be accepted, and the cases he would de- scribe as cases of "congenital antecurvature" are, in my opinion, for the most part cases in which the flexion has arisen in the manner above pointeci out, ANTEFLEXION AND ANTEVERSION OF UTERUS. 305 A peculiar variety of severe flexion of the cervix is shown in Figs. 79 and 80; here the uterus is anteflexed in about the third degree, the cervix elongated and directed forward and a little upward. It may be termed severe anteflexion of the uterus tvith posterior rotation. The history of such cases is as follows : Anteflexion to a severe degree first occurs, and persists for a considerable time. The uterus hardens in its anteflexed condition, but subsequently undergoes posterior rotation, by which it acquires the position and shape shown in the drawing. It is not easy to diagnosticate, for the Fig. 80. reason that there appears to be a tumor behind the cervix. Moreover, the sound goes in at first in the direction back- ward. The absence of a tumor in front is also misleading; this condition was first described by me in the 1872 edition of this work. I have met with at least a dozen such cases in practice. In Figs. 81 and 82 is shown (life-size) anteflexion of the uterus, of different degrees of severity, the position of the adjacent organs being also depicted. Opportunities are rarely afforded for obsQvving,post-»ior- tem,ihQ condition of the uterus in cases of anteflexion. This 3o6 DISEASES OF WOMEN. being so, I think it will be serviceable to reproduce in a slightly abbreviated form, from the pages of Dr. Ashwell's work,* a case recorded many years ago by that most care- ful and unbiased observer. Dr. Walter Hayle Walshe. The case was observed by Dr. Walshe some years before Fig. 8i. in the wards of St. Louis Hospital in Paris. He gives it as almost unique, the observation of the symptoms being followed hs post-mortem examination. Anteflexion and Anteversion terminating Fatally. — V. E., aet. 38. Jan. 9. — Worked as charwoman for last three years; previously portress and housemaid. Had six children, first * " Diseases of Women," 1S44. ANTEFLEXION AND ANTEVERSION OF UTERUS. 307 at 17, last at age of 23. Menses regular. Subject for last five 5'-ears to pain near upper border of sacrum after the least fatigue. Her food has been poor in quality: she has not for years been in the habit of eating meat. For a month before Nov. 10 sacral pain increased; only slighth^ unwell on two preceding periods. On Nov. 10, while engaged in washing, there occurred a sudden haemorrhage with large Fig 82. clots from vagina. Felt no pain, continued her work. Since has had persistent red discharge, which for a month equalled daily the quantity lost during catamenia, lately less. Inguinal pain at first severe, now less; for last fifteen days occasional pricking pain in left thigh; has lost half her former flesh; scarcely ate anything during first month. Present State. — . . . Defaecation unusually difficult for last two months and increasingly so; no complaint as to 3o8 DISEASES OF WOMEN. passing urine. Impossible to see orifice of uterus by specu- lum. Examination with finger. — Neck of uterus 2^ inches from vulva; broad, unusually hard, turned backward. Anteriorly, toward pubis, a tumor is felt formed by the body of the organ; on pushing it upward depression of the neck follows. Pulse 76, inodorous vaginal discharge, equalling about an eighth of w-hat is lost daily during menses. Feb. 12. — Discharge of late increased in quantit}^ but patient better in her general state. To-day, however, a new train of symptoms — great swelling and tenderness of ab- domen, violent pain in hypogastrium, first slightly felt three days ago. Bladder not distended; frequent vomiting of greenish matter, on increase. No relief of bowels for four days; pulse 112, regular, very small; discharge almost ceased; decubitus dorsal; knees raised, features contracted. Feb. 13. — Abdominal tension increased; extreme tympa- nitis; great thirst; pulse 126; respiration 54. Feb. 14. — Death. Fost-moriem Fxaminaiion. — Intestines adherent by false membrane; clot of blood size of tg^ in Douglas pouch, black in color: " to account for it there appear to be some vessels open." Here, too, are several loculi with pseudo- membranous walls of hardish consistence containing putrid clots. Sigmoid flexure adherent, dull red-colored fluid beneath adhesions, and surface black. "Uterus flexed on itself at an obtuse angle at the union of its body and neck, in such a manner that the fundus, concealed by the bladder, is inclined forward and down- ward, while the neck is inclined backward to the sacrum, the posterior surface of the body being antero-superior. There is a slight lateral obliquity in its direction, the neck being turned somewhat to the right of the middle line, the fundus toward the left crural arch. The body of the organ as well as the neck is hypertrophous; their substance is of a grayish hue and hardened, firm and resisting throughout, except at the union of those parts where there is a band of the organ flattened from before to behind, extremely soft, flabby, and yielding, and corresponding exactly to the angle of flexion. Anterior and posterior walls of the body each measure precisely an inch in thickness; neck is 2I inches wide, its orifice gaping." Right ovary enlarged, divided into cells containing a puriform fluid. Left ovary also divided into loculi with citron-colored serous contents; a small reddish clot in one of them. ANTEFLEXION AND ANTEV£RSI0N OF UTERUS. 309 The degree of descent of the uterus as a whole is an im- portant factor in all cases. By some distinguished gynaecol- ogists it is asserted that flexion and version are not liable to be attended with symptoms unless the uterus is very low Fro. 8-!.* down in the pelvis. It is certainly the fact that the lower the uterus the greater the evil. So far, but no farther, I * Fig. 83 represents a severe chronic case of anteflexion of probably fifteen years' duration, in a patient aged 36. There had been a mis- carriage shortly after marriage, and several attempts had been made to rectify the displacement of the uterus. The organ was jammed down- ward in the pelvis, and in a most irritable condition, much hypertrophied, and a chronic neurosis of one portion of the cervical canal established. Severe nausea, constant pain, locomotive inability, were the chief but by no means the only symptoms. 3 id DISEASES OF WOMEN. would express my general assent to the proposition. It generally happens that in cases of anteflexion the descent of the uterus as a whole is a marked feature. The uterus in its flexed condition becomes rotated and at the same time pushed lower and lower downward toward the pelvic floor. And so much is this the case that it is not uncommon to find the os uteri quite close to the tip of the coccyx. Such cases are most troublesome. A typical case of this kind would be represented as follows: The uterus in the second degree of anteflexion, rotation to second degree, the OS uteri rather far back, apparently touching the coccyx, the fundus lying very near to the pubic symphysis. Such a case is not uncommon in single women who, after many years' continuous suffering, have become finally incapaci- tated from active exertions of all kinds in consequence of the pain and discomfort produced by attempts to move about in tlie ordinary way (see Fig. 83 representing such a case). A very troublesome element in cases where the uterus is on the floor of the pelvis arises from the pressure on the rectum, and the most obstinate constipation often results. I have seen one extreme case in which the uterine cervix actually inverted the rectum and protruded at the anus. The uterus is not always, however, so low down in the pelvis. It may be acutely flexed and yet retain its normal position so far as elevation in the pelvis is concerned; the flexed fundus is comparatively high up and is reached with less ease than usual. Schultze seems to have met with such a condition rather frequently, judging from liis state- ments on the subject, or rather from tlie drawing he gives to illustrate his remarks. But it is to be remarked that Schultze believes in normal anteflexion to an extent wliich I deny. The result of the difference of view is that Schultze naturally finds few cases of (pathological) anteflexion with the fundus low down, whereas such cases are, from my point of view, very common. Another very important distinction to be made is as re- gards the degree of softness or hardness of the uterus and the difficulty or facility with which the uterus can be restored to its proper position and shape by means of the sound. This applies of course to all the several varieties of dis- placement above described. Here is an opportunity afford- ed for what may be termed the general, as opposed to the mechanical, view of the case before us. It is necessary to determine how far the uterus is fixed and hardened in its ANTEFLEXION AND ANTEVERSION OF UTERUS. 3II disturbed shape, either by a hardening process in its own tissues or by external fixation due to hardening of the celhilar tissue and connections of the uterus. Thus taking a case of the second degree with consider- able rotation, we ma}'' find the uterus soft and spongy and readily straightened and elevated to its proper position; or we may find it very hard and firm, and the attempt to straighten it is attended with difficulty; or we may find that it is so firmly imbedded and jammed downward be- FlG 84. hind the s^'mphysis that its elevation is almost impossible at the moment by the aid of tlie sound. In long-standing cases the latter difficulty is likely to be encountered. The annexed drawings illustrate the conditions referred to in the last paragraph. In Fig. 84 is represented a case of severe anteflexion at age of 19, the subject of which was a patient who had been incessantly sick for ten months, the displacement caused by a jump from a height of six feet. The uterus was large, congested, but soft and spongy in texture. In Fig. 85 is represented a case of severe anteflexion at 312 DISEASES OF WOMEN. age of 51, the subject of which was single and had received an injury in getting over a stile when 16 years old. She had been more or less an invalid for years. Here the uterus was very large, quite fixed in its low, anteflexed condition, and it was evident that the malady had been in existence for many years. The two cases above related are quite Fig. 85. alike: in both the position is much the same, but in the one the malady was recognized sufficiently early to be quite and rapidly cured; in the other it was not possible to alter the position of the uterus and the time had passed away for attempting it. All gradations are met with both in regard to the flexi- bilit}^ and mobility of the uterus. As a rule, when the flexion is in the third degree the uterus is not easily straightened. Sometimes we meet with cases where the ANTEFLEXION AND ANTEVERSION OF UTERUS. 3I3 flexion is severe but the general mobility considerable; in such cases the uterine fundus is elevated by a slight pres- sure, but the flexion remains, and although the rotation is reduced, the flexion continues. This fact has an important application in the treatment. The sound is the instrument by which we are enabled to judge of the degree of rigidity of the flexion, and of the degree to which it resists the attempt to replace and straighten it. The Degree of Congestion or Enlargement of the Uterus. — Congestion is rarely altogether absent in cases of cinteflcxion and -version. But it is very much more severe in some cases than in others. The fundus uteri is much larger tlian usual, due to long-continued chronic congestion associated with anteflexion and partly causing it, and being partly caused by it. First, second, or third degrees of anteflexion may each be associated with slight, severe, or very intense congestion, and there may be various degrees of enlarge- ment. A very common condition in women who have had no children consists in combination of anteflexion to second degree, rotation to second degree, and enlargement of the uterus, especially the fundus, to three times its ordinary size. Conditions more or less severe than this may be en- countered. Congestive enlargement with anteflexion is by no means limited to women who have had children. As a rule, the os uteri gives evidence of considerable congestion; this is more decided in women who have had children. In many cases of pluriparae the os presents considerable swelling, and congestion especially of the anterior lip. In chronic anteflexion affecting pluriparae the OS uteri presents very great hypertrophy, the result of long- continued congestion. In not a few cases, also, in pluriparae there is eversion of theliningof the cervix,and the generally depressed condition of the uterus gives rise in such cases to great friction of the OS against the vaginal floor. The congestion and irritation observed at the os uteri in many such cases has long obscured their true nature. These appearances usually result from the general congestion of the uterus itself, pro- duced in most cases by the anteflexion. In some instances they result from lacerations of the cervix uteri during labor. Complications. — Congestion of the uterus is the most com- mon of the complications of anteflexion, as has already 314 DISEASES OF WOMEN. been stated. The congestion may be very acute, giving rise to exceeding sensitiveness to toucli, to severe spasmodic pains, to great swelling of the uterus as a whole, to a sort of strangulation of the whole organ. This may pass into a sub-acute and then into a chronic stage. In the chronic stage frequent accession of acuteness may occur. In the end, the uterus acquires great size and permanent hyper- trophy. Distension of the uterine cavity is rather common as a complication of anteflexion; the cavity is often of con- siderable size, forming a large pouch, in which blood col- lects during menstruation, and puriform fluid at other times. Adhesions of a peritoneal character do not appear to be common, but fixation is not very rare. It is especially ob- served in long-standing anteflexions where the uterus is very low down in the pelvis and has carried with it the floor of the bladder. Such a condition, when of long standing, renders restitution of the uterus to its proper shape and position a work of great difficulty. It may be easily confounded (and indeed may be associated) with hardness or rigidity of the uterus itself. Cystocele is a possible complication of severe anteflexion, the uterine fundus forcing the bladder downward and partly outward. I have seen such a case in a patient who had never borne a child. In pluriparae,cystocele generally occurs in connection with ruptured perineum; the anteflexion and the cystocele are then traceable to defective perineal support. Cystitis is, I believe, more frequently the result of ante- flexion of the uterus than is supposed. It is very common to meet with extreme irritability of the bladder in cases of anteflexion owing to the mechanical pressure of the fundus on the bladder and interference with its retentive power, but I have seen some few cases of very severe cystitis cer- tainly due to anteflexion, some of which have been at once cured on relief of the uterine displacement. Chronic constipation is exceedingly common, due to mechanical pressure on the rectum. Symptoms. — It has been stated in describing the symptoms observed in flexions of the uterus, that one of the most common is pain during locomotion. This symptom, uterine dyskinesia, is not peculiar to any special form of uterine flexion, but it is a very noticeable symptom in anteflexion and -version. Peculiar interest attaches to this symptomj ANTEFLEXION AND ANTEVERSION OF UTERL'S. 315 because its intensity in anteflexion is a test of tlie degree of importance. It has been my practice always to inquire of patients wliat it is they complain of, and the following is a part of the reply given in the cases referred to. There are two series of cases, and they are taken from my case-book, the words given being generally those actually used by patients in reply to the interrogation above mentioned. Cases of Anteflexion or -version of the Uterus — Patients all belonging to tkt " Fertile " Series. 1. Constant feeling of bearing- down in walking. 2. Since a strain, two months ago, not able to walk. 3. Pain on rising from bed in morn- ing. 4. Locomotion difficult. 5. Incapable of locomotion. 6. Walking power gone last four months. 7. Locomotion very difficult and painful. 8. Locomotion painful, g. Walking power small. 10. Almost incessant unpleasant sensations, a sort of aching only going away when in bed. ir. Locomotion difficult. 12. VValking power small. 13. Strained feeling; cannot stand any time. 14. Unable to walk from pain in side. 15. Cannot walk. 16. Walking painful. 17. Feels sitting much. 18. Complete inability for locomo- tion. 19. Inability to walk. 20. Pain in walking. 21. Cannot walk far without pain. 22. Feels dragged. 23. Pain in walking. 24. Walks badly. 25. Pain right side on motion. 26. Bearing-down in walking or standing. 27. Standing difficult from pain in hypogastric region. 28. One day, six weeks ago, found could only take short steps 29. Continuous pain right side, since a week's e.xertion in shopping. 30. Cannot walk. 31. Discomfort after exertion. 32. Pain and discomfort following exertion. 33. Exertion painful. Cases of Anteflexion or -version of the Uterus — Patients either Single or, if Alarried, Sterile. 1. Walking always produces faint- ness. 2. Never could walk much. 3. Can walk only short distance. 4. Can only walk very short dis- tance without pain. 5. Tires readily. 6. Locomotion not practiced. 7. Walking power left her nineteen years ago. 8. I rtcapable of locomotion. 9. Cannot sit upright from pain in back. 10. Pain on locomotion. 11. Locomotion painful after five minutes. 12. Tired easily. 13. Cannot walk well. 14. Walking produces pain. 15. Incapable of locomotion. 16. Standing, ever so little, insup« portable. 3l6 DISEASES OF WOMEN. 17. Cannot walk. iS. Walks badly. 19 Dragging pain in back, especial- ly walking or standing; bear- ing down. 20. Peculiar sensation in groins, and a sick feeling on walk- ing. 21. Extreme incapacity for move- ment. 22. Incapacity for locomotion. 23. Pain and inability to walk. 24. Never could walk well. 25. Cannot walk freely or sit easi- ly. 26. Pain in side increased by exer- tion. 27. Very little walking power. 2S. Great difficulty in locomotion. 2g. Severe pain right groin, worse after exertion. 30. Pain in back increased by walk- ing. 31. Walking fatigues much. 32. Cannot walk well. 33. Walking power little, formerly good. 34. After walking feels tumbling to pieces. 35. Cannot walk much. The above are extracts from reports of cases observed during three years in private practice, and it does not by an\' means include all the cases of anteflexion in which the symptom in question occurred. In those cases above re- ferred to it was so noticeable a symptom that the patient generally spontaneously mentioned it on being asked " what she complained of." In point of fact uterine dyskinesia is the principal symp- tom in a very large number of cases of anteflexion and version. Certain positions of the body, even in a state of repose, give rise to great pain and irritation in many cases of ante- flexion. Thus, the sitting posture gives great discomfort in many cases, especially bending forward, as in the act of writing, sitting on a low chair, and bending forward par- ticularly. Riding in a ca-rriage in the ordinary position often produces the greatest discomfort; the combination of sitting and being jolted b}' the motion of the carriage is often very distressmg in its effects. Anything calling into action the abdominal muscles may give great pain even when the patient is otherwise quiet; even putting up the arms to dress the hair gives great pain in some cases. Spontaneous pain is very frequently observed. This pain generally in the sacral region, but very frequently also it is felt in one of the groins. In a few cases it is very severe and constant, but as a rule when the patient is at rest there is little spontaneous pain. Tenderness of the Uterus to the Touch. — This symptom is severe in some cases. In fact the anteflexed uterus is some- times so sensitive to the toucli that the greatest difficulty is experienced in making a simple examination, It is not, ANTEFLEXION AND ANTEVERSION OF UTERUS. 317 however, so common to find extreme sensitiveness in ante- flexion as in retroflexion. The tenderness affects the os uteri. In some cases the sensitiveness is not felt at the os uteri so much as within tlie canal. The internal os uteri is not seldom the seat of a very extreme sensitiveness, the patient screaming out when the extremity of the sound reaches the point in question. There is generally acute congestion of the uterus when general sensitiveness is present, and when the uterine canal is so sensitive the flexion is an acute one and is generally of long standing. In such cases a neurosis has been established at a certain situation, and the spot is usually quite definable, other parts of the uterus being comparatively non-sensitive. In a few cases we meet with chronic congestion and en- largement, together with anteflexion and severe sensitive- ness which remains so long as the flexion and congestion persist, but disappears for a time under treatment. This recurs from time to time unless means are taken to prevent the descent of the fundus forward. When tenderness to the touch is felt just above the groin on one side, the idea naturally suggests itself that it is due to some quasi-inflam- matory condition, and it has frequently been assumed that it arises from ovaritis. I have seen many such cases in which no tenderness of tlie ovary could be detected by care- ful examination from within, but where the uterus was found to be anteflexed and proved to be the source of the pain. Various abnormal sensations are experienced by patients suffering from anteflexion or -version not included in the foregoing account. A sensation of weight in the hj'pogas- trium is common, especially in patients who have had chil- dren; a bearing-down sensation is not uncommon. A sen- sation of movement, a sort of rolling-about feeling, within is occasionally described. A feeling of sickness or nausea is very common: this S5'mptom is generally brought on by exertion, or by sitting in a constrained or upright position. Dysiiienorrhxa is a very common symptom. It exists in all degrees of severity. It is very rare indeed to find a case of marked anteflexion in which menstruation is nor- mal and unattended with pain. Taking cases of dysmenor- rlioea in bulk, it will be found that the most common cause is anteflexion or -version of the uterus. The uterine canal is narrowed by the flexion, the outlet for the uterine secre- tion is restricted and pain ensues. Menorrhagia is not uncommon in cases of anteflexion. 318 DISEASES OF WOMEN. This symptom is sometimes observed in a very marked degree in young women during the first two or three years after commencement of the process. I have seen cases of this latter kind wliere the loss was almost continuous for a month together, and where the anteflexed condition of the uterus was found to be the cause. It is true such extreme cases are not common. Menorrhagia is more common in cases where the uterine flexion has existed some time, and the uterus has become enlarged, its interior greatly ex- panded, and the fundus forms a pouch hanging forward Fig. 86. in an acutely anteflexed state. (See Fig. 86.) Blood col- lects in its interior and escapes in large gushes from time to time. Leucorrhoea is very common. The discharge may be due to the congestion and irritation of the os and cervical canal, but it is not seldom an intra-uterine leucorrhoea, due to re- tention of secretion within the uterus, to an irritated, vas- cular condition of the uterine interior (so-called " en- dometritis"), concomitant with and arising out of cervical obstruction and flexion. The leucorrhoea in the latter case is often observed in form of gushes of sanious fluid. It may even become offensive to the smell. I have seen a case in a single patient who had for some time been subject to an offensive leucorrhoea, due to a flexion of the uterus, and ANTEFLEXION AND ANTEVERSION OF UTERUS. 319 which entirely disappeared when the flexion was cured. Obstinate long-standing cases of leucorrhoea will sometimes be traced to an unsuspected anteflexion. Amenorrhcea. — This symptom is occasionally met with, the orocess of menstruation having become entirely and pre- maturely arrested by the anteflexion. In other cases it is observed to be very scanty. Sterility. — Anteflexion is one of the commonest causes of sterility. Fecundation is prevented by mechanical obstruc- tion to the passage of the zoosperms, or by the altered char- acter of the uterine secretions. Sterility is primary in many cases, in others it is second- ary; that is to say, the patient, having had one or more children, becomes affected with severe anteflexion, and thereafter, or until cured of the anteflexion, remains ster- ile. Abortions. — Anteflexion is responsible for a great number of abortions. The patient has a slight anteflexion; she be- comes pregnant; the uterus does not expand properly ow- ing to the flexion; abortion results. Or the uterus is weak, and an accident or fall produces anteversion, followed by an abortion. But the former is the more common order of events. Dyspareuiiia. — Pain in intercourse is a symptom some- times existing to a great degree of severity. Physical in- jury is no doubt often inflicted by excesses in regard to inter- course, and the uterus is in some cases actually displaced in consequence. But dyspareunia may exist when there has been no such history of excess in this direction. Reflex Nervous Symptoms. — In order to avoid unnecessary repetition, these symptoms will be considered in a separate chapter. Reflex nervous symptoms are exceedingly fre- quent in cases of anteflexion or -version, especially sickness and nausea; but as these symptoms are not peculiar to this special variety of uterine flexion it w'ill be best to discuss them from a more general point of view. (See chapters on Association of Pregnancy with Flexions, and on the Vom- iting of Pregnancy.) Symptoms relating to the Bladder. — Frequency of micturition is a very common symptom in cases of anteflexion or -ver- sion. It is sometimes the principal symptom. In a few cases it is so productive of inconvenience and distress that the patient thinks of nothing else. The necessity for evac- uating the contents of the bladder may be as often as every 320 DISEASES OF WOMEN. hour, or even less. It is generally limited to the day, which means that when the patient is in the horizontal position it is not so liable to occur. It is generally worse at the men- strual periods, but I have known cases where it was always better at those times. The symptoms depend for the most part on the pressure of the body of the uterus on the blad- der and interference with its due expansion. But there is evidence of cystitis in some cases. When the anteflexion has existed for some time, the bladder either becomes more tolerant of pressure or expands in a new direction, and the irritability may cease. Pain after micturition is a condition which is met with in some rare cases of anteflexion. A curious case I have in my recollection in which a young lady had been affected for three years with this symptom, which completeh' destroyed her comfort. It appeared to depend on the contact of the opposite sides of the bladder, due to a severe anteflexion, and it disappeared on treatment of the latter condition. Symptoms i-eferable to the Rectum. — Constipation of a very obstinate character is observed in many cases of anteflexion or -version. It appears to be a mechanical effect of the al- tered position of the uterus. In some cases severe straining efforts are quite ineffectual: the uterus being forced down on the floor of the pelvis the rectum is effectually blocked. It is perhaps not at first* easy to say why this should occur in some cases to such a marked extent and not at all in others. The explanation may be that when obstruction oc- curs the cervix uteri happens to be forced down in the cen- tre of the rectum, while it avoids the exact centre in others. I have seen cases in which all kinds of medicine had been tried unavailingly, and in which restoration of the uterus to its proper position was effectual in relieving the consti- pation. A case, already mentioned, once came under my notice where the cervix uteri was actually forced by expulsive efforts into the rectum, everting it and, projecting at the rectal aperture, effectually blocked the passage, but I have only seen one such case. DIAGNOSIS. On the subject of the diagnosis much has already been said in speakingof the definition of anteflexion and -version. The diagnosis is easily arrived at in most cases, the pa- ANTEFLEXION AND ANTEVERSlON OF UTERUS. 32 1 tient being properly placed and the finger introduced in the manner described in a former cliapter (see page 27). Tho. digital examination gives the most reliable informa- tion, and unless it is thoroughly done no satisfactory no- tion of the case is obtained. In this manner the roof of the vagina should be carefully explored and the position of the body of the uterus ascer- tained — its size, width, distance from the pubic bones, and the elevation of the uterus as a whole in the pelvis. If the finger can be pushed upward in tliis position with- out encountering the resistance of the body of the uterus, as a general rule it may be taken that the uterus is not an- teflexed or anteverted. This is a rule to which there are exceptions, as pointed out at page 291. As to recognizing the body of the uterus by the touch, it is a matter of skill, requiring practice to obtain accuracy and certainty. Tlie greatest real difficulty will be found in cases where the roof of the vagina presents a hardened resisting condition, which may turn out to be either anteversion and -flexion ///^j' some exudation hardening, or exudation hardening alone. An- other cause of difficulty is the retreating or rotation back- ward of the fundus, which sometimes happens by the mere pressure of the exploring finger. The tumor or resisting mass felt through the vaginal roof is generally recognizable as the body of the uterus by its continuity with the cervix, by its shape, size, etc. The uterine body is often a little to one side of the middle line and not exactly median in posi- tion. In some cases the lateral deviation is yet more de- cided, although it does not amount to lateriflcxion. These cases give great trouble in regard to treatment unless this lateral tendency is duly recognized and adequately guarded against. When the flexion is high up and the uterus not much ro- tated forward, the ordinary digital exploration may fail to detect it. These are quite exceptional cases, however. When the uterus is very soft and pliable, the exploring fin- ger, unless carefully educated, may fail to recognize its presence through the vaginal roof. The double touch is very useful in difficult cases. A vaginal examination cannot be always made. In young single women this examination would of course be deferred as long as possible, or, at all events, not undertaken lightly. Information can often be procured by digital examination of the rectum, and an anaesthetic could be employed to ren 322 DISEASES OF WOMEN. der the examination more easy. As regards the necessity of a local exploration it is impossible to lay down a univer- sal law. Incapacity, of some months' standing, for ordi- nary exertion should induce taking the case seriously into consideration, and in the first place a rectal examination could be made. If the existence of a marked displacement were thus made out, the course would be comparatively clear; and if none were detected so much the better for the patient. The use of the soicnd is very necessary in many cases to clear up diagnostic difficulties. The sound should never be ustd first : a digital examination should always precede it, otherwise the body of the uterus may be pushed by it into a different position and the observer may be misled. Wiien the uterus is unduly soft this latter event is very likely to occur; and I know of cases in which marked anteflexion has been entirely overlooked, apparently be- cause it was found that the sound could be passed without mucli difficulty. The fact is, that in some cases the sound unbends the uterus in the act of introduction. Knowing that there is a tumor anteriorh'-, anteflexion would be suspected, and the point of the sound kept in- clined forward as it is being introduced. The introduction may be extremely difficult — generally is, in fact, when the uterus has been some time affected. I prefer to use the sound almost straight (see represen- tation of shape of sound at page 73). In cases of ante- flexion the cervix uteri is generally rather far back, often very much so — so that the first difficulty is to get the point of the sound in the os uteri at all. Having inserted it about half an inch, the next procedure is to incline the point of the sound upward and forward, and at the same time to draw the uterus as a whole a little toward the symphysis by means of the sound. The result of this usually is that the advance of the sound through the cervical canal is facilitated: the uterus really begins to be straightened. Then, by gradually depressing the handle more and more toward the rectum the sound can be introduced to its full extent. The process should be a slow one, and no force used. It may be taken for granted that if a difficulty is met with, it is due to the point of the sound not being made to assume a proper direction. There are really few cases in which the passage is so much narrowed that the entry of the ordinary sound is impossible. It is almost impos- ANTEFLEXION AND ANTEVERSION OF UTERUS. 323 sible to introduce a nearly straight sound into a uterus in the third degree of anteflexion and forward rotation, unless the above directions are carried out. When the sound is completely in the uterus tiie position of the fundus is cer- tainly indicated; but, as already remarked, the flexion may have been got rid of in the mere act of introducing the sound. The sound is very valuable in diagnosing absence of tumors in the anterior wall. Sometimes appearances are very deceptive in this respect: the use of the sound reveals not uncommonly that what was supposed to be a tumor is really nothing more than the third degree of anteflexion. The ordinary sound cannot always be introduced, a smaller one is sometimes required. In cases of anteflexion \\\ih posterior rotation the passage of the sound is confusing at first, for the sound appears to pass backward until one inch and a half perhaps has been inserted, and this may give the notion of existence of retro- flexion, but on afterward turning the point sharply upward and forward the true nature of the case is revealed. The condition of the os uteri gives some information in many cases. In pluriparae the os is a little open, or may be much open, and the anterior lip is often very much swollen and everted (the contrary to that which happens in retro- flexion), and the shape of the os is crescentic, the concavity of the crescent upward. The position of the cervix varies according to the nature of the flexion. The cervix is generally far back — it may be so far back as to be reached with great difficulty with the finger. But in cases of anteflexion with posterior rotation the OS may appear to be in its natural place. In the latter instance, however, it looks upward instead of downward. The mere fact that the cervix is very far back is almost alone sufficient to diagnosticate anteversion. ' In some cases which have come under my notice there has evidently been a misunderstanding on the part of the attendant as to the significance of a too posterior position of the cervix. I could mention cases of this kind which have been spoken of as cases of retroversion, simply from inattention to the proper nomenclature of the affection. 324 DISEASES OF WOMEN. CHAPTER XXIII. Anteflexion and Anteversion of the Uterus — {ContiimecT). Treatment. — Important. Differentiation of Cases in regard to Cause of tlie Affection — Tlie Age, tfie Duration of the Malady — Importance of General Treatment — Illustrations of Method of Treatment necessary in a recent Case — Positional Treatment very Important: How to be car- ried out — Sitting Position to be avoided — A more Severe Case — Com- bination of Local and General Treatment — Use of " Cradle" Pessary and Sound — Case in which Uterus is very Rigid and Affection of some standing — Further illustrative Cases of Treatment of Anteflexion after Pregnancy. Employment of " Incisions" of the Cervix — Former Misconceptions as to Stricture of the Cervical Canal — Utility of the Operation in Cases of Flexions considered — Necessity for Bougies or Stems afterward — The "Stem" Treatment considered — General Conclusions — Difficulties in Absolute Cure of long-standing Cases. Many cases of anteversion and -flexion can be cured by general treatment alone — that is to say, by a scientific ap- plication of a knowledge of the laws of health and of the laws which regulate the motion of the uterus, and without the necessity for local manipulation of the uterus. But when the malady has existed for a long time, and when the uterus has become firm and hard in its distorted shape, there is nothing inore difficult than to effect a perfect cure, and all the resources of mechanical dexterity are required to produce a thoroughly satisfactory result. The general treatment of flexions (already for most part fully described at p. 224) is applicable in cases of anteflexion and -version; that is to sa)', the diet, the general health, regulation of the bowels, etc., require great care and at- tention. Many cases of anteflexion and -version can be success- fully treated by general measures. In the first place, how- ever, it is important to distinguish between {a) cases where the symptoms have come on suddenly and plainly, as the result of some accident, injur}-, strain, fall, etc., and {b) cases where the approach has been more gradual, and where the case is evidently one of general weakness {e.g., malnutri- tion), with undue mobility, softness, and slight flexion re- sulting from even ordinary exertion. These two categories ANTEFLEXION AND ANTEVERSION OF UTERUS. 