! i i ! , .Jb i~.4* ^, i 1 w ji^ THE PRACTICE OF MEDICINE AND SURGERY. THE PRACTICE OF Medicine AND Surgery, APPLIED TO THE DISEASES AND ACCIDENTS INCIDENT TO WOMEN. By W. H. BYFORD, A.M., M.D., PROFESSOR OF GYN.^COLOGY IN RI'SH TTEDICAL COLLEGE, AXD OF OBSTETRICS IN THE -WOMAN'S MEDICAL COLLEGE ; SURGEON TO THE WOMAN'S HOSPITAL OF THE STATE OF ILLINOIS ; MEMBER AND PRESIDENT OF THE AMERICAN GYNECOLOGICAL SOCIETY; MEMBER AND EX-^^CE-PRESIDENT OF THE AMERICAN MEDICAL ASSOCIATION, ETC. f%.^ If y THIED EDITION. THOROUGHLY EEVISED AXD EE WRITTEN. ONE HUNDRED AND SIXTY-FOUR ILLUSTRATIONS. PHILADELPHIA: LINDSAY & BLAKISTON 18 8 1. '> Vl ^•^'. ' ' ■ Enlered according to Act of Congre??, in the year 1S81, By LINDSAY & BLAKISTOX, III (lie Ofticc of the Librarian of Congress, at Washington, 1). C PREFACE TO THE THIRD EDITION. The second edition of this work was issued almost simultaneously Avith three Gynsecological works by authors who have become world- known and been quoted by all modern writers on diseases of women. That edition was soon exhausted, and the work has been out of print several years. The above-mentioned full supply of good books on the same subject led me to neglect my own for this long time. Many of my friends in the Western section of this country, and some in other portions have, however, so kindly and frequently urged me to produce another edition that I am persuaded it might be useful to the profession. The rapid progress of medical science in the last decade, and es- pecially that department to which this w^ork is devoted, has made so many changes necessary that the present edition is almost a new book. New chapters and subjects have been introduced, and most of the old ones have been rewritten. In many instances I have expressed opinions and counselled prac- tice that differ greatly from the teachings of the last edition. This could not be otherwise, nor do I desire that it should. Surrounded as I have been by such a throng of active workers, the results of whose labors I have tried to assimilate, my former ideas have been necessarily greatly modified, and I hope also improved. While there is much new material introduced, the omission of puerperal diseases and diseases of the breasts enables the author to compress the work into about the same size as the last edition. Chicago, August 1, 1881. CONTENTS. CHAPTER I. DISEASES AXD ACCIDENTS OF THE LABIA AXD PERIX-TirM. PAGE Adhesions of the labia, . 17 Wounds, 18 Sanguineous infiltration, .19 Varices of the labia and vulva, 20 CEdema, 20 Phlegmon, 21 Abscesses of the labia, 23 Labial tumors, 23 Hypertrophied labia, 24 Elephantiasis, 24 Cancer of the labia, 24 Absence of the labia, 25 CHAPTER II. PERINEUM. Definition, 26 Eupture, 29 EflTects of laceration, . . 30 Treatment, 31 Spontaneous cure, 32 The immediate operation, .33 Perinaeorrhaphv, . 35 CHAPTER III. DISEASES OF THE VrLVA. Condylomata of the vulva, 40 Treatment, 40 Erythematous, papular, vesicular, and pustular inflammations of the vulva. . 41 Treatment, 41 Follicular vulvitis, . 42 Cause, 43 Treatment, .... , . .43 Pruritus pudendi, 43 Treatment, 44 Corroding ulcer, 46 Gangrenous vulvitis or noma, 47 Vlll CONTENTS. Urethral excrescences, 48 Vascular urethra, 49 Hypertrophy of the clitoris and nyrapha, 50 Treatment, 50 CHAPTER lY. DISEASES OF THE BLADDER. Paralysis of the bladder, 51 Prognosis, 51 Symptoms, ............. 51 Diagnosis, 52 Treatment, 52 Hsemorrhage from the bladder, .......... 53 Hyperaesthesia of the bladder and urethra — Irritable bladder and urethra, . 54 Causes, ............. 54 Treatment, 54 Chronic inflammation of the bladder, 55 2sature and progress, 55 Symptoms, 56 Diagnosis, 56 Prognosis, 57 Treatment, . . . . . .57 Stone in the bladder, 60 Symptoms, 61 Diagnosis, . . . . . ; . 61 Treatment, 62 Foreign bodies, 63 Inversion of the bladder, 64 CHAPTER Y. AFFECTIONS OF THE VAGINA. Absence of the vagina, 65 Causes, . 65 Diagnosis, 65 Atresia vaginae, , 66 Diagnosis, 67 Prognosis, . . . -. 67 Treatment of atresia, and absence of the vagina, 67 Tumors in the vagina, . 70 Vaginismus, 70 Diagnosis, . 71 Prognosis, 71 Treatment, . . . . . .71 Acute vaginitis, 73 Diagnosis, 74 Prognosis, 74 Cause, . 74 Treatment, 74 CONTENTS. IX PAGE Chronic vaginitis, . . . .75 Symptoms, 75 Diagnosis, 76 Causes, . 76 Prognosis, 76 Treatment, * . 77 Puerperal vaginitis, .78 Symptoms, 80 Treatment, 80 Urinary fistula, 81 Diasrnosis, 83 Prognosis, 84 Treatment, 84 Sims's operation, . . » .86 Simons's method, 95 Kolpokleisis, 100 Bozeman's method, ......,,.. 102 Entero-vesical fistula, ........... 107 Entero-vaginal fistula, 107 Eecto-vaginal fistula, . . . 107 Treatment, . . , .108 CHAPTER yi. MENSTRUATION AND ITS DISORDERS, General considerations, . . . . . 110 Puberty, .111 Amenorrhoea, . ^ . . . ^ . > ... . . .116 Pathology and morbid anatomy, » . . . . . . .117 Symptoms, 117 Amenorrhoea from retention, 120 Diagnosis, , . 120 Diagnosis of retention, ..... ^ 123 Prognosis, 123 Treatment, 124 Local electrization, ... ....... .128 CHAPTER YII. MENORRHAGIA AND METRORRHAGIA. Definitions, ......... .... 133 Causes, 133 Treatment of menorrhagia, . 137 Palliative treatment, . 137 Mechanical, ....... . 139 Palliative treatment, Sims's method, .... . 139 Curative treatment, ....... . 141 X CONTENTS. CHAPTER YIII. DYSMENTORRHCEA. PAGE Definition, 146 Diagnosis, 147 Prognosis, 147 Treatment, 147 The inflammatory form, 149 Symptoms, 149 Diagnosis, 149 Prognosis, 149 Treatment, 149 Membranous drsmenorrhoea, 150 Symptoms, 115 Diagnosis, 152 Treatment, 152 Obstructive dysmenorrhoea, 153 Symptoms, 155 Diagnosis, 155 Prognosis, 156 Treatment, . . . . : 156 Sims's method, 157 Peaslee's method, 159 Dilatation, 167 Storer's treatment, 168 CHAPTER IX. METATITHMEXIA, OR MISPLACED AIEXSTRUATION AND PERIUTERINE H.EMATOCELE. Definition, 170 Pathology, 171 Symptoms, 173 Diagnosis, . .' 175 Prognosis, 176 Treatment, 177 Chronic retrouterine hematocele, 179 Diagnosis, 182 Treatment, 183 CHAPTER X. CHANGE OF LIFE— MENOPAUSE AND SENILITY. CHAPTER XI. ACUTE INFLAMMATION OF THE UNIMPREGNATED UTERUS. Causes, 188 Symptoms, 188 Prognosis, 189 CONTENTS. • XI PAGE Diagnosis, 190 Treatment, 190 Acute inflammation of the mucous membrane of the uterus, .... 191 CHAPTER XII. GENERAL CONSIDERATIONS ON UTERINE DISEASE OR HYSTEROPATHY. CHAPTER XIII. SYMPATHETIC SYIVIPTOMS OF UTERINE DISEASE. Sympathy of the stomach, 201 Sympathetic disease of the bowels, 202 Sympathetic affection of the liver, 203 Sympathetic affections of the nervous system, ....... 203 Accompanying manifestations of moral and intellectual perverseness, . . 204 Syncopal convulsions — hystero- epilepsy, 205 Moral and mental derangement, 206 Cephalalgia, 207 Affections of the spinal cord, 209 Hyperaesthesia, 209 Anaesthesia, 210 Spasnis, 210 Sympathetic pains in the pelvic region, 210 Extension of inflammation to the bladder and rectum, 210 Affections of the sciatic and anterior crural nerves, 211 Muscular weakness, 211 Circulatory system, 212 Eespiration, 213 Sympathy of the excretory organs, 214 Mammary bodies, 215 LOCAL SYMPTOMS. Pain in the sacral or lumbar region, 219 Pain in the loins, 219 Inability to walk, 219 Pain in the iliac region, . 220 Soreness in the iliac region, 220 Pain in the side above the ilium, 220 Weight or bearing-down pain, or uterine tenesmus, 221 Leucorrhoea, . 221 Amount of leucorrhoea not always proportioned to extent of disease, . . 222 Yellow leucorrhoea, where there is abrasion or ulceration, .... 222 How is the pain produced ? 223 Bearing-down not always caused by displacements, 223 Severity of suffering not commensurate with amount of disease, . . . 224 Effects on the functions of the uterus, 224 Pain during menstruation, 225 Kind of pain attendant upon uterine inflammation, 225 Cramping pain, . 225 Xll CONTENTS. Effects of partial closure of the os uteri on menstruation, Manner of the flow modified by inflammation and congestion. Duration of the flow, Menorrhagia, Menorrhagia frequent in endocervicitis. AmenorAoea sometimes results, Function of generation affected by it, Sterility, Abortion, Conditions of the uterus in abortion. Effect upon labor, .... Effects upon the post-partum condition, PAGE 225 226 227 227 227 227 228 228 229 230 231 231 CH.1PTER XIV. PATHOLOGY OF HYSTEROPATHY. General considerations, 233 Mucous inflammation, 238 Seat of mucous inflammation, 238 Cavity of the body of the uterus, 239 Endocervicitis, 239 Endocervicitis with diminished size, 239 Endocervicitis in virgins, . 240 Endocervicitis in aged women, ......... 240 External inflammation combined with internal in childbearing women, . . 240 CHAPTER XY. ETIOLOGY OF UTERINE DISEASE. CHAPTER XVI. DIAGNOSIS. Position of patient for examination, ........ 246 Digital examination, . 248 Os uteri in the aged, 251 Corpus uteri, 252 A tender uterus is an inflamed uterus, 252 Examination per rectum, 252 Object in using the probe, 253 Size and length of probe, . 254 Mode of using, 257 Length of the cervical and uterine cavities, ....... 257 Hysterometer, 258 Speculum, 260 How to find the os uteri, 262 Mwle of using the speculum, . . . . » 262 Appearance of the OS and cervix in the virgin, 266 Appearance of the multiparous uterus, 266 Appearance in the aged, 267 1 1-.^■ ' -j-iLiJ u^ CONTENTS. Xlll PAGE Exceptions to the appearances, 267 Color, 267 Appearance of secretion, 267 Indication of mucus in abundance, . 268 Indication from pus, 268 Probe and speculum conjointly, 268 Dilatation, 268 Characteristic signs of inflammation, 272 Diagnosis of endocervicitis, ..,,...... 273 Diagnosis of submucous inflammation, 274 Complication of mucous with submucous inflammation, 274 Size of the uterus ordinarily increased — Exceptions, 274 Atrophy as the result of inflammation, 275 CHAPTER XYII. GENERAL TREATMENT OE UTERINE DISEASE. General treatment, 278 Spontaneous cure, 278 Change of general circumstances only temporary in effect, .... 279 Supervention of acute inflammation, . 279 Acute inflammation after parturition or abortion sometimes works a cure, . 280 Posture, exercise, and repose, 280 Sexual intercourse, 283 Main objects of general treatment, 284 General symptoms requiring special attention, 286 Nervous prostration, 286 Food, 288 Nervous excitability, 288 Ansemia, 291 Plethora, 291 Local congestions, 291 Constipation, 292 CHAPTER XYIII. SPECIAL TREATMENT. Baths, 303 Hip-bath, 304 Temperature of the bath, 305 Shower-bath 305 Sponge-bath, 305 Injections, 306 Manner of using injections — kind of syringe, 307 Quantity of injection, ........... 308 Medicated injections, . 308 Astringent injections, 309 Modus operandi, 309 Frequency of using, 309 xiv CONTENTS. PAGE Alternate astringent remedies, 310 Temperature of injections, ^^^ Position of the patient, ^^^ Accident in injection, ^11 Should they be used in pregnancy, , • • • 313 Local treatment, . . . ''^^ Topical depletion, ^1^ Leeches, 31d Scarification, ^1^ Glycerin, ^1^ Local alteratives, 319 Treatment of endometritis, 323 CHAPTER XIX. LACERATIONS OF THE CERVIX UTERI. General considerations, 329 Causes, 329 The degree, locality, and direction, . 330 Effects of the laceration, 331 Effects on the body of the uterus, . . 331 Complications, 332 Symptoms, 332 Diagnosis, 332 Treatment, 333 Preparatory treatment, 333 The operation (trachelorrhaphy), 334 CHAPTER XX. OCCASIONAL UNTOWARD EFFECTS OF UTERINE MANIPULATIONS AND OPERATIONS. CHAPTER XXI. HYPERTROPHY OF THE CERVIX. Elongation of the supravaginal cervix, 342 CHAPTER XXII. PERIMETRITIS. General considerations, 346 Causes, 349 Symptoms, 349 Diagnosis, 352 Prognosis, 354 CONTENTS. XV PAGE Local peritonitis, 355 Causes, 357 Symptoms, 357 Diagnosis, 358 Prognosis, 360 Treatment of perimetritis, 360 CHAPTER XXIII. CHRONIC PERIMETRITIS. Causes, 365 Varieties, . 365 Symptoms and diagnosis, 368 Treatment, 369 CHAPTER XXiy. DISPLACEMENTS OF THE VAGINA, BLADDER, AND RECTUM. Cystocele, 372 Kectocele, 372 Diagnosis, 373 Causes, 373 Treatment, 374 CHAPTER XXV. DISPLACEMENTS OF THE UTERUS. IS^atural uterine supports, . 377 Causes of displacements, 378 Lapse, 379 Prolapse, 380 Protrusion, 381 Symptoms, i ... 383 Diagnosis, 384 CHAPTER XXYI. DISPLACEMENTS OF THE UTERUS, CONTINTJED. Treatment of displacements of the uterus, 386 Instruments, 388 Supporters, 389 Pessaries, 390 Suspension pessaries, 395 Adaptation of pessaries, 396 Anteversion, . 396 Ketroversion, 396 Treatment of prolapse, 400 XVI CONTENTS. CHAPTER XXYII. DISPLACEMENTS OF THE UTERUS, CONTINUED. PAGE Eetroversion and retroflexion of the uterus during pregnancy, . . . 407 Causes, 407 Symptoms, 408 Diagnosis, 409 Termination, 409 Treatment, 410 CHAPTER XXVIII. DISPLACEMENTS OF THE UTERUS, CONTINUED. Inversion of the uterus, 412 Symptoms, • 413 Diagnosis, 414 Prognosis, 415 Treatment, 416 The treatment of the chronic form, 418 CHAPTER XXIX. DISEASED DEVIATIONS OF INVOLUTION OF THE UTERUS. Diseased deviations of involution of the uterus, 428 Definition, 428 Causes, 429 Symptoms, 429 Prognosis, 429 Treatment, .430 Subinvohition of the uterus, 433 Causes 435 Frequency of its occurrence, 436 Symptoms and diagnosis, 436 Diagnosis, 437 Prognosis, 438 Treatment, 438 Hyperinvolution, 441 Causes, 441 Symptoms, 442 Diagnosis, 442 CHAPTER XXX. CANCER OF THE UTERUS. General considerations, 443 Symptoms, 445 Causes, 447 Diagnosis, 448 Prognosis, 450 Treatment, 450 Palliation, 458 CONTENTS. XVll CHAPTER XXXI. EPITHELIOMA, CANCROID, EPITHELIAL CANCER OF THE UTERUS. PAGE Definition, 464 Diagnosis, 466 Prognosis, 468 Treatment, 468 CHAPTER XXXII. SARCOMA. Description, 478 Symptoms, 478 Diagnosis, 479 Prognosis, 480 Treatment, ■ ... 480 CHAPTER XXXIII. TUMORS OF THE UTERUS. Fibrous tumors, 481 Theirnature, 483 Symptoms, . 486 Diagnosis, 489 Prognosis, 491 CHAPTER XXXIY. FIBROUS TUMORS OF THE UTERUS, CONTINUED. Treatment, 496 Cases, 500 Summary of cases cured by absorption, . 515 Modes of using ergot, 516 Different preparations, 518 Auxiliary treatment, 520 Corrective treatment, 521 Modus operandi, 521 Electrolysis, 529 CHAPTER XXXY. SURGICAL TREATMENT. Kemoval of polypoid tumors, 531 Enucleation, 536 Laparotomy, 541 Laparo-hysterotomy, 542 Oophorectomy — Battey's operation — spaying, 546 Physical and psychical results, 552 XVm CONTENTS. CHAPTER XXXVI. THE OVARIES. PAGE Description, 553 Method of examining the ovaries, 553 CHAPTER XXXVII. AFFECTIONS OF THE OVARIES. Congenital atrophy, 555 Hypertrophy, 555 Displacements, 555 Symptoms, 557 Diagnosis, 558 Prognosis, ............. 558 Treatment, 559 Ovariiis, . 561 CHAPTER XXXYIII. AFFECTIONS OF THE OVARIES, CONTINUED— OVARIAN TUMORS. Nature and anatomy, ■ . . . . 565 Dermoid tumors, 567 Theories of their origin, 574 Progress and termination, 580 Causes, 582 Prognosis, 584 Diagnosis, 585 General remarks on diagnosis of ovarian tumors generally, .... 585 Microscopical examination of ovarian fluid, 591 Differential diagnosis, 594 CHAPTER XXXIX. OVARIAN TUMORS, CONTINUED. Treatment, • 602 Palliative, 603 Tapping, ■ 604 Injection of the sac, 615 Electrolysis, 621 Vaginal ovariotomy, 622 CHAPTER XL. OVARIAN TUMORS, CONTINUED-GENERAL OBSERVATIONS. Abdominal ovariotomy, 624 Treatment of the pedicle, 624 The ligature, 626 Drainage, 627 CONTENTS. XIX CHAPTER XLI. ABDOMINAL OVARIOTOMY, CONTINUED. PAGE Inflammation in the tumor, 628 Complicated with pregnancy, 629 Complications with organic disease, . . ■ 637 Ovariotomy, 643 CHAPTER XLII. OVARIOTOMY, CONTINUED. Accidents that may occur during the operation, 650 CHAPTER XLIIL OVARIOTOMY, CONTINUED. After-treatment, 654 Treatment of the wound, 655 Attention to the clothing, 655 Anodynes, 656 Tympanites, 657 Haemorrhage, 659 Traumatic peritonitis, 660 Septicaemia, 662 Treatment, 663 Eemarks and personal statistics, 664 CHAPTER XLiy. FALLOPIAN TUBES. Inflammation, 666 Dyopsy, . . 667 CHAPTER XLY. COCCYGODY^NIA, COCCY^ILGIA. Neuralgia of the coccyx, 668 Structure affected, 668 Symptoms, 668 Diagnosis, 669 Prognosis, 669 Treatment, 669 CHAPTER XLYI. ELECTRICITY. Static, galvanic, farad ic, .671 DISEASES AND ACCIDENTS INCIDENT TO AYOMEN. CHAPTEE I. DISEASES AND ACCIDENTS OF THE LABIA AND PERIX^UM. Adhesiox of the labia, and consequent occlusion of the vagina, sometimes occurs in infancy, or early childhood, as well as in adult life. The adhesions of infancy are so feeble and easily broken up, that they may be considered a trifling affair. Upon examining the parts, it will be found that there is no development of adhesive tissue, but the mucous membrane of the two sides is merely in strong coaptation. It probably is caused by the adhesive influence of mucus accumulating and drying between the parts, when in close contact, from want of cleanliness. The vaginal oritice is closed up to the urethra above, and down to the fourchette below. The treat- ment consists in separating the labia, by forcibly pressing each iu opposite directions, until the adhesion gives way, washing and oiling them once a day afterwards to keep them from adhering again. Should we not be able to separate them in this way, the point of a silver catheter may be passed down so as to effect it. There will be no need of any other instruments in the case. On one or two occasions I have seen firm tissual cohesions of the labia in childhood as the effect of ulcerative vulvar inflammation. This form of adhesions may be so firm as to require the use of the knife. They are, however, always superficial, and we may gener- ally introduce a bent probe or director behind the adhesions from above. When this is the case, it is, I believe, the best plan to sepa- rate them, by drawing the bent director through the adherent part. The same care as in the infant will prevent them from adhering again. 2 18 DISEASES AND ACCIDENTS OF THE LABIA. The most grave adhesions we meet are in the adult, as the effect of neo'lected inflammation of the vulva after childbirth. These adhe- sions are sufficient entirely to close the vaginal orifice by the coapta- tion and firm accretion of the entire inner surfaces of the labia. I have met with more than one instance in which the hairy margins of the labia were so nicely adjusted to each other, that you could not distinguish the point of original separation, from the perinseum to the urethral orifice, and the finest probe would not enter the vagina anywhere. The depth of the adhesion may be very great, involving much of the vaginal cavity. These cases are very embarrassing, and are seldom perfectly reme- died. It is decidedly the best plan not to interfere with them until the menstrual accumulation fills up all the vaginal cavity remaining inadherent, and then our object should be to reach the accumulation with a small trocar as near the middle of the adherent parts as pos- sible. Placing our patient in the lithotomy position, the catheter should be introduced into the urethra, the urine all drawn off, and the urethra held as near the symphysis pubis, or as far from the middle line of the vagina, as practicable. The catheter should be thus held by an assistant, while the forefinger of the left hand should be placed in the rectum. With this preparation we may safely in- troduce the trocar into the collection of fluid as felt by the finger. The fluid being drawn off, the outer extremity of the perforation may be increased by the knife as far as may be desired, and as deeply as the surgeon may consider it safe. The opening may be increased as much as necessary by wax or hard-rubber bougies. The whole cavity should be thoroughly cleansed by a syringe with soap and water. The size of the bougies should be increased as often as once in twenty-four hours. If the opening is superficial, the treatment will not be protracted ; but if it is deep, it will be tedious. It should be continued until all danger of closure is past, and it will be best to keep the patient under our supervision for some time after this ap- pears to be the case. Wounds. The labia are sometimes wounded by accidents of some kind ex- traneous to the patient, and they are sometimes torn during labor. When the wound is deep enough to reach the bulb of the clitoris, alarming and sometimes fatal haemorrhage is the result. Professor Meigs gives an instance of great haemorrhage from these parts in a woman who had fallen upon a chair so as to cut through one of the SANGUINEOUS INFILTRATION. 