325 of cases require a distinction in regard to treatment; for a severely and suddenly displaced uterus is as much a proper object of surgical attention and treatment as a broken limb. General treatment alone would be as a rule applicable in the class b, but it might be wholly inappropriate in the class a, as defined above. Then, again, the question of the age of the patient affects the decision as to treatment. Under the age of 18 or 19 general treatment would be preferred to local treatment — and for very sound reasons: one is obvious enough with- out necessity for mentioning it. Another is that at this age a slight tendency to distortion of the uterus is capable of being corrected by general treatment alone; the disease has not at all events had time, as a rule at least, to become a rooted one. Here, however, the duration of the suffering must be considered, for if there be evidence of existence of the malady for two or three years and the illness and incapacity be considerable, the age should be no bar to a proper remedial treatment. There are many cases occurring at 17 or 18 in which young women present symptoms clearly indicating slight degrees of anteflexion, and where the symptoms have not existed more than a few months. Such cases are quite amenable to general treatment. In regard to cases generall}'', I believe that the duraiion of the malady is on the whole a good guide as to the neces- sity for local as well as general treatment. When the duration extends over a year or two, general treatment by itself is of little service, though very necessary as an ad- junct. Even to this statement there is an exception, for if the uterus happens to remain soft during the whole time it is still comparatively easy to make it assume a more natu- ral form. The majority of cases require for their treatment a com- bination of general and local treatment. Above all they require what I have termed a " mechanical " treatment; by which is meant not necessaril}^ tlie employment of mechani- cal apparatus or instruments of any kind, but the utiliza- tion of the action of the force of gravit3\ It implies also the utilization of the conclusions expressed at p. 112, in respect to the manner in which flexions cause congestion of the uterus, and of the knowledge that the congestion is to so great an extent a natural consequence of the presence of the flexion, and can be " mechanically" removed by elevating 326 DISEASES OF ^YOMEN. the fundus uteri, that elevation being effected by the aid of gravity or by some otlier mechanically acting force. Dr. Emmet has some remarks in his valuable work which show the great importance he attaches to this principle of treatment. Speaking of the treatment of ulerine displace- ments he says, " Our first aim should be to give tone to the pelvic vessels, and to place the uterus in a position where the circulation will be the least obstructed" {op. cit., p. 144)- I now proceed to illustrate the application of general and local treatment to particular cases. Thus, a young lady of 18 is suffering from a slight ante- flexion. Duration of ill health one year only. In such a case as this a proper treatment would be to restore the nu- tritive activity by careful feeding, and attend to the general health; in the next place, to insist on the maintenance of the recumbent position during the greater part of the day: the patient to choose a chair with a very sloping back, or to use a sofa; to walk only a short distance at a time; to avoid all exertions, stooping, lifting, carrying, etc.; fresh air as much as possible, baths, friction, etc. One of the chief points in the above treatment is the posi- tional treatment recommended. Lying down is in fact most important, and after seeing much of the evil results of a misjudged "active-exercise" treatment in such cases as the one mentioned above, I have no hesitation in saying I believe it to be essential to progress in the right direction. The dorsal recumbent position is the best. This may be occasionally modified by placing a pillow under the lower spinal region to elevate the pelvis a little; and the knee- and-elbow position should be employed several times in the day as a further assistance. Some weeks of the above treatment are generally required to produce much effect. Change of air, change of scene, are adjuvants, but it is a great mistake to imagine that they will alone and unaided cure the patient if violent exercise be permitted. The sitting posture I have always found very unsuitable in cases of anteversion and -flexion — that is to say, sitting in the ordinary position in an upright chair; and for a long time I have found great advantage from advising this to be as much as possible given up in such cases. It is infi- nitely worse, according to my experience, for a patient to sit at table or at meals for an hour than to go for a long walk. Sitting is, in fact, no rest to the patient, and the flexion is ANTEFLEXION AND ANTEVERSION OF UTERUS, ^l"] thereby exaggerated. It will be found that an iron-frame chair with a back capable of being let down to an angle of 45°, whereby the vertebral column is inclined much back- ward, is excellent for patients requiring proper rest, and it may be exchanged for the sofa when desired.* The amount Fig. 87.f of walking to be done depends on circumstances. Twenty minutes twice a day would be suitable in the case above mentioned. *A chair admirably adapted for this purpose is sold by Williams, 41 New Bond Street. \ Fig. 87 represents the cradle pessary in situ. The case represented was one of a nulHparous uterus in a highly congested state, anteflexed to second degree, with much anterior rotation. The pessary is one of small size. 328 DISEASES OF WOMEN. The knee-and-elbow posture is of considerable assistance in such cases. It may be employed for five minutes at a time, five or six times a day. AVe may next take a more severe case. The patient is 22 or 27, and has been ill for some three or four years. The Fig. 88 * uterus is anteflexed to the second or third degree; there is great weakness; the uterus is soft to the touch, readily re- placed by the sound, but returns to its distorted shape on withdrawing the instrument. * Fie- 88 represents a cradle pessary of larp^e size as in action in a case of anteflexion and -version in a patient who had had children; uterus large and congested. ANTEFLEXIOX AND ANTEVERSIOX OF UTERUS. 329 This is a case which will prove most difficult to cure unless some kind of mechanical internal treatment be had recourse to. The recumbent position as described above, but more strictly so for the first few weeks, is required. Reposition of the uterus by the sound every third or fourth day. At the end of ten or fourteen days introduction of a cradle pessary, which, if well fitted and found to work well, may be retained for some weeks. Details as to the pessary to be employed will be given later on. Use of sound to be continued at intervals of a week or so, the object being to straighten the uterine canal more completely. For this purpose the sound is inserted nearly straight. It should tlien be turned gently round so as to unbend the uterus, and withdrawn at the end of four or five minutes. Con- joint use of the sound and the pessary may be found diffi- cult to carry out without withdrawal of pessary, and in some cases it may be better to dispense with the sound for some weeks at first. But the pessary should be used con- tinuously for the most part, or, at all events, if it be removed for a day or two the patient must not be allowed to move from the horizontal position, otherwise ground gained may be lost, for the action of a well-acting pessary is like that of a splint, keeping up a continuous rectifying action and preventing movement of the fundus in the wrong direction. After a period of a month or six weeks the patient may, perhaps, be allowed to move about the room a liille, but not to sit upright, and a walk out of doors ma}" be per- mitted at the end of two months. Carriage exercise, though good in one way, is very bad in another, for unless the recumbent position be maintained the jolting of the carriage is most distressing to the patient; a little walking- is infinitely preferable. The further treatment will consist in the use of the pes- sary, changed from time to time, if necessary, for one more suitable to the altered condition of the uterus, or to allow of occasional use of the sound; and it is probable that in such a case as that described it will be necessary to con- tinue tlie use of the pessary and avoidance of the upright sitting posture for perhaps a year. But after the first two or three months, or even earlier, the patient may be so much better as practically not to be an invalid. In cases where the uterus is very soft, but the case other- wise as represented above, the use of the sound would be less necessary. More care would be required in the nutri- 330 DISEASES OF WOMEN. tional direction, and a year would be probably not enough to produce a complete cure: not because it is so difficult to keep the uterus in place and in shape as it is to give it the strength to retain its place and shape unaided. We may next take a case still more severe. The patient is 27 years old; there is anteflexion to third degree, anterior rotation to third degree, uterus very low down in the pelvis, OS uteri almost touching the coccyx, space behind symphy- sis filled by the enlarged uterus, the uterus itself hard to the touch, introduction of sound difficult, unbending of uterus difficult and painful, illness six or seven years in duration. In such a case the elevation of the uterus may be diffi- cult, so also the unbending, owing to fixation and hyper- trophy of the organ. The best plan to adopt in such a case would be to keep the patient recumbent on the back for two or three weeks, using daily copious injections of quite hot water and employing pressure on the fundus by means of the finger occasionally, aiding the elevation also by the knee-and-elhow posture from time to time. After a few days the treatment by the sound might be commenced, and soon a cradle pessary might be used. But under such circumstances there is a greater risk of creating irritation by the conjoint use of the sound and the pessary, and the treatment must be modified accordingly. Moreover, we cannot expect to advance rapidly in the first part of the treatment, for the hardness and fixity of the uterus are against us. Still, by the aid of rest, hot water, and slight continuous pressure upward, distinct advance is gained, and after a few weeks more rapid progress is possible. The steel dilating instrument described at page 232 (Fig. 48) is a valuable aid in such a case as the above, for the uterus can be straightened and at the same time gently dilated by its means, and the two processes of straightening and gradual dilatation are a mutual help in the rectif3'ing treat- ment. The cases just mentioned have been given in outline only, and with the v;ew of setting forth the general method of treatment which I have found most serviceable and success- ful in the large majority of cases, details as to treatment of the various complications frequently present being post- poned for separate discussion. Necessarily hardly two cases are alike, and each case has to be treated on its merits; and the outline given above, therefore, is to be taken a§ ANTEFLEXION AND ANTEVERSION OF UTERUS. 33 1 representing the idea of principles of treatment whicli has seemed to me applicable to very many cases. With slight differences the principles in question may be extended to other cases not included in the above series. Take, for instance, the case of a patient who suffers from anteflexion dating from the birth of a child a year ago. In such a case, a vaginal pessary for a few months, combined with avoidance of the sitting position for a month or so, will probably effect a cure. Similarly an anteflexion dating from three years since the birth of a child. Here a pessary will probably not be suffi- cient — the use of the sound will be required, and a pro- longed rest may be essential to produce the necessary change in the shape of the uterus. In such a case in all probability there would be considerable hypertrophy of the wliole uterus, and this would have to be treated. Without a long maintenance of the horizontal position no progress could be made, because the patient would not bear the pres- sure of the pessary. There would very probably be other complications also requiring attention. Cases of Anteflexion with Posterior Rotation. — In these cases great difficulty is found in the treatment. When the uter- ine tissues are soft a well-adapted cradle pessary answers very well in some cases. A stem pessary may be found suitable where the cradle does not fulfil the necessary indi- cations. When the uterus has become hardened and a long time has elapsed, a continuous dilatation treatment, asso- ciated with use of a cradle, will be found best, according to my experience, but it may be necessary afterward to use a stem pessary. It may be well in the next place to mention cases in which care and caution are requisite in application of the treat- ment by means of the sound or dilator, either alone or along with vaginal pessaries. Where the flexion is of very long standing (say over seven years), and the uterus is hard and rigid, and the patient over 35 years old, there is a dan- ger of setting up irritation by the repeated use of the sound or a metallic dilator, more especially if a vaginal pessary be used at the same time. Indeed, I have known cases of this kind in which even the sound alone could not be used at all without risk of inducing an attack of pelvic cellulitis. These considerations lead to the necessity for care and cau- tion in attempting to extend the principles above mentioned to cases of long-standing flexion with a hard uierui, 332 DISEASES OF WOMEN. In view of the facts just mentioned, it may fairly be ques- tioned whether it is not preferable to employ some other method of treatment than those above described in cases of long-standing flexion — that is to say, either incision, or dilatation by means of tents, and subsequent use of the stem treatment, in order to obviate the difficulties encountered in these exceptional cases. There are two other methods of treatment of anteflexion to be described — (i) Incision of the cervical canal, and (2) ilie use of the uterine stem. These methods of treatment are, according to my expe- rience and belief, inferior in effect and general applicability to the more simple methods already described. On this subject, however, opinions differ I have not, at all events of late years, employed these methods to any considerable extent. Before alluding further to these other methods of treat- ment it may be well to point out the position of these oper- ations in regard to the pathology of the uterus. Incision of the cervical canal had for its primary object the relief of dysmenorrhoea, or the cure of sterility. And it was not at that time understood, at all events to the ex- tent it now is, that the supposed stricture of the cervix uteri which the incision was to open was in the very great majority of cases due to acute flexion of the uterus. And whereas the question would have been asked some few years ago, Is such an operation good for the cure of dys- menorrhoea? — the question now would more properly be, Is the operation capable of curing the acute flexion which is the cause of the dysmenorrhoea or sterility, or both ? It by no means follows because the operation was founded on a misconception that it was really a bad operation; and it is well known that in many cases the operation was tem- porarily successful, while in a few its success was more permanent. But in estimating its value we must, as I be- lieve, regard it from a different point of view to the original one. Incision of the Uterine Canal as a Rcfiiedy for Chronic Ante- flexion of the Uterus. — The operation consists in incising the uterine canal from within, generally on the two opposite sides — the incision being made so as to affect the part of the cervical canal at and below the internal os, and being carried downward to the external os uteri in such a manner that tlie entrance to the uterus is rendered somewhat fun- ANTEFLEXION AND ANTEVERSION OF UTERUS. 333 nel-shaped. The depth of the incision is such as to allow of the free passage of a large sound into the uterus. The cervical canal and the internal os uteri are then plugged carefully with cotton or lint saturated with an antiseptic or a styptic such as perchloride of iron. The plug is re- tained for two or three days, and then a solid plug or stem is inserted so as to maintain the degree of opening obtained by the operation. Such is the operation in its general outline, though the details are somewhat differently carried out by different operators. The permanent value of the operation above described depends on the efficiency of the subsequent treatment. It appears that in most cases the uterus returns to its previous condition, or nearly so, unless the subsequent treatment is continued for a very considerable time. The edges of the incision unite, the flexion returns, and after two or three months have elapsed the effect of the operation seems to have passed off. At least this is liable to be the case, if the flexion is of long standing — five or seven years or upward. If, therefore, a long-standing flexion be thus treated, either a stem pessary should be worn continuously for many months after, or a combination of occasional bougie treat- ment, with use of a vaginal pessary, would be necessary. It seems to me that in very obstinate long-standing cases of anteflexion, with a hard uterus, the incision treatment well followed up is capable of effecting more than can be effected in any other way. But at the same time, according to my experience, the cases in which the treatment is really required are few in number. With reference to the danger of the incision plan of treat- ment it cannot be said that it is devoid of danger; and see- ing that it is an operation for which it could be rarely said there is an absolute necessity, the possibility of a fatal re- sult should certainly be duly considered in undertaking it. Details regarding the incision treatment will be given separately later on. I propose in the next place to speak of the stem treatment for the cure of anteflexion. I have in the course of practice had a considerable ex- perience of stems, and some few j^ears ago employed them frequently. In the last edition of this work I described an apparatus for the purpose which has been extensively em- ployed since, either as originally described by myself or 334 DISEASES OF WOMEN. witli certain slight modifications. But I have not employed the stem treatment in a large number of cases of late j'ears, having preferred for most cases a conjoined treatment by- vaginal pessaries and use of the sound or dilator. The stem treatment is applicable in cases of anteflexion as a means of retaining the canal (a) pervious and (/-') straight. The advantage gained is the certainty of these two objects being secured so long as the stem is worn. When the flexion is not of long standing the use of a well- adjusted stem for a few months will very possibly result' in a satisfactory cure: provided that it excites no intercurrent irritative attack, that the general treatment of t!ie patient i.s judicious, and steps be taken to nourish and strengthen the body generally. In such comparatively simple cases, liowever, equally beneficial results without the same lia- bility to production of irritative effects can be procured, according to my experience, by other more simple measures. Taking cases of a more severe type, where the flexion has been of longer duration, the stem treatment offers in such cases advantages which will probably decide many gynae- cologists, at all events occasionally, to employ them. In reference to the dangers of the stem treatment much has been said, some authorities going so far as to say thev ought to be abolished from practice. Undoubtedly fatal results have followed their employment, and it is difficidt to say how far these fatal results have occurred from want of care or from an inherent dangerous tendency of the treatment. An interesting paper on the subject of the use of stems was published in the "American Journal of Obstetrics," in 1S77, by Dr. Ely van de Warker, and a discussion fol- lowed * which may be studied with advantage. It is there shown that opinion in the United States differs very much on the advisability of the stem treatment. Dr. Van de Warker gives it as his opinion that the treatment is capable of being employed under conditions which govern every care- ful surgeon in the use of any other mechanical device: that the contra-indications are recent pelvic inflammation, acute or chronic peritonitis, extreme hyperaesthesia of the uterus, intolerance of its cavity; that the stem should not be con- tinuously worn if the pressure is great from the flexion; that the stem should be so short as not to touch the fundus; ■'.\merican Journal of Obstetrics," 10, p. 694, ANTEFLEXION AND ANTEVERSION OF UTERUS. 335 that the support should be in the vagina and movable, non- corrosive, and that it should be managed by an expert.. I give the above resiane oi the paper because it appears to me to be a fair statement of the question. In this country the stem treatment is strongly advocated by some able gynaecologists, Dr. Routh, Dr. Granville Bantock, Dr. Wynn Williams, Dr. Thomas Savage of Birmingham, and others. Dr. Routh insists on the necessity for preparatory treat- ment and blood-letting, in some cases use of tents, in some use of the hysterotome. Dr. Bantock would recommend at first use of sound, tent, or bougie, but if the flexion be acute he would divide cervix by incision and use the stem afterward. Dr. Playfair states that he uses stems in ex- ceptional cases only and when constant supervision can be exercised. Dr. Wynn Williams and Dr. Thomas Savage state that they have very largely employed the stem treat- ment and without any bad effect resulting. For myself I can say that, having employed the stem treatment in many cases of anteflexion, I have never had a fatal result. Some further remarks appear to be required as to the action and value of the stem treatment in obstinate cases of anteflexion. Care should always be taken to ensure that the fundus of the uterus be kept in its proper position. For this reason the stem must have a vaginal frame-work on which to rest and to which it shall be so far fixed as to retain the long axis of the uterus in its proper position, and so as to prevent rotation of the fundus forward. Unless this object is secured the stem treatment is, in my opinion, likely to turn out a failure. Another point: inasmuch as the stem keeps the uterine canal straight, and continuously so, the compression of the tissues of the cervix which is the result of long-continued acute flexion, is put an end to; the atrophy has a chance of being remedied. The efficacy of treatment by the sound in this respect may be compared with that resulting from the use of the stem as follows: The object we have in view is to permanently alter the shape of the cervical canal, which in long-standing cases is liable to be much atrophied on one side. By the repeated use of the sound we are able to bend the canal in the oppo- site direction to a slight extent. The frequent repetition of this process (aided by the vaginal pessary) in time produces a considerable effect, because by means of the sound we cm 336 DISEASES OF WOMEN. do more than actually straighten the canal. Thus, by fre- quently slightly retroflexing the uterus we in time cure the anteflexion. This is undoubtedly an advantage which the sound treatment possesses but which the stem does not. On the other hand, the stem, when once introduced and found to suit, can be worn for a long time during which the uterus is always kept straight, and repeated manual treatment is not required. The cases which present most difficulty in the way of permanent rectification are those of sterile patients with an elongated cervix of a tapering character, but very much bent upward, so that the os looks directly upward. It is held by some gynaecologists that this is a congenital condi- tion. Such is not my impression. At all events the cure of these cases is confessedly difficult. A short way of deal- ing with these cases is that originated by Dr. Marion Sims, consisting of cutting along the middle line of the cervix on its posterior wall and thus opening the cervical canal, in ef- fect shortening the cervical canal to a considerable extent. This practice is advocated also by Dr. Emmet, and has been practiced by others, but so far as can be gathered the operation has not been by any means always successful as a cure for the sterility which has been the principal reason for undertaking it. Speaking generally in reference to the treatment of cases of anteflexion it must be understood Xhdii whcfi the 7nalady has existed for some years a persistent treatment extending over a considerable time is required to obtain a com- plete cure. If the patient becomes pregnant, that is a considerable help, for unless a miscarriage occurs (which has to be prevented) the uterus in its expansion and growth is favorably affected by the pregnancy. But after it is over a recurrence has to be guarded against. On the other hand, if pregnancy does not occur, the use of a vag- inal pessary is required in some cases for a year or two, or even longer, to maintain the effect of the treatment. It is impossible to cure along-standing case in a few months so far that the patient can dispense with some internal support. In process of time, however, the uterus can be consolidated in its improved shape and position; but this is necessarily a work of time, and it is unreasonable to expect it to be otherwise. In a certain number of chronic long-standing cases of anteflexion it is not advisable to initiate local treatment at ANTEFLEXION AND ANTEVERSION OF UTERUS. 337 all owing to the length of time required for treatment, or other reasons. In some it is necessary to be satisfied with sustaining the uterus a little so as to prevent further de- scent or flexion. After a gentle treatment of the latter kind it is sometimes found practicable to go on with more radi- cal measures. CHAPTER XXIV. Anteflexion and Anteversion of the Uterus — {Conti}iuca). treatment — {Continued). Pessaries for the Treatment of Anteflexion and Anteversion. — The Author's "Cradle" Pessary — Principle of its Action — Two Varie- ties, the "Bar Cradle" and "Crutch Cradle" — Various Sizes re- quired — Various Materials — Modification in Use resembling Gehrung's Pessary — Introduction and Removal of the Cradle Pessary — Precau- tions in regard to its Use — Dr. Gaillard Thomas's Pessaries — Other Pessaries : Playfair's, Galabin's, Fancourt-Barnes's, Galton's — The Air-ball Pessary. THE CRADLE PESSARY. The "cradle pessary," as it is now termed, was exhibited by me on May i, 1867, to the Obstetrical Society of Lon- don, and is figured in vol. ix. of the "Obstetrical Trans- actions." The instrument had been used by me for three or four years previously and I have now employed it, sliglitly altered from the original shape, for upward of fif teen years, in the treatment of anteversion and anteflexion. The cradle pessary acts on the following principle : It rests on the vaginal floor at two points — one near the entrance, one high up behind the cervix uteri — and with tliis basis of support it makes pressure upward and a little forward through the vaginal roof, about midway between the cervix uteri and the symphysis pubis. The general outline of the cradle pessary, looked at side- ways, is that of a triangle without a base. The triangle has unequal sides, and experience has shown that in all cases this triangle must have sides whose measurements have a certain definite relation one to the other. The line 111 a is a little longer than 111 d. 338 DISEASES OK WOMEN. In the instrument as first exhibited the measurements were a little different, but I have found by long experience the above relation of the sides of the triangle to be the cor- rect one. If a smaller instrument be used a similar propor- tion between the measurements of the sides must be pre- served. I have thought it necessary to give very precise details, because many patterns of cradle pessaries are sold, not at all agreeing either with the original shape or with that now given, and which have not consequently been found satisfactory b}' many who have employed them. Most of the instruments sold as "cradle" pessaries have the grave defect of being too long at the base — i.e., the dis- tance A to D (see Fig. 89) is too great — the result being to ..P\ distend the vaginal canal too much. The part which rests on the vaginal floor (a to d) should not exceed in length that shown below for the largest size. In the smaller sizes it should be a little less. A second defect in instruments sold is the want of suflficient elevation of the apex of the triangle, and a third is the placing of the apex of the tri- angle exactly midway over the base line a d. The proper triangle is not an equilateral triangle and the two lines a III, D III, should be of unequal length. I now employ two forms of the instrument, one of which is represented in Fig. 90, and the other in Fig. 91. The former may be described as a cradle with a bar, the other as a cradle with crutches, one on each side ; * In Fiff. 8g are shown three triangles. The largest indicates the size of the largest-sized cradle pessary; the others are smaller. The base iine is that of the vaginal floor. ANTEFLEXION AND ANTEVERSIOX OF UTERUS. 339 the terms "bar cradle" and "crutch cradle" are con- venient distinctiv^e appellations. The}^ require to be of various sizes. Three sizes are generally applicable — Fig. 90.* No. I the smallest, No. 2, and No. 3 the largest. The above figures represent the No. 3 size (largest). The action of the cradle pessary is in part a direct action; Fig. 91. t exerting pressure upward and a little in front of the fundus uteri it tends to elevate the fundus to its proper position. Moreover, by occupying a certain space it prevents occu- * Fig. go represents a larjje size bar cradle pessary. \ Fi<;. gi shows a large size crutch cradle pessary. 340 DISEASES OF WOMEN. pancy of that space by the fundus. In addition to this it has a lever action — it draws the cervix forward, and has therefore a tendency to produce posterior rotation of the whole uterus. The part of the pessary making pressure is the "bar" or "crutch," as'thecase may be. Sometimes one variety answers best, sometimes the other. The crutch pessary is scientifically the superior instrument, as it pre- vents lateral movement of the fundus. The present con- struction differs slightly from that first introduced and Fig. 92.* represented in the 1872 edition of this work in the relative position of the apex of the triangle. The apex is now a little further forward, and it has a better and more perfect action when in position. In the crutch variety of the cradle pessary, it is highly important that the surfaces of the crutch part, which is in * Fig. 92 represents outline of cradle and uterus to show its action. This drawing is different from the one in the last edition of this work ; the large ring should be. as it is here shown, posterior to the cervix. A is the posterior or large ring of the pessary, B is the anterior or smaller ring- ANTEFLEXION AND ANTEVERSION OF UTERUS. 34I front of the uterus, should be opened out so as to present a concave surface, against which the uterine body rests. Fig. 93.* This part of the construction of the crutch pessary is not evident on a lateral view. It can only be seen on looking * Fig. 93 shows a large size crutch cradle as seen from above. f Fig. 94 represents, in a profile view, the three sizes of the cradle pes- sary marked respectively I, II, and III, such as may be readily made from various sized rings bent into the crutch shape. 342 DISEASES OF WOMEN. at the pessary from above. The annexed drawing (Fig. 92) will render this explanation more intelligible. In practice it is found that the space between the two crutches a and b has sometimes to be a little increased Fig. 96.* from that shown in the typical instrument. And it is very necessary that the surface of the crutches be well rounded off, otherwise the pressure is not well borne. As regards the size suitable to different cases, it is found that in patients who have had children, a large size (No. 3) * FiR. 95 represents a medium size No. 2 crutch cradle; Fig. 96 a full size No. 3 cruicli cradle. ANTEFLEXION AND ANTEVERSlON OF UTERUS. 34^ general!}- suits best, while in others a smaller size is re- quired. Again, the width of the instrument as a whole sometimes requires to be a little different from the typical Fig. 97.* measurement. In single wunitjii a narrow cradle pessary is also essential. The cradle pessary is made of various materials ; the best * Fig. 97 represents an extra thick No. 3 size spring cradle pessary. f Fig. 98 is another view of the same pessary. 344 DISEASES OF WOMEN. material for both the bar and crutch varieties is ebonite, Messrs. Coxeter, of Grafton Street, have been at some trouble in making these two varieties of the cradle pessary Fig. 99. in ebonite according to my directions, and now keep ihcni in stock. The crutch variety can be constructed extempo- raneously of copper wire rings covered with india-rubber, and this admits of easy modification of the size or shape. Ebonite is a very cleanly material, though its hardness renders it in some ways inferior to the soft rubber-covered * Fig. 99 shows a large (No. 3) size spring cradle pessary in action. ANTEFLEXION AND ANTEVERSION OF UTERUS. 34$ pessary. I have employed cradle pessaries of all these varieties of material in very many cases during several years, and find that the great secret of their successful em- ployment is the accurate fitting of the pessary, and the preservation of the normal relational measurements of the triangle to which attention lias been already drawn. There are certain exceptional cases in which a larger Fig. 100.* cradle pessary than No. 3 may be required, but they are really exceptional. Spring Cradle Pessaries. — I have found that cradle pes- saries made of German silver covered with india-rubber are sometimes preferable to others. For cases where greater facility in introduction is required they are very useful. Messrs. Coxeter, Messrs. Meyer & Meltzer, and Mr. Rus- sell have made these pessaries in conformity with my in- * Fig. 100 exhibits a special mode of using the cradle pessary. The pes- sary is a little flattened to adapt it to this particular object. 34^ DISEASES OF WOMEN. _ structions. These pessaries are to a certain extent com- pressible and are thus more easily introduced, and retain their shape after introduction. Fig. 99 represents a No. 3 cradle pessary made in this way. The particular pessary here shown is most valuable for cases where the uterus is large and heav)'^ (as in cases of anteflexion with a congested hypertrophied uterus), and it is made purposely a little thick- er than is required for ordinary cases. Nos. I and 2, made in this material, are of course smaller than the one here shown. Another Way of using the Cradle Pessary. — In some few cases I have found that the cradle pessary acts very well when it is rotated backward so as to place the part whicli is ordinarily in front of the body of tlie uterus behind the OS. The plan acts beneficiall)^ in certain cases, but gener- ally the tilting action of the pessary backward is too strong and may convert the anteversion even into a retroversion. Fig. 100 shows a cradle pessary a little flattened, so as to lie better on the vaginal floor, and acting as above de- scribed. Gehrung's pessary for anteflexion is in principle very like the one above described. I append Gehrung's drawing of his pessary, from which it will be evident that the two act alike. I had occasionally employed the modification above described some time before the publication of Geh- rung's pessary. Introduction of tJie Ordinary Cradle Pessary. — The intro- duction of the cradle pessary is not very easy unless certain points are attended to. The large ring is to be introduced first, the bar or crutch being at this time close to the urethral orifice. When the large ring is thoroughly engaged in the vaginal aperture, pressure must be made, not upon the ring, but upon the bar or crutch part which is close to the urethra, and this part must be pushed inward under the urethra, giving the instrument a son of rotation backward. This little manoeuvre, when properly performed, pnjjects the cradle pessary completely into the vagina, and its further introduction is a matter of great ease, as it takes its proper position certainly and readily. Unless these precautions are observed, the introduction may be very difficult. It is best to place the patient on the side with the knees well drawn up, and a good deal of fresh lard or cold cream should be used to facilitate the opera- tion. In unmarried patients requiring the use of the in- ANTEFLEXION AND ANTEVERSION OF UTERUS. 347 strument the difficulties of introducing the pessciry may render necessary the aid of an anaestlietic. In cases where any considerable degree of resistance is experienced in elevating the uterus the use of the cradle pessary must be accompanied with precautions in regard to the position of the patient. The horizontal position is quite essential at first. The sitting posture is generally more uncomfortable during the first few weeks of wearing the cradle pessary than it was before, and must be generally avoided for a time at least. Although the instrument really presses on the bladder it rarely produces any irrita- FlG. lOI* ) tion of this organ. The instrument sometimes presses a little unduly on the rectum if there be too much standing c;r sitting, and the action of the bowels is frequently a little liindered by its presence. To obviate this occasional dif- liculty a daily enema is the most appropriate remedy. The ebonite instrument, when well fitted and working well, may l)e worn for months without difficulty of any kind, but, until it has done its work, will of course require to have its action supervised and regulated. But when a cradle pes- sary made of a hard material has been worn for some * Fig. loi is Gehrung's drawing of his anteflexion pessary. 348 DISEASES OF WOMEN. months it should be removed and a soft cradle used for a time. When the soft india-rubber varieties are employed, more frequent changes and daily injections with a little antiseptic fluid may be required, especially just after the periods are over. The removal of the cradle pessary may be attended with difficulty unless certain precautions are employed. The pessary must be drawn backward toward the anal aperture as well as downward, and it will be found easier to remove it by hooking the forefinger into the pessary behind and not in front of it. Various other pessaries have been employed in the treat- ment of anteversion and -flexion. Some of these will now be mentioned. Fig. 102.* Fig. 103. t Dr. Gaillard Thomas employs two or three pessaries of his own design. The principle adopted by him is to use a Hodge-shaped pessary as a foundation, and a bar in form of an arch is carried from this in front of the cervix. This arch moves on hinges, so that it can be inserted more readily. Some of Dr. Thomas's instruments are represented in the annexed figures taken from the last (5th) edition of his work. Dr. Thomas has also now an instrument which is a com- bination of the stem with a vaginal pessary. It differs * Fig. 102 shows one form of Thomas's pessary. It is in ebonite in a single piece. ■[ Fig. 103 shows a hinged instrument of Thomas's for antefle.xion. ANTEFLEXION AND ANTEVEKSION OF UTERUS. 349 little from the shape of the other vaginal pessary, but there is a sort of cup wliich supports a stem, the stem being of course placed in the uterus; a piece of thread is attached to the stem to facilitate its withdrawal after removal of the vaginal part of the pessary. There are other vaginal pessaries which have been in- vented for the treatment of anteversion and anteflexion, acting by pressure through the vaginal roof — viz., those of Dr. Playfair, Dr. Galabin, and Dr. Fancourt-Barnes. Hitherto, instruments have been described acting wholly within the vaginal canal; other instruments have been em- ployed acting from without. As a rule, certainly, any in- strument of the latter kind is objectionable to the patient and requires constant attention. Dr. Thomas describes a modification of Cutter's pessary for retroflexion, but shaped so that the pressure is applied in front of the uterus, and fixed in a similar way by means of a tape pass- ing from the stem to the waist behind. Instruments have Fig. 104.* been employed by others, the fixed point for which is ob- tained by attaching a stem to a pad in front kept in place by a pelvic band passing round the pelvis. Dr. Galton ex- hibited such an instrument at the Obstetrical Society of London in 1874. The principle of this latter instrument is similar to that of an instrument before employed for pro- lapsus of the uterus, and in some very rebellious cases there is no doubt that such an instrument would be found very useful. The Air-ball Pessary. — Some few years ago I was in the habit of employing an air-ball pessary rather extensively in the treatment of anteflexion, and I still use it in a few cases where the cradle pessary is for various reasons not found convenient. The air-ball pessary is a very efficient instrument up to a * Thomas anteflexion pessary, modified by Munde, with hinges sunk 350 DISEASES OF WOMEN. certain point, and in cases where the uterus is very heavy or large, or very sensitive, it is very serviceable. The in- strument is an india-rubber ball made perfectly 7'0U7id, and it has a small tube attached, by means of which it is inflated after introduction. The tube has a stop-cock; and a brass air syringe which fits the stop-cock is the means of intro- ducing the air. The apparatus is well made by Messrs. Meyer & Meltzer. The pessary is made in various sizes. The average size required for married patients is a ball one inch and three quarters in diameter when not distended. After insertion this is inflated until its diameter is two inches. This precise amount of dilatation can be ensured by introducing it empty, having ascertained previously how many strokes of the piston of the syringe are required to produce the necessary degree of distension. It is extreme!)^ important that the ball should be quite round, and that the distension should not go beyond what is required. A two inch diameter ball sustains the uterus in the proper manner, but if larger it displaces it as a whole backward. One drawback to the air pessary is the presence of the tube externally. This should be fastened in front to a piece of bandage tied round the waist. Another is the liability of the stop-cock to get out of order, when the air of course escapes. But when properly managed it is a very useful instrument, and has the advantage that it can be readily inserted and removed by the patient herself. Careful instructions should be given in order that the pes- sarv may continue to act properly. [Of all pessaries the inflated air bag above described is the least satisfactory. It is seldom used in this country, at least by men who understand the principles that should guide us in the treatment of uterine displacements.] LATERAL DISPLACEMENT OF THE UTERUS. 35 I CHAPTER XXV. Lateriflexion, Lateral Displacement and Alternat- ing Ante- and Retroflexion of the Uterus. Lateriflexion of the Uterus. — Treatment. Alterxating Ante- and Retroflexion. — Nature of these Cases — Condition of the Tissues of the Uterus — Treatment, General and Mechanical. LATERIFLEXION OF THE UTERUS. As a general rule flexion of the uterus is very decidedly either forward or backward, although it is common enough to find that the inclination of the uterus is a little to one side, the flexion not being exactly in the middle line. But in some few cases it is found that the flexion is very markedly in a lateral direction. I find, on referring to my case-books, that during six years the uterus was in a con- dition of decided lateriflexion in three cases — not a large number, and showing that the condition is a rare one. The relation of the uterus to the broad ligaments, and its lateral fixation by these structures, prevents lateral dis- placement. Of the three cases referred to, one was a single lady, aged 24, who had been thrown from a horse a year before applying for advice, since which she had been subject to considerable pain and incapacity for locomotion. In the other two cases there was no history of a severe accident; one patient was 46 years of age, and the displacement was of long standing; the other was only 18, and had walked excessively since her marriage, two years previously. I have seen other cases in which the uterus was ante- flexed and distinctly inclined to one side; but these are not included in the above category. The diagnosis of these cases can only be certainly made by means of the sound. [We rarely use the sound for this purpose. The bi-manual method is alone sufficient.] Treatment. — The treatment I have found successful con- sists in the employment of the sound, whereby the uterus is replaced, and a careful positional treatment. If the uterus is inclined to the left side the patient should lie principally on the right. The horizontal position is of 352 DISEASES OF WOMEN. course requisite. As regards the use of pessaries in such cases, it is not easy to adjust one which shall carry out the indications. When the uterus is decidedly in a state of lateriversion, with slight inclination forward, a cradle pes- sary can be fitted so as to meet the difficulty. For this purpose the crutch cradle pessary should be so bent that the crutch projects more backward than usual on the side to which the uterus inclines. The stem pessary would undoubtedly be the best instrument to employ when the uterus is very decidedly bent to one side. LATERAL DISPLACEMENT OF THE UTERUS. I have seen a few cases in which the uterus without being flexed was displaced very decidedly from its median posi- tion in the pelvis, this condition being the result of an acci- dent or fall and giving rise to protracted and obscure suf- fering. Thus in one case a 3-oung lady fell down stairs, broke her arm, and was laid up for some time with it, but when she attempted to walk found it difficult and painful to do so, and she became affected also with "hysterical" symp- toms. The uterus was found packed away, as it were, in the left posterior corner of the pelvis, where it had evi- dently lain since the injury. By positional treatment the uterus was brought to the middle of the pelvis with satis- factory results. Another patient had sustained a severe fall on the floor from sitting down when there was no chair. Obstinate pain in the back resulted, and it was subsequently found that the uterus was driven backward close to the sacrum, and a little to one side. ALTERNATING ANTE- AND RETROFLEXION. A very important and interesting class of cases is that in which the flexion alternates backward and forward. These cases are by no means rare. I first became acquainted with this alternating variety of flexion eight years ago while attending a case which proved to be one of this kind and which was under observation for a considerable time. It was very difficult to cure, and the facts observed from time to time in connection with it fur- LATERAL DISPLACEMENT OF THE UTERUS. 353 nished me with information which has been found very valuable in other similar cases. These alternating cases are typical cases of the " soft" uterus. This softness is the result of malnutrition. The case above alluded to was that of a lady threatened with phthisis, and in a low state of nutrition generally. There was very intense uterine dyskinesia; complete inability to walk more than a few yards. The uterus was found retro- flexed. Treatment for this retroflexion was for a time suc- cessful, but it afterward failed and it was then found that the uterus was anteflexed. Again, a fresh adjustment was made, but it was found that tlie slightest pressure in front produced retroflexion, while the slightest pressure behind the uterus produced anteflexion. Tlie uterus was so weak that it had no power to keep straight. After observing these oscillations long enough to be aware of the true nature of the case, a peculiar shaped pessary was applied which had the effect of simultaneously giving pressure in front and behind the uterus. When this was got into proper working order the patient was able to walk and a cure was eventually obtained by supporting the uterus and carefully improving the general health by suitable dietar3^ I may mention another case which has been under obser- vation for the last eight or nine years. A young married lady was found suffering from anteflexion, coupled with very great debility — chronic starvation. The uterus was treated successfully and the patient had her first child about two years afterward. After the pregnancy was over the uterus became again troublesome and a cradle pessary was again required; a second pregnancy with subsequent recur- rence of the flexion, and a third with similar result; a fourth pregnancy occurred after a longer interval, and after it had ended satisfactorily the patient again came to me in conse- quence of feeling ill and in pain. On this last occasion I found to my surprise that the uterus was not anteflexed, as I expected to find it from former experience, but retroflexcd. This extremely interesting case, with all the circumstances of which I am perfectly familiar, offers an example of a uterus originally very soft and which has never, spite of repeated pregnancies, become really firm and solid. The case is rare and probably exceptional, but it teaches some valuable lessons. I have seen at various times a considerable number of cases less marked than those above described, but well 354 DISEASES OF WOMEN. characterized. In some of these cases no internal support was used, the alternating flexion being nevertheless ob- served to occur. In other cases the alternation followed on the use of a vaginal pessary, a retroflexion changing to an anteflexion under the use of a Hodge-shaped pessary, and the opposite result following from the use of a cradle pes- sary in a case of anteflexion. This is a very important cir- cumstance to bear in mind, for a pessary which does its work well and satisfactorily at first may be found afterward not to be acting well. In those cases where this unusual flexibility of the uterus exists the pessary (properly ap- plied) tilts the uterus, not only into its place, but may have the effect of producing the opposite kind of flexion. I have on some few occasions been consulted by patients w^ho have been subjects of retroflexion and treated by the Hodge-shaped pessary by other practitioners, but w^ere still in search of relief. In these instances I have in five or six cases found that the uterus had gone over from retroflexion to anteflexion. In one case very great anxiety and trouble had resulted from the supposed impossibility of giving the patient relief, but the true cause was found to be the over- action of the pessar3\ This over-action may of course in some cases be real, the pessar}' being worn too long or being too large, but that explanation does not apply to the cases I have now in my mind in which it was certain both tliat the original diagnosis was right and that the pessary was skilfully adjusted. These facts offer evidence of the necessity for carefully regulating the action of vaginal pessaries and for ascertain- ing that they are acting as intended. This can only be done certainly by the careful use of the sound. If the case be originally one of anteflexion and a Hodge- shaped pessary be employed, one effect is very likely to occur — viz., an exaggeration of the anteflexion. I have met with cases where this result has been observed, the Hodge pessary having been used under a mistaken notion of the nature of the case. I'reatment of Alternating Flexions. — These peculiar cases require a corresponding peculiar treatment. Probably the difficulty is capable of being surmounted in more than one way. Tiie plan which I have followed in the cases which liave come under my notice, and which has been successful, consists in using a pessary which is a combination of the Hodge and the cradle pessary. It might be described as a LATERAL DLSPLACEMEXT OF THE UTERUS. 355 cradle pessary with the posterior ring elongated so as to resemble the corresponding part of the Hodge pessary. The accompanying drawing gives a better notion of the instrument than a description. The object of the instru- FlG. 10= ment is to give a support both behind and in front of the uterus, and the pessary in question has been found to fulfil these indications in the cases in wliich I have employed it. In some of these cases it is probable that the pessary known as Fowler's pessary would prove serviceable. This is an instrument made of ebonite, and having a conical or funnel * Fig. 105 shows a profile view of the "alternating" flexion instrument. A should be placed behind the cervix; B corresponds to the vaginal aperture. + Fig. 106 represents a ground plan of the same instrument. 356 DISEASES OF WOMEN. shape, into which the uterus falls. It is sold in various sizes. Another instrument Avhich would fulfil the indications required is the stem pessary. I have not employed it, however, in the cases of alternating flexion which have come under my notice, having found the arrangement above described to answer extremely well. In conclusion it must be stated that no amount of pre- cision and mechanical skill will be effectual in giving relief in these cases, unless it be conjoined with great care and attention in regard to the strengthening of the uterus. Careful and incessant nutritional treatment for as much as a year or more will be required in a case of alternating flexion in order to really cure the disease. If this latter element in the treatment be neglected, the uterus will, after the removal of the pessary, relapse into its former trouble- some condition. CHAPTER XXVI. Incision and Dilatation of the Cervical Canal of THE Uterus — Stem Pessaries. Incision or Division of the Os and Cervix Uteri. — Various Methods of performing the Operation — Means for maintaining the Canal open afterward — Dangers of the Operation — Treaiment of Cases of Imper- forate Os Uteri. D11.AT.A.TION OF THE Canal of the Uterus. — Dangers of the Proced- ure — Means of effecting Dilatation — Various kinds of Tents — Method of Introduction — Metallic Dilators. Stem Pessaries. — Various Kinds — Simple Stems— Stems with support- ing Vaginal Framework. incision or division of the OS and cervix uteri. Incision or division of the os and cervix uteri is an opera- tion practiced chiefly for the relief of dj'smenorrhoea or for the cure of sterility. But it is also a means of facilitating the rectification of the shape of the uterus in chronic cases of distortion of the organ. In order to enlarge t-he calibre of the uterine canal, Sir J. Y. Simpson first employed a metrotome cache, b)' means of which he effected an incision extending up to the os in- INCISION AND DILATATION OF CERVICAL CANAL. 357 ternum, first on one side and then on the other. The knife was guarded until the instrument had been introduced sufficiently far. Various modifications of this instrument have been employed. Dr. Greenhalgh's metrotome is double-bladed, and by it a bilateral section of the cervical canal is made, rather wider below than above. Dr. Barnes uses scissors to open up the lower part of the canal. Mr. Coghlan's metrotome is adapted for making an incision of the internal os ; it has a probe point, and is then flattened out with a short cutting edge on each side. In some cases a careful use of a very small probe is required to inform us as to the direction in which the cervical canal goes, and a narrow director is now and then useful in guiding the knife when we are dealing with the internal os uteri. It is very desirable to limit the extent of the incision at the external os uteri as much as possible. There is no doubt that it is unwise to divide the cervix widely, as was formerly done ; and it is only necessary to incise the os uteri exter- num to such an extent as to admit of free access to the in- ternal OS uteri, and of the manipulations required for incis- ing it, and inserting material for maintaining the aperture patent. There are cases in which the os externum is so small that the wall must be cut quite through to a certain extent. The external os may be incised by a pair of curved scis- sors or by Sims's knife, and the internal os by the latter in- strument. During the operation the patient is on the side in the Sims's position, the Sims speculum being used, and the OS drawn down by the tenaculum or hook. After the incision a small pyramidal-shaped piece of lint. Steeped in perchloride of iron and glycerine^ is carefully packed into the cervix, and to retain it in situ a piece of wetted bandage a yard or so in length is packed in the vagina. The bandage is drawn away at the end of twelve hours, but the cervical plug remains for two or three days. After removal of the cervical plug an ebonite plug can be inserted. Some operators introduce one immediately after the incision. The difficulty in maintaining the aperture is great, and has been mentioned by all who have performed the operation. After a month or six weeks the wound may become greatly contracted, but the canal does not usually return quite to its former dimensions. The ebonite stem is preferable to other methods for pre- venting the canal from closing ; for to maintain the patency 358 DISEASES OF WOMEN. of the canal at the situation where tlie contraction mostly happens — viz., at the internal os — is often a matter of ex- treme difficulty. A stem of ebonite acts in a double capac- it}', keeping tlie canal straight as well as open. The dangers of incision of the cervix uteri * are as follows : 1. Hcemorrhage is liable to be very considerable when the uterus is deeply incised ; but this is not likely to occur when the depth of the cut does not exceed half the thick- ness of the uterine wall. Cases in which haemorrliage has been troublesome are probably cases in which incisions have been made deeper tlian this. The bleeding is generally capable of easy control by means of the plug. 2. The danger of septicaemia is the chief one. It is very slight when ordinary precautions are taken. Dilatation appears to be dangerous after a cutting operation, and it is probably most dangerous when the incised surfaces are cov- ered with puriform secretion. It may be connected with undue depth of the cutting operation. In any case it is no doubt dependent on entrance of putrescent material from the canal of tiie cervix into the cut vessels (veins or lym- phatics) of the uterus. The free use of carbolized oil in manipulating the cervix uteri, and especially the avoidance of dilatation during the few days after the operation, are recommended. Treatmctit of Cases of Imperforate Os Uteri. — In some rare cases the os uteri is imperforate congenitally, and there is no outlet for the menstrual fluid. And the os uteri may become occluded after labor, from effects of operations, etc. Under these circumstances, also in cases of physometra, we may be called upon to evacuate the contents of the uterus artificially. * Dr. Montrose A. Pallcn (1S77) gives a valuable summary of the sub- ject of incision and division of the cervix uteri for dysmenorilioea and sterility, in "Am. Journ. of Obst.," vol. x. p. 364. It appears that Dr. Sims has since 1874 adopted a plan of incising the cervix, and then dilat- ing it directly after incision by a dilator ; after which operation he in- serts a plug of glass, ebonite, or aluminium into the cervix, which is re- tained for from two to six days afterward, together with iron cotton. Dr. Fallen states that since 1865 he has himself operated 337 times, the incisions varying in different cases. The results were in fifty per cent relief of the dysmenorrhoea and thirteen to fourteen had children, while a quarter were not benefitted. In three cases cellulitis followed. In two death occurred, but not as a result of the operation. Comparing these results with cases in which Dr. Fallen used tents, it appears that in 150 cases, where tents were employed, two died rapidly of mciro-peritonitis, while fourteen had pelvic cellulitis. INCISION AND DILATATION OF CERVICAL CANAL. 359 In congenital cases, we have to make a communication between the uterus and vagina in the best manner the cir- cumstances may admit. We endeavor to find the os uteri, and not succeeding in this, search is made for the cervix. We may fail in discovering any trace of either, the disten- sion of the uterus having obliterated all traces of it. In such a case a point is to be chosen which is nearest the sup- posed seat of the cervix, and the opening is to be made at that point, taking care that the instrument used be directed toward the centre of the enlargement, so as not to run a risk of wounding the bladder or rectum. In reference to the manner in which the uterine contents are to be allowed to escape, certain precautions are necessary. It is, I con- sider, advisable to allow the fluid to escape very slowly. After the first part of the treatment — the evacuation of the fluid — has been gone through, we have to take measures for maintaining the canal of the cervix open. This is not unfrequently found troublesome, there being a tendency to reclosure of the canal, necessitating a new operation. Grad- ual dilatation by means of bougies or by the use of tangle tents is most appropriate under such circumstances. The puncture of the tumor from the rectum is only ad- missible in cases wliere the other operation from the vagina is absolutely impracticable. In cases of acquired occlusion of the os uteri or cervical canal, the canal is to be opened and made pervious by a carefully performed operation, which must be determined by the nature of the case. In many of these cases it is pos- sible to find out the track of the old canal by means of probes, and, if this can be done, it renders further proced- ures more easy. A small canula and trochar, long enough to reach the uterus, is sometimes necessary to evacuate the fluid. The canal once opened the occasional use of the sound, or of graduated metallic bougies, is required to pre- serve its patency. DILATATION OF THE CANAL OF THE UTERUS. Dilatation of the uterine canal is a procedure required in a certain number of cases and for various reasons. It is an operation of delicacy and not seldom attended with consid- erable difficulty. And it is a procedure which is not unat- tended with danger. 360 DISEASES OF WOMEN. The objects for which the operation is undertaken are, as ah'eady remarked, various: To facilitate introduction of a stem-pessary, to relieve dysmenorrhoea, to cure sterility, to explore more completeh' the uterine cavity, as a help to- ward the cure of anteflexion or retroflexion of the uterus, etc. It will be well to speak in the first place of the dangers of the procedure. The great danger is the setting up of the pyaemic process, or local cellulitis. Sponge tents, under certain circumstances, cause rapidly fatal pyaemic disease and peritonitis; but other dilating agents are also capable of producing serious or even fatal illness of a similar kind. Abrasion of the cervical canal, or a partly healed wound of the same, appears to favor occurrence of dangerous symp- toms. A wound, or laceration, or contusion of the cervi- cal canal, in the process of dilatation may lead to the same result, and this is more especially liable to happen when puriform secretions are lying either in utero or in such a position that they obtain ready access to the abraided or lacerated surface. The action of a sponge tent is rapid, and the stretching of the cervix produced is considerable; the sponge, if not rendered antiseptic, very speedily under- goes a putrescent change, and after a few hours is gener- ally foetid. The expanded and partly abraded surface of the cervix is then in contact with the putrescent product, absorption occurs, and serious symptoms set in forthwith — at least, this result may occur. Introduction of a second sponge tent immediately on withdrawal of the first, espe- ciall}^ if the first has been allowed to remain as long as two days, is still more likely to prove prejudicial. Repeated slight abrasions or lacerations of the cervical mucous mem- brane, liable to be produced by use of bougies or by me- tallic dilators, may give rise to similar results. The pres- ence of a wound or abrasion of the cervix seems, so far as my experience goes, to be the predisposing condition; but the presence of an exciting cause such as putrescent or puri- form fluid at the spot so abraded or wounded, appears to be equally necessary. In illustration of the foregoing statements, it may be mentioned that at a discussion on sponge tents at the Philadelphia Obstetrical Society in December, 1873, vari- ous cases of death were mentioned by speakers: (i) Death after insertion of a third sponge tent, the last retained two days, patient having moved contrary to order; (2) death INCISION AND DILATxVriON OF CERVICAL CANAL. 361 after a second tent, interval being two days; (3) death after a third tent, interval between each one day; (4) death after use of three sponge tents. Sponge tents are unequalled for certainty and rapidity of action, but must be used with great care. One operation appears to be safe enougli, but not so a repetition of opera- tions. Sponge tents are sometimes antisepticized before being used, but it seems difficult to render them certainly aseptic. Sponge is certainly better adapted for cases re- quiring quick and extensive dilatation than for cases when slight dilatation only is needed. Thus it is not easy to thread the internal os as a primary operation in cases of acute fiexion — the stiffness of the tent becoming often lost before it has passed the narrow part of the canal. When sponge, or indeed any like material, is employed, carbolized injections should be always freely employed. St-a Tangle. — Tents of this material, first introduced by Dr. Sloan of Ayr, have been frequently used during the last few years. They are tolerably manageable, and very pow- erful in action. The material is very hard when dry, and can be shaped by a knife. Tents of this material are some- times made hollow, as first suggested by Dr. Greenhalgh, to induce more rapid swelling. When the uterine canal is much fiexed or tortuous, the introduction of the tent is not easy unless it be a little softened before introduction. And under any circumstances the operation is one requiring some little skill and attention in order that it may be suc- cessfully carried out. In cases where it is required to dilate the cervical canal extensively, bundles of sea-tangle tents may be employed according to Dr. L. Atthill's suggestion. Such a dilata- tion may be required in order to obtain access to an intra- uterine polypus or fibroid tumor. The slippery elm and tupelo are other materials from which uterine tents are constructed. In introducing a sponge tent, the lateral Sims's position is the best, the Sims speculum being employed and the os drawn down and fixed by a hook. This has also the effect of somewhat straightening the uterus and thereby facilitat- ing entry of the tent. An instrument such as that shown in Fig. 107 is a good sponge tent introducer. Six or eight hours is the proper time for the action of the tent: it must be then removed. Another good tent introducer is Fig. 108, in which a me- 3^2 DISEASES OF WOMEN. Fig. 107. Fig. 108. INCISION AND DILATATION OF CERVICAL CANAL. 363 tallic pointed needle supports the tent during introduction, and is readily detaciied from it when it is well placed in the cervical canal. [The forceps are preferable because the tent can be firmly held at any angle.] In order to procure proper dilatation of the uterine canal, the tent must be made to pass through the internal os uteri and be there maintained while it is at work. Otherwise it is found, perhaps, that the tent has slipped and no material advance is made. The tent should of course be long enough to reach just beyond the internal os ; and it should project a short distance into the vaginal canal. It should be always firmly attached to a silk or strong hemp liga- ture for withdrawal. Another method of dilatation is that known as Mr. Law- son Tait's,* consisting in introduction of a series of three box-wood conical plugs into the os uteri, and applying pressure thereto from the outside by means of an india- rubber elastic band. The first plug is removed after a few hours when it has done its work, and is replaced by a larger one; the second by a third. In this way the canal is grad- ually dilated. The plug is kept in place by a vaginal stem which screws on to the plug, and the elastic band is at- tached to this stem outside the vagina. The elastic thread is fi.xed to a bandage encircling the waist. Metallic Dilators. — These are undoubtedly convenient and efficacious in cases where slight dilatation only is required, and are also very useful in the treatment of chronic flexions, especially anteflexion. A set of metallic bougies regularly graduated, very applicable for these purposes, are now kept by surgical instrument makers. There are various metallic dilators — Dr. Marion Sims's, Dr. Priestley's, Dr. Ellinger's, etc. After having tried several of these, I have found the most serviceable one which I had constructed by Coxeter some few years since, which is a modification of one origi- nally made for the late Dr. Rigby by Mr. Ferguson of Giltspur Street. It is on the principle of a glove-stretcher, and can be inserted wherever the ordinary sound can be made to pass. It possesses a knob like that of the ordinary sound to indicate the depth of insertion, and should also have a slight groove cut on the opposite side for similar purposes. After insertion, the two blades are opened by * Lancet, November i, 1879. 3'^4 DISEASES OF WOMEN. Fig. 109.* Fig. 1 10.* * Fig. log: Graily Hewitt's uterine dilator (reduced). Fig. no shows a lateral view of the part of the instrument which is introduced into the cervical capiil (actual si?e), INCISION AND DILATATION OF CERVICAL CANAL. 365 Fig. III.* Fig. 112.* B * Fig. Ill represents Dr. Priestley's dilator. Fig. 112 represents Dr, Marion Sims's dilator. \66 DISEASES OF WOMEN. a screw slowly and deliberately, and the force exercised is expended at the spot where it is most needed — i.e., the os Fig. 113.* Fig. ii4.f uteri internum. It is an instrument of very great power, and sliould therefore be employed very carefully. It has * Fig. 113 represents Dr. Chambers's stem and apparatus for intro- duction. ("Obst. Jour.," vol. i.. p. 2.) f Fig. 114 represents Dr. Granville Bantock's stem and mechanism of uiiroduciioii. ("Obst. Journ.," vol. xiii., p. i.) INCISION AND DILATATION OF CERVICAL CANAL. 367 the great advantage that it does not slip out of the canal. I employ it frequently, but am careful to do only a very little at a time with it, and generally to allow an interval of two days between each dilatation — that is to say, in cases where the instrument is used for the purpose I most com- monly employ it, in the treatment of a chronic flexion, and with the view of permanently straightening a tortuous and contracted canal. UTERINE STEMS. Uterine stems may be divided into two classes — (i) Those which are intended to be used alone, and (2) those which are used in conjunction with a supporting vaginal disk or framework. Simple Stems. — These are generally provided with a small button-shaped portion, which, when the stem is in position, rests on the vaginal floor. With few exceptions the material employed has been rigid — ebonite (hard rubber), metal of various kinds, and glass (Dr. Meadows). Various Shapes. — Dr. Chambers recommends a modification of the late Dr. Henry G. Wright's stem. It is a vulcanite stem, double; but the two arms are kept together until the stem is inserted by the stylet. Withdrawal of the stylet allows the arms to separate, and the opening out of the two arms prevents the escape of the stem. Dr. Granville Bantock's stem is partly of vulcanite, and the intra-uterine part consists of two arms of German silver; these latter spring apart and retain the stem after introduction. Dr. Clement Godson's stem is of aluminium, made in five sizes; it is retained by a spring within the tube, which pro- jects at apertures near the extremity and within the uterus. Mr. Lawson Tait's stem is a galvanic instrument with a slight projection of india-rubber to act as a retaining agent. Dr. Alfred Meadows's stem is of glass with a small button of ebonite. A quite elastic stem, composed of india-rubber tubing, vi^as recommended by the late Dr. Squarey. Stem with Supporting Vaginal Framework. — The instrument here figured, which has been sometimes termed the " pad- lock" pessary, was devised by myself, and described in the last edition of this work (1872). Fig. 117 shows at b tlie ?68 DISEASES OF WOMEN. Stem of ebonite, one and a half inches in length, the lower portion hollow to admit the inserting stylet. At A is shown the supporting vaginal disk, of an oval outline, having a socket into which the stem fits when in situ. The stem is intended to fit rather loosely in its socket. The plug or stem which I have employed for this purpose is one and three quarter inches long, conical in shape, with a bulbed Fig. 115. ■^ Fig. ii6.t termination. The diameter varies; the smallest has a diameter of three sixteenths of an inch at its bulbed ter- mination. The stem ends below by a broad basis half an inch in diameter, and is perforated for a short distance for facility of introduction, the ordinary uterine sound fitting into the perforation, and acting as a handle. The stem is * Fig. 115 shows Dr. Clement Godson's stem. ("Obst. Journ.," vol. .xvii.. p. 2S6. j- Fig. 116 represents Mr. Lawson Tftit's stem. INCISION AND DILATATION OF CERVICAL. CANAL. 369 retained in its place — for it has a great tendency to slip out — by the oval support, made to fit the vaginal canal. In order to introduce the instrument, the sound, as a han- dle, is passed through the collar of the vaginal framework, and on it is placed the ebonite plug. After the plug is placed in situ, the ring is made to slip up the sound until finally the little plug finds its place in the supporting collar. The sound is then withdrawn and the work is done. Only those who have attempted to introduce rigid plugs into a contorted or contracted canal, and to maintain them there, Fig. 117.* will appreciate the necessity or usefulness of this contri- vance, which I have found to answer extremely well. This instrument is made by Coxeter & Son. I have found that it works well in practice, and it has been very largely employed by Dr. W. Murray of Newcastle-on-Tyne; the vag- inal part requiring to be generally one and three eighths inches by tw'o and three eighths, but sometimes smaller. Dr. Routh's instrument is on the same principle. His stem is articulated to a cross-bar attached to a Hodge pes- * Fig. 117 represents Graily Hewitt's stem pessary (so-called "pad- lock" pessary). B is the stem (actual size): A shows the stem fitted into the supporting vaginal framework (reduced in size). As at present made the framework is more flattened than it here appears. !;o DISEASES OF WOMEN. sar}', its position in regard to which can be regulated by a screw. Dr. Wynn Williams's instrument is another modification of the same principle. In his pessary the vaginal frame- work is of wire, covered with india-rubber, and admits of lateral compression. It has an india-rubber diaphragm per- forated with holes, the stem is set near the distal part of the vaginal supporting framework. In a more recent, im- proved form the stem rests in a cup-shaped depression in Fig. 1 1 8.