19 labia. A case of fatal liaemorrhage was caused in this city about four years since, in the following manner, as well as it could be learned from a le^^al investigation : A drunken husband returned home late at night, and, as was his wont under such circumstances, beat and kicked his wife, who was probably also inebriated. He kicked her with great violence in the genitals^ and the square-toed heavy boot, in penetrating the pelvis, had cut off one labium and deeply wounded the other. In six or eight hours after the occur- rence the woman was found dead, with such copious effusion of blood from the wounds as, in the opinion of the examining jury, to account for the fatal result. I saw a case many years ago, where the patient was wounded by a knife in one labium so as to cause very profuse haemorrhage. The hsemorrhage being the important effect of these wounds, our efforts should be directed to its suppresssion, and this may in most cases be easily accomplished. The bleeding part should be pressed by the hand firmly against the pubic ramus of the side upon which it is situated until temporarily arrested, when an elastic air-bag or plug of oiled cotton or lint, may be introduced to fill up the vagina, and a hard compress placed and held firmly by bandages, so as to press the wounded part between the two. When wounds of the labia are large and gaping, the hair should be removed, and the wound treated according to ordinary rules for external wounds. The rents occur- ring in labor do not, in the great majority of cases, require any special treatment, cleanliness and quiet being all that is required. Sanguineous Infiltration. During labor, when the parts are stretched to their utmost extent, some of the arterial twigs occasionally give way and extravasate the blood in the loose structure of one labium. The infiltration usually shows itself after the child has been delivered ; but sometime^, before the head has passed, the swelling becomes very great, and proves an obstacle to the expulsion of the head. When this last is the case, the blood is effused from a large branch of the pubic artery, and the forcible injection into the tissues is so extensive as to fill a large part of the space between the vagina and the pelvic walls. This is a very serious state of affairs, and calls for prompt and judicious inter- ference. I once saw, in consultation, a case of this kind, so exten- sive as to arrest labor for several hours. These effusions, however, do not always call for surgical treatment, but when, as in the case here 20 DISEASES AND ACCIDENTS OF THE LABIA. alluded to, the effusion is extensive, we must make a free incision in the inner surface of the labium and allow the blood to escape ; if it is coagulated, we should introduce the fingers and dislodge it. Water- dressing, some evaporating lotion or cooling discutieut wall be suffi- cient, and absorption will be effected in from one to four weeks. Suppuration occasionally, I think not frequently, is excited by a small amount of effusion. This should be treated as an abscess. If the amount of blood is great and the parts are tensely distended even after the child is expelled, it is better to liberate it by incision, for fear of sloughing or extensive suppuration and serious damage. Varices of the Labia and Vulva. This condition of the vulva may be of greater or less extent. Gen- erally the varicosities are scattered about on the inner side of the greater labia ; sometimes only one or two exist of any size, but occa- sionally one labium is permeated by large blue veins in every direc- tion until they seem to have almost entirely replaced the other tissue. When the venous enlargement is great there is danger of rupture and profuse haemorrhage, even enough to bring about fatal results. The veins are especially large during pregnancy, and if wounded re- quire prompt and energetic treatment. For the emergency, pressure on the point of rupture will enable us to immediately arrest the haemorrhage. The ligature, however, will be necessary to secure the patient from an immediate repetition of the accident. This should be applied so as to completely control the loss. The radical cure re- quires the obliteration of the veins, effected in the same manner as elsewhere, by injection with the persulphate of iron, ligating with or without pins, etc. A radical cure should never be attempted in the absence of pregnancy, unless demanded by some great emergency. (Edema. The distensible nature of the structure of the labia renders them liable to great oedematous infiltration in cases of general dropsy. Ordinarily, such distension is a matter of trifling importance, but the supervention of labor at a time when they are very largely swollen is often an embarrassing condition. They are sometimes so swollen as to occlude the vaginal entrance, and yield only after protracted efforts, and even then, sometimes, only after one of them has been more or less torn. When excessive oedema is discovered before the head presses upon the external parts or even then, no time should be lost PHLEGMON OF THE LABIA. 21 in taking measures to lessen their size. This may be best done by everting first one and then the other, and making from ten to twenty small punctures through the mucous membrane only. A very sharp- pointed knife, taken between the thumb and finger of the right hand, so as to show only about the eiglith of an inch, is the best instru- ment. Several quick, smart strokes with the instrument thus held, suffice for the operation. The serum exudes from the punctures, and in half an hour the swelling is very much reduced. Phlegmon, Abscesses in the labia are apt to occur in three different forms. The first is common phlegmonous inflammation, occurring in the central part of one labium, very rarely in both. The heat, swelling, and pain are very great, and the inflammation runs its course quite rapidly, generally suppurating and discharging in from six to eight days. This form of inflammation results from bruises, acrid dis- charges from the vagina, or the extension of inflammation from that cavity. It is located about the centre of the labium, and the swell- ino^ and tenderness are o;reat from the bes-innino;. The second form originates in overdistension of Duverney's gland, from a stoppage of its excretory duct. It is situated deeply at the lower or posterior end of the labium, and generally more slow in its progress. If the patient is intelligent, and has observed the case with care, she will tell us that there was a little tumor in the seat of disease for several days, sometimes weeks, slightly tender at first, but gradually becom- ing more so until the abscess was fully formed. In this stage the labium is enlarged, tender, and hot, but there is not the acuteness of inflammation that is seen in the first variety. If the surgeon has an opportunity to examine the parts during the progress, he will per- ceive a well-defined tumor, pyriform in shape, with the small ex- tremity directed to the vulva, while the larger passes beneath the ramus of the ischium. It will not seem to be, as it is not, in the central part of the labium, but beneath its under surface. It will bear handling somewhat freely, and by pressing against the ramus, and directing the pressure toward the vulvar end of it, the contents may sometimes be pressed out. The contents in the early stages are, for the most part, mucus. If examined later, the surrounding parts, the labium particularly, will be found in a state of phlegmonous in- flammation, which, in ten days or two weeks, suppurates, and the pus is evacuated spontaneously. In this form of inflammation, if the duct 22 DISEASES AND ACCIDENTS OF THE LABIA. of the gland can be opened before the inflammation becomes consid- erable, suppuration may be avoided. This may be done by pressing the fluid out, or introducing a very small probe into the canal of the gland, thus opening it. If these are both impracticable, it is better to puncture it and squeeze the contents through the outlet thus made. If inflammation has begun, we may treat it like the former variety, with leeches, purgatives, evaporating lotions, etc., in the earlier period, find afterwards by poultices and anodynes until the suppuration is complete, when it should be evacuated by puncturing it on the mu- cous surface of the labium. The third variety is characterized by a succession of small furunculi. They first show themselves as small points of induration immediately below the mucous membrane or skin, which are very tender, and in the course of a few days suppu- rate. One scarcely passes through these stages before it is succeeded by another, and thus a continuation of them prolongs the march for weeks, and even months, before they cease to return. This condition has existed only in such of my patients as were the subjects of some form of uterine disease, attended with leucorrhoea. They are gener- ally anaemic, constipated, and dyspeptic. The radical treatment con- sists in curing the disease of the uterus, correcting the state of the bowels by mercurial and saline cathartics, and reinvigorating the patient by the judicious employment of tonics. We may palliate the siiflerings of the patient by cleanliness, as bathing the parts thoroughly several times a day with pure cold water, and using cold-water in- jections per vaginam, and making such application to every hardened point as soon as it shows itself as will arrest its progress. I have used successfully the strong tincture of iodine applied to the part, and the solid nitrate of silver. If either of these applications is used as soon as the inflammation begins to come, sometimes it will be arrested, and the patient escape for several days, or until another begins to form. Should we be unable to thus cut short the inflam- mation, we must use poultices of bread mixed with a solution of acetate of lead, and anodynes, until suppuration is perfect. These small points of suppuration usually break themselves, and they will seldom be lanced. Notwithstanding the fact that inflammation of the labia is very painful, the patient will bear her distress until sup- puration is complete, or at least unavoidable in almost all cases, so that our treatment is confined generally to that appropriate to the suppurative stage. The whole process of inflammation is rapid, so that this may be an additional reason why the first stage is not the subject of observation. ABSCESSES OF THE LABIA — LABIAL TUMORS. 23 Abscesses of the Labia Sometimes become chronic, especially such as find their origin in Huguier's gland. An interesting case of this kind is recorded in the Gynaecological Journal of Boston, second volume, page 136, by Dr. H. E. Storer : " For many years the lady had found coitus almost impossible, owing to occlusion of vulvae opening by lateral pressure. She was now several months pregnant, and the labial tumor was rapidly increasing. The tumor was very irregular in outline, with lobulations and depressions such as might easily have been occasioned by convolutions of intestine within a thin hernial sac. There were present many symptoms of strangulated her- nia, and the patient's distress and local suffering were extreme. It was impossible, by the most careful examination, to make a positive differen- tial diagnosis, though Dr. Storer was strongly inclined to believe it was a labial abscess of many years' standing, taking its rise from inflamma- tory obliteration of the duct of Huguier's gland. He cut carefully down upon the most presenting portion of the tumor, and obtained a free discharge of fetid pus. The sac was treated by carbolized tents, and the patient made a rapid recovery." Labial abscesses become chronic in another way; the duct of Hu- guier's gland becomes obliterated ; an abscess and discharge of pas take place by spontaneous eruption ; the opening closes, and this is followed by reaccumulation, rupture, etc., and this is repeated for an indefinite length of time. This form of chronic abscess is best treated by laying the sac open freely and emptying at once, or keeping it open until the contents are evacuated, and then every second or third day injecting a solution of nitrate of silver or tincture of iodine, or some other irritant that will awaken granular inflammation in the lining membrane of the sac. This kind of treatment should be per- severed in until the cavity is obliterated completely. Labial Tumors Do not diifer in any important respects from those observed in other parts of the body. In structure they may be fibrous, fatty, or en- cysted. The latter kind I have met with more frequently than either of the others. The fibrous are next in frequency, and the fatty per- haps least. In no respect does the treatment differ from the treat- ment of the same kind of tumors elsewhere. They should be dis- sected out thoroughly, no portion of tumor or cyst being left behind from which to be reproduced. The vulvo-vaginal gland is occasionally developed into a cystic tumor by the closure of the duct through 24 HYPERTROPHIED LABIA — CANCER OF THE LABIA. Fig. 1. which its contents are evacuated. This and the other forms of en- cysted tumors of tlie labia may be treated by evacuation and stimu- lating injections until the sac is obliterated. Hypertrophied Labia. The labia are sometimes hypertrophied, without much alteration of structure, to such a degree as to become cumbersome and trouble- some, requiring amputation. This may be done by the knife or ^cra- seur according to the shape and size of the superfluous part. These organs are very rarely the seat of elephantiasis, Fig. 1 (Scan- zoni). They sometimes are enlarged by this disease lo an enormous size, extending down to the knees, as shown in the figure taken from Scanzoni. If we meet with this af- fection before it has involved too much of the substance of the parts to be completely excised, we are justified in removing it; but if the skin on the thighs or abdomen is affected, so as to require extensive and dangerous dissection, we should not operate for this purpose, but content ourselves by palliative treatment, cleanliness, anodyne lo- tions, etc. It should be remem- bered while considering the pro- priety of removing small tumors of this kind that they very often return and resist every species of treatment. Cancer of the Labia Is not of unfrequent occurrence. I have only seen the epithelial Fromscanzonrs variety in this locality. Two cases have come under my observation within three years. The last one was a Scotch woman fifty-one years Elephantiasis of llic Laljia Dinamcs of Women mnmmm CANCER OF TOE LABIA. 25 of acre. The disease was located on the left side. When I first saw it the whole left labium presented an appearance so similar to a case illustrated by Fig. 2, in Dr. !McClintock's work on women, that I have availed myself of that figure. In my case the disease was on the opposite side. AVhen the disease has not advanced so far, but that it may all be removed, we are justified in excising it. We should be very particular to remove all the morbid substance. Scir- FlG. 2. rhus probably very rarely invades the labia majora. Dr. McClintock gives one case only. It does not seem, from the consultation of other authors, they have often met with it. The soft or fungoid variety seems to occur with even less frequency than the hard form of cancer. Cancer of the labia is attended with similar symptoms, and presents the same appearances that it does in any other organ. I need not stop to give it more attention in this place. Absence of the labia is very rarely observed. 26 PERINEUM. CHAPTER II. PEKIX-EUM. "Midway between the posterior vulvar commissure and the anus. Those perineal structures which meet there become, as it were, fused together by a great accession of elastic tissue without altogether losing their identity; the result is a body or structure at once highly elastic and resistant." This is Savage's definition of the periu^eam. The structures are the superficial and deep fascia of the pelvis, portions of the levator ani, internal and external sphincter ani, transversalis perinei, con- strictor vagina, and connective tissue. As are all other structures associated with the genital organs, it is richly supplied with vessels and nerves. The vessels are so numerous and large that when in- jected during pregnancy this body becomes softer, more elastic, and distensible, and, in fact, undergoes a sort of hypertrophy, less marked, but not less real, than the uterus and ovaries. The bilateral halves of the perineal tissues unite in the centre of this body, and their junction corresponds with the raphe as marked out on the skin. This central line is the weakest part of the peri- nffium, and is the track pursued by lacerations in a great majority of instances. The perinseum is suspended in its position by the differ- ent muscular, fascial, and tendinous organs and tissues which con- verge to it. It is, therefore, displaceable, and is, in fact, easily dis- placetl by force applied to it in any direction. In defecation it is often displaced forward. It is moved out of its normal position bv the downward displacement of the contents of the pelvis and tlie contents of the uterus as they are expelled during labor. The elas- ticity of its attachments quickly restore it after the forces has'e been withdrawn. The displacements are usually greatest in the direction from the weakest points of attachment. In labor and displacements of the pelvic organs it is pushed downward and backward toward the anus. AVhen split in the centre each half has the appearance of an irregu- lar triangle. The side next the vagina is nearly twice the leuoth of either of the other two sides and decidedly convex. The posterior portion of the triangle, or the side in contact with the rectal tissues, is shorter than the anterior, while the lower one next the inteoument is still shorter and slightly conclave. Situated at the bottom of the pelvis, between the rectum and vagina, it forms the floor of that cavity. Its upper angle is not directed upward but obliquely backward, with reference to the centre PERINEUM. 27 of gravity, and if extended would strike tlie lower part of the sacrum. Its anterior angle in many instances, when normal, extends forward nearly to the symphysis, while its posterior angle, when the rectum is empty, points toward the coccyx. It will be seen by looking at the figure that the vaginal convex side is the part upon which the viscera above have their bearing. While considering the perin?eum the floor of the pelvis, we must not forget that it antagonizes the diaphragm and abdominal muscles and is a part of the wall of the great infrathoracic cavity. For while that cavity is divided into the abdominal and pelvic they are con- tinuous, and some of the organs of the abdomen in the usual condition Fig, (Thomas.) of things extend into the pelvic cavity, and in pregnancy the pelvic organs rise into and fill up the abdomen. The impairment of the tone, or a loss of a portion or the whole of its structure, has a similar effect to the loss of tone or a portion of the structure of the abdominal wall. It permits the contents of the abdomino-pelvic cavity to pass out just as hernia is produced by a deficiency in the abdominal parietes. The shape, size, and firmness of different perinsei differ very greatly. This body indicates with some degree of correctness, the muscular vigor of the patient. In strong, muscular women it is apt to be thick, strong, and unyielding, and is probably more frequently lacer- ated than in weaker persons. In women of low muscular development it is often almost useless as a means of support. Its firmness and efficiency are also depen- 28 PERINEUM. dent upon the age and general condition of the patient. It keeps pace with the development of the genital organs. In early childhood it is rudimentary in structure and size ; stronger in youth ; com- pletelv developed in the middle period of life, and becomes atrophied in old age. In pregnancy it becomes thicker and stronger, through a species of hypertrophy, to successfully resist the continued pressure of the diaphragm and abdominal muscles. A very short time before labor it becomes more than ordinarily vascular and distensible. After labor its vascularity subsides, it undergoes a process of invo- lution, which results in the removal of its redundant tissue, it be- comes dense and resisting. At this time the lax condition of the alxlomiual walls and consequent diminution of pressure from that direction favors complete involution of theperin^eum. The consideration of the antagonism of the abdominal muscles and the perinseum would lead us to question the propriety of using a tight- fitting binder after labor. The binder when snugly applied restores the abdominal tension, while the perineum is weak and unable to resist the downward pressure. I think the binder when applied in the usual way is of doubtful value, because it interferes with that freedom of circulation intended by nature, pressing the uterus lower in the pelvis and retarding the involution of all the organs concerned. The position and relationship of the peringeum are such that it partakes of all the morbid influences to which the pelvic organs are subjected; especially lesions of circulation, excessive coition, labor, and gonorrlioea affect the peringeum more than the oi^ns higher up. In estimating the effects of loss of function, we should steadily bear in mind that diseases and accidents affecting the perinseum simulta- neously affect the organs associated with it and dei>endent upon it for support. While, therefore, we say that ruptured perinseum prevents complete involution of the uterus, we ought to remember that the two were simultaneously and equally subjected to the morbid effects produced by protracted or disastrous labor. The interdependence of the pelvic organs is such that I have no doubt but that subinvolution of the uterus and vagina sometimes keeps up a state of hyperaemia that prevents a ready repair of the damages done the perinseum. We know that rupture of the perinseum does not always arrest its involu- tion, and it is only when associated with disease of the pelvic organs that incK>nvenience arises from a small rupture, and in fact, extensive ruptures are not always a source of suffering. These considerations have a very important bearing upon the treat- RUPTURE OF THE PERINEUM. 