* the diaphragm. It is very easily applied and is a very ingeniously constructed instrument. Dr. Meadows's instrument is on alike principle, and also allows a certain degree of motion of the stem on the frame- work. Dr. Thomas describes a combination of stem with an anteversion pessary which he has found useful in certain cases. * Dr. Wynn Williams's stem pessary. " Obst. Trans.," vol. xiv., p. 308. PREGNANCY WITH FLEXIONS OF THE UTERUS. 3/1 CHAPTER XXVII. Association of Pregnancy with Flexions of the Uterus. General Observations. — Frequency of Abortions in such Cases: Rea- sons for this — Difficulty of Expansion of the Uterus. Retroflexion AND Retroversion of the Gravid Uterus. — i. Flexiort before Pregnancy occurs — Natural History, Symptoms, and Effects. 2. Flexion occurring after Pregnancy has commenced — Diagnosis — Treatment — Reduction by Positional Treatment; by other Means — Treatment of the Bladder. Anteflexion of the Gravid Uterus— a Frequent Condition and a Frequent Cause of Abortion. — i. Cases where the Anteflexion occurs after Pregnancy has begun — 2. Anteflexion precedes the Pregnancy — History of these various Cases — Reasons why the Complication is not generally recognized as an important one — Diagnosis — Severe Nausea a Common Symptom — Author's Views on ihis Subject — Retention of Portions of Ovum another Result of the Flexion — Treatment in various Cases according to severity of the Case — Elevation of the Uterus, how to be effected — Relief of the Sickness — Mains operandi of the Treat- ment — Dr. Copeman's Method — Dilatation of the Cervix for Cure of Sickness discussed and explained. Subsequent Treatment. The subject of the association of flexions witli pregnancy is a very interesting and important one. Retroflexion of the uterus associated with pregnancy has been long known; but concerning the association of anteflexion with preg- nancy little has been published. When the uterus is in a flexed condition pregnancy may not occur at all. When pregnancy does occur under such circumstances, the result varies in different cases. It is necessary to point out, and to endeavor to explain, the various results observed in different instances. If tiie flexion be slight in degree and not of long duration (say not over two years), pregnancy may proceed to the full term. It is generally, however, noted in such cases that the early part of the pregnancy is attended with a troublesome amount of nausea, and there may have been o;!ier discomforts observed as soon as pregnancy set in. When the flexion is more chronic or more severe in de- gree, it generally happens that an abortion occurs during the second, third, or fourth month. The pregnancy may begin before the uterus becomes affected with flexion. There are instances in which the 3/3 Diseases of women. uterus, having been in a normal condition, becomes gravid, and soon after falls into a flexed condition. In cases where abortion happens during the early months of pregnancy, we cannot tell without a careful inquiry into the previous history aud other facts whether the flexion followed the pregnancy or preceded it. Abortion is a very frequent result of the association of pregnancy with uterine flexion, and such association is really the most common of all the causes of abortion. The reason why abortion is so liable to occur in cases where the uterus is flexed appears to be, principally, the interference which the distortion of the uterus offers to the proper expansion of the cavity. But the distortion would have very much less influence than it is found to have if the body of the uterus were free to move. Owing to the action of gravity on the one hand, and the hindrance offered to the ascent of the uterine fundus by the sacral promontory (in cases of retroflexion), and by the symphysis pubis (in cases of anteflexion), the uterus is, however, not free to move and expand in the normal manner. If we suppose the uterine walls to be in a condition of health, the conditions just mentioned above would be the only ones to be considered. Given freedom to expand and space in which to expand, there would be no reason why the uterus, though bent upon itself, should not unbend, expand, and do its proper work in the ordinary manner — the above difficulties being removed. But in many cases we have further obstructive conditions. When the flexion is a chronic one, the uterine walls are liable to become changed in thickness, and in other respects. Too thick in some parts, unduly thin in others, corrugated, compressed, sometimes constricted on the peritoneal surface by adhesive bands, — under such circu mstances the expansion of the uterus is a matter of difficulty, and an abortion may result at an early period of the pregnancy. There are good reasons for believing that in some cases the difficulties in the expansion of the uterus, though not immediately resulting in expulsion of the ovum, produce interference with the placental growth in such a way that premature labor and delivery of a dead child occur later on. The hardening and compression of the uterine tissues re- sulting from flexion are more particularly liable to be pres- ent near the os uteri internum, and there are various curious PREGNANCY WITH FLEXIONS OF THE UTERUS. 373 clinical facts hereafter to be mentioned which are only to be interpreted by supposing a condensation of the uterine tis- sues to exist at this situation. If the puckering and con- densation be considerable, it is evident the uterus may be so held and maintained in its distorted condition that ex- pansion of the organ is difficult. The difficulty in question finds a solution, in many instances, in the occurrence of abortion. But a further result of the existence of acute flexion is probably actual disease of the decidua vera, and consequent abortion brought about in this way. The growth of the decidua, wliich is a part of the natural process of preg- nancy, cannot proceed normally at certain situations, and, as has been shown by examination of actual specimens, it may become actually disorganized, and thus lead to the occurrence of abortion. Such is probably the explanation of two very interesting observations made by Dr. Slav- jansky, and published in 1873, entitled " On Endometritis Decidualis Chronica as a Cause of Abortion in some cases of Displacement of the Pregnant Uterus." * AH cases of uterine flexion in which pregnancy occurs are not followed by abortion, but it is mechanically almost impossible for pregnancy to continue if the flexion be un- relieved. As a matter of fact, many cases of this kind are so relieved; the uterus becomes straight by expansion. In others the flexion remains, and as the uterus goes on ex- panding the result is in many cases to actually increase the flexion. RETROVERSION AND RETROFLEXION OF THE GRAVID UTERUS. Desgranges (1715), Gregoire (1746) and William Hunter (1754), described cases of " retroversion" of the gravid uter- us. Gooch in his lectures (quoted by Ashwell, " Disear.cs of Women," p. 597) gives a full narrative of William Hun- ter's celebrated case. In this case the patient was four months pregnant, when she began to suffer from retention of urine. This was relieved by catheter but again occurred. Mr. Wall, who was the medical attendant, recognized the case as one like that published by Gregoire. He tried to reduce the retroverted uterus, but failed, and then sent for William Hunter, who recognized the nature of the case also, and * Paper read before the Obstetrical Society of Edinburgh, July, 1873. 374 DISEASES OF WOMEN. attempted reduction unsuccessfully. There was obstinate constipation. The patient died in a few days. A second case, it appears, occurred soon after, and the patient could pass neither urine nor faeces. The catheter could not be introduced; it was proposed to puncture the bladder; the patient refused, and at length felt something burst, which proved to be the bladder, and she expired in a few hours. In both these cases the state of the uterus was substantiated by an autopsy. In Ashwell's work will be found recorded several of the most interesting cases of retroversion of the gravid uterus which have been observed since William Hunter's case, in- cluding some noted by himself. • These cases made evident the great importance of the retention of urine and faeces as clinical features of such cases; for death was usually found to occur either from irritation, by inflammation involving the peritoneum, or by rupture of the bladder. Great relief always occurred when the bladder could be emptied, and in some cases, when the disease was detected early, rectifi- cation of the uterus followed the careful daily evacuation of the bladder. On the other hand, evacuation of the bladder, when effected, did not always ensure the possibility of reduction of the displacement. Thus in one case (Mr. Wilmer's) the bladder was relieved, but death soon occurred, and the uterus was found so firmly wedged in the pelvis after death that it could not be raised up till the symphysis pubis had been sawn away. In Dr. Ashwell's time he found reason to blame the little importance attached by author- ities to replacing the uterus, and he forcibly directs at- tention to the advisability of reducing the displacement, and at as early a period as possible. He also gives direc- tions for accomplishing it which we have hardly improved upon since his time. Ashwell used and recommended careful pressure upward, the patient being in the knee-and- elbow position. The pressure was to be made by the fingers in the vagina or, if that plan did not answer, in the rectum. Dcnman, followed by Blundell, also employed the knee- and-elbow position, and speaks of it as sufficient, if kept up sufficiently long to procure the reduction of the uterus, provided that the bladder be kept empt)'. But Ashwell disbelieved the efficacy of this positional treatment alone in severe cases. As to the difficulty in introducing the catheter sometimes PREGNANCY WITH FLEXIONS OF THE UTERUS. 375 found to occur, Ashwell states that a long flexible male catheter can always be employed without delay or suffer- ing. Should it be impossible to use the catheter the supra- pubic puncture of the bladder is required. In a case re- lated by Ashwell eleven pints of ammoniacal urine was obtained by a long catheter, the uterus was reduced, but abortion and death in five days followed. An interesting paper by the late Dr. Phillips is recorded in vol. xiv. of the "Obstetrical Transactions," "On Retro- flexion of the Uterus as a frequent cause of Abortion." Dr. Gervis also communicated some most instructive cases to the Obstetrical Society, recorded in vol. xvi. of the " Ob- stetrical Transactions." The discussion which followed the reading of these papers may be consulted with advantage. The dislocation is primary or secondary. Formerly it appears to have been taken for granted that it was always a primary affection. The late Dr. Tyler Smith was one of the first to point out that the flexion frequently precedes the pregnancy. It is now well known that this view is ac- curate so far as a large majority of cases is concerned. But, on the other hand, tlie dislocation is also undoubtedly pri- mary in some few instances. In the chapter on Retroflexion of the Uterus some ac- count has been given of the frequency with which abortions occur in cases of this disease. I. Castas in which Flexion precedes the PregJiancy. — Tlie natural history of cases when pregnancy occurs in a case of retroflexion is as follows: Pain is usually felt more or less from the commencement, or there is at all events a sense of discomfort, bearing down and weight, and inability to move without producing pain. Difficulty in defaecation, due to the pressure of the body of the uterus on the rectum, is commonly observed. Nausea, sometimes to a most dis- tressing extent, is commonly present. In some cases it is the most severe of all the symptoms. (The connection of obstinate vomiting with existence of retroflexion of the gravid uterus will be discussed later on.) As the preg- nancy advances these symptoms increase in severity, and it is found difficult to pass urine, the bladder is liable to be- come distended, and there is retention. In not a few cases, the fact tliat the patient passes urine very often disguises the real nature of the case and conceals the existence of re- tention. By the third month, the uterus, being now of con- siderable size, exercises great pressure on all the organs and 37^ DISEASES OP WOMEN. structures near it. At this time, or before this time in a few instances, nature shows herself equal to the emergency and the uterus rises upward, the posterior rotation dimin- ishes, and relief of the symptoms follows. But if the pa- tient be not thus relieved naturally, and if its true nature be not understood, one of two events results — either (i) the uterus throws off the ovum and abortion occurs; or (2) the uterus continues to expand, though under increasingly un- favorable conditions. The whole pelvis is occupied by the uterus. The cervix is tilted high up above the symphysis pubis, and the bladder becomes so much dilated by the re- tained urine that it may reach to a point above the umbili- cus. All the symptoms increase in intensity. The pressure is exceedingly painful, labor-like forcing pains are experi- enced, the rectum is impassable, the urine escapes in drops onh', the ureters probably undergo dilatation, and the pelves of the kidneys also. The sickness may be incessant, the prostration extreme, the pulse quick and small, and irrita- bility alternating with great exhaustion (see chapter on Vomiting of Pregnancy). When this latter condition of things persists up to the fifth month death may result from the accumulation of evils then present: there is fever, quick pulse, gradual prostration, uraemia probably; in some cases rupture of the bladder may occur and destroy the patient. A third course is sometimes observed: the uterus continu- ing to expand sends an extension upward into the abdomen, and does in fact become partly an abdominal organ; but at the same time the part within the pelvis remains there. The uterus thus acquires a curiously abnormial shape; and in the celebrated case related by Dr. Oldham* no abortion occurred, but the uterus continued to retain this shape until the full term of pregnancy had been reached. Rectification of the position, as already remarked, some- times occurs naturally, and if so, it generally happens before the fourth month has been reached. The larger the uterus the greater the difficulty offered to the elevation of the now greatly distended organ, owing to the projection of the sacral promontory. It seems probable that the great dis- tension of the bladder sometimes operates at a critical mo- ment in preventing the rectification. The rectification may occur suddenly or gradually. The disturbance of the functions of the bladder are among * " Obst. Tr.ins.," vol. i. PREGNANCY WITH FLEXIONS OF THE UTERUS, m the most serious of the effects produced by retroflexion of the gravid uterus. The distension of the bladder and irri- tation of its mucous membrane sometimes produce actual exfoliation of the lining, and even when this does not occur the lining may become seriously damaged. The whole lin- ing has in some cases come away in a single piece. When the condition is unrelieved tlie distension, beginning at the bladder, extends up the ureters and affects the pelves of the kidneys, in some cases causing fatal arrest of the kidney functions. As already stated, rupture of the bladder has occurred in some cases. Certain peculiarities of the subsequent history require notice. Thus, it frequently happens that when abortion occurs the abortion is an incomplete one, the foetus being expelled but the membranes left behind. The retort shape of the uterus favors retention of the thickened bag of tlie ovum, and it may be some days or even longer before it is expelled. Septicaemia may follow. Further on still, the condition cf the uterus is liable to be rendered worse than before. The uterus, having discharged its contents, but being considerably enlarged and retaining its flexed condition, the process of involution is arrested and much additional trouble results; so that a retroflexed uterus which has become impregnated and has thrown off the ovum is liable to become even more flexed, and to give rise to more irritation than before. We sometimes meet with cases where there have been a succession of abortions from this cause, the uterus becoming finally so much dis- torted that pregnancy ceases to be possible. 2. The Flexion and Displacement occur after Pregnancy has commenced. — An accident, such as a fall, or lifting a heavy weight, or a continuous exertion of any kind, may suddenly produce retroflexion of the gravid uterus. There are several well-recorded cases of this kind, where the uterus was ap- parently in a sound state previously and was evidently afterward displaced. And the displacement may occur as late as the fourth month — possibly even a little later. Once produced, the symptoms and course of the affection are similar to those in the former class of cases. The chief difference is that the symptoms usually set in with abrupt- ness when the displacement happens after pregnancy has commenced. The diagnosis of the existence of retroflexion of the gravid uterus is most important, for very serjf>"<: results may fcl- 378 DISEASES OF WOMEN. low from its being overlooked. The diagnosis is not diffi- cult if a proper examination be made. The tilting upward of the OS uteri behind the pubes, the difficulty of reaching it, the evident displacement of the bladder upward, are easily recognizable in most cases. The presence of a large tumor above the pubes when the bladder is distended is rather misleading, for it has been sometimes taken to be the normally placed gravid uterus. A vaginal examination is imperative; and tlie rounded tumor of the uterus behind the vagina, reaching down, it miglit be, close to the vaginal outlet, is easy to appreciate by the touch. The only diffi- culty is in deciding that the tumor so felt behind the vagina is really the uterus, for it might be due to haematocele or to hardened effusion, the result of pelvic cellulitis, or possibly be an ovarian cyst. The use of the catheter would, of course, clear up any doubt as to the nature of the abdom- inal swelling felt above the pubes. It is to be remarked *Fig. 119 represents the gravid uterus in a state of retroflexion at about four months of pregnancy. PREGNANCY WITH FLEXIONS OF THE UTERUS. 379 that the tumor felt behind the vagina may be a little to one side of the middle line, but when the pregnancy is farther advanced it is median. The treatment is not difficult when the malady is recog- nized at an early date. Take, for instance, the case of a patient six weeks preg- nant, the uterus being retroflexed. Here the treatment con- sists in gradually pushing up the fundus uteri by pressure from behind, or aiding its ascent by positional treatment alone. If the retroflexion is not of long standing, posi- tional treatment — i.e., avoidance of sitting, occasional knee- and-chest position — may prove sufficient. Generally, how- ever, it is best to insert a Hodge-shaped pessary. A rather thick pessary of the Albert Smith type, is best for this pur- pose. Such an instrument, properly fitted, is most effica- cious. The pessary is worn till the middle of pregnancy, and is then removed. It has happened in my experience many times that patients under treatment for retroflexion liave become pregnant while wearing a pessary of this kind. Under such circumstances it has been my practice not to remove the pessary until about the middle of pregnancy. Taking a case where the pregnancy has advanced to three months, or a little beyond that time, the patient in a condition of much suffering, and the nature of the case only for the first time recognized, the treatment is more difficult. The bladder should be first relieved, and the uterus replaced as soon as the circumstances of the case render it possible. Sometimes it is found practicable to effect the reduction at once. In other cases the uterus has become so fixed by the swollen condition of the tissues ad- jacent, or so jammed down in the pelvis by the actual size of the uterus, that, without exercising a good deal of force, a rapid reduction is not advisable, or even possible. In cases where the condition of the patient has become a really critical one, and the constitutional and other symp- toms of very intense character, it may be advisable to defer operative reduction for twenty-four hours after the use of the catheter. Indeed, there appears to be danger in sud- denly removing a very large quantity of urine from the bladder and simultaneously attempting the operation of re- duction of the uterus, on account of extreme shock liable to be produced. It remains to be pointed out how the reduction is to be effected. One method consists in placing the patient in 380 DISEASES OF WOMEN. tlie knee-and-chest position, opening the vagina by the Sims speculum, and allowing air thus to pass into the vagina. Dr. Munde * records a case where this procedure succeeded at once in the case of a patient eleven weeks pregnant. The same author refers to a case where Dr. Solger,of Berlin, had a like result in a patient four months pregnant. The manoeuvre is one first suggested by Dr. Campbell, of Georgia, for reduction of retroversion (non- gravid condition). This method would probably not suc- ceed where there is great swelling and compression of the adjacent tissues. Another method consists in placing the patient in the same position (as practiced by Denman and Blundell), and then exercising pressure on the uterus from the vagina by means of the fingers; or the pressure may be made from the rectum in the same way. A sustained pres- sure thus made has generally been found to answer ex- tremely well. A round india-rubber air ball introduced into the rectum and distended with air offers a means of producing continuous pressure in a convenient direction, and it is a method which has also been found successful. Unless the case were one of extreme character, one or other of these methods could be adopted, the pressure being graduated according to circumstances. If too much force be employed there is a risk of inducing abortion. In the ver}'^ worst cases, the patient being in extremis, and the case practically untreated previously, it would be best to evac- uate the uterus by drawing down the os uteri with the finger, breaking the membranes, and allowing an abortion to occur. After reduction of the displacement a pessary should be introduced to prevent possibility of recurrence, the pessary to be removed at mid-term of pregnancy. Various precau- tions are requisite in the treatment, w-ithout which failure may result. The horizontal position must be rigidly main- tained in most cases for two or three weeks after the reduc- tion, and it will be a help to direct the knee-and-chest posi- tion to be employed five or six times a day during this time. The bowels must be kept in good order by daily enemata. The sitting posture is the worst of all; a little walking is far less objectionable. As regards the pessary to be worn, it is sufficient to refer the reader to the chapter on Retroflexion for information. It is best to employ a * "Am. Obst. Trans.," vol. ix., p. 293. PREGNANCY WITH FLEXIONS OF THE UTERUS. 38 1 pessary rather thicker, though not necessarily larger, than in cases where the uterus is in a non-gravid state. We have not yet done with the subject. It is found that when pregnancy is over, the uterus has frequently a great tendency to return to the retroflexed state. In one case some time ago under my care, the displacement returned no less than three times after three successive pregnancies. The following was the order of events: retroflexion with gravid uterus, treatment by pessary, removal at mid-term, pregnancy continuing to full term; uterus found returning to retroflexed condition a month after delivery, insertion of the pessary, pregnancy recurring during the wearing of the instrument, removal at mid- term, etc. This is by no means a solitary case, and convej's a lesson as to the neces- sity for precaution in the subsequent management of such cases. ANTEFLEXION AND ANTEVERSION OF THE GRAVID UTERUS. There can be no doubt that the most common cause of abortions is the presence of anteflexion of the uterus. The result of observations extending over many years has at least convinced me of the truth of this statement. That it is not as yet a matter of general professional belief is due to the fact that cases of anteflexion of the non-gravid uterus are often passed over and not recognized as such. The following is a very characteristic case related by Boivin and Duges: * Anteflexion at the Beginning of Pregnancy. — A young woman aet. 24, third pregnancy, the last four years previously, one only at full term. Supposed now to be in second or third month. In a few weeks the os descended lower than usual. The cervix uteri lay on internal surface of coccyx. There was a rounded tumor somewhat larger than the natural size of the fundus uteri, and painful when pressed, situated between the anterior parietes of the vagina and the blad- der. It was the body of the uterus directed horizontally forward and recurved at a right angle upon the cervix; a deep sinus into which the top of the finger was easily in- serted answered anteriorly to the point of the flexion. This was owing to a firm contraction of the tissues; for upon pushing the body of the uterus the cervix was raised with *" Diseases of the Uterus" (translated by Heming, 1834), p. no. 382 DISEASES OF WOMEN. it. The cervix not at all congested, but longer than usual, labia prominent, especially anterior, and its orifice open. In a few weeks pregnancy no longer doubtful; later on cer- vix found higher up, the body of uterus stilT inclined on cervix; intervening fold much diminished. No doubt the anteflexion would cease as cervix, expanding, became short- ened. Equally characteristic is the following, related by Ash- well: * Anteflexion in Early Pregnancy. — The wife of a medical man, aet. 36, in first month of pregnancy fell from a steep stair, the bowels being at the time very constipated. No haemorrhage, but syncope for an hour. For six or seven weeks she was never free from a heavy bearing-down sen- sation in front, rendering micturition frequent and painful, defaecation not improved. She was irritable and feverish. The husband thought the womb was retroverted. At the end of third month I found the cervix uteri in its natural position, but not so the fundus, which, in the form of a rounded and solid tumor, was lying forward between the anterior wall of the vagina and the bladder. She com- plained of pressure at the part when the body was curved. The cervix was elongated, fuller and harder than natural; the OS open. I placed the fingers of my left hand behiml the pubis, endeavoring in this way to reach the fundus, while with the forefinger of my right hand I tried to draw the cervix downward and forward. I did not succeed, and no further manual efforts were made. Care was taken that she observed the recumbent position for a month. An ex- amination at the sixth month satisfied her husband that the curvature had nearly disappeared, and though not dur- ing the pregnancy ever quite free from suffering, she was delivered without difficulty and recovered remarkably well. There are two classes of cases — (i) those in which the uterus was in a normal condition when the pregnancy be- gan, and (2) those in which the uterus was anteflexed be- fore the pregnancy commenced. I. Anteflexion occurring after Pregnancy has begun. — This is not so common a condition as the following one, but it is by no means rare. A sudden jerk, or blow, or fall, or a long-continued exertion of any kind, may displace anteri- orly the gravid uterus. An accident severe enough to pro- *" Diseases of Women" (1S44), p. 596. PREGNANCY WITH FLEXIONS OF THE UTERUS. 383 duce such a result very frequently has the further result of inducing an abortion; but in some instances the abortion does not happen at the time; the patient feels ill, and as the pregnancy proceeds becomes worse, and very possibly an abortion occurs a month or two later, or, under favorable circumstances, pregnancy ends at the proper time. 2. The Antefiexion precedes the Pregnancy. — When the ante- flexed uterus becomes gravid, it frequently happens that it is able to expand, and to rise up out of the pelvis; and so the pregnancy proceeds, at first with more or less difficulty, but later on without difficulty. The obstacle to the eleva- tion of the uterus in process of expansion is less than in the case of the retroflexed uterus. Taking indiscriminately one hundred cases of anteflexion and one hundred cases of retroflexion it might be predicted that an abortion would certainly occur more often in the latter class of cases tiian in the former. The promontory of the sacrum hinders re- duction of the retroflexed gravid uterus, but the symphysis pubis does not project so as materially to interfere with the elevation of the anteflexed gravid uterus. Thus abortion is not so frequent a result in cases of anteflexion as in cases of retroflexion. Yet in regard to absolute frequency of abor- tions anteflexion stands before retroflexion. Absolute in- carceration of the gravid uterus is not, for the reasons just mentioned, so liable to occur in anteflexion as it is in retro- flexion. But nevertheless such incarceration does some- times occur. When the incarceration occurs it is more generally for a limited period only, the uterus either (i) ris- ing up out of the pelvis, or (2) expelling its contents, and in either case the patient becomes relieved. Fatal incarcera- tion, such as may occur in retroflexion, is very rare. Ulrich, however, records a remarkable instance of it. The case will be given in full in the chapter on the Vomiting of Pregnancy. In this case the condition was recognized during life, but the attempts at alteration of the position of the uterus failed. The uterus lay in this case obliquely across the pelvis. This oblique position appears liable to occur as the pregnancy proceeds, seeing that the oblique diameter is longer than the antero-posterior, and there is more room, therefore, in the oblique position. The history of many cases is as follows: The uterus is anteflexed in the first or second degree, with first degree of anterior rotation. Pregnancy occurs. An unusual de- gree of nausea is observed almost from the moment preg- 384 DISEASES OF WOMEN. nancy begins. There is great frequency of micturiilon. Walking and sitting aggravate both of the latter symptoms. The patient is more or less uncomfortable in other respects. This condition persists up to the middle of the third month. Then the symptoms undergo a change — either improve, or become very much worse. If they improve, that indicates that the bend in the uterus has given way, the organ is expanding more easily, and rising up out of the pelvis. If, on the contrar}', there is intensification of the symptoms, this means that incarceration is present. The incarceration is perhaps only temporary; at the end of a few days the expansion does the work required and the uterus rises xip- ward. In another set of cases the history is as follows: The uterus has been anteflexed for some time. It is hard, rigid, and firm in texture. Pregnancy occurs. Instantly great pain is felt; nausea is very troublesome, so also fre- quent micturition. The patient continues to go about; the uterus is not kept at rest; at the end of about two months abortion occurs. In some cases the patient loses blood from time to time, the indication often of impending abortion, but not of course necessarily so. The difficulty in cases such as above described arises from three sources — (i) The hardened, contracted condition of the uterine tissues (in chronic cases). (2) The down- ward pressure of the abdominal viscera. When these two difficulties are conjoined the result is more likely to be un- favorable. Experience shows that while in many cases re- moval of the latter source of difficulty by keeping the patient in the horizontal posture is successful in averting an impending miscarriage, there are others in which this precaution alone is insuflficient. (3) A further source of difficulty in some cases is the cedematous effusion surround- ing the uterus. I first became aware of the importance of this subject about eighteen years ago. A lady who had been .treated by me previously for anterior displacement became preg- nant, and soon after the beginning of the third month presented all the symptoms above described. The uterus was incarcerated in the pelvis, there was considerable cedematous swelling of parts surrounding the vulva, and the uterus was jammed downward behind the symphysis pubis. The horizontal position, kept up for a week or PREGNANCY WITH FLEXIONS OF THE UTERUS. 3S5 ten days, relieved the symptoms, and pregnancy proceeded to about eight months when the patient was delivered of a Fig. 120.* dead child. Since then I have seen many such cases, and have become impressed with the conviction of the extreme * Fig. 120 represents anteflexion of the gravid uterus at about the fourth »nonth of pregnancy. 386 DISEASES or '\VOMEN< importance of anteflexion as a cause of abortion, and liave obtained valuable information as to the means of preventing it. DIAGNOSIS. This presents little difficulty. The patient is usually known to be pregnant. The pain and distress, together with the nausea, announce that pregnancy is not proceed- ing normally. Unless an examination be made, it is diffi- cult to say whether retroflexion or anteflexion be present. The position of the os uteri, which is very far back, and the presence of a dense resisting tumor (the anteflexed body of the uterus) felt through the vaginal roof, indicate the nature of the case. The uterine tumor is rounded, elastic, generally symmetrical, and usually in the middle line; but as the uterus increases in size it comes to occupy an oblique position in one of the oblique diameters in the pelvis. This oblique position was present in Ulrich's fatal case, and I have observed it in two cases. A case of extra-uterine pregnancy might present somewhat similar symptoms, but the tumor enclosing the foetus would be probably unilateral. It must be recollected that in ordinary normal pregnancy the uterine body would be, say at the end of two months, rather readily felt by the exploring finger through the vaginal roof, but it should not of course be jammed down- ward behind and close to the symphysis pubis. There is a perceptible interval between the uterus and the pubic bones when the gravid uterus is in a normal state at the end of two months. In the chapter on Anteflexion and Anteversion statistics are given as to the frequency of abortions due to this con- dition of the uterus. The repetition of abortions is a notable feature — thus four or five times in succession the abortion may occur. The success in arresting the occurrence of abortion by treating the anteflexion is one of the man}- argu- ments adducible in favor of the above views. A most interesting feature in cases of anteflexion with pregnancy is the great frequency of obstinate nausea under these circumstances. It may be predicted, almost with certainty, that if a patient affected with anteflexion becomes pregnant she will suffer severely from nausea during the early part of the pregnancy. We now and then meet with cases when the patient is suffering from what is PREGXAXCV WITH FLEXIONS OF THE UTERUS. 387 termed uncontrollable vomiting in pregnancy. These are generally cases of the kind liere alluded to — viz., cases of severe anteflexion associated with pregnancy. Not always of anteflexion, because in some cases there is retroflexion; but practically it may be said that anteflexion is chiefly re- sponsible for these cases of severe vomiting. The special significance of nausea in relation to preg- nancy will be found fully discussed in the following chap- ter. It may be mentioned that another result connected with Fig. 121.* abortion is the reteniioii of the ovum in the uterus after its death. For instance, a patient has a miscarriage due to anteflexion: the ovum dies and the patient loses perhaps a great quantity of blood. In a certain number of these cases the ovum will remain in the uterus a considerable number of days, and the reason it does not come away is that the shape of the canal prevents it. Unless properly assisted, there occurs a considerable delay in its escape from the uterus. The difficulty results from the acutely flexed state of the organ, and the knowledge of this fact is the secret of success in the treatment of such cases of retention * Fig 121 represents the condition of the uterus when distended by a retained ovum or clots in a case of anteflexion. 388 DISEASES OF WOMEN. of the ovum. The cavity of the uterus may become cort- siderably distended by blood or clots, as shown in the an- nexed figure (Fig. i2i). In these cases of miscarriage, if the ovum is retained, a frequent result is that it becomes putrid, and gives rise to an offensive discharge which may continue for some time. When, however, the uterus is artificially straightened, the ovum is generally easily evacu- ated, and the offensive discharge ceases. Such retention of part of the ovum may occur equally in anteflexion and retroflexion of the gravid uterus. With reference to the im- portance of this relation subsisting between retention of the ovum in early miscarriages, and flexions, I do not hesi- tate to say that, since my attention has been directed to the mechanism of these occurrences, I have not seen a case in which the relation described has not been most obvious. The difficulty in relieving the patient and putting an end to her various discomforts has ceased on taking measures to straighten the canal, and thus allowing the uterus to exert advantageously the proper expulsive action on its contents. TREATMENT. In simple cases, where the symptoms are not severe and the patient has not had an abortion, the following treat- ment will probably prove sufficient: The patient should be instructed to avoid all severe exertion until after the end of the fourth month; she should avoid the sitting position whenever practicable; carriage exercise only in the recum- bent position; short walks to be preferred; as a rule, the patient to use a chair with a very sloping back, or the sofa; nothing tight to be worn over the abdomen; and the bowels to be carefully regulated, so as to avoid any straining effort. In more severe cases the patient must at once take to her bed in order to have the advantage of perfect rest in the horizontal position. If relief of the symptoms does not follow very speedily — i.e., within a day or two — it may be necessary to assist the elevation of the body of the uterus. This may be done best by inserting a small air-ball pessary about one and three quarter inches in diameter into the vagina, and inflating it to two inches with air. This may be left in situ for twenty-four hours, and then removed and reapplied if necessary. To aid in the elevation of the uterus a pillow may be placed under the pelvis for an hour PREGNANCY WITH FLEXIONS OF THE UTERUS. 