29 ment of a deficient perinseum, and often the best course to pursue to secure success in our treatment is to cure the associated disease first. A large uterus in a state of prolapse, or a hypertrophied and ex- tended vagina, if not properly treated before the operation will fre- quently undo an otherwise successful perinseorrhaphy. In reading the reports of uterine surgeons this fact will not unfre- quently show itself. In calling attention to the above considerations I do not desire to detract from the importance of a surgical opera- tion when the perinseum has been impaired by laceration, but I wish to apprise the student of the fact that when an operation is clearly necessary, like all other important surgical operations, it requires preparatory treatment to insure success. Rupture of the Perinceum. The perinseum and labia majora are liable to be torn during severe labor. A number of causes may, under certain circumstances, lead to these accidents. A straight sacrum, by allowing the head to emerge from the pelvis farther back than usual, although not a fre- quent, is an occasional cause. Rigidity of the perinseum, or undi- latable state of the external organs, a condition frequently found in aged primipara and occasionally in other patients, is also a cause. A large and unusually ossified head, malposition of the head when the occiput emerges too much posteriorly, and a too narrow arch to the pubis, may also act as causes of rupture. The perinseum may be, and doubtless is, not unfrequently ru23tured by the unskilful use of the forceps : First, by not making the proper spiral change in the position of the head so as to bring the occiput under the arch of the symphysis; or, secondly, by not causing this part to keep close to the symphysis, by raising the handles at the proper time, and to a sufficient extent; or, thirdly, by elevating the handles of the forceps too much, the points of the blade may be brought in forcible contact with the perinseum, and thus, added to the great distension, cause rupture; fourthly, the forceps may be allowed to slip off the head under powerful traction. Mere slipping of the forceps, when the points of the blades pass behind the head, and become detached entirely, and the convexity of them is not in- creased, will not generally produce this effect. When this is the manner of missing the hold of the instrument, the blades will be pressed close together, and pass through the parts without great disten- sion. But if, instead of this mode, the blades spring so that the points are made to pass out over the largest part of the head, and thus widely separate the blades, the convexity becomes so great as to 30 RUPTURE OF THE PERINEUM. distend the parts enormously, and thus split through thefourchette first, and then the perinseum, and finally, in some instances, the sphincters. The injudicious use of ergot, by expelling the head so rapidly that the parts have not time to dilate, in some cases is undoubtedly the cause of ruptured perinteum. The head is not always the part of the foetus by which the rupture is produced, for sometimes the passage of the shoulders, if they are large and delivered rapidly, lacerates this part very badly; and I knew one instance in which the rupture was caused by bringing down the knee, and another case of breech presentation where the elbow caused a complete laceration of the perinseum. The breach of substance, of course, differs very considerably. It generally begins at the fourchette and extends backward to a greater or less extent. Mr. Brown divides the accident into slight and grave. He regards those as slight which are not ruptured through the sphincter, and believes that when the sphincter is violated, and then only, need much importance be attached to the accident. The exter- nal sphincter is sometimes injured considerably, and the rupture stops short of its complete division, and at others both are torn through, and half an inch or more of the recto-vaginal septum also divided. I saw one instance in which the two sphincters were torn through, while the larger part of the substance of the peringeum in front of them was uninjured, the child having passed through the septum into the lower rectum, and through the anus, producing the above rupture. This case did well without any operation. The wound generally commences at the fourchette, and extends backward towards the anus, but occasionally it takes a direction to one side and passes outside the sphincter, leaving the anal opening untouched. At other times the rupture, commencing at the fourchette, is directed laterally outward, so as to separate to a greater or less extent one or both of the labia from the perinseum. Effects of Laceration. We must not underrate the importance of the slighter forms of this accident, for, reason as we may as to the means adapted to the support and maintenance of the uterus in its proper position, as the floor of the pelvis the perinseum serves an important part in sustain- ing that organ. When the perineal support is lost, the positions of all the pelvic viscera are likely to be disturbed in their relations one to the other. It is very rare to see, indeed I have never seen, the uterus, bladder, or rectum, protrude from the vaginal orifice when the perinseura retained its perfect integrity. On the contrary, one TREATMENT. 31 or all of tliem, when other causes co-operate, may be comparatively easily displaced after the main portion of the perineal substance is lost. It will only be necessary to remember that the perinseum being in the virgin triangular, the base at the skin, and the apex looking up and backward into the cavity of the pelvis, and that the upper part, or apex, extends at least an inch, and reaches obliquely above the tuberosities of the ischium, and that farther behind is quite a depression, into which the uterus, bladder, and rectum, in a state of distension, are lodged, gravitating there in a direction with the supe- rior strait, to understand the great inconvenience of its loss. When the perinieum anterior to the sphincter is split, this muscle will draw the anus farther back, and thus destroy the pelvic pouch, leaving its contents to settle still lower down. I think that it is in this wise the most distressing protrusion of the vagina, bladder, rectum, and uterus, one or all of them, is permitted, if not caused. It is true that in all cases of loss of the perinseum, protrusion of these organs will not necessarily occur, but when extensive displacement of this kind is observed, it is almost always in connection with deficient perineal support. More serious and invariable are the consequences of the most extensive ruptures — the loss of the functions of the peri- nseum and sphincter both. Prolapse of the viscera and involuntary discharge of the contents of the rectum result. If the fseces are hard, the patient can generally manage to seek a proper place to perform defecation ; but if fluid, there is no warning until they flow upon the person. The mucous membrane of the vagina is generally irritated and inflamed, while the skin is chapped and excoriated from frequent contact with the fseces. Treatment. Prevention, always the best treatment when available, will vary with the cause of the rupture. When, in labor, the perineum is very rigid, and relaxes with difficulty, the patient should be placed under the influence of chloroform, which induces relaxation with more certainty, perhaps, than any other remedy. Minute nauseating doses of tartarized antimony, every half hour, is next in efficiency to chlo- roform. I would not consent to bleeding in such cases, unless there was evident approach to inflammation in the part, and in no case is tobacco to be thought of. In this condition of the perinasum, the irritability of the structures ought not to be increased by attempts to support it. The perinseum may be supported when greatly distended, and when its integrity is threatened by too great inclination of the presenting part backward. The object of the support, in cases where 32 RUPTURE OF THE PERINEUM. it is deemed advisable, should be to keep the head as close to the pubic arch as possible, but not to retard its expulsion. Not much force is allowable for this purpose, or any other in relation to the perinseum. It is needless, after what has been said as to the manner in which this accident occurs from the use of the forceps and ergot, to indulge in special admonitions as to their use. Spontaneous Cure. Occasionally nature is capable of curing some of the worst forms of lacerated perinseum. The first bad case of ruptured perinseum I ever saw was completely cured by nature wdth very little aid from art. It was in the person of a large and very fleshy primipara forty years of ao^e. The rupture extended from the fourchette to the in- ternal sphincter inclusive. Our ideas as to the proper mode of treat- ing recent cases of this kind at that time were not so decidedly in favor of immediate operation as at present. The only treatment this patient had was confinement upon the side and coaptation of the parts bv flexino; the knees somewhat and binding them securelv too:ether. „ CI O * o An examination three months after confinement showed a complete restoration of the periusum. This case occurred in the hands of a midwife. A more remarkable case occurred in my own practice. The patient was a large muscular woman who enjoyed robust health. In her first confinement she suffered a rupture of the entire perinseum and sphincter and three-quarters of an inch of the recto-vaginal septum. With the perinseum in this condition she bore two children. The operation to restore the perinseum, according to Baker Brown's method, was performed six years after the occurrence of the accident. The rent in the septum and perinseum was perfectly closed, and the vaginal opening was restored to its primitive dimensions. One year after the operation pregnancy ensued for the fourth time. When labor begun I was sent for, and arrived in time to find the occiput, which was posterior, ploughing through the periucTum, and by the time the condition of things was recognized my work was completely demolished. The perin?euin was gone. I proposed an immediate operation, but no persuasion or entreaty would induce my patient to submit to it. She was confined to the side, the limbs secured, and opium administered to prevent the passage of faeces through the rectum. Her recovery was perfect, and she has had two children since without a rupture. These two patients were alike in being large and fat, with fleshy limbs, so that when lying on the THE IMMEDIATE OPERATION. 33 side the parts were pressed firmly together. They both had very short labors, and the perinsei were torn without being braised by long contact with the head. A patient is now under my care for subinvolution, who was sent by a physician of the interior of this State. Rupture of the perinseum had occurred as the result of forceps delivery, and, according to the statement of the gentleman who referred the patient to me, was en- tirely through the sphincter It is now five months since the acci- dent, and there is only the cicatricial trace of it left. The fastidious- ness of the patient forbid an examination, but the doctor was so sure of the existence of the laceration that he sent her to me for an opera- tion. From mv knowledo;e of his intellio^ence, and the amount of obstetrical experience he has had, I believe his statement in reference to the case. The spontaneous closure of slight lacerations is in fact so common that many practitioners of great experience regard them as of but little importance. The Immediate Operation. The cases in which patients escape from subsequent evils directly referable to ruptured perinseum are very properly regarded by ad- vanced gynaecologists as exceptional. An array of names, that must have weight with the profession, is made up of those of Munde, Fal- len, Xoeggerath, Skein, Garrigues, Emmet, and Thomas, of New York; Jenks, of Chicago; Lyman, Richardson, and Renolds, of Boston; Albert II. Smith and William Goodell, of Philadelphia; and Howard and Wilson, of Baltimore. To these names might be added many others of great respectability who favor immediate opera- tion for restoring a ruptured perinseum. An accoucheur can hardly be considered as performing his whole duty to his parturient patient unless he ascertains what effect has been produced by labor upon the perinaeum, and if there is rupture of even a moderate character take^ome efficient measures to restore its integrity at once. Most Avriters upon the subject recommend sutures of silk, catgut, or silver, applied as soon after delivery as possible. Any one of these substances will answer the purpose, but I think silver wire is the best. It will not generally be necessary to give an anaesthetic, as the sensibility of the parts is exhausted by the great pressure and distension to which they have been subjected. The application of the stitches should be made carefully and deep enough to include the whole of the cleft substance. Dr. Garrigues, in an excellent article 3 34 RUPTURE OF THE PERINEUM. in the April number, 1880, of the Ameriean Journal of Obstetrics, recommends the serre-jine as being sufficient in most cases of recent rupture. Dr. Garrigues tells us that they were invented Fig. 4. and introduced by Vidal de Cassis, of Paris, in 1849 (Fig. 4). After an operation, or the use of the serre- jine^ the perinaeum will not always unite by first inten- tion; it so frequently does, however, as to encourage the effort. The operation inflicts so little pain that occasional failures should not deter us from the trial. Cases in which there has been protracted pressure and conse- quent bruising of the perinaeum will be more likely to fail than those in which the fcetus has been expelled with great precipitation. When the operation to heal a moderate laceration has failed, or the case does not come under observation until cicatrization has begun, the immediate operation is not advisable. If we do not perform the immediate operation for the first four or five days after confinement, the patient must be confined to her side, and it would be better, also, to surround the limbs at the knees with a roller, or bandage, to keep them constantly in contact. By lying on the side with the limbs close together, the parts are kept in almost perfect contact, and the lochial discharges flow out anterior to the wound. These two circumstances are essential to a cure. A diligent observance of the position on the side for a number of days, and a close proximity of the knees, is apt to result in adhesion of a part of the wound by the first intention, and much more of it by granulation. After the lapse of eight or ten days, the parts ought to be ins|)ected, and a healthy state of granulations encouraged by clean- liness, good diet, and, if need be, by a stimulating application of tinct. cantharides every four or five days. After the opportunity for treating such cases in their recent condition is past, and prolapse of the bladder, rectum, uterus, or vagina, renders interference necessary, the operative procedure is so similar to that necessary for the worst cases, that I will consider them in this respect together, and point out the difference as I proceed. A patient, to undergo this operation and be cured by it, must be in good general health. If she is not so, the operation ought to be de- layed until proper means can be used to effect it. A firm, plastic state of tlie solids, without unusual tendency to suppuration, will be the most favorable condition. Patients coming from the country wiJl do better to have the operation performed at once, and it is PERINEIORRHAPHY. 35 better, if practicable, to send our town patients into the country for a month or more. Thirty-six hours before tlie operation is to be performed we must administer an efficient but not drastic laxa- tive; castor oil or rhubarb will do very well. The patient should be placed in the lithotomy position before a strong light. If an anaesthetic is administered, — and it will very much facilitate the management of the patient, — it may be given at this stage of the pro- ceeding. One assistant is placed at each side of the patient to steady the knees and hold the legs, while another assists in the use of instru- ments. The instruments necessary are a scalpel, a blunt-pointed bistoury, a pair of scissors, three large curved needles, or one large curved needle mounted upon a handle, tenaculum, dressing forceps, needle-holder, and wire-twister, and plenty of silver wire. Sponges, warm and cold water, of course, must be at hand. The surgeon seats himself in front of the patient wnthin easy reach. He commences by removing the hair from all the parts on which he is to operate. After which the edges of the cleft part are to be thoroughly denuded with knife or scissors. The cicatricial tissue should be all removed smoothly and evenly on both sides and up to and along the front surface of the septum. No part of the mucous membrane or super- ficial tissue of any kind should be left, as it will inevitably prevent union. Professor Edward W. Jenks, of the Chicago Medical College,* de- scribes his very ingenious method of denuding the parts in cases where the sphincter is not entirely torn through. He says : ''I begin by nicking with scissors the anterior margin of the surface to be denuded, at the juncture of integument and mucous membrane; next, I introduce two fingers of the left hand into the rectum, while as- sistants hold the labia apart, it being important that they are held uni- formly tense. I use scissors slightly curved and sharp-pointed (Fig. 5) Fig. 5. m — m to denude the mucous membrane. I use neither tenacula nor tissue-for- ceps, but, with the parts tense, snip a hole in the mucous membrane in the median line, close to the integument, and then inserting the scissors * Op. cit. 36 RUPTURE OF THE PERINEUM. Fig. 6. with a cutting motion into the small hole made, I continue to dissect the mucous membrane away from the subjacent tissues without removing the scissors, first going up the septum as far as is desired, and then later- ally, first on one side, and then on the other, without removing the scissors or once bringing their points out from beneath the mucous membrane, as shown in Fig. 6. " Sometimes, instead of beginning my dissection at the median line, I begin at the nick on the left labium majus, running the points of the scissors beneath the mucous mem- brane, and dissecting it away from the subjacent tissues back on the left lip, then up the recto-vaginal septum as far as I deem it neces- sary, and from thenceforward on the right lip to a point opposite from which I started (marked by the nick), without allowing the scissors to come out from beneath the mem- brane, unless they are accidentally turned out by cicatricial tissue. Then with blunt-pointed scissors cut away the dissected flaps. The bared sur- face thus exposed is much the shape of a right-angled triangle, with the base directed outward, or it has been compared in shape to a butterfly, with wings spread and tail directed upward. " The advantages of this mode of denuding are : (a) the rapidity with which it can be done ; (6) the absence of haemorrhage in the vagina, as no blood escapes except at the locality where the scissors enter beneath the mucous membrane ; (c) the ability by which the operator can make complete denudation, as the discoloration between the membrane marks the route the scissors have taken. Several of my brother gynaecologists have tried this method of denuding, and are highly pleased with it. Among them is my friend Dr. Albert H. Smith, of Philadelphia, who, thinking he could better denude with a knife than scissors, had one made, which he found after several trials to be a very satisfactory instrument, by which he can denude much more rapidly, and yet on the same prin- ciple as with scissors. The knife (Fig. 7) has a dart-shaped thin blade with double-cutting edges. The patient, when the knife is used, is put in the same position, and with the same degree of tension of the parts as for the scissors; the knife is inserted beneath the mucous membrane in the median line, at its juncture with the integument, and from thence PERINEIORRHAPHY. 37 the submucous incisiou is made on one side, then 'upon the other, then up the septum the required distance, after which the flaps are cut away with blunt-pointed scissors. I have, up to the present time, used the knife devised by Dr. Smith only three times, and although, as a rule, having preference for the scissors over the knife in all plastic operations, Fig. 7. I have been delighted with the rapidity and ease by which I have been able to operate with the knife which he kindly sent to me." In complete laceration, where the septum is involved to any extent, the edges of the rent should be denuded and closed by silver sutures first, and the perineal sutures placed afterwards. The object of the perineal sutures should be to bring the ends of the torn sphincter together. If we use the long curved needle, it should be threaded with silk, and the point entered on the left side as far back as the posterior border of the anus, and passed forward and inward as high as the septum, including the lower edge of it, and then brought out on the right side, including the sphincter, in the 38 KUPTURE OF THE PERINEUM. same manner as on tlie left. The silver wire is then attached to the thread and bronght through. The next suture is to be introduced exactly as the first, but about one-quarter of an inch further for- ward. These two sutures are intended to bring the ends of the sphincter muscles together. They generally do this quite effectually. Dr. Emmet was the first to insist upon this method of bringing the ends of this muscle in coaptation. Three or four more sutures are introduced, the third one deep enough to include the septum, aud the others of a depth sufficient to give solidity of surface. After placing the wires and being assured that their position is such as to secure perfect coaptation they may be twisted, beginning with tho^e behind, until the wound is accurately closed. If it has been iiece-ssary to close the septum, the wires should be left long enough to project beyond the vulva, to facilitate their removal. If the rup- ture does not involve the sphincter, the posterior suture is introduced anterior to the sphincter, but in such a manner as to draw forward the posterior angle of the wound and deep enough to include the septum. The other sutures may be placed as in the case of complete rupture. If there is rectocele in connection with the laceration, the anterior wall of the septum should be largely denuded, and the perineal sutures made to include a sufficiency of the redundant vagina to do away with the protrusion. As the silver wires do not cause ulceration and suppuration, like the hemp or silk sutures did when they were in use, it will generally not be necessary to remove them so soon. Unless the tissues included are somewhat strangulated, the sutures ought to remain nine or ten days, but if any tendency to ulceration shows itself, they must be re- moved early — five or six days. When the operation is complete, a rectal tube should be introduced and kept in the rectum for the first six days to permit the discharge of gas. If this precaution is not observed, the intestines may be so distended as to prevent union at the lower edge of the septum. When the operation for restoration of the perinseum is performed immediately after the injury, it is done, in everything but denuda- tion, similarly to that just described. I think the silver wires, when they can be obtained, are better than any other material for sutures. Where much delay would be necessary, however, to procure the proper material, the surgeon may use a straight cambric needle armed with silk. This hi^t material, if carbolized or well waxed, will answer very well for sutures. The only instrument absolutelv neces- PERINEIORRHAPHY. 39 sary in these recent cases, is tlie needle with tlie silk. Sometimes they are all we can get without important loss of time. It is advisable, I think, before, or immediately after the operation, to give the patient about two grains of opium, or its equivalent in some of its preparations, and continue it at intervals, to keep the bowels from moving and allay irritability and pain. The patient is to be placed on her side, and have the limbs secured by a bandage at the knees. The position may be carefully changed from one side to the otl>er, being always particular to keep the legs close together, and not to allow them to be used so as to contract the muscles at the pelvis. Every six hours, or oftener, the catheter is to be used to draw off the urine, lest it run into the wound and vitiate the inflamma- tion. Dr. R. Stanbury Sutton, in an unpublished letter to me, says " the catheter is not necessary in perineal operations. I let the woman pass her water over a bed-pan, and then let the nurse wash out the vagina with a quart of hot water slightly carbolized. The wound should be kept covered w^ith pledgets of lint saturated with simple cerate or cold water." If suppuration occurs we cannot be too care- ful about cleanliness. Plenty of clean tepid or cold water must be injected into the vagina and rectum two or three times a day, while the external parts are sponged and cleansed as often. The young operator need not be discouraged if, upon examination, the wound is not all closed by adhesive inflammation. My experience is that this immediate and perfect closure does not usually take place, but that much of the deepseated portion is left to be filled by granulations, and it is sometimes several weeks before this is accomplished. The skin and integuments generally unite by the first intention, and when this is the case, there is not much danger of failure, provided we keep up a granulating surface all over the unhealed portion of the wound, and observe perfect cleanliness. At the end of twelve days some laxative will be necessary if the bowels have not been moved. The diet and medicine of the patient while in bed, after the opera- tion, cannot be the same in all cases, and are to be governed wholly by the state of the system; it will be better, I think, to err in favor of good supporting diet, stimulants, and tonics, rather than risk im- pairing the general health by abstemiousness. Adhesive inflamma- tion is promoted by a high state of physical health, and suppuration by a low condition of it, and aside from imperfection of the operator's proceedings, we have most to fear from early, copious, and persistent suppuration. CHAPTEE III. DISEASES OF THE VULVA. Condylomata of the Vulva. WaPvTY excrescences in great variety make the vulva the seat of tbeir growth. Thev are often flat, smooth elevations, small usually, but sometimes as large as filberts, isolated or congregated. Some- times they are sparsely scattered over the cutaneous surface of the labia, the mucous covering of the vulva, but not unfrequently they are thickly crowded together, with deep fissures between them and excoriations on their surfaces, that give origin to acrid sauious dis- charges, which excoriate the neighboring skin and soil the linen. The smell from this sauious discharge is sometimes very offensive. These excrescences are not always smooth and rounded even when isolated, but occasionally are rough and ragged, and in a few in- stances those springing from the margin of the vagina are arborescent, slender, and from half an inch to an inch in length. We again find tliem yellow, flat, and fragile. In most instances these growths are confined to the vulva and labia, but sometimes they cover a large part, if not the whole of the mucous membrane of the vagina and cervix uteri. I saw a case quite recently in which arborescent ex- crescences — many of which were three-fourths of an inch in length — sprang from the whole of the vaginal mucous membrane. This patient was pregnant by a syphilitic husband. The cause of these growths appears to be the syphilitic taint. So far as I now remember all observers agree that syphilis is the onlv cause of them. Treatment. We may very properly trust the alterative course calculated to remove the syphilisni under which our patient is laboring for the relief of the milder forms of these excrescences, and we should not fail to institute alterative treatment for even the more harassing va- rieties; but in many cases we shall relieve the patient more readilv by removing a part or the whole of the larger growths with scissors, and afterwards dressing the wounded surfaces with mercurial oint- ment. INFLAMMATIONS. 41 Erythematous, papular, vesicular, and pustular inflammations of the vulva are not unfrequently observed, as are also squamous diseases. They resemble the same form of disease in other muco-cutaneous cavi- ties and the skin, and hence will not here claim a separate description. A disease somewhat more distinctive, however, and yet resembling a disease of the mouth, is known as purulent vulvitis. This affection is characterized by severe inflammation of the mucous membrane of the vulva, attended with minute points of ulceration, numbering from one to two dozen. The ulcers are small, an eighth of an inch in diameter, slightly excavated, and almost always covered with pus. The vulva is intensely red, and bathed in. pus and mucus. The in- flammation sometimes extends, into the vagina and causes a copious flow of pus and mucus from that cavity. Not unfrequently the labia are very much swollen, and occasionally the deeper tissues are involved in phlegmonous inflammation. This form of inflammation is not unfrequently, in its early stages, attended with considerable febrile excitement. To a superficial observer it strongly resembles gonorrhoea, from the swollen labia, burning pain, copious muco- purulent discharge, and the difficult and painful micturition. Its occasional sudden and unexpected development adds to this similitude, and legal proceedings have been instituted against parties supposed to have been instrumental in imparting the disease to little girls. It occurs in children generally from two to ten or twelve years of age, and probably results from want of cleanliness, heat, and local irri- tants accidentally applied. If allowed to pursue its course undis- turbed by treatment, other than cleanliness, it will generally subside spontaneously in two or three weeks, or in the course of that time become very much subdued, and run into chronic inflammation without ulceration. This last is often extended into adolescence, and, as vaginitis, gives origin to the leucorrhoea of girlhood, and finally to the endometritis of the woman. It sometimes attends upon a de- bilitated and scrofulous constitution, and is complicated with indiges- tion, constipation, and ascarides; but it is not likely originated, thouo^h it is ao^ojravated and fostered, bv these attendant circumstances. Treatment. The treatment is general and local. In the beginning, where the inflammation is high, it should be antiphlogistic and soothing. We mav administer a mercurial cathartic, and quicken its action by a 42 DISEASES 0? THE VULVA. saline laxative, and after the bowels have been thoroughly moved, nitrate of potassa may be given internally, every three or four hours, in doses to suit the age of the patient. The parts should be frequently bathed or fomented with a decoction of poppy-heads, or with the watery extract of opium. In the course of four or five days the acute symptoms will begin to subside, when, in addition to attention to the bowels, we may administer an acid solution of quinine internally, and begin the use of astringents locally. A solution of tannin, sul- phate of zinc, acetate of lead, or other such astringent, weak at first, and afterwards increased in strength, may be applied freely to the parts four or five times a day. These remedies will generally remove the inflammation in a reasonable time. The astringent should be increased in strength to a sufficient degree for the purpose. If those mentioned are not strong enough, the chloride of zinc, sulphate of copper, or even nitrate of silver, may be very properly resorted to. Should the inflammation extend into the vagina, the astringent may be injected into that cavity by means of a small hard-rubber syringe. We ought to be careful to use a very small syringe, and not to introduce it too far. The nurse should be carefully instructed in this kind of application. I feel impelled to insist upon the complete removal of the inflammation as early as it can reasonably be done, believing that if it continues until puberty, the inflammation extends into the body of the developing uterus, and entails a very distressing train of suffer- ing upon the patient, that might have been avoided by an early and complete cure of the vaginitis. I am persuaded that too much im- portance cannot be attached to these views. Follicular Vulvitis. Inflammation of the vulva, instead of affecting the mucous mem- brane, as in the purulent form, is sometimes confined to the follicles and glands of the vulva. In this form of the disease minute papil- lary elevations on the mucous surface of the labia majora, the nym- phse, the prepuce of the clitoris, and elsewhere in the orifice of the vagina are first observed. These increase in size and become red, while the intervening mucous membrane is often very much inflamed. In many instances a number of these elevations become pustules, their bases hardened, red, and very tender. Oftener there is only a copious flow of mucus stained with pus-corpuscles from the follicles. The acute form will generally run its course and subside in a few weeks, sometimes in from ten to twenty days. But follicular vulv- PRURITUS PUDENDI. 43 iris occasionally becomes chronic, and then is exceedingly obstinate and difficult of cure. Causes. AVant of cleanliness, vaginitis, pregnancy, and malignant affec- tions of the vagina and uterus are the most frequent causes. Treaiment. Rest in the recumbent posture, alterative and saline cathartics, cleanliness, first emollient poultices, and afterwards astringent washes and applications. If the patient is debilitated, the bitter tonics, quinine especially, will be found useful. The subjects of this form of vulv- itis generally require supporting and tonic treatment. When the secretions are oflPensive, carbolized glycerin should be freely applied, two or three times a day. When it is chronic, there will be necessity for the use of stimu- lants so strong as to modify the inflamaiatiou. Xitrate of silver in substance applied once in seven or eight days to the whole of the in- flamed surface will sometimes cause the disease to yield. In con- nection with this glycerin, with tannic acid dissolved in it, or im- pregnated with creasote, may be used between times. Alteratives are often found to be very beneficial. Iodide of po- tassium, sarsaparilla, stillingia, and, in plethoric patients, mercury are the ones on which most reliance may be placed. Dr. Thomas speaks of having made a cure by " dissecting off the whole mucous membrane lining the vulva.'' Pruritus Pudendi. A very annoying and often obstinate affection of the genital or- gans is an inordinate itching of the vulva. The itching returns in paroxysms. The patient will sometimes be free from it except when standing by a warm fire, or becoming heated by exercise, passion, etc. Or she may be affected only at or near the menstrual period. Again, the paroxysms return without any apparent reason. The sensation sometimes is that of a burning glow, attended with an irre- sistible desire to rub or scratch the parts, a desire which the most delicate sense of propriety cannot always keep within due bounds. At other times the sensation is such as might be produced by the crawling of pediculi, and the patient is assured that thousands of these insects are moving upon her person, and will be convinced 44 DISEASES OF THE VULVA. to the contrary only by inspection. This sense of formication, al- thougli very disagreeable, is a slight inconvenience compared to the sufferings of the other variety. The former variety is almost always attended with inflammation of the mucous membrane of the vulva. The accompanying inflam- mation may be simply erythematous, papular, or vesicular. Dr. Dewees describes a variety of vesicular inflammation resembling aphtha, attended with pruritus. I am sure that the papulae or ves- iculse are neither of them always present in very distressing cases of this affection, although I have not seen it when the parts were not in some way inflamed. It may be observed that, in the formication variety of pruritus, the itching is generally mostly, if not wholly, confined to the cutaneous surface of the labia. It will be inferred that I consider pruritus but a symptom of several diseased condi- tions generally of the genital organs, but sometimes it undoubtedly may be caused by the state of the intestinal tube, particularly the rectum, or by some other remote condition. An intelligent scrutiny of the cases as they arise will most frequently result in the discovery of the originating condition. It is often an obstinate affection, last- ing for weeks, months, and even years, in bad cases, but more fre- quently it is amenable to treatment, and a judicious course will be rewarded by success. Treatment. The first thing to be done is to remove the cause, when practicable. In order to do this, the abdominal organs will require attention. The sluggish secretions and bowels must be corrected by alteratives and laxatives. A mercurial, say five grains of blue pill, may be given at night, to be followed in the morning by a saline laxative, sufficient to cause one or two stools. This may be repeated at intervals of from one to four days, until the object is gained. Meantime, if the stomach is weak and digestion imperfect, the bitter infusions, with alkalies or acids, as the condition may require, will be demanded; and should the patient be anaemic, iron may be given. Sometimes the patient will be plethoric, when the alteratives, with spare diet, will do better. With the above treatment, if the health be faulty, or without, if this is not the case, we will generally be obliged to resort to local remedies. AmX first of all is cleanliness. The parts, externally and internally, must be subjected to thorough and fre- quently repeated ablutions. The syringe may and should be brought into use for this purpose from three to a dozen times a day. The water used for ablutions may be impregnated with sal soda very ap- PRURITUS PUDENDI. 