389 at a time, the head being only slightly raised. I have fre- quently employed a cradle pessary in severe cases of ante- flexion of the gravid uterus, removing it when pregnancy has reached the end of the fourth month. In several cases, this instrument having been used to remedy the anteflexion, the patient has continued to wear it uninterruptedly up to the end of the fourth month; but I do not recommend that, in such cases, the cradle pessary should be employed in a haphazard way, or by any one not accustomed to its use. I regard the positional treatment above described as quite essential in such cases. A remarkable proof of the adequacy of the explanation of the occurrence of severe sickness in pregnancy is afforded by the success of this positional treatment in relieving the patient: for I have records of many cases where the sickness has been relieved almost at once by mere positional treatment alone. The very severe class of cases remains to be considered — that, namely, in which the condition of the patient is criti- cal owing to long-continued and irrepressible vomiting. These cases present themselves almost (but not quite) without exception just before the mid-period of pregnancy. It is in this class of cases that it has been thought right to advise the induction of abortion in order to save the pa- tient's life. The late Dr. Copeman of Norwich, a few years ago found that by dilating the cervical canal of the uterus the nausea is arrested. He had dilated the cervix as pre- paratory to the evacuation of the uterus; but the day after the dilatation, as the nausea had disappeared, it was not necessar}' to complete the process, and the patient had no more sickness. He repeated the operation in other instances with a like result — finding thus, as he believed, an im- portant and valuable means of arresting the vomiting in these dangerous cases. A more particular account of these cases and of the deductions to be drawn from them will be found in the succeeding chapter. A perusal of the particulars of his cases will, I believe, sustain the belief that they were cases of anteflexion of the uterus, coupled in some instances with very marked rigidity of the cervix, and great resistance and firmness of the structures around the internal os uteri; in other words, that the uterus was either markedly anteflexed, or that there was hypertrophy and contraction, the result of pre-existing flexion of the uterus. The success of the procedure, which Dr. Copeman him^ 390 DISEASES OF WOMEN. self did not attempt to explain, is to be accounted for as follows: (i) These are cases, usually, of anteflexion, the os is far back, the body of the uterus low down behind the symphysis. Now it is impossible to introduce the finger — indeed, any dilating agent — into the cervical canal without drawing forward the os uteri; equally impossible to draw the OS uteri forward without at the same time dislodging the uterus from its abnormal position; in other words, the procedure of dilatation of the cervix had as one of its re- sults the rectification of the position of the uterus. (2) The actual dilatation of the cervix uteri. This dilatation, in cases where the cervix is contracted and hardened by pre- vious disease, releases the tension of the parts, and, in fact, it does artificially what the uterus has been vainly trying to do before for itself. Experience has shown that this con- dition of things is liable to be met with in certain cases, and they will probably be almost invariably found to be cases where there has been marked flexion of the uterus previously, and generally cases in which there have been previous pregnancies. Two kinds of difficulty may be met with in cases of ante- flexion of the gravid uterus: (i) The position of the uterus cannot be rectified, or (2) the cervix is very hard and con- densed, and hypertrophied. The two difficulties may be met with in conjunction or separate. When the condition of the patient is a critical one, it may be assumed that one or both of the difficulties described exists, and requires mechanical assistance. 1. As regards the liberation of the uterus. Carefully applied pressure will hardly ever fail in elevating the uterus, and in cases where this is impossible the method of pres- sure by use of an elastic, air, or water pessary in the vagina may be tried. It is to be expected that, in some cases, one or two days or more might be required to effect the reduc- tion, the pressure being gradually increased from time to time. 2. Concurrently with the rectification of position of the uterus, or separately, or subsequenth^ as circumstances might indicate, the dilatation of the cervix may require to *be performed. The best means of accomplishing it will be described in the next chapter on the Treatment of the Vomiting of Pregnancy. I have in my own practice only had occasion to use dila- tation of the cervix once in a case where rectification pure THE VOMITING OF PREGNANCY. 39I Riid simple failed in relieving the nausea. In this case the uterus was exceeelingly hard and almost cartilaginous, and the nausea persisted in spite of rectification of the anteflexion. In this case I adopted the dilatation method of Dr. Copeman and found the tissues around the internal OS very unyielding, and the dilatation was effected with the greatest difficulty. The nausea became relieved, but abor- tion followed in this instance. SUBSEQUENT TREATMENT. When abortion has occurred in consequence of anteflex- ion of the uterus, the malady is likely to become much exaggerated afterward, unless care be taken to prevent it. Tlie patient must be kept in the horizontal position for some days after the abortion and means taken to promote tlie involution of the uterus in a proper manner. If no care be taken, the uterus is very apt to settle down, as it hardens and contracts, into a condition of flexion even worse than existed before; and a repetition of abortions produces chronic hypertrophy and exaggeration of flexion, and the other usual effects of these complications. A few days after tlie abortion is over, and before tiie uterus has firmly contracted, is an excellent opportunity for moulding the organ into a better shape, and at that time a pessary may often be employed wtth great advantage. CHAPTER XXVIII. THE VOMITING OF PREGNANCY. Author's Explanation, and Paper on Subject in 1871. Severe or Dangerous Vomiting in Pregnancy. — Historical and Criti- cal Inquiry into the Subject, with Summary of Observations recorded by Others — Account of Cases published — Dr. Copeman's Cases: Ex- planation of these — Cases observed by the Author — Aubert's Observa- tions on Influence of Movements of Uterus in producing Nausea — General Rhume of the Subject. Treat.ment of the Vomiting of Pregnancy. The subject discussed in the present chapter is one which more usually finds a place in works on the subject of mid- wifery, but the close connection which appears to subsist between the presence of distortion of the uterus and the 39^ DISEASES OF WOMEN. occurrence of severe vomiting in pregnancy renders it de- sirable to discuss the question as a sequel to the preceding chapter, wherein the association of flexions of the uterus with pregnancy has been considered. In a paper presented to the Obstetrical Society of Lon- don, 187 1,* I ventured to offer an explanation of the cause of the vomiting of pregnane)'. Nausea and vomiting are associated with pregnancy. Nausea and vomiting are associated with disease of the uterus. Both these propositions are true But nausea and vomiting are not akvays present in cases of pregnancy, nor are these symptoms always present in cases of uterine disease. Looking at the question from a broad point of view, it is quite evident that the condition (whatever that ma}' be) which gives rise to nausea and vomiting in uterine disease is possibly the cause of it in pregnancy. Unquestionably, the occasional obstinacy of the symptom is equally observed in pregnancy and uterine disease. An attentive comparison of the phenomena witnessed in the two, and a close scrutin}' of clinical facts, mutually throw light the one on the other. Having frequently observed severe sickness in cases of flexion of the non-gravid uterus, and observing the occur- rence of marked sickness during pregnancy in the same cases, I was led to the conclusion that the flexion of the uterus is the condition which gives rise to the severe sick- ness in both conditions. Carefully testing the accuracy of this conclusion by observation of cases I was induced to frame the theory that the sickness of pregnancy is due to the combined effects of the increasing distension of the uterus and an associated flexion of the organ. Facts led me to the conclusion that in cases of flexion it is the com- pression undergone by the uterine tissues (markedly by the nerve-fibres) at the seat of the flexion which is the cause of the nausea and sickness, both in the gravid and in the non-gravid state. The patient generally experiences the symptom in ques- tion on first rising in bed in the morning, or while dressing. Why is this ? Is it not because the body of the uterus falls a little downward in obedience to the law of gravity, thereby * " Obst. Trans." vol. xiii. : "The Vomiting of Pregnancy: its Causes and Treatment." THE VOMITING OF PREGNANXY. 393 producing a slight flexion and a compression of uterine tissues at the seat of the flexion? During the first three and a half months the temporary flexion is possible, because the uterus is still in the pelvis. Generally, after tliat time it rises out of the pelvis, and flexion decreases with the de- crease of nausea. Is it not the fact that, for the most part, the liability to nausea and vomiting ceases at precisely this period ? It is also a fact, which will be confirmed by all who make the experiment, that, in ordinary slight cases of nausea and vomiting, by ordering the patient to remain absolutely in the horizontal posture the disturbance ceases. Since the publication of my original paper in 1S71 the subject has much occupied my attention, and many new facts have been recorded by various observers. I propose now to consider the subject as it stands at the present time, giving an account of the principal recorded facts bearing on the subject. The principal interest attaches to those cases in which the vomiting seriously endangers life ; and it is therefore desirable that the facts relating to such cases should be carefully considered. SEVERE OR DANGEROUS VOMITING IN PREGNANCY. A tendency to nausea and vomiting have been from time immemorial associated with the existence of pregnancy — so much so, indeed, that the presence of nausea and sick- ness have come to be regarded as a sign of the existence of pregnancy. In a mild form nausea and vomiting are rather common in the early months of pregnancy ; but as many cases occur in which the symptom is absolutely wanting, it cannot be regarded as essential to pregnancy. As a rule, the degree of nausea or vomiting observed is not severe, only producing inconvenience ; but in a few cases it is ex- ceedingly severe, and becomes dangerous, (i) because of the exhausting effect of the repeated efforts of vomiting, and (2), because of the starvation it produces. The dan- gerous cases are those in which the vomiting is uncontroll- able, and in which it continues for weeks or months. While, therefore, as a rule the sickness of pregnancy is not a matter calling for serious attention, the exceptional cases just alluded to, where the malady is so serious as to imperil life, have been the subject of much attention ; for in not a few instances death has actually occurred as the result of severe uncontrollable vomiting in pregnancy. 394 DISEASES OF WOMEN. Respecting the very severe cases of vomiting in preg- nancy, it is necessary to state, in the first instance, that in the large majority of cases the records of autopsies have thrown but little light on the cause of the excessive vomit- ing which destroyed the patient. In some rare instances lesions of other organs have been encountered, presumably in some measure explaining the sickness ; in some cases the uterus was in an abnormal condition ; but in the large majority of instances no lesion of any kind was found. A good account of the published literature of the subject was given by Anquetin in the year 1865.* More recently f Dr. McClintock has written an essay summarizing the prin- cipal known facts relating to the subject. I. It has been shown that in some of the few fatal cases in which autopsies have been made the fatal nausea was probably due to lesion of some other organ t/iafi the uterus. Under this head may be mentioned — a case recorded by Valleix where chronic gastritis was found to be present (Query — Was the gastritis the result of the vomiting?) ; a case by Taurin, of redness and softening of the stomach ; cases by Dubois, Chomel, and Sandras, of similar character ; a case by Depaul, where cancer of the pylorus was found post mortem j a case by Pipelet, of epigastric hernia ; a case by Lanceraux, where Coesarean section was performed, and after death atrophy of the muscular system and of cellulo- adipose tissues was found to exist ; a case by Trousseau, where scirrhous induration near pylorus was found after death ; a case by Schutbach, where a tumor the size of an ^ZZy near the pylorus, was found in a state of ulceration after death (these cases are quoted by Anquetin). In addi- tion to the foregoing, Anquetin mentions cases of tubercle of lungs (Schilachigla), tubercle of brain (Rayer and De- paul), alterations of mesenteric glands (Sandras), of glands of epigastrium (Blot), fatty degeneration of liver (Chomel), biliary calculi (Taurin), redness of semilunar ganglia of solar plexus (Lobstein), congestion of meninges (Sandras). Burns J gives a case where a biliary calculus was found to be impacted. Robert Lee § gives a case where bronchitis and fever had occurred before the vomiting set in. * " Rev. Mfed." (1865), pp. 205, et seq, j Diihl. Med. Jour^t., May, 1S73. I "Midwifery," p. 265. § "Clin. Med.," p. 107. THE VOMITING OF PREGNANCY. 395 2. Next we come to cases where the uterus was found on post-mortem examination to present something abnormal. Dance * observed two fatal cases — I. In tlie first, death occurred in six weeks; there was found to be pus between the uterus and phicenta, and pseudo-membranous concre- tions between the uterus and decidua; II. in the second, death in twelve weeks; the uterus was found beginninp^ to rise out of the pelvis; its walls were scarcely one and a lialf lines thick, unusually soft, deeply enj^orged, and of a violet- red color. III. In a case by Chomel pus was found on the external surface of the decidua. 3. The next category of cases is that in which some abnor- mal condition of the uterus 7i'as discovered during life. I ha\e collected a considerable number of cases, particulars of which are subjoined, tlie facts of which have a bearing on the present discussion: but there are probably others on record which have escaped my notice. One of the most important cases is the following: I. Case of Vomiting in Pregnancy caused by Retroversion of the Uterus. — Brian records f a most interesting case, for reference to which I was originally indebted to Dr. Barnes, and of which the following is a slightly abbreviated account: X., aet. 25. First pregnancy, six years ago, ended normally; second ended favorably, three years ago, but there was some nausea and slight pains. Soon after recovering, sustained accident, being thrown out of a carriage, and very much frightened. Leucorrhoea then noticed and continued; has had also digestive troubles. Third pregnancy commenced in March, 1856. Vomiting began following month, and in- creased in severity. In May she kept to her bed. Intoler- able gastralgia, constipation, insatiable thirst, no kind of nourishment retainable, next observed; also painful clonic spasms of limbs, profound exhaustion and depression, and sleeplessness. On May 2 first seen by Brian, who was im- plored to procure abortion. Nothing was then done, but Professor Moreau saw the patient, and thought the vomit- ing would cease as the womb rose out of the pelvis. Case now fell under other treatment. On June 9 Brian again in charge of the case, the patient's condition much aggravated; he insisted on a careful examination. No abdominal tumor to be felt, as it should easily have been in the patient's * Rupert. Gen. d Anat. et de Physiolog. f Gaz. Hebdomad., July 18, 1856. 396 DISEASES OF WOMEN. emaciated state. On June 4 Professor Moreau again saw lier, and by vaginal examination discovered existence of incomplete retroversion, fundus deeply lodged in the cavity of the pelvis. "He ascertained that the uterus was impris- oned in the curvature of the sacrum and confined on all sides by the osseus cul de sac, without being able to rise up above the sacral promontory. As soon as he was aware of these circumstances, by a skilful manoeuvre he disengaged the fundus uteri from its abnormal position, causing it to ascend, and thus bringing it into the longitudinal axis of the abdomen." After this operation the patient felt imme- diately relieved, the vomiting ceased, and complete recovery took place. II. Stolz records a case in which the uterus was retro- verted, and the excessive vomiting was at once suspended on replacing the uterus. Eventually abortion was induced. III. In a case by Depaul, at seventh month, it was found that the internal os uteri was completely obliterated. In- cisions were performed, and the child born alive. IV. Clay * records a case of sixth pregnancy, aet. 40, at seventh month. He determined to induce labor. Intro- ducing the finger, he found the uterine cervix so sensitive that the slightest touch produced vomiting. Finding this to be the case, he resolved to try the effects of rest. Patient was kept in bed, and in twenty-four hours could take food. Persistence in the rest treatment produced a perfect cure. The following is a very important and interesting case recorded by Ulrich,f for reference to which I was originally indebted to Dr. Barnes, and which, owing to its being the first recorded case of the kind, is here given in full: V. Anteflexion of the Gravid Uterus; severe Nausea; Death. — Frau Freudenburg, thirtj'-four years of age, had been healthy, and menstruated regularly up to the date of her marriage on April i. Since that date coitus had caused her on each occasion a painful feeling in the abdomen, which soon became so great that she at last resisted all attempts at intercourse on the part of her husband. On April 30 the menses appeared as usual; during May she continued in her usual health. At the end of May the menses did not appear. On June i, without being in any other way unwell, she was attacked with frequent vomiting. * Gaz. Hebdomad., 1857. f " Monatsschrift fiir Geburtsk." 1858. THE VOMITING OF PREGNANCY. 39/ At first a part only of the food she took was returned, but very soon the evil increased to such an extent that all food taken into the stomach was vomited, solids as well as fluids, and when the stomach was empty a nauseous sensation re- mained for a long time. At this period she was also at- tacked with pains in the epigastrium, which came on in acute paroxysms. By medical advice leeches and blisters were applied to the epigastrium, and all sorts of narcotics and antispasmodics were given internally, without avail. The patient continued vomiting from day to day, and the pains robbed her of her night's rest, and reduced her to a weak, nervous condition. Siie resolved, on July 8, to seek relief in St. Hedwig's Hospital. Her condition on admis- sion was the following: Bodily frame weak, muscles relaxed and flabby, atrophy of the subcutaneous fat, on the front of the body several scattered pigmentary spots, pulse small and frequent always, no tenderness of subjacent organs by light pressure on the abdomen; on vaginal examination so high that the posterior lip could with difliculty be reached, the OS, rounded and with smooth surface, could be felt in the left posterior portion of the pelvis. The enlarged and doubled-up body of the uterus could be felt lying behind the right horizontal ramus of the pubes. By the aid of gentle pressure with the other hand through the abdominal wall the uterus was found to be markedly anteflexed. The position of the flexion could be distinctly felt through the roof of the vagina. The breasts were enlarged, and the areolae darkened. Menstruation had ceased since the end of April. During the first day of her stay in hospital the patient sat up in bed in a bent-over position; she was tor- mented with continuous nausea and vomiting, all food was returned as soon as swallowed, and large quantities of tena- cious mucus were brought up from the empty stomach; rest and ease were impossible, owing to the complete loss of sleep, fearful thirst, and obstinate constipation. The diagnosis was asthenia from the vomiting of pregnancy, but the false position of the uterus must be regarded as the essential cause of the evils, and its further expansion would render matters worse, and produce greater irritation of the uterine nerves; therefore an attempt must be made manu- ally to replace the dislocated uterus. Many attempts were made, but they all proved unsuccessful; as the strength of the patient became more exhausted, so was the indication greater for the artificial production of abortion. However, 398 DISEASES OF WOMEN. I did not resolve on this until I had made a last trial with the various well-known internal remedies, of which tr. iodi is most recommended. With the consent of her husband, according!}', as a last resource, three to four drops of tr. iodi were administered daily. After fort}' hours of this treat- ment, the repugnance of the patient to this treatment be- came so great, that only by repeated persuasions could she be induced to continue it. As all was useless, on July 24, with the consent of her husband, an attempt was made to introduce the uterine sound, but failed, and again after two days; this was partly owing to the restless movements of the patient, and partly owing to the high position of the cervix uteri; the sound was only just able to be introduced into the cervix uteri. I made a third attempt on July 31, in consultation with Dr. Brandt, and managed at last to introduce the sound as far as the bend; to have pressed it on further would have been impossible, owing to the danger of wounding the patient. Unfortunately, at this time the strength of the patient was so far exhausted, that even in the case of the complete emptying of the uterus an unfavorable termina- tion was probably to be expected. Up to August 2 little change occurred in the health of the patient; then the vom- iting ceased suddenly, whilst at the same time the intellect became disturbed, light delirium alternating with deep drowsiness, the pupils were fixed and dilated, and conver- gent strabismus set in, occasioned by the paralysis of the external rectus. On August 4 she died. No further vaginal examination had been made after the last introduction of the sound. In laying out the body for post'inortevi examination twenty-four hours after death, the foetus fell out of the vagina, the placenta lay within the OS and was brought out by light traction on the umbilical cord. The post vwrtcm revealed the following: On the surface of the hemispheres underneath the arachnoid were a small number of jelly-like serous exudations, free from blood-staining; the substance of the brain was extraordi- narily ancemic; at the base of the brain, around the origin of the sixth nerve, there was no evidence of anything ab- normal. The chest-organs were healthy, the lungs notably dry, the heart small and firmly contracted. In the intes- tinal canal, liver, and spleen, no pathological changes were found. The body and fundus of the uterus, considerably enlarged, lay directly behind the right horizontal ramus of THE VOMITING OF PKEGNAXCY. 399 the pubes, much anteflexed; the length of the body of the uterus was five and a quarter inches, tlie position of the flexion was three inches from the os. On the under surface the walls of the uterus were soft and flabby; on the upper surface they \vere much condensed and very firm. On opening the cavity of the uterus the placenta was seen to have had its attachments to the lowest segment of the uterus, and thus had harbored the foetus above. Above the seat of flexion in the upper segment of the uterus no free cavity existed; ttie small interval between the rigid walls of the uterus was filled with a mass like a placenta firmly ad- herent everywhere. The foetus was five inches long, the umbilical cord six and a half inches. It appears evident that pregnancy had existed for nearly four mouths, and that after conception the menses appeared on one occasion; and it is my decided opinion that the bending of the uterus, and consequent hindrance to the regular expansion and growth of the uterus, was the influ- ence producing the obstinate vomiting. VI. Dr. Tyler Smith* recorded a case in which nausea set in early in the pregnancy. When the patient was two months pregnant there was incessant vomiting and extreme emaciation. She was kept alive by teaspoonful doses of l)eef-tea every half hour, and injections of beef-tea. When four months pregnant, the uterus could be felt above the pelvic brim. Abortion set in spontaneously at five months. The patient did well for three weeks, and then rapid phthisis set in. Dr. Tyler Smith believed that "an almost poisonous in- fluence seems to be exerted by the gravid uterus in some constitutions." Also that nausea is " probably cured by the distension and evolution of the dense structure of the uterus after impregnation, or by the pelvic irritation caused by the gravid uterus before it emerges from the brim, or from both these causes." f Ulcerations of the os uteri have been considered to be the cause of the excessive vomiting by several authorities, in- cluding Dr. Henry Bennet; and scattered through medical literature will be found cases in which relief from sickness has been to a certain extent obtained by topical applications to the OS uteri. Severe Nausea associated with Anteflexion. — The following * " Obst. Trans.," vol. i. f " Manual of Obstetrics, "p. 99, 400 DISEASES OF WOMEN. case, observed in consultation with Dr. Royston, was quoted in my original paper:* VII. Tlie lady, £et. 24, quite recently married, had men- struated last October 14, 1S70, a very slight discharge being observed on November 3. Since November 3 there had been occasional sickness, and from the end of January up to February 21, when I first saw her with Dr. Royston, the sickness had been severe. Dr. Royston informed me that the lady was pregnant, that when first called in to see her, about a fortnight before, the sickness was most severe, and no article of food could be retained. On hearing Dr. Roy- ston's account of the symptoms I expressed my opinion that the uterus was acutely anteflexed, that the fundus of the uterus would be found to be low down, jammed in the pelvis, and that this was the explanation of the symptoms. On proceeding to make an examination mj'' opinion was found to be exactly verified: the os uteri lay far back, the roof of the vagina was projected downward and backward by the enlarged and anteverted and -flexed uterus, and the body of the uterus was scarcely to be felt at all through the abdominal wall, although the pregnancy was probably of about four months' duration. The patient had, in my opinion, suffered from anteflex- ion before marriage, and, pregnancy having occurred, the uterus had gone on growing and expanding without los- ing its vicious shape, and, indeed, with an increasing ag- gravation of that vicious shape, up to the time of my seeing her. The evidence that anteflexion existed prior to marriage was as follows: The patient was never able to dance with- out discomfort. She had, six years prior to marriage, taken for six months violent horse exercise, to which she was pre- viously unaccustomed, and this was followed by losses sim- ilar to those of the menstrual periods, and by diarrhoea. On another occasion, a year later, horse exercise again brought on similar symptoms. In this case the advice given was that the patient should remain altogether in the horizontal position in order to allow the expanding uterus a better chance of escaping from the pelvis, and that the bowels should be kept regu- larly open. The result of this treatment was that the chief symptom — the nausea — underwent at once a most mate- * "Obst. Trans.," vol. xiii. THE VOMITING OF PREGNANCY. 4OI rial alleviation, soon disappeared, and delivery at full term occurred. VIII. Dr. ^neas Munro* in 1872, shortly after the ap- pearance of my paper, published a case which, to use his own words, "in a very remarkable manner bears out to a certain extent what Dr. Hewitt has said on the matter." The case was that of a primipara, aet. 21. When seen first, in the third month of pregnancy, the vomiting had become intense. The uterus was found acutely anteflexed and quite fixed. An attempt to push the uterus up failed. The sound passed in about five and a half inches. Some days later, no relief being obtained, and symptoms being very urgent, premature labor was induced. Recovery complete. Dr. Munro in one place states that there was no jamming of the uterus in the pelvis; but in another he says that he found it so fixed in its abnormal position that it could not be moved upward. Dr. McClintock,f in an essay on the subject published after the appearance of my paper in the " Obstetrical Transac- tions," gives a collection of cases of severe vomiting in which premature labor was induced to relieve the patient. He confesses that "we are yet very much in the dark" as re- gards the etiology of the sickness. Dr. McClintock declined in his paper to accept the explanation which I had offered as to the influence of flexion of the uterus. IX. Dr. McClintock J gives a case, that of a primipara aet. 24, who at the end of two months was found suffering se- verely from sickness. "The uterine tumor could not be distinguished above the pubes; but per vaginam the body of the organ was felt enlarged and slightly anteverted, as is often found to be the case at this period of utero-gesta- tion." Ten days later the patient was in a highly danger- ous state, and abortion was induced. Dr. McClintock accepts the dictum of Dr. Barnes that the normal position of the uterus in early pregnancy is ante- version, and evidently considers that in the above case there was nothing abnormal in the condition of the uterus. It is probable, however, from the facts related that the body of the uterus was really abnormally low in the pelvis. One of the arguments used by Dr. McClintock and some others, which seem to them to tell against the influence of * Glasg. Med. Journ., Aug., 1872. f Dub. Med. Jourti., 1873. X Ibid., May, 1873. 402 DISEASES OF WOMEN. flexion and displacement of the uterus in producing the nausea of pregnancy, is that in cases of retroflexion of the gravid uterus sickness is not always present. True; but the same holds good respecting retroflexion of the non- gravid uterus. Sickness is not a constant symptom in cases of the latter kind, but I have known most severe and dis- tressing sickness to be produced by retroflexion in the non- gravid state which has been almost magically relieved by elevating the fundus, thus showing in the most indisputa- ble manner that the sickness was due to tlie flexion. So again with anteflexion: neither in tlie gravid nor in the non- gravid state is sickness an invariable symptom, but this does not prove that the anteflexion is not responsible for the sickness when it does occur. A very important contribution to th.e patholog}- of the subject is that of the late Dr. Copeman, of Norwich. In 1875 Dr. Copeman published* a paper in which he related three cases, of which the following particulars are given in brief: X. A patient, six months pregnant, so reduced by sick- ness that fears were entertained for her safety. It was re- solved to induce premature labor. The cervix was dilated with the finger as a preparatory step. An hour later, when further measures were about to be taken, the patient was so much better that it was thought best to wait. From that time improvement set in, there was no return of sick- ness, and delivery at full term occurred. Dr. Copeman was struck b)' this case, and "wondered whether the relief could have been effected b\' his having dilated the os uteri and thus removed any undue tension that might be producing sympathetic irritation." XI. In a second case (where "there was some degree of anteversion") the same procedure had a like good effect. XII. In a third case equalh^ good effects, in relieving a patient from severe sickness, followed the dilatation of the OS uteri with the finger. This paper of Dr. Copeman's attracted my attention, and in a communication to the British Medical Journal a fort- night after,f in speaking of Dr. Copeman's cases, I stated * B^it. Med. Jown. May 15, 1875. Dr. Ely Smith {Brit. Med. Joiati., Aug. 21, 1S75) says that Dubois first noticed this effect of dilating os in arresting vomiting. f Ib;d., May 29. 1S75. THE VOMITING OF PREGNANXY. 463 that they offered a strong confirmation of the truth of the doctrines I had previousl}'' expressed on the subject. The explanation of Dr. Copeman's success I held to be that the operation of dilating the os uteri was itself the means of righting the uterus, for the os must have been pulled for- ward in order to dilate it, and this would have the effect of tilting the body of the uterus upward, and thus (assuming that they were cases of anteversion: Dr. Copeman himself stated that one was) the operation reduced the displace- ment. I further added, "It may be said, How do you ex- plain the cases in which the vomiting persists as late as the eighth month, which was the fact in Dr. Copeman's third case ? The answer is, that where there has been an acute flexion in the early part of the pregnancy, as the uterus en- larges (if abortion does not occur) the flexion is in most cases abolished, and the effect of this is, that the sickness generally disappears under such circumstances. But the tissues of the uterus at the seat of the flexioti are so met ivies left in a diseased state, being stiffened and unduly resistant, and thus the irritation is kept up. Dr. Copeman's treatment would undoubtedly tend to remove this stiffening and constraint." Dr. Copeman in a further paper* comments on various opinions elicited by his first paper, and says that his own opinions were not sufficiently matured to enable him to give any positive explanation of tlie causes of the sickness, but he is " inclined to believe that in such cases there is always some irritating condition present, which induces a strain upon the neck of the uterus, or perhaps also on other parts of the uterus." In this his second paper Dr. Copeman relates a case which most curiously corroborates the views I had ex- pressed as to displacement being the cause of the sick. i:ess: XIII. A lady in her second pregnancy, five months ad- vanced, was very sick; she had frontal neuralgia also. She had for some weeks taken violent exercise. The sickness and the neuralgia continued. The abdomen did not appear to enlarge as much as usual. On examination per vaginatn the head was found low down in front, and the os uteri cor- responding with the promontor}^ of the sacrum. " It seemed to me," says Dr. Copeman, " that the uterus was anteverted so as to allow the head to be felt below the level of the os * Brit. Med. Journ., Nov., 1875. 404 DISEASES OF WOMEN. uteri." Dr. Copeman, b}^ gentle, continued pressure, raised the protruding portion of the uterus out of the lower pel- vis and restored the os uteri to a more natural position, after which he prognosticated no further vomiting would occur. And, in fact, so it happened — the cure was com- plete. In this case, therefore, the nausea was cured by reducing the uterus to its proper position. Dr. Copeman not having em- ployed any dilatation of the os as in the other cases, and it offers a remarkable illustration of the truth of the critical remarks which I had before offered on the iiwdus operandi of Dr. Copeman's procedure. In fact, the patient was cured without dilatation of the os uteri at all. XIV. Case by Dr. Copejuan* — Pregnant eleven weeks; se- vere and uncontrollable vomiting lately. Fundus tender on pressure; and displaced forward. The displacement was rectified and bowels opened. Sickness much less next day, but as it continued slightly os was dilated with finger. Cure. XV. Case by Dr. Cope7nan.\ — Six weeks pregnant; three weeks sickness. Position of uterus thought to be normal; posterior lip hard and unj-ielding; os gradually dilated, and, after two days' rest, cure. XVI. Case by Dr. Copeman.\ — Six weeks pregnant; nearly incessant sickness two weeks. After dilatation of os by finger as far as os internum, vomiting ceased. I subjoin some published cases in which dilatation of the OS uteri after Dr. Copeman's plan was followed. XVII. Case by Mr. Atkinson% of Halifax. — Incessant vomiting at six months, in a multipara. Vomiting ceased after digital dilatation of os uteri. XVIII. Case by Dr. Minot\ of Boston. — A sponge tent in- troduced into the cervix allayed the vomiting. XIX. Case by Dr. Dukes.