45 proprlately, or some fine toilet soap. I have found much advantage, when there was no eruptive accompaniment, from two drachms of the tincture of the chloride of iron in a quart of water, three or four times a day. This is especially useful when there is leucorrhoea, and a congested, dark appearance of the raucous membrane. When there is a vesicular eruption, the recommendation of Dr. Dewees, to sprinkle the parts with powdered borax, and keep them exposed as much as possible to the air, will be of great service. Professor Simpson uses chloroform, in the forms of vapor, liniment, or ointment, with good effect. The infusion of tobacco, applied freely, two or three times a day, is recommended by the same author. When the mucous mem- brane is much inflamed, a solution of hydrocyanic acid, ten drops to the ounce of water, often gives great relief. A strong solution of tannin and aqueous extract of opium is also applicable to this class of cases. An excellent palliative is pure glycerin. It may be in- troduced into the vagina by saturating a plug of cotton with it, and passing it up through a glass speculum and allowing it to remain there for ten or twelve hours. We should take the precaution to attach a thread or cord to the cotton so that it may be readily removed. One of them introduced every twelve or twenty-four hours is often enough. We should also apply it between the labia in the same way. As explained by Dr. Sims, who first recommended its use, the glycerin induces copious serous depletion from the congested mucous mem- brane, thus relieving it. In cases of some duration I have often been enabled to produce a decidedly favorable change by applying the tincture of the chloride of iron in full strength with a brush once a day to all the mucous membrane of the vulva, and as far in the ostium vaginae as I could pass the hair-pencil. The first burning sensation is succeeded by great amelioration of the sufferings, and finally, in many cases, by a cure. When this fails, we may sometimes succeed by making a similar application of a solution of nitrate of silver in the strength of OSS. to o] of water. This last application should not be used oftener than once in two days. In the use of all these remedies we must not lose sight of the ablutions, nor fail to search for particular local causes, and try to remove them. As has been very judiciously remarked by Professor Simpson, we will find great advantage in al- ternating the use of appropriate remedies, instead of using the same kind all the time. The obstinacy of this affection will require great patience in many instances, as well as ingenuity in using remedies. 46 DISEASES OF THE VULVA. Corroding Ulcer. I have met with a number of cases of corroding ulcer of the vulva in children, which have been the cause of great suffering and appre- hension. It occurs most frequently in children, but is occasionally met with in adults. There is in each case usually but one ulcer, and it is most commonly situated on the lesser labia at first, and spreads to surrounding parts. The ulcer is ragged and irregular, not much excavated, wMth a dark foul-smelling covering, and the discharge from it is sanious, fetid, and excoriating. It is not generally rapid in its progress, and sometimes lasts for months, creeping from one part to another until the anatomical features of the vulva are almost entirelv effaced. I have not met with this form of disease except in very debilitated, sallow, and badly nourished persons. The state of the system leading to this sort of ulceration I have thought to be more particularly the result of living in poorly ventilated houses, but coupled, also, with imperfect nourishment, or with nourishment of an improper character. It is generally obstinate, and yields but slowly to judicious treat- ment. We should endeavor, as one of the main objects, to correct the constitutional condition as speedily as possible. To this end the circumstances of the patient should be changed to the most favorable sort. Good ventilation at home, frequent and prolonged exposure to the fresh air, nourishing diet, of which animal food should be a large ingredient, and comfortable clothing, w^ith thorough cleanliness, are indispensable to success. The bowels should be kept in as correct a condition as possible by gentle laxatives. The digestion, which is always feeble, if not otherwise faulty, may be improved by the ad- ministration of infusion of cinchona, quassia, or colomba, with the mineral acids, the sulphuric being perhaps the best. The chlorinated tincture of iron is also an excellent oreneral remedv. The next thiuo- to be accomplished is to convert the ataxic, half-sloughing, and cor- roding chronic ulcer into an acute inflammatory one. This is done by profoundly stimulating it with the stronger caustics. The one which has seemed to me to be most successful is the caustic potassa. It should be applied to the whole surface by passing a stick, not very rapidly, all over it. After this burning we may dress the ulcer with calamine ointment twice a day. This will almost immediatelv im- prove the condition of the sore. Unless there is some considerable firmness around and beneath it, caused by the effusion of fibrin in the submucous substance, in thirty-six or forty-eight hours after the GANGRENOUS VULVITIS. 47 application not much good will result from it, and it will be necessary to resort to it or some other in a few days. The strong nitric acid is also very useful. I have not tried the actual cautery, but should expect it to be very useful. We may often cure this ulcer by the weekly use of the solid nitrate of silver to it, dressing between times with lint saturated with black wash or calamine ointment. We ought not to be afraid of strong treatment, nor to continue it, in conjunc- tion with a highly roborant general course of exercise, diet, and m.edication. Gangrenous Vulvitis, or Noma. This is a very severe and generally fatal affection of the genital organs, occurring almost, if not wholly, among children. It may attack one or both sides simultaneously. In the few cases I have seen there appeared a bleb or blister on the inside of the mucous sur- face of the labium, which at the same time became enlarged, hard, tender, and painful. In a few hours the blister breaks, and from its side a not very abundant but acrid serum is discharged. At this time a peculiar odor is emitted from the parts. All around the ash- colored surface, which represents the place where the blister was de- veloped, the substance of the labium is very hard and much swollen. In two or four days the affected side is in a state of gangrene, the discharge is very much increased, the parts upon which it runs are excoriated and injflamed, and an intolerable stench is exhaled. I have not seen an instance in which the gangrenous parts were cast off, the patients having died beforehand. Generally, though not always, in the very beginning, the circulation and nervous system are very much disturbed. The pulse is quick and feeble, the patient nervously restless, or else stupid, the extremities cool, the body — particularly about the pelvis — hot, the tongue furred, generally brown, and the skin dingy and sallow. As the disease advances the pulse becomes still more rapid and weak, the extremities cold, the mind wandering, and the restlessness amounts to the frantic efforts of some sort of delusion. The tongue becomes dark brown or black, the teeth are covered with sordes, and in the end the patient sinks into profound collapse, and often coma, and dies. The disease runs its course sometimes in forty-eight hours, and again, in milder forms, it may last five or six days. The causes, although unknown, must undoubtedly be of a depressing nature, overwhelming the organism very rapidly. It occurs sporadically, when it is comparatively mild, and epidemically when severe. In this last state it is very rapidly fatal. 48 DISEASES OF THE VULVA. The prognosis is very bad, as it is always, or pretty nearly always, fiital. The profession, so far as I am aware, has not decided whether the disease is a general one, and the affection of the genital organs an incident, or whether the local disease inaugurates the general symp- toms. The former is most likely the truthful interpretation of the phenomena. In such a disease there is little prospect of a cure by treatment; we should, nevertheless, institute a course clearly indicated by the symptoms and signs. The general treatment should be strongly stimulant, tonic, and supporting; quinia, brandy, tincture of can- tharides, and beef essence, as much as the patient can bear, should be administered. I do not think the strong caustic local treatment, generally advised, any better, if as good, as the charcoal and yeast poultices, chloride of lime, anodyne fomentations, and cleanliness. Much attention should be devoted to thorough ventilation, isolation of the patient, and the neutralization of the fetor by disinfectants. Urethral Excrescences. Caruncles of the urethra; vascular tumor at the orifice of the ure- thra : These names have been given to small tumors springing from the mucous membrane of the vulva, immediately round the urethral orifice, or from the lining of the urethra itself. They are generally solitary, but sometimes there are several. Sometimes they are sessile, and seem to be a hypertrophied fold of the mucous membrane of the orifice ; at others they are polypoid in their attachment. In size they vary from a pin's head to a small nut. They also vary in their appear- ance. As before remarked, they sometimes resemble in color, con- sistence, and polish the mucous membrane upon which they are planted; while in other cases they are quite red, almost scarlet, very soft, and easily broken. They differ in their anatomical properties quite as much as in appearance, seeming, in some instances, to have no more vessels and nerves than other portions of the neighboring tissue, while at others they are formed mostly of capillary bloodves- sels and loops of nerves. They are a morbid development of existing tissues instead of a growth of abnormal substance. These tumors are often observed, particularly the more dense and light-colored varie- ties, without giving origin to any symptom that would lead to their detection; on the other hand, in many instances, they often produce the most excruciating suffering. The kind of caruncle that has seemed to me to be the important one is the blood-red tumor pro- VASCULAR URETHRA. 40 jecting from the mouth of the urethra and attached by a small neck. A few weeks since I met wnth one of these of crescentic shape, at- tached by a neck that arose from the concave margin, and had its other attachment inside the urethral orifice. It would not have weighed two grains, but it caused agonizing symptoms. It must not be supposed that all of the varieties will not occasionally cause great pain. The symptoms of their presence are almost always connected with the evacuation of the bladder and attempts to handle the part. The passage of urine causes the most excruciating suffering from pain and tenesmus, the patient often straining for several minutes after the complete discharge of the urine. The slightest touch, also, is the cause of great pain. The diagnosis cannot be clear without an ocular examination. If the parts are exposed to a good strong light, and the labia separated, the excrescence will be at once discovered, unless it be quite inside the urethra. If any doubts exist, we should intro- duce the finger into the vagina, and press the urethra forward. It is difficult to say, with truthfulness, what are the causes of these carunculas. My cases have been in patients obviously deficient in cleanliness. This seems to have been the case in that which came under Dr. AVest's observation. The treatment is simple, and consists in two main objects : 1st, the removal of them ; and, 2d, the production of a profound impression upon the point of origin. In fact, the tissues from which they spring should be destroyed to a slight depth. The first object may be most readily gained by snipping off with scissors; and the second by hold- ing caustic potassa, or the actual cautery, to the place until the nidus is destroyed. Vascular Urethra. Analogous to the caruncle is the vascular urethra. It gives rise to the same train of symptoms, though not so intensely distressing, and is very persistent. It occurs more frequently in patients near the climacteric period, although I have seen it in much younger per- sons. When the labia are separated, and the parts exposed to a good light, the urethra is seen to be patent, and the tissues around the orifice swollen and of deeper hue than usual. The mucous membrane of the urethra is of an intensely scarlet color, and, upon minute in- spection, the vessels may be seen enlarged ; it is very tender and sen- sitive to the touch, slight contact producing exquisite pain. There is great burning and sense of cutting when urine is voided, and all the symptoms, even the sympathetic nervous derangements, attendant 4 60 DISEASES OF THE VULVA. upon caruncle. This condition is not incipient caruncle, for there is no elevation, no protrusion, and the condition lasts for years withoat material change of substance. The treatment I have fouud most effective is strong nitric acid or caustic potassa appKed cautiously to the membrane inside the urethra. I have not tried the actual cautery, but believe it would be very effective. An application of the acid on a piece of lint moistened by it to the whole membrane in sight every ten days, for two or three times, generally is sufficient; sometimes once only is required. Hypertrophy of the Clitoris aiyi Nympha, It is very rare that we meet with hypertrophy of these oi^ans without morbid change in the tissues. There is either cystic devel- opment in their substance or degeneration of the membranous tissues. The two diseases that seem to contribute most frequently to this en- largement are syphilis and elephantiasis. Treatment. Removal by the thermocautery. CHAPTER IV. DISEASES OF THE BLADDEE. Paralysis of the Bladder. Paralysis of the female bladder is often an accompaniment of hemiplegia or paraplegia from cerebral or spinal affections, and be- comes a part of that more extensive affection. From my own obser- vation, however, I should say that in women, retention of urine in such cases is not so uniformly a troublesome symptom as it is in the paralysis of men. Women have paralysis of the bladder more frequently associated with hysteria, probably, than with cerebro-spinal disease, which con- dition, of course, is a part of the hysterical affection. Again, paralysis of the bladder may arise from reflex causes. I once knew an instance caused by the presence of a tapeworm. Still more frequent is the paralysis succeeding tedious, difficult, or instrumental labor, as the result of injury to the muscular structure of the bladder from long-continued direct pressure on the organ, or to the nerves supplying the bladder, by the use of instruments, or by long-continued pressure of the head. The inflammation succeed- ing labor may also affect the organ sufficiently to cause paralysis. Prognosis. Usually paralysis occurring as the result of labor is temporary and amenable to judicious treatment, if it does not spontaneously subside. Unfortunately, however, this is not 'ahvays so. I know of two in- stances that have resisted such management as could be devised for them by several able practitioners, one for twelve years and the other for seven years. Both of these patients use the catheter for themselves when there is an accumulation of urine. Symptoms. The main symptoms indicating paralysis of the urinary bladder are inability to pass urine and distension of the organ. The reten- tion is not always absolute ; in some instances the urine dribbles away constantly by drops, keeping the clothing wet. 62 DISEASES OF THE BLADDER. The patient and inexperienced friends often believe that there is incontinence instead of retention, on account of this continued dis- charge. In other cases, however, wliere the paralysis is more pro- found, there is no discharge. The distension sometimes becomes very great, extending beyond the umbilicus half way to the ensi- form cartilage. Retention of the urine sometimes occurs as the effect of inflamma- tion of the urethra. This canal becomes so sensitive to the passage of that fluid through it, that the sphincter closes spasmodically when there is any attempt to urinate. Diagnosis. Paralysis of the bladder may be diagnosticated without much diffi- culty generally. The patient is conscious of inability to exert suffi- cient power to expel the urine, but often has no sensitiveness or pain upon voiding it. The hysterical form is usually attended with other symptoms of this affection, appears quickly and disappears as suddenly, while the urine is copious and clear. There is something in the manner of the patient which will often lead the inexperienced to think that she de- sires to have it drawn by the catheter. Cases resulting from injury at the time of labor may be traced to that event. Treatment Treatment for temporary relief will consist mainly in the use of the catheter. I think this instrument is generally used at too long in- tervals, especially in the form arising from injury during labor. I have often known cases of this kind to be neglected for twenty-four hours at a time. As a general rule, to pass the catheter every six hours is not too frequent. The muscular fibres " should not be stretched by a consid- erable and prolonged distension, as that will prevent them from re- covering their tone. And if the organ is kept well emptied, there is no danger of decomposition of the urine and the consequent irri- tation and inflammation of the mucous membrane. An intellio-ent nurse can be taught to perform catheterism very easily, and may be trusted to do so according to instructions as to time and other cir- cumstances. If the paralysis is connected with any general condition, as hys- teria, this latter should be attended to by general treatment. If the paralysis is general, the vesical affection will share in the general treatment of that affection. HEMORRHAGE FROM THE BLADDER. 63 The general health is usually impaired even when the paralysis is purely local in its origin, and often it is one of prostration. When this is the case, generous diet, exposure to and, when practicable, ex- ercise in the open air, with tonics and proper alteratives, will be in- dicated. Strychnia, quinine, and iron, separately or combined, will be useful remedies. The strychnia is particularly indicated as giving tone especially to muscular fibre and hence operating favorably on the debilitated tissue of the bladder. Phosphoric acid is also usually an excellent tonic in such cases. The bowels should be kept in a soluble condition by the gentlest of laxatives. "When there is evidence of inflammation of any of the pelvic vis- cera, we should remove it by the proper means before resorting to direct remedies to remove the paralysis. After all inflammation is removed, if there is any, we may employ electricity to stimulate the muscular fibres to contraction. An electro-magnetic current may be passed through the bladder in various directions, so as to stimulate all the fibres successively, applying the positive pole over the spine and across the posterior part of the loins, iliac and sacral regions, while the negative may be brought in contact with the symphysis, periuseam, and labia, and a catheter introduced into the urethra and passed slowly into the bladder. The whole of this faradization should not last more than five minutes at first, and should be re- peated once a day. After the patient has had three or four sittings, the force of the current and the duration may be gradually increased. It is sometimes very beneficial to pass the current from the anterior part of the abdomen into a metallic speculum in the vagina. I have seen many cases yield to this plan of treatment. A remedy that seems to have a very ready effect, and to which I think I may attribute a cure in some cases, is the secale cornutum. The fluid extract of ergot admin- istered in decided doses, once in a half hour for four or five doses, when the bladder is somewhat distended, often acts very promptly. A good way to administer the ergot is to induce decided ergotism, or give enough for that purpose every day and suspend the remedy in the intervals. I have been in the habit, also, of administering biborate of soda in doses of twenty grains four times a day with benefit. It is probable that all the substances that induce uterine contraction will influence the bladder sirailarlv. Hcemorrhage from the Bladder. A bloody discharge from the female bladder, not the result of or- ganic lesion of that viscus, is far from infrequent. It occurs more 54 DISEASES OF THE BLADDER. frequently, judging from my own obser%'ation, about the time of the menstrual period and in persons whose flow is small in quantity. It is seldom, if ever, sufficiently copious to cause alarm, and the treat- ment of it may be trusted to the remedial measures required for the accompanying disease, whatever it may be. Hypercesthcsia of the Bladder and Urethra — Irritable Bladder and Urethra. An irritable condition of the bladder and urethra is a very com- mon occurrence among women, and is sometimes very distressing and persistent. The symptoms are frequent desire to urinate, with the discharge of but a small quantity at each time, vesical tenesmus, heat and weight, together \^ith a scalding sensation at the time of passing the water. This irritable condition may sometimes last, with varying severity, for weeks and even months without being attended with any considerable amount of ap^^arent disease in the parts. Causes. It is many times associated with inflammation and hypersesthesia of the vagina, with chronic metritis in some of its various form^, with displacements of the uterus, and irritation of the rectum from haBmor- rhoids, fissures, etc. But sometimes we meet with it when we can assign no cause whatever. Treatment. When it is possible to discover and remove the cause, that, of course, should be done. It will often subside under the treatment for the vaginitis that often attends it, or that made use of to remove ulceration and inflammation of the cervix uteri. So, also, when dis- placements are corrected, when we cannot trace it to any of these causes, the urine should be examined, and if found of strong acid re- action this condition should be corrected. This irritable condition of the bladder is quite common in women advanced in age, as the re- sult of a highly acid state of the urine, and may generally be re- lieved by the alkalies, of which the ]ireparations of potassa are prob- ably the best. The liquor potasste, in doses of from ten to fifteen drops, before and after eating, is often very efficacious. In young women of sedentary habits the vegetable acids will often improve the condition of the urine and render it less irritatincr. In either case the bitters may generally be given with advantage. There are some medicines that seem to have a peculiar influence upon the urinary organs, and may often be given in cases of this kind with CHRONIC INFLAMMATION OF THE BLADDER. 