^^ — Patient, set. 33. Has had five children and five miscarriages. The previous pregnancy, after eight months' incessant vomiting, was relieved by in- duction of premature labor. Now pregnant two months. Remedies now failing, the os was dilated digitally, the tis- sue being found very hard and cartilaginous. Vomiting was at once relieved and soon ceased altogether. * Brit. Med. Journ., Sept., 187S. f Ibid., May. 1879. } Ibirl., June. 1879. § Ibid., Nov. 6, 1S75. I Ibid., Sept., 1S76. t Ibid., Feb. 23, 1878. THE VOMITING OF PREGXAN'CY. 465 XX. Case by Dr. Gooch* of Eton. — Mother of two chil- dren, pregnant eight months. Incessant vomiting for two months; lying on back produced the vomiting. The os uteri found hot and painful. Dilatation by finger and separation of membranes round os; escape of much offen- sive discharge; relief of vomiting; pregnancy went to full term. XXI and XXII. Tk'o Cases by Dr. L. Rosenthal. \ — Cure by digital dilatation of os — one patient in second pregnancy, the other a primipara. XXIII. Case reported by Mr. J. T. FryX of Swansea. — The cervix, and especially the posterior lip, was hard and gristh'. Neither the finger nor tangle tent could be intro- duced. A long and slightly anterior curved throat forceps was used, and gently but with some force dilated; the os was thus dilated. The effect immediate in removal of the vomiting. The patient had been obliged to have premature labor induced in previous pregnancy. XXIV^. Case by Dr. Murifio'^ of Santia^^o. — Primipara, a^t. 22, in third month of pregnancy; sickness severe. On four occasions, at intervals of a day or two, the finger was introduced into the softened cervix as far as internal os. xVfter a week sickness ceased. The following is a series of cases which have been ob- served by myself during the last ten years, illustrative of the question now under consideration, and of whicli I have preserved notes; but I have seen others of a similar kind, records of which have not been kept. XXV. Retroflexion of the Gravid Uterus causing Severe Nausea. — The subject of this case, now published for the first time was the wife of a medical man. She consulted me first in January, 1869, for severe pain in the chest and heart. The uterus was found to be retroflexed, and the last catamenial period was on December 5, about seven weeks previously. On February 20 a second omission of menstruation was noted. She was then suffering much from sickness, and pregnancy was considered to be pres- ent. This pregnancy ended favorably; but I saw nothing of the patient further until the year 1872 (January 24). Patient now 26; has had three children, two of these since I last saw her; last child is a little over three years old. * Brit. Med. Jount., Sept. 23, 1878. \ Ibid.. Aug., 1879. X Ibid., March 13, 18S0. § Lond. Med. Record, Feb. 15, 1878. 406 DISEASES OF WOMEN. Patient now six weeks pregnant. She is suffering from severe sickness. The uterus is found to be retrofiexed. A ring pessary (Hodge-shaped) was applied, and she went liome. On February 22 I was sent for and found her ex- tremely ill, suffering from intense sickness. The sickness had induced severe jaundice and an extreme depression and feeling of collapse. The ring pessary had ceased to do its work properly, being too small for the increased size of the uterus, and the organ was retroverted over the top of the pessary. A larger instrument was applied. The patient, who was in a most alarming state of depression, very speedily felt better, and she visited me at my house on April 2, also on April 17; but on April 19 I was sum- moned to see her again with a repetition of the same severe symptoms, the vomiting having returned in a most intense degree. Again I found the mechanism of the support at fault; the exertion of coming to my house had been too much, and the uterus was still displaced. Relief followed its readjustment; but great difficulty was found in retain- ing the uterus in its place (though it was easy enough to replace it) owing to the indisposition of the patient to keep quiet. Whenever the uterus was in proper position the symptoms abated as if by magic; but recurred as speedily when the fundus succeeded in eluding the action of the pessary. Finally, an end was put to the case by the occur- rence of premature labor on June 26, the patient being then a little over six months advanced in pregnancy. The husband of this lady informed me, in answer to a letter in May, 1876, that since that time she slowly recovered her strength, but that every now and then she is liable to attacks of " biliary colic." She does not, he states, now suffer from the retroflexion. She has been pregnant once since, but did not go her full time owing, he believes, to anxiety and fatigue in nursing her sick children. He re- marks, as a curious circum,stance, that she has only been sick when pregnant with girls. The case is a most interesting one, the history of retro- flexion as affecting the pregnancies being, in regard to many of the details, known to me from personal observation. I saw her suffering from sickness at the beginning of her second pregnancy, and relieved her from the displacement so that she went her full time. Further, I saw her in her fourth pregnancy again affected with retroflexion, and again suffering from sickness, but on this occasion in a THE VOMITING OF PREGNAN'CY. 4O7 much more severe form. On three or four distinct occa- sions during this fourtli pregnancy the sickness actually threatened to destroy her, but each time it was arrested by the raising of the uterus from its retroflexed position. The repetition of the disorder, however, ended in premature labor at about six and a half months; but had the patient been more careful and less wilful, it is probable that preg- nancy would have gone on to full term. XXVI. Haiisca due to Anteflexion of the Gravid Uterus. — A. M., aet. 21, patient at University College Hospital, 1874. The notes by Dr. E. M. Skerritt. Married two and a half years, no children, no miscarriages. Menstruation never regular, intervals occasionally three or four months, and always scanty and very painful. She has not menstruated for the last four months, the last time after a previous interval of four months. The present illness for the last four months; gradually the symptoms have become worse. For the last three weeks she has been confined to her bed. Her chief complaint is of pain of an aching or griping character at the lower part of the abdomen, mucli more intense of late, and accompanied by nausea and vomiting occurring both on getting up and during the day. Ex- pression painful, areolae enlarged, distinct brown pigmen- tation, areolar glands enlarged; abdomen not distended, resonant, more resistance to pressure on left side. Pain referred to umbilicus, described as "cutting," with occa- sional exacerbations. General abdominal tenderness. On deep pressure over pubes a tumor is felt rather far back, giving impression of being the top of a tumor rising up from the pelvis, with a smooth rounded upper surface, two or three inches wide, flattened from before backward, and very tender. Bladder had been previously emptied. Os uteri found to be very high up and rather far back. In front of it can be felt what seems to be a considerable swelling, extending laterally, firm, smooth, rounded, and very tender. Such was the state on admission. The vomiting continued at intervals for a few days, the pain also, the tumor felt above pubes slowly increasing in size. On March 15 Mr. Rigden, the resident medical officer, ex- amined her, and expressed his belief that the tumor was the anteflexed uterus inclined more to the left side than right. On March 18 the tumor had risen higher, reaching now to within two inches of the umbilicus. The vomiting and retching still occasionally severe. Placental bruit 408 DISEASES OF WOMEN. heard above right Poupart's ligament. On March 19 I was requested to see the patient for the first time. I noted that the condition of the breasts alone sufficed to indicate existence of pregnancy. The tumor above the pubes is of the shape and size of a four months' gravid uterus. The OS and cervix are high up and far back, but not changed in regard to softness in the way usually met with in preg- nancy. The body of the uterus not now to be felt through vaginal roof. I expressed my opinion that the patient was certainly pregnant; that the previous observations made by Mr. Rigden and others left no doubt that the uterus had been up to quite recently anteflexed, and that the enlarged uterus had now escaped from the pelvis. March 20. — No vomiting or retching last night, no pain, no vomiting this morning. March 21. — Pain latter part of night, felt very sick before breakfast, and on taking food vomited at once. Tumor still tender. Says that as long as she lies still there is no nausea, but that it occurs on moving in bed. March 23. — Slight nausea when she sits up in bed early in the morning. Free from nausea now as a rule. March 24. — Nausea still a little; vomited at teatime. Afarch 28. — Was sick on first sitting up in bed this morn- ing; not sick since, though she has felt so. Not sick yesterday, but had nausea as before. Got up for first time to-day. Complains of occasional shooting pain in abdo- men. March 30. — Patient has not vomited since 28th, though she feels nausea at first sitting up. The patient left the hospital to-day convalescent. XXVI I. Retroflexion of Gravid Uterus; Severe Nausea. — Mrs. , set. , has had three children; suffered from severe sickness in all the pregnancies. Is now two and a half months pregnant, and suffering from severe sickness. The OS is found far forward, the uterus much retroflexed. Ordered to lie on the face. Report later on states that the sickness was relieved at once; she had it slightly up to four months, when it absolutely ceased. She was delivered safely at full time. XXVIII. Anteflexion of Gravid Uterus; Severe Nausea. — Mrs. , set. 33, has had eight children and three mis- carriages. Now three and a half months pregnant; always suffers severely from sickness during pregnancy, together with intense mental depression during the first half of preg- THE VOMITING OF PREGNANCY. 409 nancy, and during the latter half from swelling of the legs, varicose veins, and general distress. On this occasion tents have been introduced to procure abortion and relieve the sickness, but ineffectually. On examination the uterus is found to be anteflexed, the os uteri swollen, the anterior wall of cervi.x thin. Rest was ordered. Further history not known. I have one case to record in which dilatation was had re- course to: XXIX. Mrs. , aet. ;^;^, multipara. Very severe sick- ness arising from anteflexed uterus, with great hypertrophy and hardening of cervix and os. At the seventh week of pregnancy, death tiireatencd by continued sickness, al- though the sickness was at first relieved by use of a pes- sary. Cervix dilated by metallic dilator, resistance to dila- tation very great. Following day relief, but abortion oc- curred on second day after. Patient died a little over a fortnight later from exhaustion. XXX. Anteflexion of Gravid Uterus ; Severe Nausea. — Mis. , aet. 34, has had four children, now pregnant for fifth time. Last child four years ago. Is pregnant three months. Her expression was, "Can you relieve me of the constant sickness?" On examination it is found that the uterus is anteflexetl, and the body is quite low down in front while the OS is far back, the uterus being thus jammed downward behind the symphysis pubis. The patient was ordered to remain in bed for a week, and to lie on the sofa for three weeks afterward. Food to be given every hour in small quantities. A fortnight after reported to be much better, sickness hardly more than once a day. A month later, a'ole to move about easily without sickness. Visited me, when eight mo'iths pregnant, quite well. The cases which have been recorded in the preceding pages convey sufficient proof of the great efficacy — it may be almost said of the eomplete efficacy — of certain mechani- cal procedures at the os and cervix uteri in relieving the sickness of pregnancy in its severest form. I'think there can be no doubt that the phenomena recorded are thorouglily explained by adopting the view that in these cases the tis- sues round the internal os uteri are prevented undergoing proper expansion. This impediment to expansion is either an actually present flexion of the uterus or a contraction and condensation of these tissues, the result of a previously existing flexion. 4IO DISEASES OF WOMEN. It is a noteworthy fact that in some of the cases recorded the cervix was found so hardened and resistant that very- great difficulty was found in expanding it. Cases of this kind were always multiparae, and the inference is natural that only in multiparae is it likely that this inordinate resist- ance to mechanical ar///?67'cz/ expansion will be met with. Dr. Aubert* in his essay, "Influence of the Movements of the Uterus on the Vomiting of Pregnancy," describes a case where during digital examination the attempt to push the uterus to one side by the finger produced immediately nausea, which would have ended in vomiting had he per- sisted. The patient was, as afterward appeared, in the second month of pregnancy. A second examination, made at the end of the fifth month, showed that lateral pressure produced nausea, but less severe than on the former occa- sion. Aubert discusses the subject of this provocation of nausea as a diagnostic measure in the early months of pregnancy. He cites Gueniot, who gives cases wheie rest in bed appeared in some cases to arrest the vomiting of pregnancy. He notes also that Stolz found pressing the uterus upiuard did not give rise to vomiting. Aubert ob- served vomiting in 17 out of 37 primiparse, while of 17 mul- tiparae only 4 had vomiting. Gueniot in 51 severe cases had 12 primiparae and 39 multiparae. In the discussion follow- ing Dr. Aubert's paper it was stated by M. Icard that in certain intractable cases vomiting, having lasted three or four months, had disappeared on rectifying the displace- ment found to exist on digital examination. M. Chatin had seen many cases where the vomiting ceased on altering the position of the uterus when displaced. XXXI. In a case by Prof. Tarnierf of Paris, a multipara, three months pregnant, had incessant vomiting, which was allayed by plugging the vagina with wadding, thus pre- venting, as he thought, the uterus from moving about and being shaken. GENERAL COMMENTARY, Some writers, as Dr. Barnes, consider the vomiting of pregnancy, in severe cases, due to tension or stretching of the uterine fibres. This may be in part the cause. For it seems likely that irritation might be produced by an undue * Lyon M^dic, Oct., 1871. p. 431. \yourn. de M/d. et Chir. and i?nV. Med. Journ., Aug. 28, 1875. THE VOMITING OF PREGNANCY. 4II degree of such stretcliing. But, supposing flexion to be present, this would be likely to give rise to undue stretch- ing and tension of the uterine fibres. While undue com- pression is present on the concave side of the bend, there would be increased tension and stretching on the convex side. To those, therefore, wlio consider the tension theory the best, I would point out that in the flexed uterus while undergoing the process of expansion such tension will be greatly increased and irritation arising therefrom consider- al)ly aggravated. My own impression, however, is that compression is the particular and tangible irritating ele- ment in such cases. The very decided effects produced in some of Dr. Copeman's cases by dilating the cervi.x illus- trate the efficacy of removal of condensation and tension around the internal os uteri in relieving the sickness; and Dr. Copeman's cases offer evidence of the most convincing character in this direction. Where vomiting persists to the latter months of preg- nancy, the condensation at the internal os has not been entirely removed by the unfolding and expansion of the uterus (see p. 372). The structures round the internal os uteri are not fully dilated up to quite the end of pregnancy in primiparaj, and thus, although the uterus may have lost its flexion, it by no means follows that the nervous filaments around the internal os are relieved of condensation, tension, and pressure at the same moment that the flexion is re- lieved. When the flexion is not of long standing, by the fifth month the uterus will have become relieved either by miscarriage or by unfolding. But if the cervical tissues are much condensed by long-standing flexion the arrival of mid-pregnancy may not give the expected relief. Dr. Aveling's remarks on the subject of the nausea of pregnancy* are as follows: Vomiting during Gestatio7i. — This troublesome and occa- sionally dangerous disorder has undoubted relations to posture. It has the name of morning sickness from the fact that it appears when the patient leaves her bed and assumes the erect posture. It is evidently reflex in its cliaracter, and is probably produced by hypostatic hyper- emy and hyperaesthesia of the uterus. Certain it is that all obstetricians recommend the recumbent position for its re- *On Influence of Posture on Women. Obst. Jour., F,eb., 1S77 (No, 47'. P- 7=2. 412 DISEASES OF WOMEN. lief, and often with great success. But Dr. Clay of Man- chester goes further than this, and, believing gestational sickness to be dependent upon congestion and tenderness of the cervix uteri, advises a position of the body calculated to relieve the os and cervix from pressure against the pelvic viscera, best accomplished by lying on the back with the hips raised and head low. . . . Displacements of the uterus have been suggested as producing vomiting during gesta- tion, and this is not unlikely, for mechanical hyperemy is often caused by them, and it would have the same effect as hypostatic hyperemy upon the uterine nerves." As bearing on the discussion of the present question, it must be recollected that until recently it was not generally known or understood that anteflexion of the uterus in the non-gravid state is a common affection, nor that anteflexion of the gravid uterus is common. In the various text-books on obstetrics, anteversion of the gravid uterus is not even mentioned as a possible occurrence. This observation does not apply to some of the text-books published on the Con- tinent. One of them, at all events (M. Cazeaux), alludes to it. I myself was not aware of the possibility of its occur- rence until I had encountered a case in actual practice — a case which I described in the year 1865 at a meeting of the Obstetrical Society of London.* I believed it then to be a very rare disorder, but my observations since that time have convinced me that in a mild form it is very common; and further, that it is, as I have already fully stated, in a more severe form associated with obstinate sickness. Looking back to my notes of this first case I find it recorded that obstinate sickness occurred, although I did not then attach any particular signification to the symptom. Anteflexion of the uterus is more commonly found to be the cause of sickness in pregnancy than retroflexion, be- cause it is rather more rare for the retroflexed uterus to become impregnated. Hence the result, clinically, that when obstinate sickness occurs it is infinitely more likely to be due to anteflexion than to retroflexion. The principal arguments in favor of the view that the vomiting of pregnancy is due to flexion of the organ may be briefly recapitulated: (i) Many women have no sick- ness, therefore it is not an essential part of pregnancy. (2) It is mostly limited to the first half of pregnancy, being, *"Obst Trans.," VvjI. vii., p. 170, THE VOMITING OF PREGNANXY. 413 indeed, in many instances limited to the first two or three months. This is precisely the time during which the uterus is most liable to suffer from flexion; for when it rises into the abdomen such flexion can hardly occur. (3) It is pro- duced almost universally by the standing or sitting posi- tion, which would be likely to intensify or exaggerate tem- porarily an existing flexion. (4) It is suspended, in all but the very severe cases, if the patient remains in bed for a day or two, during which time no such exaggeration of the flexion by standing, etc., occurs. (5) It occurs to a very marked degree in cases which are known to be the subject of flexion at the time of pregnancy. (6) Severe sickness and a decided tendency to abortion are very frequently associated in the same case, from which it follows that it is not unlikely, at all events, that the same cause is operative in producing both effects. (7) Lastly, I would mention my own observations as to the effect of positional treatment in cases of flexion of the gravid uterus, attended with sickness more or less severe. These are to the effect that since my attention has been particularly directed to the subject I have treated several such cases, and that I have found the sickness always to subside, or to undergo an immediate and remarkable amelioration, by so placing the patient or by so changing the position of the uterus as to favor the reduction of the existing flexion. The history of these cases is, I believe, as follows: The uterus is, at the time pregnancy begins, in a state of flex- ion — generally slightly so, sometimes more marked in de- gree. The uterus expands, the walls increase in thickness, there is consequently an additional degree of compression of the tissues at the seat of the flexion. The natural effect of the increase of the expansion would be to unfold the uterus and straighten it, and in point of fact this result is achieved in most cases. But while this process is going on the tissues at the flexure are compressed unduly, particu- larly in certain positions of the body, and reflex nausea or vomiting may be thus produced. TREATMENT OF THE VOMITING OF PREGNANCY. In ordinary simple cases it will be found that this trou- blesome symptom can be effectually relieved by attention to certain rules as to the position of the body. The pa- tient must be induced to maintain the horizontal position 414 DISEASES OF WOMEN. as much as possible, and it will generally be found that this is sufficient. Attention should of course be paid to the state of the bowels. After the fourth month the tendency to sickness disappears in most instances, and the patient can then move about or sit upright witliout nausea. The degree to which it is necessary to enforce the horizontal position depends on the severity of the sickness. In severe cases, where the above treatment has no suffi- ciently good result, the state of the uterus must be ascer- tained, and means should be taken to rectify any malposi- tion which may be detected. Various mechanical devices may be put in force to aid the body of the uterus in rising up into its proper position. These will vary according as the body of the uterus is turned forward or backward. A simple air-ball pessary acts well in cases of anteflexion, and a well-fitted Hodge-shaped pessary is proper for cases of retroflexion. The action of the pessar}' must be aided by maintenance of the horizontal position. When the uterus is restored to its place a pessary may not be further re- quired. Indeed a pessary ma)^ not be required at all if the uterus can be raised into its place by pressure with the fin- ger, aided by positional treatment. Where the sickness is not relieved by any of the above procedures, the case will probably be one in which the cer- vix uteri is very hard and unyielding. Under these cir- cumstances the plan recommended by Dr. Copeman should be put into practice, and the cervix dilated art'ficially in order to remove the compression and tension around the internal os uteri. In my opinion, this treatment will be found really necessary in exceptional cases only; in m}^ own practice I have only found the other and more simple meas- ures fail in relieving the sickness in one instance. In most of the cases recorded as treated by Copeman's plan the dilatation was easily effected, and in these instances probably it was not really necessary; but in two of them cer- tainly the dilatation was more difficult to accomplish; in one of these a two-bladed dilator was employed for the purpose, in another a throat forceps. There is of course danger of producing abortion b}' the employment of any instrument passing through and beyond the internal os uteri. The fin- ger would be the safest dilator, but in the really difficult cases it may be found, as in the case related at page 409, that the finger could not be introduced at all. Careful dilatation with & steel two-bladed dilator — on the principle of the one repre- DISEASES OF THE OS AND CERVIX UTERI. 415 sentecl at page 365, but larger at the extremity of the blades — seems to me to be the best method of accomplishing the desired end, if the finger cannot be made to enter the cervix. The dilatation should not be rapidly effected, the object being to gently release the tension of the structures without exciting contractions of the uterus. When the os externum admits or can be made to admit the finger it would be best to employ the finger for the further dilatation of the canal higher up. It must be recollected that the cer- vical canal has a length of rather over one inch, and it ap- pears necessary to dilate the canal at its upper extremity in order to give the necessary relief under such circum- stances. The employment of the finger has one drawback — namely, that as a rule the finger cannot be readily intro- duced so far as the internal os uteri without passing a con- siderable part of the hand into the vagina. The induction of premature labor could be practiced, as a last resource, when other measures are found to be of no avail and the life of the patient is at stake. CHAPTER XXIX. Diseases and Injuries of the Os and Cervix Uteri. The " Ulceration" Theory of Uterine Disease — Laceration of the Cervix Uteri: its Effects and Results — Dr. Emmet's Views on the Subject — His Method of Treatment — Importance of Eversion of the Cervical Lining: Causes of the same — Hypertrophy, Cystic Degeneration of the Os Uteri, etc. Ulcerations of the Os Uteri — Erosions — True Ulcerations — Syphilitic Ulcerations. DISEASES OF THE OS AND CERVIX UTERI. "A whole generation of physicians," says Dr. Emmet,* "has been misled by the delusion of chronic inflamma- tion and ulceration of the uterus — conditions which no one has yet been able to demonstrate on the dead body." While, however, most of the so-called ulcerations and in- flammations can be shown to be referable to changes of other parts of the uterus, we have of late learned that there * Loc. cit,, p. 129. 4l6 DISEASES OF WOMEN. are local conditions and diseases of the os and cervix which appear to require more attention than they have yet received — namely, the changes incident upon or following after the laceration of the cervix uteri during parturition. It is not a little remarkable that, largely used as the specu- lum has been in the investigation and treatment of the dis- eases of the uterus, cases of severe lacerations of the cervix seem to have been overlooked until a very recent period even by those who were most in the habit of employing the instrument. It will be necessary to consider systematically the changes observed at the os uteri, and in so doing, to en- deavor to show the relation of these changes to the dis- eases of the other portions of the uterus. LACER.\TION OF THE CERVIX UTERI. It not unfrequently happens that in the process of partu- rition the uterine cervix is more or less injured, the vagi- nal portion being lacerated in various degrees. But it can- not be said that these lacerations have been considered as constituting lesions of any considerable importance until recently. The subject has, however, attracted much atten- tion in the United States during the last few years, and it is evident that the lacerations in question are very impor- tant factors in the production of diseases or discomforts ref- erable to the cervical part of the uterus. Dr. Goodell, writing in 1879, states that about one sixth of the women who have had children, applying at the University of Pennsylvania Dispensary, have an ununited laceration of the cervix. The second edition of Dr. Emmet's valuable work con- tains a full account of the subject, together with the re- sults of his own observations and inquiries. Since 1862 Dr. Emmet has practiced an operation in such cases. In 1874 he published a paper on " Lacerations of the Cervix Uteri as a frequent and unrecognized Cause of Disease." Roser,* it appears, first described what he termed "ectropium," of which there are two forms — one arising from cicatricial distortion, the other by the crowd- ing forward and swelling of the mucous membrane. Roser indicates as causes, excessive fissures, also probably ob- * " Archiv. f, Heilk.," Leipzig, No. 298. DISEASES OF THE OS AND CERVIX UTERI. 417 Stetrical incisions and gangrenous destruction of the os uteri. Roser regarded many of the cases of obstinate and inveterate hypertrophy thus arising as incurable; and as regards the cicatricial ectropium says, " One will scarcely be prompted to undertake a curative experiment." Dr. Emmet thinks the term "cicatricial ectropium" not well-chosen, for "the flaps in the cervix are first rolled out and forced apart from the enlarged uterus resting on the floor of the pelvis, and this is increased as the circulation becomes obstructed, and as the mucous follicles undergo cystic degeneration. The condition at length becomes one Fig. 122.* of partial strangulation, as in paraphymosis." He thinks the English term better than trachelorrhaphy or hystero- trachelorrhaphy. Of 500 fruitful women who have come under his care in private practice, 32-80 per cent who had been impregnated and now suffered from some form of uterine disease, were found to have laceration of the cer- vix. The injury on the left side is the most common, and double laceration the next. More than thirty per cent of the cases were attributed to tedious labor. He thinks rapid labor must be a cause to a greater extent than his figures prove. Sterility resulted in 71 "34 per cent of cases * The drawing exhibits results of double lateral laceration, showing also enlarged mucous follicles. The dotted line shows the outline when the flaps are brought together (Emmet). 41 8 DISEASES OF WOMEN. where the cervix was so injured. Menstruation is in 51 '59 per cent of cases increased (in length of days). The occur- rence of cellulitis in connection witli or as a consequence of laceration of the cervix is the most important and most fre- quent complication. Thus, of the 164 women last under observation, ^^, or 2o'i2 per cent, had cellulitis at the time of the first examination. The laceration is common, is often overlooked owing to softness of the parts, and it is most common in the middle line, anterior more common than posterior. If in the median line and limited to cervix it generallj' heals rapidly. It may of course pass into bladder and then may leave fistula. Laceration through posterior lip also heals rapidly and may not be suspected unless the inflammation extends sufficiently into posterior ciil de sac \.o set up attack of in- flammation. If cellulitis occurs at this point it always in- duces a most intractable form of retroversion, owing to the formation of a cicatricial band felt as a cord. This form of laceration seems from the history of the cases due to " pos- terior occipital " position. When, however, the laceration is in a lateral direction and extends beyond the crown of the cervix, a condition arises which defeats the reparative power of nature. There will exist a tendency for the tissues to roll out from within the uterine canal when the upright position is assumed. The lips are forced apart b)' the weight of the uterus above, the posterior being pushed backward, the anterior forward. The angle of tlie laceration becomes the starting-point of an erosion, which gradually extends over the everted surfaces. The involution is retarded, the erosion bleeds readily as it extends, and the woman gets about; a profuse cervical leucorrhoea ensues, and the appearance of a frequent show causes the patient to seek relief. This laceration was until recently universall)^ mistaken for ulceration, and it long baffled all treatment: improvement from rest was followed by relapse on attempt at exercise. The mucous follicles of the cervix will be found to have gradually undergone cystic degeneration. When the laceration is double and lateral, the flapsflatten against the posterior wall of vagina or floor of the pelvis, so that all appearance of laceration becomes lost. On digital examination the cervix is found to be larger than the body of the uterus. The relative size of such a cervix to the body of the uterus is about that of the top of DISEASES OF THE OS AND CERVIX UTERI. 419 a half-grown mushroom to its stem. These flaps can be rolled in on using the speculum witli the patient on the side, and by seizing the an- terior and posterior lips of the cer- vix with a tenaculum in each hand. There is a variety when the lacera- tion is unilateral, giving obliquity to the uterus. Treatment. — Dr. Emmet considers an operation is required where the condition is evident, where enlarge- ment of the uterus still remains, or where the woman suffers from neu- ralgia. T\\& preparatory measures are, use of vaginal hot-water injections, use of a pessary to lift uterus from floor of vagina, application of tinc- ture of iodine or iron twice a week with glycerine dressings, and pled- gets of cotton, one before and one behind, to keep flaps together. It is often necessary to puncture the overloaded cysts and so reduce the strangulation and swelling; iodine is applied after this scarification. The operation is best performed with the patient in the Sims posi- tion on the side. First the flaps are brought together by tenacula. Then the uterine tourniquet — Fig. 123, a special instrument for the purpose, constructed of a piece of watch-spring — is applied, for the haemorrhage is often excessive. Emmet now only uses it when tissues are unusually soft; the use of hot water before the opera- tion renders it less liable to occur. The scissors is the instrument preferred to freshen the surfaces. Fig. 123.* m Fig. 123, watch-spring tourniquet used by Emmet. 420 DISEASES OF WOMEN. The uterus is drawn down, if possible, to outlet of vagina during operation. A short i-ound needle is best, and wire sutures are employed as shown in the drawing. The sutures are removed in seven days. The patient is kept in bed for twelve days. The pessary, which is removed for the operation, is replaced soon after it is completed. Dr. Emmet says that the hypertrophy and elongation of cervix will almost invariably be found due to laceration of cervix uteri, and the remedy is to repair the laceration. Fig. 124.^ He denounces amputation with scissors, knife, or cautery, as malpractice, and denounces, as most uncalled for, cautery or caustics to heal a so-called ulceration. "Amputation of the cervix or the repeated application to it of cautery or caustics, will maim any woman and most likely render her sterile, and for the want of the support which the cervix normally affords she will be liable to suffer from displace- ment of the uterus. f At the Cambridge meeting of the British Medical As- * The drawing (Fig. 124) shows the shape of the raw surfaces after denudation (Emmet), f Op. cit., p. 483. DISEASES OF THE OS AND CERViX UTERI. 421 sociation, held 1880, Dr. Montrose A. Fallen of New York exhibited instruments employed by him in repair- ing the lacerated cervix. In his operation scissors of various shapes are employed to facilitate proper denuda- tion. Dr. Fallen strenuously recommends the operation, and expresses his conviction of the necessity and advan- tages of the operation in suitable cases. Looking over the records of my own cases, I find cases in which lacerations of the cervix have been noted as being present. From what I now hear of the cases related as observed in America, it seems evi- dent that in developing the subject and pointing out how the lesion is to be reme- died, our transatlantic breth- ren have done a good service to gynaecology. I believe Dr. Playfair was the first to perform this operation in England, and he has re- cently communicated a pa- {ier on the subject to the Obstetrical Society of Lon- don. I have myself success- fully performed it, and have come to recognize it as a most necessary and valuable operation. [Where the cervix is much engorged and very vascular, * Fig. 125 shows an instru- ment (reduced in size) made by Meyer & ML-!tzer, admirably adapt- ed for holding the uterus during the operation. Fig. 125. S^^ 422 DISEASES OF WOMEN. we are sometimes annoyed at the profuse bleeding which accompanies the operation. Dr. Clement Cleveland, of New York, has recently invented a neat little double-edged saw, of which I insert a wood-cut, for use in just such cases. It cuts with the backward stroke only and takes off the tissue very neatly. I have used it two or three times, and like its working. Of course it is only intended as an adjunct to the scissors, and is not meant for use in all cases.] A severely lacerated cervix implies a removal of the proper support to the bod}'^ of the uterus, and dislocation of the organ is no doubt favored thereby. A further effect is the exposure, the friction, the irritation of the lining of the cervix, resulting in abrasion, bleeding, hyper-secretion, etc., of the irritated surface. It is true that by elevating the uterus the latter class of evils is greatly lessened; so much so, in fact, in many cases, that the laceration itself becomes, or appears to become, a minor evil. Dr. Emmet's account is in conformity with this view of the matter; and it is evident that, while considering it necessary to repair the cervical laceration, he found it also necessary in many cases, both before and after the operation, to sustain the body of the uterus in position by a vaginal pessary. An important practical question is to determine how far eversion of the cervical mucous viembrane is possible without laceration of the cervix. It is now perfectly clear that in a considerable number of cases eversion arises in connection with cervical laceration, but there can be no doubt also that very extensive eversion may occur without such lacera- tion. As a rule, in long-standing cases of acute flexion, there arises a thickening, swelling, and eversion of the os uteri on the anterior or posterior aspect, and this ma}- even occur in patients who have not had children. Thus, in ante- flexion cases the anterior side of the os, in retroflexion cases tlie posterior side, becomes swollen and the mucous mem- brane expands. In women who have had children it is most liable to occur undoubtedl)', but my observation en- ables me to say that it may occur even to a considerable degree in cases where there has certainly been no lacera- tion. Hypertrophy, cystic degeneration of the lips of the os uteri, eversion of the mucous membrane, abrasion or ero- sion of the mucous membrane so everted, are all liable to be met with, and when excessive in degree may be found to have originated in a lacerated cervix, while in other cases DISEASES OF THE OS AND CERVIX UTERI. 