55 great benefit. Among such are pareira brava, buchii, and uva ursi. The fluid extracts of these medicines are the most convenient forms for administration; but sometimes the extracts are not good, and hence I have been in the habit of relying more on the decoction than any other form. I often combine the buchu and uva ursi with, I think, excellent effect. AVhen the distress is considerable we may very properly use belladonna suppositories, per vaginam, at night. A half grain of the extract in cocoa butter, the same amount of sul- phate of morphia, will often quiet the patient and enable her to rest, when otherwise she would be annoyed by frequent desire to urinate. Vaginal injections of tepid or warm water often relieve the suffering, so do hip-baths and water compresses over the lower part of the ab- domen. ChroniG Inflammation of the Bladder. Although women are subject to acute cystitis, — probably not as often as men, — there is nothing in the course of the disease, or the treatment, that requires special consideration in a work of this kind. The chronic form, however, so far as I can judge from my own ob- servation, is more frequent in women than in men, and its course and treatment are both, in some respects, quite different, so that I am in- duced to give it distinct consideration here. It often complicates the various diseases of the uterus and vagina, and the displacement of these organs. It is also caused by foreign bodies in the bladder, as calculi, and substances introduced from without. Nature and Progress, In the beginning the inflammation in most cases is confined to the mucous membrane ; after awhile the muscular tissue becomes affected. In the early stage of the affection, while the inflammation is confined to the mucous membrane, the bladder empties itself completely but with great pain. As soon as the muscular structure is injured by the processes of inflammation, especially by the deposition of fibrin, the walls become thickened and uneven, contraction is imperfect, and hence the urine is retained, at first in small quantities and afterwards in larger; decomposition of this fluid takes place, the inflammation is aggravated, and ulceration follows in many instances; the patient sometimes dies from protracted suffering, or life is suddenly termi- nated by the ulceration perforating the wall entirely and causing fatal inflammation in the peritoneum or cellular tissue. Occasion- ally the inflammation spreads to the ureters, and through them to the 56 DISEASES OF THE BLADDER. kidneys. The urethra may or may not be involved in the inflam- mation. Generally the cystic portion is more or less affected, and the ulceration in this direction will, in extremely rare instances, perforate the vesico- vaginal septum and thus cause fistula. The inflammation from foreign bodies contained in the bladder would be more likely to effect this condition than inflammation arising from any other cause. Symptoms. Dysuria, if not the most frequent symptom, is certainly one of the most frequent. The presence of even a small quantity of urine in contact with the inflamed mucous membrane irritates and causes a desire to evacuate it. There is also heat, a sense of weight or drag- ging in the loins, the region of the bladder, and in the pelvis, with a great amount of general suffering ; constipation, indigestion, some- times nausea, and various nervous symptoms being among the gen- eral symptoms. The urgency of the symptoms will depend, in a great measure, upon the amount of inflammation, but somewhat also on the consti- tutional peculiarities of the patient. The frequency of the discharge becomes very great, as there is constant pain and desire to urinate on account of the irritating character of the urine. With the urine is discharged a large amount of mucus, and as the disease advances pus and blood globules are found in the urinary sediment. The ap- pearance of the sediment is almost characteristic. It occupies the bottom of the vessel, is pellucid, tinged with yellow if there is pus in it, or red if it contains blood-corpuscles, and when poured out either comes in a jelly-like mass or in long strings of mucus that may be drawn out to great lengths. At the bottom of the sediment are usually found an abundance of the phosphatic salts. As the disease advances, the odor of the urine becomes highly ammoniacal and not unfrequently fetid. Generally the odor is quite unnatural. The diagnosis is not difficult. The sediment of the urine, under the microscope, will show the presence of pus-globules in grave cases, and sometimes blood-globules. When pressed upon above the pubis the bladder will be found tender. This tenderness will be more evi- dent upon introducing two fingers into the vagina and elevating the bladder upon them, while pressure is made above the pubis. The bladder may be thus included between the two hands. The tenacious CHRONIC INFLAMMATION OF THE BLADDER. 57 ropy sediment, the pus and blood globules, especially the former, and the tenderness of the bladder upon bimanual pressure are the main diagnostic symptoms. Prognosis. Chronic inflammation of the bladder is an obstinate di'sease, and is very difficult of cure; yet it probably does not often prove fatal. Treatment. The complicating conditions — as the disease is associated with others in the majority of instances — should be attended to with great diligence. The pelvic viscera are so near each other that inflamma- tion seldom exists in one for a great length of time without spread- ing to others. I believe this affection is often the result of extension front the vagina or uterus, and in many instances it arises from pelvic peritonitis and cellulitis. Many of the remedies used for the cure of one of these affections will benefit the others also. The use of the hip-bath once or twice daily, copious w^arm-water injections as often, poultices, compresses, iodine ointment, vaginal suppositories, — of anodynes especially, — will all have the effect of relieving intra- pelvic hypersemia and hypersesthesia. Counter-irritants of a decided character may frequently be made of great service. One or two setons introduced just above Poupart's ligament, in one or both sides, are very effective means of making it. They may be controlled better than blisters or eruptive irritants. We have a number of articles in the materia medica that exert a curative influence by contact with the mucous membrane of the bladder. They are eliminated from the blood by the kidneys, and held in solution or suspension in the urine, thus becoming applied to the diseased surface. Probably chief among these is pareira brava. I think the best way to administer this is in decoction, although the fluid extract, when properly made, is a good form ; buchu, uva ursi, and juniper, are also very useful. I think more good, in most cases, results from the use of buchu and uva ursi together than from either alone. Iodide of potassium, permanganate of potash, and some other salts of this alkali, the acetates and nitrates for instance, exert an excellent alterative effect upon the mucous membrane of the bladder. The terebinthinates may be used with great advantage in the milder forms of this inflammation. Perhaps balsam copaiba is the most uniformly beneficial of this class of rem- edies. Cubebs may also be employed occasionally with good effect. The above treatment is applicable and often sufficient in the earlier stages and milder forms of chronic inflammation of the bladder ; but 58 DISEASES OF THE BLADDER. after contraction of the organ is impaired by the extension of the inflammation to the muscnlar strncture, surgical treatment becomes indispensable to a successful issue. It is necessary that the acrid urine be completely removed from the bladder before it enters into chemi- cal decomposition, which it does very quickly. At the same time the direct application of medicine to the inner surface can and ought to be made, while alterative and tonic general treatment is instituted to overcome interstitial inflammation and remove the fibrinous de- posit. Often we may accomplish the processes of emptying the bladder and applying the medicinal agents by means of the double catheter. To insure the eflicacy of these measures the organ may be washed out by warm water thrown through the catheter by a David- son syringe, and after all the urine is washed out the medicinal solu- tion may be introduced, and allowed to remain until its action is accom- plished. When there is much pain a quarter or half grain of morphia once in twenty-four hours will secure immunity from suffering. We may combine with the morphia a solution of iodide of potassium, permanganate of potash, tannic acid, acetate of lead, or other astrin- FlG. 9. Skene's Double Perforated Catheter. gent; or we administer in the same way a small amount of an emul- sion of balsam copaiba. Nitrate of silver will also frequently cause a better condition of the inflamed surface. The ingenuity and ex- perience of the practitioner will generally suggest remedies of the above character best suited to the particular case. Due caution must be observed not to use the remedies in too concentrated strength until the tolerance of the inflamed surface is ascertained. These medica- tions should be applied once a day at first, and afterwards as often as may be required. It should be borne in mind that the raucous membrane of the bladder is very sensitive and that medicines are readily absorbed by it. In connection with this surgical treatment ergot and strychnia may be given to insure tone in the muscular structure. They ought not to be administered, however, until the activity of the inflammation has somewhat subsided. Dr. J. L. Papin, of St. Louis, has practiced a plan for relieving the irritable and inflamed condition of the bladder by dilating the urethra so as to CHRONIC INFLAMMATION OF THE BLADDER. 59 paralyze the contractile fibres and leave the canal patulous, thus allow- ing the urine to pass out as fast as secreted, instead of permitting it to remain in the bladder to irritate it. The treatment is described in a paper written by Dr. M. Yarnall for the January (1872) number of the Medical Archives, published in that city. The operation is thus described : The urethra is dilated " with a long pair of dressing forceps to such an extent as to produce a temporary incontinence of urine, by rupturing a few of the fibres of the sphincter of the blad- der, and repeating the operation when necessary, at intervals of a week or more, until the patient is completely relieved." Twenty cases are mentioned as having been treated in this way, and the report is : " In nearly every instance the relief afforded is almost imme- diate ; but in the course of a few days the irritability of the bladder usually returns, when the operation has to be repeated, and, if neces- sary, again repeated until a cure is accomplished." In one case the operation was repeated five times, in some others three and four times. The experience of Dr. Papin is such that he does not fear incontinence of urine. " The operation being at first very painful, it will usually be found necessary in performing it the first time to place the patient under the influence of an anaesthetic ; but its subsequent performance being much less severe, as a rule the anaesthetic will not be necessary, unless the patient be of a very nervous temperament." This dilatation will much facilitate the use of medicated injections and preclude the need of a double catheter. This operation is very simple, and, according to the report of Dr. Yarnall, very efficacious. I have practiced dilatation of the urethra quite frequently with results not inferior to those here reported. I invariably use the finger in place of any other instrument. One of the dangers of dilatation of the urethra is laceration of the circu- lar fibres of that canal, and consequent incontinence of urine. I have not met with an instance of this kind, nor have I seen anv other serious consequences follow dilatation. The finger may be passed through so slowly that the fibres will stretch, and endowed as it is with a delicate sense of touch, it easily recognizes the unyielding tension which indicates care. In this it would be entirely prefera- ble to any kind of instrument. Compressed sponge or laminated tents dilate so slowlv and remain in contact with the canal so lon^ as to induce inflammation and softening of the muscular fibres, and instead of preparing the way for further safe dilatation would predispose to laceration. 60 DISEASES OF THE BLADDER. Dr. Goodman, of Louisville, uses a catheter with a small bulb on the vesical extremity of it, with which he secures an empty state of the bladder. Dr. Sims's well-known practice of incising the vesico-vaginal septum has for its support the favorable report of its distinguished originator and Dr. Emmet, his successor in the Woman's Hospital of New York. The latter gentleman has written, and read before the Academy of Sciences of New York City, quite an elaborate paper advocating the propriety of making a fistula through which the urine will pass without accumulating in the bladder, and through which very effective medicinal application may be made to the inflamed surface. The patient may be placed in the position advised to operate for vesico-vaginal fistula, and the parts exposed by Sims's speculum. The surgeon may then pass a grooved director into the urethra with the groove toward the vaginal septum, and cut down upon the director until an opening is made large enough to answer the purpose. There is probably more danger of having the opening too small than of getting it too large, as the parts contract and have a strong tendency to close up before the cure is effected. The opening should be about an inch in length. With this free communication with the interior of the bladder the medication may be complete Tincture of iodine, a solution of nitrate of silver, and the various astringents may be applied through the artificial opening. The injections for washing out the bladder can be used with such freedom as will insure cleanliness. Dr. Emmet assures us that this method of treatment has been almost uniformly successful in his hands. The operation to cure the fistulous communication between the bladder and vagina is so well understood and so generally suc- cessful, that the surgeon will not dread the consequences of this plan as it would have been dreaded some years ago, and I need hardly say that the opening should not be closed until the inflammation is en- tirely cured. It often closes spontaneously. Stone in the Bladder. Vesical calculus in the female is of very rare occurrence, absolutely and relatively. Of all the cases of vesical calculus only about one in twenty is met with in the female sex. This may be accounted for by the size, straight form, and dilatability of the urethra, and consequent direct escape of small sanguineous and mucous accumulations, and even sandy concretions. Indeed, quite large stones are expelled through the urethral canal, making their way out, in some instances, in a few moments with acute suffering, while in others they are many hours STONE IN THE BLADDER. 61 iu forcing a passage. It would seem that these hard substances are evacuated more readily during the state of pregnancy than at any other time; doubtless, because of the urethra partaking in the general increased dilatability of the genital organs which precedes labor. Si/m.2:>toms. There are probably no symptoms attendant upon stone in the bladder in woman but what are produced more frequently by other causes, hence they are quite unreliable, and can be taken only as suspicious instead of diagnostic evidence of its presence. They are great and persistent irritability of the bladder, severe pain after void- ing the urine, sudden cessation of the flow while there is yet a desire to urinate and evidently some fluid in the organ, enlargement or relaxation of the urethra, and incontinence of urine. The urine is also charged with mucus, pus, or blood, or all three of these in greater or less quantities. The symptoms will be more strongly marked if the calculus is rough and jagged in shape, and less so if the surface is smooth and even. All these symptoms are not present in any given case, but some of them are certain to be prominent and very distressing. Diagnosis. The only way to positively determine the diagnosis is by physical examination of the cavity of the bladder. This is done by means of the fingers and the sound. If two fingers be passed deeply into the vagina, as far as the cervix uteri, the most dependent part of the bladder may be pressed strongly up against the internal fiice of the pelvis, or lower portion of the anterior abdominal wall. If this latter be pressed w^ell down into the pelvis with the other hand, while the fingers are still in the vagina, careful manipulation will scarcely fail to distinguish a calculus of moderate size. When the bladder is full of water, if the calculus is large, it may be raised and its presence pretty conclusively determined by ballottement. The stone is felt, however, more distinctly througli the urethra by the sound, used the same as in the male. The operation may be facilitated by the fingers in the vaccina movino^ the stone around. The same difficulties in preventing or making difficult and perfect diagnosis are met with, as in the male, if the stone be encysted or adherent to the upper or anterior wall of the bladder; but if the instrument is sufficiently curved and moved about in various directions it will be detected, and its position and size ascertained with more precision and certainty than in the male. 62 DISEASES OF THE BLADDER. Treatment. The only means of relief available is the entire removal of the calculus. This may be done by dilating the urethra, and extracting through it ; by litliotomy or lithotrity. All these operations are less hazardous in the female than in the male, in fact, we scarcely take the subject of danger to life into consideration in operating for stone on a woman ; but one very great inconvenience likely to follow dila- tation of the urethra and lithotomy is incontinence of urine, and the attention of recent o]3erators is turned mainly to the matter of avoid- ing this most distressing sequel. The preference is given by some surgeons to lithotomy, because they think this evil less frequent after it, while for the same reason others resort to dilatation of, and extrac- tion through, the urethra. Very few now practice lithotrity in the female, and this operation is looked upon as attended with more hazard than either of the others. It is astonishing with what facility the female urethra may be largely and rapidly dilated. I have seen it stretched so as to admit the index finger in ten minutes without violence to its integrity. Where the stone is not very large, not over half an inch in diameter, we may expect to succeed by dilatation with- out much damage if proper caution and gentleness are used. When the stone is much larger, and especially if it is rough, we should cut. The operation of dilatation is simple. It may be performed by the finger more readily and safely as directed in chronic inflamma- tion of the bladder. As soon as the finger can be made to enter freely the bladder, other fingers should be passed into the vagina and caused to press the stone forward so that its size, shape, consistence, and the character of the surface be ascertained. If there is a lono- diameter, the end must be directed to the urethral opening, and re- tained with as much security as may be until the forceps are intro- duced and the stone seized. Traction should be made in the direction of the urethra with the instrument, while with the fingers in the vagina the efibrts may be governed so as to keep up the right direction and steadiness, and also to push the stone into the urethra. Swaying the instrument in different directions, and performing slight rotation, the force used should be very gently applied and slowly increased, giving the parts time to stretch, and no more exerted than is just sufficient to accomplish the extraction. We should not be in a hurry, but take plenty of time; more damage is done by too great hurry than too great dilatation, I think. The parts are torn instead of being stretched. If the stone is too large to be removed in this way, we may perform lithotomy. FOREIGN BODIES. 63 Dr. Sims has proposed and performed litliotomy throngli the vesico- vaginal septum. He exposes the parts as for operation for vesico- vaginal fistula, introduces a curved director through the urethra, and cuts into the bladder upon it until the opening is large enough to permit the stone to pass. The finger is then passed through the ar- tificial opening by which the forceps is guided, the stone seized and extracted through it. The wound is then closed with silver sutures, and the patient otherwise treated as for fistula. Foreign Bodies Are sometimes introduced into the bladder by accident or design. Lead-pencils, hairpins, quills, etc., are found in the bladders of hysteri- cal girls. They may be generally easily extracted by dilating the urethra, seizing the substance with strong forceps, and withdrawing them. Several instances are recorded of the open-barred pessaries of Dr. Hodge being removed from the bladder, where they had been introduced by mistake. The practitioner, starting one limb of the instrument into the urethra instead of the vagina, and afterwards manipulating in the ordinary way, would easily pass the whole into the bladder without observing any difference in the passage through the parts. Dr. H. R. Storer, of Boston, has now had three cases of this kind, and others have also met with them. I have seen but one instance of the accident, or rather mistake. In that case the instru- ment was introduced by an intelligent physician, who was sick and stupefied by opium. As he died a few days afterward there was no opportunity of hearing his account of the matter. The pessary re- mained in the bladder several months, during which time the patient was married and became pregnant. Three months after conception the instrument was discovered and removed without interrupting gestation. The removal was not attended with much difficulty. The urine was all drawn, and as the bladder emptied and contracted the pessary, coming down upon the anterior wall of the vagina, was distinctly felt, and its shape and size easily distinguished. The little finger was first pressed into the urethra until it passed into the bladder, then the index, by which the end of one of the branches of the in- strument was drawn to the vesical end of the urethra. The finger was then withdrawn, and Ricord's phimosis forceps introduced until in contact with the limb of the pessary. To facilitate the prehension of it by the forceps, the index finger of the left hand in the vagina held the pessary against the pubis. In this way it was not at all 64 DISEASES OF THE BLADDER. difficult to fasten the forceps on the end of the limb lying in contact with the neck of the urethra, and to extract the whole instrument. This was done by first bringing the point of the branch seized upon out of the meatus, depressing it toward the perinseum until the angle at the junction with the cross-bar appeared, after which the changes were the same as removing from the vagina. This case was recorded by Dr. Buckley, of Freeport, Illinois, in the Medical Record. Es- sentially the same plan enabled Dr. H. R. Storer, of Boston, to re- lieve his patients. A foreign body that has been introduced through the urethra can, by this kind of manipulation, be removed through it. Inversion of the Bladder. In childhood the bladder sometimes becomes inverted and partially expelled through the urethra. Dr. John Croft, in ^'St. Bartholomew Hospital Heports/^ American P7'actitioner, gives the following methods of diagnosticating and treating inversion of the bladder : " A small, red. pyriform, vascular, elastic tumor, situated between the lahia below the clitoris, and in front of the vaginal orifice ; the urethra not distinguishable ; the ureters may be exposed, and perhaps distilling urine; a history of more or less incontinence previous to the appear- ance of the tumor : these symptoms should lead one to recognize an inversio vesicce, and to distinguish such an affection from a solid polypoid growth. Mr. Holmes has described a vaginal hernia in his work on Diseases of Children. In that malady the urethra can be found in front of the tumor, which has not the red vascular appearance of an inverted vesical membrane. The best mode of reduction seems to be by taxis, and the thumb and fingers the best compressors. They should be used gently. If the child struggle much, it would be better to employ chlo- roform." A properly constructed compress will retain the parts in position until the urethra attains its normal tone. CHAPTER V. AFFECTIONS OF THE VAGINA. Absence of the Vagina. "We observe absence of the vagina when the tissues and organs in near relations to it are in one of two conditions : First, when the rectum, bladder, and vagina are all absent and replaced by one great cavity, through which the urine and faeces are passed. This cavity is called by authors cloaca, being a common excretory canal for the urinary, genital, and alimentary organs. Sometimes the vagina is imperfectly formed, and the rectum perforates it posteriorly, while the urethra enters it anteriorly. Secondly, the vagina may be absent while the rectum and bladder are properly situated, perfect in their formation, and the anus and meatus urinarius both also occupying their normal places and performing their functions properly. In this last condition of the parts the vulval organs are generally all present; in one case the hymen was to be seen. In by far the most instances there is an absence of the uterus when the vagina is not found, but this is not always the case. I feel confident of having seen two cases in which the uterus and vulva were normal. Causes. Absence of the vagina is, of course, always a congenital condition. Diagnosis. In cases where there is a common cavity for the rectum and blad- der, we shall have no difficulty in ascertaining it by inspecting the parts with the eye and passing the probe into the rectum and bladder if necessary. The discharges, however, will generally enable us to decide without this last measure. When all the adjacent organs are normal, we are to distinguish between occlusion by an abnormal hymen, rudimentary vagina, and this condition. Physical examination alone will enable us to do this. We shall not often be called upon to determine the question of diagnosis until there is a collection of menstrual fluid in the cavity of the uterus, or the patient is married. 5 66 AFFECTIONS OF TEE VAGINA. When there is occlusion bv the hymen, with a collection of fluid in the vagina, the vulva will be occupied by a tumor formed of the pouting membrane, generally of a dark-purple color and hemispherical in shape, giving the sense of fluctuation when pressed upon at the time the hypogastric region is percussed. When the vagina is absent, there will be a tumor perceptible between the bladder and rectum, but no protrusion between the labia. The ordinary sign so often mentioned of a cordlike hardness extending from the vulva upward is of no use, as this is obscured by the globular mass between the rectum and blad- der. In one case recently under observation the uterus was absent, and the rectum and bladder seemed to be in immediate proximity. The treatment of absence of the vagina will be given in the treat- ment of atresia. Atresia Vagince. This condition arises very much more frequently from puerperal inflammation of the vaginal parietes than any other cause. But any- thing that produces inflammation enough to destroy the epithelium of the mucous membrane may cause atresia, as mechanical or chemi- cal agencies, scarlatina, measles, sy])hilis, etc. After extensive ulceration from these or other causes, if the denuded surfaces are allowed to remain in contact and at rest for a time, they contract adhesions, thus narrowing, or even at times completely clos- ing, the cavity. In atresia occurring as the effect of inflammation every variety may be observed. The vagina may be closed at the vulva and not above, the centre may be contracted and the upper and lower ends be of normal dimensions, or the adhesion may take place at the upper part, including or not the os uteri. In all these varieties, however, the parts not involved in the ulceration are but little affected. Atresia may also be a congenital defect in the organi- zation. Congenital atresia is more frequently caused by the forma- tion of a membrane across the cavity, closing it in some part, as the hymen occasionally closes the vulva, and which is often so low down as to be confounded with that membrane. Such a closure, however, is usually farther up the cavity, sometimes near the os uteri. Partial congenital atresia is sometimes represented by a very narrow canal, only large enough to admit a probe, and which seems a very im- perfect outlet for the menstrual discharge, and is so small as to pre- vent sexual intercourse. This form of atresia may be complete and ^'the organ changed into a solid cord,'' extending in part or the whole of its length. ATRESIA VAGINAE. 67 Diagnosis. Judging from my own observation we are more frequently called upon for a diagnosis in atresia after puberty than before. Previous to puberty the closure of the external opening to the vagina would be the only condition likely to lead to its discovery. The diagnosis in such cases is of little importance compared to what it becomes after adult age, as the defect does not interfere with the function of the organ. The failure in the appearance of the menses at the proper time in life, pain in the pelvic region, and enlargement of the abdo- men generally cause physical investigation. If it has originated in ulcerative inflammation, the retention of menstrual fluid, pain, and enlargement would soon excite suspicion ; or, if the patient is married, the husband would be likely to discover the unusual state of things. Practically a very large majority of the cases we meet with will be attended with an accumulation of fluid. The history of the case, the fluctuating tumor between the bladder and rectum, felt by the finger in this last cavity and the catheter in the first viscus, and the presence of some part of the vagina in a distinguishable condition will enable us to decide as to the nature of the difficulty. Prognosis. There are very few cases of acquired atresia which do not admit of more or les^ complete relief. Congenital atresia with membranous formation across the cavity is generally curable, and when the vaginal cavity is so contracted as to be nearly, but not entirely obliterated, we may hope for a cure, but when it is attended with defective de- velopment of the other genital organs we may expect much difficulty, even if a cure be practicable. Treatment of Atresia and Absence of the Vagina. The object of treatment is to overcome the obstruction to the dis- charges from the uterus by surgical means. The vagina is a viaduct for the uterine discharges. In this word, to be sure, is not expressed all the uses of that organ, but to make it an efficient channel for the menses is really almost the only reason for operations in the graver varieties-(5f vaginal atresia. We are not, therefore, justified in sub- mitting our patient to the dangerous operation of opening up the vaginal canal for any other purpose. In cases, therefore, in which the uterus is absent we are not justified in attempting to form an artificial vagina, or in any way endeavoring to perfect the organs for 68 AFFECTIONS OF THE VAGINA. conjugal purposes merely. I have known but one attempt of this kind, and in that case no success attended the persevering and in- genious efforts of Dr. Brainard. The patient was a married woman, who said she assumed matrimonial relations without knowing that she was not like other women. The vagina terminated in a cul-de- sac about an inch in depth. Her husband complained of her inca- pacity to fulfil the duties of a wife. They visited Dr. Brainard for surgical aid, and he had the kindness to allow me to witness his operations. Although the artificial canal that resulted from his efforts was two inches in depth, it had a constant tendency to con- tract, and required the steady employment of a glass plug to keep it open. The husband was not satisfied and the law allowed him to separate from her. The occlusion should not be operated upon until the menstrual fluid fills up the uterus and distends the parts between its cavity and the vulva. Ordinarily, when the vagina is absent, the uterus is bound by areolar and fibrous tissues to its usual situation in the pelvis, and as distension occurs the lower portion of the organ ap- proaches very near the vulva,- — in two instances of absence of the vagina it was not more than an inch and a half from the vulva. In thus approaching the external organs it widely separates the bladder and rectum; pressing the former up behind the pubis, and the latter strongly into the hollow of the sacrum. This condition of things makes an operation for the opening of the vagina, or making an artificial canal, comparatively easy and safe. To attempt to reach the uterus of a girl before puberty has estab- lished the menses, by cutting up toward that organ from the vulva, is to undertake a task of very great difficulty and hazard, which, after the distension has brought about the changes above described, may be accomplished with great certainty and facility and much less risk. Much delay, permitting of great distension, should also be avoided, for Puesch tells us that in 258 cases of atresia 18 died of rupture of the Fallopian tube. The right time, then, to operate for complete atresia is as soon as the uterine tumor fairly fills the pelvis, and when by touch through the rectum with the finger, with a catheter in the urethra, we can assure ourselves that the uterus can be easily reached without en- dangering any important organ. Scanzoni was so impressed with the danger of wounding the blad- der and rectum that he advises evacuating the imprisoned menstrual fluid by introducing a curved trocar, of large calibre, into the rec- ATRESIA VAGINA. 69 turn, and plunging it into the most dependent part of the tumor. After the flow of blood has ceased, the can u la should be left in the place for some time in order to establish a permanent opening. I think the danger of this operation is overestimated by Scanzoni, and cannot recommend the student to follow his teaching. With the precautions as to time and circumstances, and the proper care, the hazard is much less than he has estimated it. The patient may be placed in the lithotomy position, a catheter introduced into the blad- der and a finger into the rectum. The catheter will be directed strongly up behind the symphysis pubis, and the finger pressed firmly back against the sacrum. These preliminary measures being instituted, an exploring trocar may be passed into the central line of the vulva about half an inch below the urethral orifice, and pushed backward into the tumor. If the trocar has entered the cavity containing the menstrual fluid, this will begin to pass the canula upon the with- drawal of the stilet. When thus assured of the right direction, we may be guided by the trocar in an incision that should be run along the lower side of it, until the opening is large enough to press the forefinger through it. With this member we may tear the opening large enough to admit the middle finger with it. Through this open- ing the blood will soon be evacuated. As soon as this is the case, the cavity of the uterus and vagina ought to be thoroughly cleansed by tepid water thrown plentifully through a tube long enough to reach to the fundus. The artificial opening thus made must be kept open by confining a glass plug large enough to keep it patulous. This plug should be worn for several weeks and recourse be had to it when retraction threatens to obliterate the canal. Hewett recommends tearino^ throuo^h the obstructino^ tissue instead of puncturing or cutting. Others dissect through with the knife. Dr. Emmet advises us to use the scissors for incision into the tumor. And, again, a large trocar sometimes is used to penetrate the cavity at the point I have directed, and the finger used to enlarge the open- ing made by it. It happens in some cases that severe symptoms follow this operation for the sudden evacuation, such as peritonitis, metritis, etc. Dr. Sims, to avoid this, evacuates the fluid very slowly, allowing the uterus to contract on the receding fluid as fast as evacuated. In cases where a membrane closes the vaginal canal, the considera- tions above stated should induce us to wait until there is a moder- ate accumulation of menstrual fluid in the vagina. The division may then be made with scissors carried up to the membrane. The 70 AFFECTIONS OF THE VAGINA. opening should be free. Not much danger will exist of cicatricial contraction closing up the divided part, yet for several days the finger should be passed above the obstruction daily to prevent any tendency of that kind. When the vaginal canal is contracted to very small dimensions, amounting to almost complete atresia, we may dilate this small opening by introducing sea-tangle tents or metallic bougies grad- uated in size, the smaller first and larger afterwards. Sponge- tents may be used after the dilatation has been fairly begun. Perseverance in the use of tents will enable us to succeed without cutting, and I would very much prefer it to any other method of procedure. Tumors in the Vagina. Fibrous tumors in the vagina are occasionally met with. They are generally less firm, although resembling in most other respects the fibrous growths of the uterus. They grow in the anterior wall of the vagina so as to project into the bladder and vagina to about the same extent, or more or less in either of these cavities, according as they are developed nearest the membrane of the one or the other. Some- times they are pendulous or polypoid, hanging into the vaginal cavity by a neck of greater or less size. All I have seen of the intramural form of these tumors were encysted, and were removed by excision. The cyst was opened and the tumor turned out and the wound al- lowed to close by contraction and granulation. The polypoid form may be removed by the ecraseur or ligature. The ecraseur is very much to be preferred. Fatty encysted tumors of the vagina are more rarely met with, and may be dissected out, in the same manner as if situated elsewhere. Vagi^iismus. Dr. Sims described this affection first to the Obstetrical Society of London, December, 1861, and has since given it to us in his Clinical Notes on Uterine Surgery. It is an " hypersesthesia of the vulva and hymen, attended with involuntary contraction of the sphincter vaginae." The parts are so very sensitive that the slightest touch with the finger causes great pain, and in some instances, coition is entirely impracticable. In all the cases I have ever examined, there was very decided redness and increase of the secretion of the parts exposed by separating the labia. Dr. Sims thinks that the sensitiveness is confined to the vulva and hymen, but I apprehend that more extended observa- tion will convince him that the whole vaajina is often involved. In VAGINISMUS. 