423 they result from long-standing congestion of the lips of the OS uteri, the primary cause of which has been a severe flex- ion of the uterus. In some cases we find the os uteri repre- sented by two rounded protuberances, hard and firm, red and angry-looking on the cervical aspect, irregular as re- gards the surface from nodular swellings the result of cystic degeneration, and secreting freely a sanious, yellow- ish fluid. The cystic degeneration, as it has been termed, appears to be the result of overgrowth and distension of the Nabothian follicles. In process of time the lips of the OS have become hypertrophied, hardened, and otherwise diseased, and the two factors wiiich singly or Jointly operate in bringing about this state of things appear to be chronic flexion of the uterus and laceration of the cervix during parturition. The opinion has been expressed by more than one author- ity in America tliat the existence of laceration of the os uteri constitutes predisposition to cancer of the os uteri, and that for this reason, if for no other, the lesion in ques- tion is one demanding operative interference. (Further re- marks on this subject will be found in a later chapter, on Cancer of the Uterus.) ULCERATIONS OF THE OS UTERI. After what has been said in reference to laceration of the cervix and eversion, due either to this injury or to the existence of flexion, the consideration of the subject of "ulcerations" of the os uteri is simplified. Simple eversion of the cervical lining has been frequently taken to be " ulceration." Dr. Farre some years ago * said: "In the more common degree of hypertrophy with ever- sion, a crescentic protrusion only of the cervical lining oc- curs. The unevenness of the surface caused by the slightly swollen and prominent rugae, and as often by the numerous little depressions consisting of enlarged mucous crypts, ac- cording as one or the other of these is the predominant normal structure in the cervix, gives to the part during life the appearance of a raw and granular surface, while the natural boundary between the lower edges of the cervical canal and the lips of the os tincae being now transferred on the latter in consequence of this eversion, an abrupt to * " Cycl. An. and Phys.": article Uterus. 424 DISEASES OF WOMEN. semicircular line becomes visible, which, while it only in- dicates the natural termination here of the vaginal epithe- lium, is frequently mistaken for the margin of an ulcer." The stretching of the parts, which is sometimes produced by the mere introduction of the speculum, may give rise to this kind of eversion of the lining of the cervix, whenever the OS uteri is a little lax and soft, and slightly open. Erosions of the everted cervical lining are not very un- common, but they rarely pass into the state of true ulcera- tion. The loss of tissue involved is generally merely re- moval of the epithelium of the part affected, the vascular or proper tissues underneath being unaffected. The re- moval of the epithelium, however, leaves the villi uncov- ered, and these are apt to undergo hypertrophic changes, and increased vascularity also results. What is termed a "granular" change is sometimes noticed in cases where the abrasion or erosion has been in existence for some time. During pregnancy, as was observed by Cazeaux some 3^ears ago, the villi of the cervical mucous surface undergo hypertrophic changes, and are more vascular than usual. Moreover, they readily bleed when touched, and these " physiological "changes (for such they are) must not be confounded with ulceration or erosion produced by dis- ease. Erosions of the everted cervical lining appear to be in great part due to the friction of the surface against the vaginal floor produced by the movements of the body. A great secretion of fluid often occurs in cases of this kind, the fluid being ichorous, or watery, or sanious, according as the blood-vessels of the exposed villi are lacerated or not. I have observed a tendency to exfoliation or erosion of the mucous membrane at the os externum, in cases of chronic flexion with the retentive form of leucorrhoea. Here the retained uterine secretions become irritating, and this irritation probably has an eroding effect on the deli- cate mucous membrane at the os uteri. True ulcerations of the vaginal portion of the cervix uteri are sometimes met with. They are generally associated with enlargement and hypertrophy of the cervix uteri, whatever may be the cause of that enlargement; or with those affec- tions of the uterus usually classed under the term " prolap- sus uteri." They are produced by the mechanical irritation to which the prolapsed cervix is exposed, and have all the characters of ordinary ulcerations. DISEASES OF THE OS AND CERVIX UTERI. 425 Another form of ulceration of the os and cervix uteri, which is rare, is by some authors believed to be of cancer- ous nature, by others to be of tuberculous nature. Dr. West, in whose work* will be found a careful re'sutnc' oi what has been said by different authorities on the subject, believes that these intractable ulcerations are instances of epithelial carcinoma; and he agrees with Robin in considering that this kind of ulcer is to the uterus what lupus or cancroid ulcers are to tlie face. There appears to be no reason, how- ever, why both sides should not be right, or for denying that both tuberculous ulcers of chronic nature and lupoid disease of the cervix uteri may be witnessed, though not of course in the same individual. It can very rarely happen that this question will arise practically for determination, these intractable ulcerations being very uncommon. Syphilitic Affections^ Ulcerations, etc. , of the Os and Cervix Uteri. — Concerning true chancre — primary syphilitic ulcer — of this part, th.ere is but little difference of opinion. It is pretty well understood that it is very rare, although it has been observed. Chancre of the os or cervix uteri presents an appearance like that of chancre observed else- where; it is said that there is a greater disposition on the part of the ulcers here situated to bleed. The only con- clusive evidence of the nature of the ulcer would be its re- production by inoculation. Respecting secondary syphilitic eruption, or ulceration of the OS and cervix, there has been much discussion, nor is it at all settled how frequently ulceration is present in indi- viduals affected with secondary syphilis. It does not ap- pear that there is anything peculiar about the character of the ulcerations present in these cases, or which would en- able us to say at once that such and such an appearance was due to sypliilis. My own observations induce me to agree with Dr. Tyler Smith, who held that "in almost all cases in which leucorrhoea and disease of the os and cervix uteri are present in women suffering from constitutional syphilis, the uterine symptoms are a genuine manifestation of the constitutional or secondary disorders."! The diagnosis of secondary syphilitic ulceration of the os and cervix will be materially influenced b}' the presence or absence of a syphilitic history in the particular case, and before proceeding to form a decision on the point all the * Op. cit., p. 361. f " On Leucorrhoea,'' p. gS. 426 DISEASES OF WOMEN. antecedents of the patient must be carefully scrutinized. The effects of anti-syphilitic remedies would frequently as- sist us in coming to a conclusion. Treatment of Ulcerations and HypertropJiy of tJie Os Uteri. — An exceedingly important element in the treatment of these cases is rest, and careful ablution at frequent intervals with warm water. It frequently happens that, by these measures alone, the size of the os uteri is very greatly diminished (see Treatment of Congestion of the Uterus, page 139), and in all cases, whether subsequently requiring operative treatment or not, these measures may be advan- tageously cai'ried out. Styptic applications should be sub- sequently employed; and a solution of nitrate of silver, or tannic acid, or dilute iodine tincture, is useful in further reducing the hypertrophy (see page 142). CHAPTER XXX. Chronic Inversion of the Uterus. Chronic Inversion of the Uterus. — Causes, Effects, and Varieties. Diagnosis. Treatment. — Reduction by Systematic and Continuous Pressure aided by Anaesthesia — Treatment by Excision. We are here concerned only with cases of chronic inver- sion of the uterus. The consideration of the condition in a recent state belongs to the domain of obstetrics proper. Inversion of the uterus may occur during, or soon after, parturition, and this is its most frequent cause; but it may occur also in connection with the presence of fibroid growths — polypi — attached to the internal surface of the organ, and thereby distending it. It may be partial of complete. In its complete form it may arise after parturi- tion; poh'pi generally occasion an incomplete form of the displacement. When there is complete inversion, the whole organ is turned inside out; the uterus lies wholly in the vaginal canal, and in recent cases projects considerably out- side the vulva. When occurring in connection with partu- rition, the uterus gradually diminishes in size, though less quickly than under ordinary circumstances, and at the end of a few months tlie uterus may be wliollv within the vagina, but completely inverted. CHRONIC INVERSION OF THE UTERUS. 427 The symptoms and effects of inversion of the uterus are generally of a striking character, but not invariably so. Haemorrhages, and almost incessant loss of blood in smaller quantity, are usuall)^ observed. Pains of a dragging char- acter, and asense of great discomfort more or less continu- ous, are experienced by the patient, these effects being not seldom of a very aggravated character. The patient frequently becomes very anaemic, and there may be great general prostration, breathlessness, and loss of power of locomotion, with oedema of the lower extremi- ties, etc. Chronic inversion of the uterus may exist for many years; cases of twenty-five or thirty years' duration are well authenticated. In cases of inversion of the uterus a tumor is felt occupy- ing the vagina, which varies in size according to the degree of the inversion and the time which has elapsed since its occurrence. Tlius, if the inversion be recent and complete, the tumor in the vagina may be so large as to project be- yond the vulva; but if some weeks have elapsed, it may be no larger than the fist, although still complete. The tumor is smooth, uniform, and no opening is to be detected on the surface. On digital examination, it is found that the vagina terminates above, round the pedicle of the tumor, in a per- fect cul de sac, and the surface of the tumor is actually con- tinuous with that of the vagina. At the point where the os uteri should be situated this pyriform tumor projects down- ward into the vagina. The tumor itself is hard and firm, and resistant, when the inversion has lasted a few weeks. If the patient have been recently delivered, if a tumor has occupied the vagina since delivery, and if, further, it be known that there was no tumor previously, the diagnosis is not usually difficult to establish, provided the inversion be complete. This statement is, however, not quite uni- versally true, for pregnancy may be associated with poly- pus, and the polypus may be thrust down into the vagina immediately after the expulsion of the child. Gooch and otliers have related cases of this kind. There is no possi- bility, in complete inversion, of passing the finger above the pedicle of the tumor, nor can the uterine sound be made to pass in this direction. The symptoms attending the pro- duction of inversion during labor are characteristic: exces- sive pain — which may, however, be absent — prostration, syncope; the uterine tumor is no longer felt above the pubes; haemorrhage is usually observed. Inversion may 428 DISEASES OF WOMEN. occur just at the end of labor, or a few days after, from in- cautious exertion on the part of the patient. Inversion of the uterus usually gives rise to frequent and profuse haemor- rhages, together with great discomfort and pain; but it does now and then happen that the symptoms are not so urgent as to attract much attention until the disease has lasted for some time. That the symptoms and histor}' of the case are not always demonstrative of its true nature, is proved by the fact that inversion of the uterus has been frequently looked upon and treated as polypus. With reference to the diagnosis of complete inversion fiom polypus : in both cases the tumor is generally more or less pyriform; in both cases it is hard, resistant, smooth; in both the tumor terminates above by a constricted portion; in both there are haemorrhage, leucorrhoea, and symptoms produced by pressure on the adjacent viscera; but in the case of inversion, neither the sound nor the finger can be passed upward beyond the pedicle of the tumor, whereas, in the case of a polypus projecting down into the vagina from the interior of the uterine cavity, an instrument can be passed into a cavity beyond the neck of the tumor; the neck of the tumor being encircled by the os uteri, the sound can be made to pass into the interior of the uterus. This distinction is not a perfectly reliable one, for there is occa- sionally a difficulty in detecting tlie cavity above when it really exists,* and sometimes there is found to be adhesion of the sides of the polypus to the adjacent wall of tlie vagina or to the interior of the cervix uteri (West, Blundell); and, further, it may happen that the polypus grows from a part of the uterine cavity close to the orifice (Gooch). It is said that in cases of inversion the tumor is very sensible; that this sensibility is wanting in cases of polypus; that the sur- face of the inveried uterus is rough, whereas the surface of a polypus is smooth; but no reliance can be placed on such supposed distinctions. If an examination be made within a week after the labor, the fact that tlie normal uterine tumor is absent from the hypogastric region, associated with that of the presence of a rounded firm tumor in the vagina, will demonstrate the nature of the case; at a later period this remark would not hold good, or at least in the same degree. Another mode of examination, enal^ling us to distinguish between inversion and polj'pus, is the com- * See leaned, 1S27-2S, vol. i., p. 327. CHRONIC INVERSION OF THE UTERUS. 429 bined examination by the rectum and by the bladder — i.e., the finger introduced into the recturti and a sound into the bladder, by which means an absence of the body of the uter- us from its normal position can be substantiated (Arnott). In cases of pa>-iial inversion of the uterus the difficulties as regards the diagnosis are more considerable than when the inversion is complete. Here the pedicle of the tumor is en- circled by the os uteri, as observed when a polypus projects downward from the uterus into the vagina. In cases of partial inversion, however, the sound cannot be passed so far beyond the encircling band formed by the os uteri as usual, whereas in cases of polypus the cavity may be even longer than ordinary. A complex condition has been now and then observed, in which the diagnostic mark alluded to might fail; that, namely, in which there is a polypus of the uterus forming the lower part of the tumor, this tumor having dragged down the fundus uteri with it and produced partial inversion, where, in fact, the two conditions, polypus of the uterus and inversion of the uterus, are associated. Dr. McClintock* has directed attention to a new diagnostic sign of the presence of inversion. It is this: When the case is one of inversion, on drawing the tumor downward the lip formed by the os disappears; on ceasing this traction the lip is again evident. A very careful consideration of the previous history, combined with examination of the parts, are necessary to come to a correct conclusion in these doubtful cases. The tumor due to a partially iaverted uterus is hard and firm, like a fibrous polypus; the symp- toms produced by it are pretty much the same — haemor- rhages, discharges, etc. — but there is more pain, more dis- comfort to be looked for in the case of inversion than when there is only a polypus present. Again, the double exam- ination by the rectum and bladder is very important in as- sisting the diagnosis, the more so as in cases of poh^pus partly projecting from the os — the particular cases, in fact, which most closely simulate this partial inversion of the uterus — the body of the uterus is generally more or less enlarged, owing to the presence of the polypus within it. TREATMENT. There has been usually found but little difficulty in re- placing an inverted uterus when the condition has been de- ^ Op. cit., p. 91, 430 DISEASES OF WOMEN. tected at once, as in the process of labor. Wlien, however, the disease is a chronic one, the difficulties to be encoun- tered are great. We must first speak of the treatment of cases of chronic inversion of the uterus of the simple and uncomplicated kind. Formerly these cases were only treated by excision; the patient was relieved of the tumor and of her troubles by means of the knife, at the expense necessarily of loss of all power of bearing children subsequenth', and not unfre- quently at the expense of loss of life altogether. Happily art has stepped in to the rescue of these cases, and a method has obtained general adoption in the profession, by means of which the normal shape of the uterus is restored, even in long-standing cases. M. Valentin,* in 1847, reduced an inverted uterus after the lapse of upward of a year from the date of its occurrence. The reduction was performed by the aid of the two hands, the left placed over the hypogas- tric region, the right in the vagina, the tumor being grasped by the finger and thumb of the right hand. These manip- ulations were performed while the patient was under the influence of ether; and after application of continuous pressure in this way for about ten minutes the reduction was accomplished, and the patient completely cured. The etherization in this case enabled the patient to bear the operation, it having been relinquished previously owing to the great pain produced. Mr. Canney,f of Bishop Auck- land, reduced a ciironic case of inverted uterus of five months' duration, in 1852, under the influence of chloroform, and by manipulations pretty much the same as those de- scribed above. M. Barrier's | case, also in 1852, is the next reported, the duration having been considerable. These three cases had escaped my notice in preparing the first edition of this work. Dr. Tyler Smith, § in 1856, success- fully reduced an inverted uterus of twelve years' duration after several days' treatment, the uterus being pressed and moulded by the fingers for about ten minutes night and morning. After repeated trials, the cervix uteri, which was firmly contracted round the neck of the projecting tumor, began to yield a little, and the tumor could be slightly sunk in the os. After each operation, a large india-rubber air- * Quoted from Gaz. M/d. in Ranking's "Abstracts." vol. vii. I Ranking, vol. xvi. % Ibid. § " .Medico Chir. Trans.," vol. xlii., p. 183. CHRONIC INVERSION OF THE UTERUS. 43 1 pessary was placed in the vagina, and inflated to as great an extent as the patient could bear. The air-pessary was worn, with few exceptions, day and night. "After more than a week of these proceedings," says Dr. Tyler Smith, the patient felt a good deal of pain through the whole of one night; and in the morning, when an examination was made, it was discovered that complete reinversion had taken place. A small air-pessary was afterward worn for a few (lays, and the recumbent position maintained. Subsequent- ly the patient became pregnant. The principle of the successful reductions effected in ob- stinate cases is to maintain a persistent pressure on the inverted part, or rather a combination of moulding and pressure by means of the fingers and thumb introduced into the vagina, counter-pressure being applied externally, and when this does not succeed, to apply a more continuous but less forcible pressure by means of an india-rubber air- pessary. The part which has been inverted last should be l^ushed upward first, as Dr. McClintock has very properly remarked. The uterus is capable of being readily moulded, and on this property of the uterus our attempts are to be based; sudden, too forcible, and too abrupt manipulations must be avoided. Chloroform or ether, as the reports show, are invaluable adjuncts in the treatment. Dr. Marion Sims proposed, in difficult cases, to make a vertical incision through the uterine tissues on each side, at the part corresponding to the os uteri, so as to allow more easily of the reduction of the tumor. Dr. Barnes* also performed an operation on this principle successfulh'. The case was one of some months* standing, where continuous pressure had failed. He drew down the uterus and made three vertical incisions. The uterus was at once reduced by taxis, and the case did well. He recommended that in future two incisions only should be made, and that contin- uous elastic pressure (by water-bags) should be employed to restore the inverted uterus. Dr. Emmet's method of reduction is as follows: With one hand in the vagina, the fundus, in the palm of the hand, is firmly grasped and pushed upward, the fingers then immediately separated to the utmost; at the same time the other hand is emploj'ed over the abdomen in the at- tempt to roll out the parts forming the ring by sliding the * " Med. Chir. Trans.," vol. liii. 432 DISEASES OF WOMEN. abdominal parietes over its edge. This process is contin- ued some time, and later on the tips of the fingers are used to complete the re-inversion. Dr. Emrnet has also em- ployed sutures for closing the lips over the fundus after a partial reduction, to preserve temporarily the advantage gained.* In Dr. Emmet's operation an important element is the application of counter-pressure over the uterus from above, and the taxis performed in this way has proved very suc- cessful in his hands. Dr. Tate, of Cincinnati,! records an interesting case where counter-pressure was made above by two fingers carried up in the rectum, the fundus being then pushed up by the two thumbs. As this procedure tired the hands, the urethra was dilated and one finger of the other liand inserted so as to get counter-pressure in front as well as behind. The reduction was finally effected by pressure from a stem placed below instead of the two thumbs. Silver wires were placed in the os for three davs. Dr. Jas. P. White states that his experience is that "well- directed pressure upon the fundus, if continued longenough, will in all cases, unless prevented by firm adhesions, result in restoration or reposition, no matter how much time may have elapsed since inversion has occurred." J His method of reduction is as follows: The operator kneels on the ground, the patient is placed on the back at the edge of the bed, anaesthetized. The uterus is then manipulated by the right hand introduced into the vagina entirely. The hand grasps the uterus and presses upon the tumor; at the same time Dr. White's apparatus is brought into play. It consists of a hard rubber cup and stem, the latter a little curved; the stem ends externally in a pyra- midal-shaped spiral spring of steel wire. The cup is placed against the fundus uteri, the base of the spring against the breast of the operator. The left hand of the operator is used to make counter-pressure on the upper part of the uterus through the abdominal walls. Dr. White relates three typical cases, of six months', three years', and twenty-two years' duration respectively; in the last case reduction was effected in less than two hours.. Dr. White says he has performed the reduction successfully in this way in nine other cases. * Op. at. (2d edit.), p. 424. ■| Cincinnati Lancet and Observer, March, 1878. \ " Transactions of Philadelphia Medical Congress," 1876. CHRONIC INVERSION OF THE UTERUS. 433 The more recent experience of various operators would seem to be in favor of reduction of the inverted uterus by a process of continuous elastic pressure spread over some • ittle time, in preference to a more rapid and summary method of procedure. And various methods have been successfully adopted of applying such continuous elastic pressure. Fig. 126.* Thus Dr. Barnes used a stem iMovidcd with an elastic cap for the purpose of keeping up the pressure. (This was employed after incising the os uteri at two or three points in its circumference so as to relax or weaken the constric- tion: incisions one third of an inch deep and two thirds of an inch long.) * White's method. 434 DISEASES OF WOMEX. Mr. Lawson Tait has employed a stem with a cup-sliaped end, six inches long, and pressure is made by means of elastic ligatures fixed to the stem outside the vagina and attached to a band round the waist. Dr. Aveling * has improved the stem used as above by giving it an external perineal curve. Dr. John Williams records a case thus treated: a cup of vulcanite was mounted on a metallic stem having a perineal curve, and to it affixed four elastic bands, two carried in front and two behind. Fig. 127. +■ At the end of twenty hours removed, partial re-inversion having been effected. The instrument re-applied and bands tightened, and after another twelve hours the operation completed. In this case the inversion was of two years and four months' duration. Dr. Aveling records two cases of his own, and states that the average time occupied in three cases in reducing the uterus was forty hours only. J A case of inversion is recorded by Dr. Gervis.^ treated in a similar * " Obst. Journ.," Ix.xiii., p. 21. f Fig. 127 shows the shape of Dr. Aveling's instrument; the line A B the direction of the pressure. I Rrit. M,\i. Journ., Sept 6, 1S79. § " Obst. Journ." Ixxx., p. 373. CHRONIC INVERSION OF THE UTERUS. 435 way after other methods had been only partially successful. Dr. Wing, of Boston, U. S. of America, reports a case of fi^urteen months' standing cured in three days b}' the above method. Reduction after Abdominal Section. — Dr. Thomas, of New York, performed a remarkable operation in an obstinate case. He cut into the abdomen, dilated \.\\e.cul de sac oi tlie uterus from within the abdomen, by a steel dilator, and thus vl X / ,/^ /-^^^ ^^fe^ Jei^ reduced the inveisiu;. , > ...c taxis. Recovery followed. Previously the pressure and incision method had failed. In three other cases, by ingenious variations of the pressure treatment, Dr. Thomas succeeded in restoring the uterus. The treatment of cases of inversion of the Jiteriis associated wit/i polypus of the I. terus requires a few words. When the polypus has a large basis of attachment, the fundus may * Fig. 128, from a preparation in University College Museum, repre- sents inversion associated with a large polypoid tumor. The tumor has produced complete inversion of the uterus and of the vagina. 436 DISEASES OF WOMEN. be so drawn downward that what appears to be the pedicle of the polypus is really the uterus itself. Thus a specimen was exhibited at the Pathological Society, and referred to Dr. Marion Sims, Dr. John Ogle, and myself, for examina- tion, in which such a tumor had been excised, and a cir- cular piece comprising the fundus uteri had been removed with it.* The case shows the necessity for great caution in excising tumors projecting through the os uteri. In most cases where a polypus projects into the vagina from the uterus, it draws down the wall of the uterus a little, and when the pedicle is broad this partial inversion of the uterus is more likely to be extensive. The use of the sound would in such cases give valuable information. CHAPTER XXXI. Prolapsus of the Uterus. General Remarks on the Pathology of the Subject — Mechanism by which the Uterus is kept in its Place — The various Conditions present in Cases of Prolapsus — Illustrations of various Conditions and Com- plications — Mechanism of the Process — Relation to Cystocele, Recto- cele, and Fle.\ions — Hypertrophic Elongation of the Cervix and its Varieties — Symptoms and Progress of Prolapsus. Dl^gnosis. Treatment. — Must be adapted to the Peculiarities of the Case — Treat- ment of Prolapsus from Hypertrophy of the Cervi.\ — Excision of the Part — Other Forms of Prolapsus — Measures directed (i) to the Condi- tion of the Uterus; (2) to the Condition of the Uterine Supports — Arti- ficial Means for maintaining the Uterus in its proper Place in the Pel- vis, by Pessaries, by external Appliances, by Constriction of the Vag- inal Aperture, or the Canal itself — Description of various Operative Procedures. Prolapsus, or falling of the womb, is an affection to which women are, in one form or other, exceedingly liable, and it is one which is not unfrequently productive of very much in- convenience and distress. Intimately connected as the uterus is with the adjacent organs, its displacement downward is almost necessarily attended with more or less displacement of these organs also. Prolapsus of the uterus, then, is rarely a simple affection; and, for this reason, it will be convenient * "Trans, of the Pathological Society," vol. xvi., p. 210. Prolapsus of the uterus. 437 to consider together the various displacements associated more or less frequently with it, viz., prolapsus of the uterus, prolapsus of the bladder (cystocele), prolapsus of the va- gina, and prolapsus of the rectum through the vagina (rec- tocele). The term " prolapsus" is in this country generally used to designate all grades of the displacement. In America it appears that ''prolapsus" means falling of the womb within the vagina, while " procidentia" is used to designate its ap- pearance externally to the vaginal aperture. In this place one term — prolapsus — will be applied to both these contli- tions. The anatomical relations and connections of the uterus are of the utmost importance in all that concerns a right understanding of the subject of prolapsus. The uterus is supported by a complex mechanism, the various parts of which are mutually dependent, and a failure or weakening of one leads to derangement of the others. It frequently requires no little attention to ascertain where the "break- down," literally as well as figuratively, first happened; but unless the investigation be successful, we can have no true basis for our curative efforts. Natural Supports of the Uterus. — In a former chapter, the structures by which the uterus is retained in its place have been described, but principally in reference to the preven- tion of what have been termed the minor displacements of the uterus (see p. 167). We have now, however, to consider how far these natural supports of the uterus prevent those further and more severe displacements which come properly under the head of prolapsus or procidentia of the organ. The. peritofieuiii SQVwcs little purpose in restraining the down- ward movement of the uterus. The round ligament has an influence Vv'hich is exerted for the most part in restraining the movement of the fundus backward. Still in a case where the uterus had descended a little, it would aid in preventing further descent. The utero-sacral ligatnents are so placed as directly to prevent falling of the uterus. They are firm, fibrous bands, passing one on each side straight between the cervix uteri and the sacrum. Dr. Farre justly drew attention to the importance of these ligaments. The broad ligaments — not, properly speaking, ligaments, being simply the mesentery of the Fallopian tubes — have, in the early stage of prolapsus, little restraining effect as regards descent of the uterus, but they would necessarily assist in 438 DISEASES OF WOMEN. checking its further progress downward. The uiero-vesical ligaments connect the uterus very closely with the bladder, and, supposing the distended bladder to be fixed, it would Fig. 129. be almost impossible for the uterus to descend below its proper level in the pelvis. The bladder, however, is not so fixed. A movement of the whole bladder downward neces- sarily carries with it the uterus, and correspondingly the uterus cannot descend without carrying with it that per- PROLAPSUS OF THE UTERUS. 439 tiori of the bladder with which it is connected, viz., the pos- terior part. Lastly, the general connections of the uterus with the adjacent parts, and constituted by a verj' consid- erable quantity of blood-vessels and connective tissue, form, as Dr. Savage* has shown, a very important additional ap- paratus for restraining undue mobility of the uterus. Dr. West considers that the canal of the vagina contributes very much to supporting the uterus in proper position. The re- searches of Mr. D. B. Hart, referred to at p. 169, explain how the vagina prevents prolapsus of the uterus, and the im- portance of the firm support which the normal perineum gives to the floor of the vaginal canal. In his eleventh plate, f Dr. Savage has delineated experi- mental observations ^post mortem) on the ligaments of the uterus and the resistance they offer to descent of the organ. Moderate traction on the uterine cervix by a vul- sellum was found to compress the bladder against the pel- vis, to straighten and put on the stretch the utero-sacral ligaments, to curve, but not to stretch, the round ligament. Cutting through the utero-sacral ligaments allowed the uterus to descend still lower, until the os uteri was just outside the vagina: the results were that the bladder was drawn down closely following the uterus, the rectum not disturbed, the broad ligament now for the first time put on the stretch. Dividing the broad ligament allowed of the further descent of the uterus to the extent of an inch: but the sub-peritoneal pelvic cellular tissue, particularly where it surrounded the uterine blood-vessels, and where it was strengthened by additional trabecular filaments, was found to restrain further descent of the organ. Complete pro- lapsus was produced on the yielding of the pelvic reflex- ions of the broad ligament. The round ligament was last put on the stretch. The perineum is undoubtedly a most important struc- ture in relation to the prevention of complete or partial uterine prolapsus and procidentia. This has been forcibly put forward by Dr, Thomas in his last (1880) edition, and Mr. D. B. Hart's views are in accordance therewith. Dr. Thomas, in his latest edition, gives drawings exhibiting the shape and size of the perineum to illustrate his views. * " Illustrations of the Surgery of the Female Generative Organs," 1863. Plate IX. t Op. at. 440 DISEASES OF WOMEN. He regards the perineum in the normal state as a concavo-- convex triangle, anteriorly supporting the inferior wall of the vagina, while its posterior side supports the anterior wall of the rectum. The accompanying drawing (Fig. 129) is one published by myself in the " Mechanical System of Uterine Pathology" two years ago, and the shape and size of the perineum here shown is closely in conformity with that represented by Dr. Thomas in his lately published work. The foregoing suggests valuable inferences regarding the controlling powers ^//^ROLAPSUS OF THE UTERUS. 449 portion in a young woman. In Fig. 135 is shown elonga- tion of the infra-vaginal portion from a woman who had had children. In Fig. 136 we have hypertrophic elonga- tion of the same portion in association with retroflexion, a rare combination. I have seen cases in which the external tumor consti- tuted by the prolapsed organs has been as large as the foetal head. Under these circumstances there is great thickening of the cellular tissue around the uterus. The organ itself is greatly thickened and hypertrophied laterally as well as longitudinally, and in some cases, togetiier with the bladder and uterus, certain coils of the intestine pass downward and help to enlarge the tumor. Huguier's statements as to the frequency of hypertrophic elongation of the cervix are not borne out by my own ex- perience. In other respects, as regards the collateral con- tlitions in these particular cases Huguier's account has seemed to be exact. The foregoing represent, regarding prolapsus generally, the generalizations I have been led to adopt. The very great importance of flexions, as in many instances the starting-point of the displacement, is a matter which it seems desirable to make prominent. Various secondary effects result from prolapsus. Thus, in cases of cystocele the bladder is evacuated with diffi- culty, retention of a small portion of urine is apt to occur, and chronic cystitis may be added as a complication. The uterus itself, when prolapsed, often becomes ulcerated and excoriated, broad patches, the size of the palm of the hand, raw and bleeding on the slightest touch, are observed round the os uteri, these ulcerations being produced by the friction of the tumor against the thighs. The tumor itself, from long exposure, becomes sometimes hard and leathery to the touch, the inverted vaginal mucous membrane losing the characters of mucous membrane and looking more like the adjacent skin. The discomforts connected with de- fsecation are great, and, as already stated, in the case of rectocele they may themselves become actually torturing. Needless to say, the general discomfort induced by the presence of a tumor at the vulva, changing in size from time to time, impeding locomotion, distressing the patient by giving rise to profuse leucorrhoea, occasional losses of blood, and in many other ways — all these constitute grave ailments. 456 DISEASES OF WOMEN. Lastly, in some cases, the tumor may be so large and so much swollen that it becomes actually strangulated and mortification sets in; again, inflammatory adhesions may occur to such a degree round the pedicle of the tumor that its return is found difficult, and in a few cases impossible. DIAGNOSIS. All cases of prolapsus uteri have this in common, that the OS uteri is the lowest point. In other respects, the variations observed are exceedingly great. In the most simple form of the affection the cervix uteri is felt rather lower than usual, and the vagina proportionately shortened. In its extreme degree, on the other hand, the uterus de- scends so low down as to be almost altogether outside the ostium vaginae; and in this case the vaginal canal is com- pletely inverted, the bladder is dragged externally also, and the rectum may be displaced in like manner. Thus, in a bad case of prolapsus uteri we may have combined, de- scent of the uterus with prolapsus of the bladderand rectum (vaginal cystocele and rectocele). If we find a conical, firm tumor, smooth on the surface, projecting downward in the vagina or beyond it, and the OS uteri situated at, or close to, its extremity, the case is one of hypertrophy and elongation of the vaginal portion of the cervix uteri. With such a condition there is usually found no considerable amount of prolapsus of the vagina, and the finger encounters the cul de sac of the vagina in about its usual position (see Figs. 134 and 135). The shape of the tumor is generally conical, but it may be larger at the ex- tremity than at the base; one portion of the lip may be larger than another, in which case the opening appears to be not quite at the extremit)' of the growth, and the os it- self ma}' be fissured and ulcerated according to the degree of irritation to which the part is exposed. The general shape, the firmness of the tumor, and the position of the os uteri, sufficiently distinguish it from other tumors occupy- ing the vagina. Hypertrophy of the Supra-vaginal Part of the Cervix. — In this class of cases there is prolapsus of the vagina, and the finger cannot consequently be introduced as far as usual. The use of the sound will render it evident at once whether the descent of the os uteri, bringing with it the vagina, is due to descent of the whole uterus, or to hypertrophy of PROLAPSUS OF THE UTERUS. 451 the lower part of this organ — the cervix. The attachment of the cervical part of the uterus to the bladder in front is such, that when the cervix is projected downward the blad- der comes with it; the extent of the prolapsus of the blad- der is, as a rule, dependent on the degree of the former. l''g- 137 (fi'om Dr. Farre) represents such a condition. (See also Fig. 133.) In like manner, the rectum is liable, but in a less degree, to be prolapsed with the lower part of Fir,. 137. the uterus; and the result is that in cases of extensive pro- lapsus of the cervix, whether with or without hj'pertrophy of the part, tliere is a soft tumor in front — the bladder — and a smaller one behind — the rectum — between which two the OS uteri is situated. A combined examination of the rectum by the finger and of the bladder by means of the sound, will determine whether or not the fundus uteri is in its proper position; the use of the uterine sound gives in- formation of a like character. True prolapsus of the ivhole uterus may be found associated with ascites, ovarian tumors, or both, or with relaxation of the vaginal structures, consequent on frequent child-bear- ing. 452 DISEASES OF WOMEN. Prolapsus, complete or produced by hypertrophy of the supra-vaginal portion of the cervix, could hardly be mis- taken for polypus, inversion of the uterus, or large tumors growing from the os uteri, if attention were paid to the position of the os in reference to the body of the tumor. Cases of hypertrophy of the vaginal portion alone might possibly be confounded with a polypus projecting into the vagina from the interior of the uterus, in those instances in which the os uteri is distorted, partially effaced, or so altered as not to be recognized as such by a casual observer. I have known an instance in which a lady was treated for prolapsus and made to wear a pessary for several months, the tumor being a well-marked specimen of polypus, at- tached b)' a slender pedicle to the interior of the cervix uteri. Prolapsus combined 7c) Cases of Hypertrophy of the Supra-vaginal Portion of the Cervix Uteri. — Cases of hypertrophic elongation of the cervix are now not uncommonly treated after the manner proposed by Huguier — viz., by excision; and this plan I have satisfactorily carried out in some few instances. When the hypertrophy is very great this is the onl)'' sat- isfactory treatment; but before deciding on its necessity, the patient should be kept in bed for a week or two, in order that it may be ascertained how far tlie affection is re- duced by this rest. It is the fact, as pointed out by Kiwisch, that rest materiall}' reduces the bulk of the cervix under these circumstances. Rest and prolonged use of cold ef- fusions would do still more. But when the disease is of long standing, and the uterine canal exceeding a total lengtli of four inciies, such palliative measures are inadequate. And the poorer classes, amongst whom the disorder is most marked, can ill afford the prolonged rest and attention requisite. Two plans of a palliative nature are open to us — (i) The use of pessaries, and (2) the closure of the vagi- nal orifice to such an extent as to prevent the escape of the cervix uteri, after a plan to be presently described. Each of these methods of treatment has peculiar advantages, according to the nature of the case. In many instances the}' prove sufficient; but in some few cases, as might be surmised, they are either inapplicable, or, in the long run, unsatisfactory. The operation of Huguier is accomplished as follows: An incision is made behind the os uteri through the vaginal wall, of a semicircular form, and directed toward the cen- tre of the cervix. Dissection is now made upward, in order to expose the hypertrophied cervix, and separate it from its connections posteriorly — great care being necessarj' to avoid the reflection of peritoneum there situated. A correspond- ing incision and dissection is made now in front; here, how- ever, great care is necessary to avoid injuring the bladder. As much of the cervix having been exposed as is considered advisable, it is removed by the knife. Huguier at first em- PROLAPSUS OF THE UTERUS. ployed the knife in removing the cervix, but subsequently the ecraseur, finding the haemorrhage trou- blesome when the knife is used. Such is an ^^*^- ^38. outline of the operation in question. The result is that a conical piece of tissue is re- moved, including the os uteri, the vaginal, and a portion of the supra-vaginal part of N \ the cervix. In the original memoir before referred to, Huguier states that he had per- formed the operation in fourteen cases. In only one of such cases a fatal result — not due, however, to the operation — followed. The operation is, judging from my own ex- perience, a sound one, and in some instances offers the shortest road to the cure of the patient. The dissection and exposure of the cervix is the part attended with most diffi- culty, and it must be done with care. The bladder may extend to within half an inch of the OS uteri, in which case it is evident that great caution must be required to avoid wounding it; again, the peritoneal reflection behind must be sedulously preserved intact. By keeping close to the cervical hard tissue these objects are secured. A sound in the bladder shows the position of that viscus, and acts as a good guide during the opera- tion. For the dissection itself scissors should be used; the knife occasions trouble- some bleeding. I believe that a deep dis- section — beyond an inch and a half, or at most two inches — is rarely required; for if the hypertrophied and, usually, thickened cervix be excised to this extent, the rest, which necessarily follows the operation, will suffice to com- plete the cure. Retraction of the severed cervix must be guarded against by previously transfixing the uterus above that point. The edges of the mucous membrane maj' be brought over the stump, and the opposite side secured by sutures so as to cover it, after Dr. Sims's plan, if it be pre- ferred. Of the various forms of the ecraseur, the steel wire-rope * Ecraseur to be used with annealed steel wire. (Meyer & Meltzer.) 456 DISEASES OF WOMEN. ecraseur is more useful in amputating the cervix in such cases, in Messrs. Meyer & Meltzer's instrument (see Fig. 138) the wire and the slit fit accurately, and there is less liability to draw in extraneous tissues, while the power of the instrument is exceedingly great. Prolapsus without Elongatio7i of the Cervix. — These include the more ordinary cases of prolapsus. In dealing with this class of cases, the indications are almost always various; the treatment must have regard both to the primary cause and the secondary effects, (i) The condition of the uterus itself, and (2) the condition of its supports, have to be con- sidered, and appropriate measures devised for rectifying defects and disorders. 1. The Condition of the Uterus. — In most cases of prolap- sus the starting-point has been a defective or altered con- dition of the uterus, which would have proved perfectly and completely amenable to treatment. Apart from those special cases of hypertrophic elongation of the cervix which have been alread}' dealt with, the condition of the uterus which most frequently calls for therapeutic measures in cases of prolapsus, is undue size and fulness of the organ, very frequently indeed associated with long-standing flex- ion and other troublesome alteration in its shape. The treatment required in cases where there is flexion, so far at least as the uterus itself is concerned, has been discussed under the head of Flexions, and it need not be here re- peated. It must not be forgotten, however, that cases of prolapsus, really due primarily to flexion, cease to present that element in a recognizable form when the affection has lasted many years. All we see then is the extremely ad- vanced prolapsus; the uterus itself is by that time other- wise changed. Among the general measures always required in these cases, rest, verj' careful attention to the bowels so as to avoid necessity for straining, injections, and a careful dietary, are very important. 2. The Condition of the Uterine Supports. — The methods of treatment which have formerly been had recourse to for preventing or curing prolapsus were based on the one idea of keeping the tumor from escaping at the vaginal aperture. Bandages, external pads, boxwood or disk-shaped pessaries applied internally, were the principal measures of "sup- porting" the uterus and supplying defects of the natural supports. Next came improvements in the shape of opera- PROLAPSUS OF THE UTERUS. 45/ tions for constricting the canal of the vagina, and thus re- storing the lost support in a more natural manner. But there is yet room for improvement, and that improvement is only to be attained by a careful attention to the restora- tion not simply of the outlet of the vagina, but the position of the uterus in the pelvis. In other words, it is not suffi- cient to simply shut up the uterus in the vagina by means of a perineal operation, for most assuredly, if the uterus be in a chronic flexed state, it will continue to excite ex- pulsive efforts, and the restored perineum will by and by give way. Even in single women who have never had children, and when the perineum has never been dilated or destroyed by a foetal head, very extreme degrees of pro- lapsus are sometimes witnessed. Supposing the uterus to have been reduced by treatment to its proper size and shape, we have next to consider hoiu to maintain it in its proper place in the pelvis. It must be quite obvious that unless this indication is complied with, the evil is likely to recur. It is in this direction that improve- ments in the treatment of prolapsus must be made. The cervical part of the uterus should occupy a position in the pelvis which is as nearly as possible its centre. The mechan- ism applied and the operations devised must have regard to this important circumstance. Instead, therefore, of endeavoring simply to keep the uterus within the vagina, attempts should be made to main- tain it in position at the top of this canal, which is its proper place. Admitting that this perfection of treatment is not possible in all cases, it is nevertheless practicable in most instances. The principle of treatment which fulfils this indication is to render tlie vaginal canal rigid, thereby giving support to the lower part of the uterus, and to adopt such otlier measures as may maintain the vaginal canal in this rigid condition. In many cases this rigidity of the canal can be supplied by means of a pessary which, adapted to the re- quirements of the patient, becomes practically an artificial vaginal stem to the uterus; and in certain other cases, where the vaginal aperture has become too large to retain such an instrument, it must be constricted by operation. Apply these principles to the consideration of actual cases. Cases of slight cystocele associated with anteflexion may be generally cured by the wearing of a well-adjusted "cradle" pessary as described in the treatment of ante- 458 DISEASES OF WOMEN. flexion; but if the cystocele be of long standing, a constric- tion of the vaginal aperture by operation is necessary, the instrument being worn subsequently. An air-ball pessary is a palliative measure in some of these cases, where the cradle is inconvenient, or difficult to adjust, and where the perineal aperture is not much increased in size. In the case delineated in Fig. 131 no treatment short of a consider- able narrowing of the vaginal aperture was sufficient, the prolapsed portion of bladder being hypertrophied and much thickened. In cases where the prolapsus is dependent simply on ret- roflexion of the uterus without much laceration of the perineum, the Hodge pessary is a most admirable instru- ment when properly adjusted. It carries out the indica- tions above alluded to, maintaining the vagina in its proper position, and, at the same time, and often quite efficiently, preventing the uterus from resuming its retroflexed posi- tion. Within certain limits it acts very well, but attention must be paid to the following points. As stated in the chapters on Flexions, if the flexion be of long standing the pessary alone may fail to cure it, other measures being re- quisite; but, once cured, the pessary will prevent its recur- rence, and, moreover, it will, if there be sufficient perineal support below, prevent prolapsus occurring. The instru- ment must be adapted to the size of the vagina. A pessary made from a ring three inches or three and a quarter inches in diameter, having the shape shown at page 266, generally answers the purpose in such cases as those contemplated; it must sometimes be made broader below than above. The copper-wire india-rubber covered rings which I em- ploy lend themselves admirably to the necessary process of fitting, for nothing can be a greater mistake than to sup- pose that one instrument will fit all cases. The instrument must be adjusted to the case, and, when properly fitted, may be worn for months without inconvenience. In some cases the watch-spring india-rubber covered round pessary answers very well; but only when the perineum has been properly repaired. If there be rectocele, whether associated with retroflexion or not, the case generally requires an operation to restore the injured perineum. Subsequently, the uterus often re- quires to be sustained in its position by a pessary, as above directed for retroflexion. The rectocele may be slight in degree, the tumor small, but instruments are useless in PROLAPSUS OF THE UTERUS. 459 such cases, because the prolapsed bowel is so near the vaginal aperture. The discomfort attending these cases of rectocele is sometimes relieved by giving very small (tea- spoonful) doses of castor-oil every morning. We next come to those cases where the mass protruded is large, and where the vaginal aperture is very large, be- cause it has been very much torn in labor. When the whole mass prolapsed does not exceed the size of a hen's egg, we may hope, under favorable circumstances, to satis- factorily treat the case, without an operation, by the use of instruments. Sometimes we are foiled even then, for what appears to be a tolerably good perineum may not give suf- ficient basis for maintaining a suitable pessary in its place. When the mass exceeds in bulk the size of an egg, a real cure is rarely obtained without an operation. First of all we may speak of palliative measures, for even in the worst cases some patients reject operative measures, and in some the age of the patient or other circumstances put an operation on one side. The mere reJuctioii of the tumor is sometimes ver}' difficult, when the parts have been some weeks prolapsed, and the neck thickened by inflammation. To eff< ct reduction the urine should be removed by catheter, the patient placed in a favorable position, and the pedicle or neck of the tumor well covered with oil. Seizing the tumor between the two hands it is then gently compressed from side to side, and pressed upward, the attempt being made in such manner that the part last prolapsed shall be first reduced. Attempts made otherwise and by simply pushing the mass in an up- ward direction may altogether fail, but the plan above directed I have always found successful. Dr. McClintock suggested strapping the tumor in order to reduce its bulk. I have never found this necessary. The ulcerations or abrasions of surface seen in such cases readily heal when the tumor is reduced. There are no doubt many cases in which the uterus is much hypertrophied and has become prolapsed with or without considerable increase in the size of the cervix, and which at first sight may seem difficult to treat without some operative procedure, but it will be found that by a continu- ous system of rest, irrigations of the uterus, use of astrin- gents, etc., the bulk of the organ becomes greatly reduced, and the case loses its formidable characters. Dr. Emmet in the last edition of his valuable work tells an amusing 460 DISEASES OF AYOMEN. Story, illustrative of this part of the subject. An eccentric but shrewd physician of the Currituck district, after having been shown Dr. Emmet's cases and practice in cases of pro- lapsus, told him he could cure any case in ten days. His practice was among the negroes. "His plan was to swing the woman in a sling from a beam, in the knee-and-chest position. This was maintained for ten days, during which time the vagina was kept filled with a strong decoction of oak bark, which was changed every day by means of a syringe. The sling was padded, the woman slept all the time, and was not disturbed except to receive her food or answer a call of nature." " The principles of the treatment were," Dr. Emmet states, "correct." Internal Supports. — In a case where the uterus has been in a state of retroflexion a pessary must be adapted suited to the case. It generally happens that in the cases coming properly under consideration in this place an ovoid ring answers extremely well, but the Albert Smith type of Hodge pessary is necessary in many instances. The quite round, rather thickly covered watch-spring pessary answers well in some cases. In a few the disk-shaped ebonite pes- sary is found suitable; various sizes are required. In some cases I have found a rather large cradle pessary most ser- viceable, particularly in cases where the uterus has been previously in a state of anteversion. The use of these sup- ports is, in bad cases, not generally satisfactory, unless the perineum has been effectually restored by operation. Various forms of air pessaries, globular as well as disk- shaped, are kept by the instrument makers, but they are not satisfactory for prolonged treatment, while open of course to objections already mentioned. Zwank's pessary has been in rather general use. It is an unscientific instrument, inasmuch as it distends the vagina very greatly from side to side, and perpetuates the prolap- sus by dragging the uterus still lower toward the vulva: the only merit it possesses is, that it prevents the escape of the mass from the vulva. External Supports. — Under this head are included me- chanical contrivances for preventing prolapsus, having their fixed point from without. The perineal pad and bandage consists of an elastic, or non-elastic, abdominal belt, whicli is the fixed point, and a perineal pad, which is of a flattened egg shape, and is so adjusted by x strap fixed anteriorly and posteriorly to the abdominal bandage as to press upon PROLAPSUS OF THE UTERUS. 461 the edge of the perineum. The pad is sometimes made elastic by means of an india-rubber air-ball. This appara- tus supplies in some degree the deficiency of the perineum, and prevents in some cases of prolapsus the expulsion of the mass outside the vulva. Here of course its function ceases. In some cases straps passed over the shoulders are the fixed points, being used instead of, or as an assistance to, the abdominal bandage. Another principle of treatment consists in the use of a rigid stem of metal or other material, which, terminating above in the form of a small ball, or cup-shaped, is main- tained in the vagina by means of a perineal strap, attached to an abdominal bandage. External frameworks of metal fixed anteriorly to the abdominal bandage, or to a kind of liernia belt, may be made the basis of support to such intra- vaginal stems. It is obvious that from without it is possi- ble in this manner to adjust an internal support very firmly. The inconvenience attached to the wearing of such external solid mechanical supports is a great objection to them, but if external supports are to be made really eflicient, some such principle of construction as this is required. Obvi- ously, the alternative is the performance of an operation which will radically cure. Radical Operations. — The success with which the very worst forms of prolapsus can now be treated by operation will render this method more and more popular, especially if after such operations care be taken to deal with the uterus, and promote its restoration to shape and position in the pelvis. The principle of the operation is to constrict the vaginal canal. Dr. Marshall Hall seems to have been the first lo suggest it, and Mr. Heming the first to have prac- ticed it. The part of the vaginal canal so dealt with was at first the lower apertuie or entrance of the vagina, and this operation received later on important developments at the hands of Mr. Baker Brown, Dr. Savage, and others. A further step consists in the constriction of the vaginal canal higher up as well as at the vaginal aperture. With respect to the merits of these various operations, much will depend on the case itself. A simple perineal operation is sometimes quite sufficient when the vagina has not been much distended, but when the protruded mass is considerable the vagina is necessarily much stretched, and simply to close the aperture of the vagina is attended with no permanent benefit. Many cases require a sort of com- 462 DISEASES OF WOMEN. bined operation, a restoration of the perineum and a nar- rowing of the canal itself for some little distance upward. The Perineal Operation. — It may be well in this place to consider the treatment of ruptured perineum in its entirety, including recent as well as chronic cases. When the perineum is torn in the process of labor, the rent extends to a variable depth backward, sometimes de- stroying the whole sphincter of the rectum, in other cases not affecting the sphincter at all, but subtracting little or much from the perineum. If the rent looked at immedi- ately after the labor is over exceeds an inch in depth, it may be said to be a case for operation. By "immediately" is meant in this place a few minutes after the birth of the child, at the time the parts are customarily inspected. Some days later a rent one inch in depth originally will have be- come diminished — even in cases when no union has occurred — very materially. And what has appeared a rather large rent perhaps is then found to be comparatively trifling. When the rent is at all considerable, however, the operation is required. The primary operation should be performed within one hour from the birth, while the surfaces are still raw and bleeding. The surfaces are generally very well secured in apposition by rather deeply applied silver-wire sutures: two or more may be required. I have found them most easily introduced by means of a needle two and a half inches long, and bent into a completely semicircular shape. Such a needle can be employed with the patient lying on her side in the ordinary obstetric position. The sutures should go to the bottom of the wound, and they should come out on the surface some way from the edges. So performed, the operation is very simple. The nurse carefully and fre- quently dries the parts with soft lint, not using water, the knees are tied together, the catheter is employed, the bowels not allowed to act for at least three days, and on the fourth or fifth day the sutures can be removed. The result is gen- erally very satisfactory. It is quite true that by rest and position union will sometimes occur without use of sutures, but this result cannot be depended upon, and the primary operation is so little troublesome or painful to the patient, that unless the rent is very slight, it is best so to perform it. It is of very little use inserting sutures when the labor has been over some hours; union rarely then occurs. The secondary operation (a) should not be performed until PROLAPSUS OF THE UTERUS. 463 at least one month after the labor. Careful inspection of the parts is required to determine on the line of procedure. Good health, avoidance of erysipelatous influences, a dry, well-ventilated room, are essentials to success. The bowels should be previously carefully evacuated. Dr. Thomas very properly insists on the necessity for use of aperient medicine for some days previous to the operation, in order to dislodge any possible accumulations, but it is best, I consider, to use injections and not medicine during the two days preceding the operation. In long-standing cases of prolapsus, complete rest in bed for some days is quite requi- site, and all ulcerative processes should have ceased. The Fig. 140. hairs near the part to be operated on are first removed by a razor, the patient having been placed in the lithotomy po- sition at the edge of the table. A semilunar incision is first made corresponding to the edge of the perineum, and indicating the outer edge of the surfaces to be bared. A corresponding internal semilunar incision is next made within, as shown in the annexed figure (Fig. 139); and the internal and external lines of incision connected by two horizontal cuts. The strip of mucous membrane enclosed is then removed by the scalpel or scissors. Some operators prefer the scissors, as the bleeding is less. The extent of this surface so removed varies in different cases. It should * Fig. 139 shows the shape of the raw surface in ordinary cases. The dotted lines indicate the position of the hidden deep wire sutures. 464 DISEASES OF WOMEN. always be deeper in the middle line (the floor of the vagina) than at the two extremities of the horns of the crescent; from one inch to an inch and a half in width is required in the middle line. The opposite sides, thus rendered raw, are next brought together b}^ deeply inserted sutures. The quill suture, or modifications of it, were formerly employed. I have used for some time past beads made of ebonite, and of such a form as to allow of the wire used being easily attached to them (see Fig. 140). They are little balls with a projecting neck, and perforated through the middle. They possess the great advantage of permitting any easy regulation of the tightness of the suture, and allow of a better circulation in the soft tissues implicated. The quill suture is apt to give rise to great swelling and even slough- ing of the new perineum; but I have never seen this hap- pen with the bead suture. The deep sutures, two or three in number, are inserted at a distance of about three quarters of an inch from the edge, and the needle carrying the suture should so pass as not to be visible initil it emerges on the skin on the opposite side. One of the sutures at least should pass as deeply as this. When the deep sutures are inserted, they should be temporarily tightened in order that it may be ascertained by the touch internally that the internal edges are really in apposition, otherwise gaping results, and union will not occur. Failing this, the deeper ones must be re-inserted. The finger should be inserted in the rectum in order to be sure that the suture does not enter this canal. Rather stout silver wire is, I consider, preferable, and the needle used must be a perforated one, having a nearly semicircular large sweep, and a large firm handle. It is rather more difficult to pass such a needle through, but the purchase thus obtained is more perfect. The ends of the wire are readily secured to the perforated beads. When the deep sutures have been fixed, two or three super- ficial ones are generally requisite, for which a smaller wire serves best. The knees are then tied together, and the patient removed to bed. In my opinion the best after- treatment of the wound is to use no water, but simply a piece of dry lint for the purpose of drying the surface, which latter should be done frequently. Position on the side, but the side may be changed from time to time. The deep sutures to be loosened or removed at the end of three days, the superficial ones rather later. As regards the ma- terial for the sutures, silk or catgut are preferred by some PROLAPSUS OF THE UTERUS. 465 operators to silver wire. Dr. Granville Bantock prefers silkworm gut, and he employs no beads or other appliances externally, simply knotting the sutures in the middle line. Dr. Chambers uses wire, fastening the wire in the middle line by means of Aveling's coil and shot. It was formerly the practice to give opium for some days, to prevent action of the bowels, but some operators — Dr. Bantock for instance — prefer to evacuate the rectum after two days by means of an injection of olive oil. This should be carefully injected by means of a small tube, or mischief may be done. If the operation is simply a restoration of the perineum, without involving the rectal sphincter, the difficulty of procuring an evacuation without interference with the reparative process is much less considerable. The use of the catheter for the first three days was considered essential, but it is now frequently dispensed with. The combined operation (b), consisting of constriction of the vaginal canal as well as its lower aperture, I have practiced in the following manner: One plan is to remove a triangu- lar strip of mucous membrane about two inches broad below, and about half an inch broad above, from the floor of the vagina, the upper end or apex of the triangle being quite close to the os uteri. The ordinary operation (a) is then performed as described above. The shape of the surface thus bared is shown in the annexed drawing (Fig. 141). Another plan is to remove two triangular strips from the vaginal canal, one on each side of the floor of the vagina, the operation (a) being superadded. When the edges of these triangular bared spots are brought together, the va- gina is of course proportionately constricted. The method which I have pursued of maintaining the edges in apposi- tion is to use a stout piece of silver wire. By means of a short curved needle, such as is used in vesico-vaginal fistula cases, the stitch used d^iX-^x post-mortem examinations is em- ployed to bring the edges together, beginning from above. As the wire is drawn through it is straightened, and finally constitutes a kind of splint. In Fig. 141 the arrangement of the suture is shown before the wire is pulled straight. The upper end of the wire, which is close to the os uteri, is turned downward to prevent its scratching, and cut off short; the lower end projects at the perineum, and is twisted round one of the beads when the operation is completed. This splint-stitch, as it may be termed, answers very well; healing generally occurs, and the wire, having done its 466 DISEASES OF WOMEN. work, comes away in four or five days without trouble or necessity for stretching tlie perineal wound. If two tri- angular strips are removed, the same procedure is adopted with each of them. This combined operation at once re- stores tlie perineum and removes the superabundant and hypertrophied vaginal walls.* The two operations may be readily performed at one and the same time. Dr. Savage describes a method of operating which sub- stantially much resembles the above. He extends the Fig. 141. perineal operation by removing the mucous membrane up- ward along the floor of the vagina, but he relies on deep sutures for producing coaptation. Such coaptation along this internal line can only be produced by the deep sutures at the cost of shortening the vagina altogether. Such shortening, inasmuch as it implies descent of the uterus, I consider objectionable, and therefore the use of separate sutures for the vaginal floor are to be preferred. I have * This method of constricting the vagina was first described by me in the Lancet, June 5, 1869. PROLAPSUS OF THE UTERUS. * 467 performed the above combined operation in several cases, and find it a satisfactory one, and I know that it has been performed and found satisfactory by others. The plan of extending denudation along the floor of the vagina in form of a triangle, as in the above operation, has been also practiced by the late Professor Simon and others under the term " posterior colporrhaphy;" the edges being, however, approximated by ordinary stitches. Another method of narrowing the vagina in the same part is that of Bischoff of Basle, described by H. Banga* Fig. 142. of Chicago, the effect of which is that the lower part of the vagina is not only narrowed, but, owing to the elongation of the perineum, its axis is brought forward. A tongue- shaped flap is separated in the direction upward, and each edge of it is united by sutures to the posterior edge of the ordinary lateral denudation. The procedure is very ingenious. Banga states that since 1875 forty such opera- tions have been performed by Bischoff, Engli, and Banga, with only one death, and that when amputation of the cer- vix was also performed. * Amer. Journ. of Obst., vol. xi., p. 247. 468 DISEASES OF WOMEN. Operation for constricting the Upper Part of the Vagina.-^ Dr. Marion Sims* describes tliis operation as follows: The operation consists in removing a V-shaped piece of the mucous membrane forming the roof of the vagina, and therefore covering the bladder. The apex of the V is near the urethra, and the two arms reach to the side of the cer- vix uteri. Finally, the shape of the excised surface is that represented in Fig. 142. The opposite denuded surfaces are next brought togetiier by means of sutures, a X.o b, c to Fig. 143. \= Fig. 144. Fig. 145. d. The effect is, tnat the vagina has its canal much con- tracted; a little pouch is left opening at e (into which the uterine cervix might slip if the opening be left too large, as in cases reported by Dr. Emmet) for escape of the secre- tions of the part. Dr. Sims advises that, subsequently to the operation, the patient be kept in bed, or in the recum- bent position, for two or three weeks, the bowels to be con- fined for a week, the catheter to be used. The lower sutures are removed in eight or ten days, the upper ones in a fortnight. The principle of Dr. Sims's operation is to Op. cit., p. 310. PROLAPSUS OF THE UTERUS. 469 constrict the vagina superiorly, and the constriction is effected by removing part of tlie roof of the vagina. Perineal Rupture with Destructio- of the Rectal Sphincter. — In cases where the sphincter ani is entirely destroyed the difficulty in restoring the integrity of the parts is very great. Dr. Emmet in 1S73 published the results of his ex- perience as to the best method of dealing with such cases.* He points out that the fibres of the severed muscle are in a state of retraction, those which formed the inner surface of the circle being more retracted than the others; the result being that a convex surface is presented at the floor of the rent. It is necessary to denude the surface on each side far- ther back than at first sight seems necessary. The diagram (Fig. 143) shows the retraction of the fibres after rupture. The suture a b will, Emmet points out, only imperfectly bring the parts together; Fig. 144 shows the action of the suture. It is necessary to introduce a suture at a lower level, as at c d; and the action of tliis suture is shown in Fig. 145. The suture c d is first secured, the bowels are re- lieved on the sixth day by castor-oil, the sutures being re- moved the day after. Dr. Emmet has exhibited great in- genuity in detecting and in surmounting what had before seemed a great difficulty, and any one who has attempted the operation will appreciate the truth of this. Mr. Lawson Tait practices an operation for the cure of severe perineal rupture coupled with laceration of the spliincter.f He denudes the surfaces in a peculiar way by cutting into the tissues along the line of the laceration to a certain depth, and then opening out the raw surfaces thus produced and bringing those of the two opposite sides together by sutures, which are so introduced as to bring the deep angles of the incisions into approximation. The innermost of the sutures are in the vagina, the outermost are on the perineal surface. * Latest particulars in his 2d edit., 18S0, p. 402. f " Obst. Trans.," vol. xxl., p. 292. University of California SOUTHERN REGIONAL LIBRARY FACILITY Return this material to the library from which it was borrowed. 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