71 one of my cases, now under treatment, the sensitiveness of the vulva has almost entirely disappeared ; the finger may be introduced into the vagina, but the upper part of this cavity is so exquisitely tender that the patient screams with pain as the finger approaches the cervix uteri. The general symptoms of this affection are grave according to the chronicity of the case. It generally shatters the constitutional ener- gies of the patient, rendering her, according to the expression of Dr. Sims, a wreck. Dr. Sims says it is independent of inflammation. Mr. I. B. Brown agrees with him. It is, according to them, mere hypersesthesia. In my cases the parts were always in a state of inflammation ; but I cannot think the hypersesthesia was wholly of inflammatory origin. Of course I am not prepared to say that inflam- mation is even a general attendant. The observation of the profession will soon determine that point, as the disease is now fairly set before it, and, from its distressing symptoms, will attract much attention. My patients have apparently not been aware of their condition until married. The intensitv of the sufferins^ is not alwavs sufiicient to prevent coition, and sometimes is much greater than others. The sensitiveness is greater near the menstrual epoch, occasionally in a very marked degree. My patients have all been barren. Diagnosis. The sensitiveness and contraction are characteristic, and hence there is no need of much labor in formino; a diao^nosis. The least touch of the mucous membrane of the vulva, with a feather, soft brush, or fingers, gives the patient great suffering, and sometimes agony unlike anything else. Prognosis. Judging from all I have seen and read upon the subject, there is very little, if any, tendency to spontaneous subsidence. Its duration, therefore, is perplexingly long. But all agree as to its curability. Treatment. Dr. Sims has succeeded in curing all his cases by dividing the sphincter vaginae deeply on either side of the vaginal orifice. He makes the division sufficiently deep to permit of free dilatation, and then keeps the vagina open with large bougies until the wound cica- trizes. The results of this operation are all that might be expected from it. The hypersesthesia disappears, and the obstacles to coition 72 AFFECTIONS OF THE VAGINA. are removed, but there is necessarily great mutilation. A long time Wfore Dr. Sims wrote on the subject, forcible dilatation was recom- mended to overcome the spasmodic contraction of the sphincter va- giure. Perhaps the best and most convenient way to dilate the vagina is to introduce the thumb of each hand into the vagina, with the palmar surface turned outward, and then forcibly separate them as far as possible. This will stretch the vulva, but not often rupture the muscular fibres to any great extent. After thus forcibly dilat- ing, we should introduce the glass plug, recomuiended by Dr. Sims, twice a dav. mornino; and evening:, and allow it to remain each time from one to two hours. The plug ought to be from one to two inches in diameter. The in tro<^l notion and presence of this hard sub- stance at first gives great pain, and we may be under the necessity ot using anaesthetics or anodynes, to enable our patient to bear it ; but after having been several times introduced, the parts tolerate it better, and finally we can use it without giving the patient any great incon- venience. The decreasiug sensitiveness thus manifested will be a guide to us in deciding when to discontinue ir. Mr. I. Baker Brown, in his Surgical Diseases of Females, condemns Dr. Sims's operation as severe and needless, and gives two cases where the sensitiveness was cured by the relief of fissure of the rectum. He thinks the hy- persesthesia is a symptom of some disease of the rectum, generally fissure ; and that by incision of the fissures it will disappear. Dr. Braun, of Vienna, according to Mr, Brown, has curefl one case by removing the clitoris. A case of some severity is reported in the Lonrlryn Lo/iicd, American repriut for March, 1867, in the care of Dr. G. C. P. Murray, in which the hypertesthesia appeared to de- j>end upon iuliammation of the cervix uteri and vagina. It was cured by making a free application of the solid nitrate of silver over the inflamed cervix, and a solution to the vaginal surface. These applications were repeated in a fortnight, and were succeeeled by the tincture of iodine. While there c-an be no doubt that Dr. Sims^s plan is efficacious, I cannot think it necessary-, and the success of other means by different practitioners bears me out in this opinion. We almost always find the patients in a state of unsatisfactory health, and, according to my observation, evident local disease be- sides that of sensitiveness ; and, from what we have learned from Mr. BroM-n and Dr. Murray, more than one kind of local disease. As in the treatment of all other diseases, therefore, we should carefully and diligently search for and cure the cause of the hypertesthesia. If it ACUTE VAGINITIS. 73 is fissure of the rectum, this should receive our first attention ; if in- flammation of the vagina, uterus, or vulva, Ave ought to cure this. In all the cases I have seen, and I now have three under treatment, nothing I have tried has been of so much advantage as remedies di- rected against inflammation of the vagina and vulva. The course I usually pursue is to apply the solid nitrate of silver to the vulva every ten or fourteen days, and in the interval use glycerin and tannin. The first application reduces the sensitiveness very decidedly, and it becomes less after each successive touch, until finally cured. We should bear in mind that the hypersesthesia does extend into the vagina and to the uterus, and that it is as necessary to treat the vagi- nal cavity as the vulva. I have been in the habit, at first, of man- aging it as I would vaginitis. The strong astringents, glycerin and narcotics, applied by means of medicated pessaries and injections, are valuable adjuncts. With the local treatment, rational general treat- ment is very beneficial. Attention to the bowels, the condition of the stomach, and the secretions generally ; tonics, exercise, change of air, bathing, attention to clothing, and all the regimenal circumstances calculated to benefit the general condition of the patient. Acute Vaginitis Begins generally in the lower part of the vagina, with swelling, intense redness, and dryness of the mucous surfaces of the labia, vulva, and vagina. There is great heat in the parts, and the patient complains of burning pain in them. Difficult, painful micturition, pain in passing the faeces, sense of weight in the pelvis, and tenesmus are generally present also. Not unfrequently there is backache and pain, radiating down the thighs, into the hips, up the spine, and into the head. Sometimes the symptoms are so acute as to produce general febrile disturbance. When this is the case, there is chilliness alternating with heat, an increased frequency of the pulse, furred tongue, pain in the limbs, etc. In the course ot thirty-six hours the pain, redness, and swelling spread to the whole of the vaginal cavity, and soon there is a profuse secretion of mucus, which, after two or three days, or even sooner, is mixed with pus- globules in some abundance. When this last is the case, the dis- charge is either green or yellowish in color, and less tenacious. This state of things lasts for from ten to twenty days, when the inflamma- tion gradually subsides, becomes less in quantity and lighter in color, until in four or five weeks the disease is entirely gone, or it merges into the chronic form. The inflammation usually involves the urethra, 74 AFFECTIONS OF THE VAGINA. and sometimes the bladder, and its greatest intensity is almost always in the lower third of the vaginal canal. The inflammation some- times spreads to the rectum. Sometimes it attacks the mucous mem- brane of the cervix uteri, and even invades the cavity of the corpus uteri, remaining longer in these localities than iu the vaginal cavity. Diagnosis. The diagnosis of acute vaginitis is not difficult, as the parts may be easily seen and touched. Prognosis . As has been heretofore intimated, it subsides spontaneously, and leaves the parts free from disease, or in a state of chronic inflamma- tion. The prognosis, therefore, is favorable. Cause. It is caused by contagion more frequently, perhaps, than anything else, but does doubtless arise from abuses, injuries, and want of clean- liness, and probably other causes. I have seen the non-contagious form in children very much more frequently than in adults, spreading usually from the vulva upwards. Non-contagious acute vaginitis is not a very common aifection. At first it involves the mucous membrane and submucous tissue, but before many days it is confined to the membrane alone. Treatment. This at first should be slightly antiphlogistic. A few grains of calomel, followed in ten or twelve hours with a saline cathartic, should be the first step. This may be succeeded by nauseating doses of tartar emetic, until the dryness and swelling have subsided. In the meantime, perfect quietude in the recumbent position should be enjoined, the parts bathed every hour or two thoroughly with tepid water, and the patient should abstain from stimulating or nutritious ingesta. As soon as the discharge has become copious, and yellowish or green, and the swelling of the parts has entirely subsided, the treatment should be changed for astringents, specifics, laxatives, and baths. We may give half a drachm of balsam copaiba in emulsion or ca]isules every six or eight hours, and have the vagina syringed copiously with a saturated solution of alum, or acetate of lead, two or three times in twenty-four hours. Every third day a few ounces of a solution of nitrate of silver, the strength of ten grains to the CHRONIC VAGINITIS. 75 ounce, may be advantageously used. The bowels sliould be kept open, and the patient should abstain from stimulants at all times during the treatment. The astringent injection ought to be changed every five or six days, using alum, sugar of lead, and sulphate of zinc alternately. Perseverance in this treatment will very materially shorten the course of the disease. Chronic Vaginitis. This is a more frequent form of disease than the acute, and its im- portance will be understood from this consideration. It is in many instances a very distressing affection, and often mistaken for diseases of the uterus, bladder, or rectum. Symptoms. There is generally pain in the back, more frequently in the sacrum and coccyx, but not seldom higher up ; pain in the groin, weight and sense of bearing down in the perinseum, dragging in the hips and pelvis. A burning sensation in the vagina, extending all over the lower part of the person, very distressing and depressing, is some- times the chief symptom complained of by the patient. In married patients it is the cause of distress during the act of coition, to such a degree sometimes as to entirely preclude such indulgence. I am now treating a patient who assures me that although she has been married fifteen years, she does not remember a single instance of sex- ual intercourse that did not give her discomfort; generally it was the cause of decided pain, and sometimes was entirely intolerable to her. Leucorrhoea is a common, but not invariable symptom ; it may be yellow or white in color, but when the case is not complicated with cervical inflammation it is always thin. In chronic vaginitis there is generally a long train of sympathetic symptoms not unlike those ob- served in diseases of the uterus. The nervous centres are disordered in their functions, and we have nervous symptoms of almost every description. The mind is sometimes affected by it to irascibility, despondency, suspiciousness, peevishness, and purposeless instability. In other or, perhaps, the same cases there is palpitation of the heart and large vessels to such a degree as to cause alarm for the life of the patient. Headache should be mentioned as quite common ; it is more commonly located in the occipital region, but may be in the top, forehead, temples, or all over the head. The eyes are generally weak. The stomach is frequently deranged to a considerable extent, 76 AFFECTIONS OF THE VAGINA. and in various ways ; and there is generally a constipated state of the bowels, though diarrhoea is an occasional symptom. There often is pain, too, in urinating, and in passing the faeces through the rectum. The uterus is almost always affected, also, and through it the symp- toms mav become sreatlv diversified and increased. We should ex- pect this complication. Diagnosis. Upon examining the vagina, the introduction of the finger will give some pain, sometimes a good deal, and the speculum causes a great amount of suffering. There is general redness of the mucous membrane ; sometimes it is smooth and moist merely, or covered with a copious secretion of mucus ; in some instances numerous granu- lations may be seen. The granulations may be situated at the upper end of the vaginal cavity entirely, as I have often seen, or the lower portion of this cavity may be the location in which they are found ; rarely they extend from one end of the vagina to the other. And again the membrane may be so raw as to bleed upon the use of instruments in making the examination. The sensitiveness, redness, and exaggerated secretion are conclusive and diagnostic symptoms when they are permanent. Causes. Chronic vaginitis is often the result of an acute attack. The in- flammation only partially subsides at the time, and is continued in- definitely. Some of the most obstinate cases I have met with have thus resulted from gonorrhcea. Another set of cases are seen in patients whose husbands were the subjects of syphilis in early life, but who have been to all appearances cured. I am inclined to the opinion that chronic vaginitis is not an uncommon occurrence in women thus situated. It is more likely to follow recent cases of syphilis, and is sometimes subacute in grade. Another form is ap- parently produced by abortions, colds, and other causes, with, at the same time, inflammation of the cervix uteri. Constipation, causing sluggishness of the vaginal circulation, or other causes producing this vascular condition, as the pressure from pelvic tumors, phlegmonous effusion, etc., contribute to the production of chronic vaginitis. There is no doubt but that certain constitutional taints, as scrofula, rheuma- tism, and, as before intimated, syphilis, are efficient co-operating causes. Prognosis. Chronic vaginitis, in its simpler forms. Is apt to be obstinate and resist judicious treatment for years. It is more particularly so when CHRONIC VAGINITIS. 77 oricrinatino; in constitutional diseases. When connected with incurable tumors it will, of course, resist all sorts of treatment. Treatment. The constitutional treatment of chronic vaginitis is sometimes or the first importance, while at other times it is unnecessary, or nearly so. The variety which seems to be connected with the syphilitic condition requires the alterative remedies which are found beneficial in this affection under other circumstances, the preparations of mer- cury, iodine, and the vegetable alteratives, for instance. AYhen asso- ciated with scrofula, the vegetable tonics, with alterative treatment, cod-liver oil, plenty of outdoor exercise, cold bathing, sea bathing, etc., will be appropriate measures to be employed. As it is not un- frequently complicated with rheumatism, or this diathesis, it may be necessary to prescribe for it with such a consideration in mind. But in more simple cases, where there are no such taints or com- plications, conditions exist that require a judicious course of general treatment for their removal before we can be successful in our main object. Such is a torpid state of the bowels and portal circle, w4th scanty secretions. Mercurial and saline laxatives, vegetable tonics, as the bitters, also alkalies, will, when judiciously used, assist us verv much. We should be particularly careful to avoid a loaded or im- pacted state of the rectum, as this is the cause of much vaginal con- gestion. An injection once or twice a day, when necessary, will suffice for this. In all forms, in addition to the general treatment, when that is necessary, we shall be under the necessity of resorting to local measures. Much benefit will be derived from a sitz-bath twice a day. The bath should be tepid, as a general thing, as being more likely to agree with the largest number of patients. When it is more agreeable, the bath may be coolor. It should be large enough to cover the hips, and the patient should remain in it for an hour at least, and often it is better to use it for a greater length of time. Ot more importance are injections. Simple water in large quantities is sometimes sufficient, but more frequently astringent substances will be found essential. The injections should be administered through a perpetual syringe, and the quantity should be large, say from one quart to a gallon of water at each time. The common astringents, as alum, sulphate of zinc, acetate of lead, of the strengtli of one drachm to the quart of water, will generally suffice. We find cases, however, in which none of these substances can be used, because they 78 AFFECTIONS OF THE VAGINA. disagree with the patient, producing dryness of the parts or increasing the inflammation. In such cases we must carefully search for the right local remedy. AYe may find it in tannin, tincture of the chlo- ride of iron, astring^ent decoctions, nitrate of silver in solution, etc. The last, used once in four or five days, with a glass syringe, and the other astringents between, often proves to be the best course. An excellent and very convenient mode of applying medicinal substances to vaginal surfaces is to make small sacs of gauze or linen, and fill them with the substance intended for use, and introduce them into the vagina. A sac the size of a small glove finger, with a piece of thread attached to it, will hold an abundance of almost any remedy we desire to use. Tannin in powder or ointment, gall oint- ment, belladonna ointment, and other articles are used in this way. A mixture I have used very commonly consists of two drops of crea- sote, half drachm of tannin, and one grain of belladonna extract, in- troduced at bedtime each night. The little bag may be removed in the morning by traction on the string. There are, I think, some advantages in the use of these little bags over the other sorts of medi- cated pessaries used. I not unfrequently inclose copaiva capsules in these little sacs, and think it an admirable mode of making balsamic applications to the vaginal mucous membrane. Where the astringents or other remedies are thus used they Avill not replace the injections wholly. Indeed, the vagina should be well washed out before the introduction and at the time of the removal of them. Patients^ of course, can manage these applications without aid. Perseverance and time are important items in the treatment. If we can remove this chronic inflammation in three or even six months, we ought to be satisfied. And we ought not to be surprised to have it return one or more times after it is apparently cured. It is well, also, to teach our patient patience in this respect. Puerperal Vaginitis. It might not seem necessary to consider the vaginitis occurring after labor as a separate affection, but there is so much difference — in the causes, nature, symptoms, and termination — between ordinary vaginitis and this form that I think it may be profitable to do so. In some cases of labor, circumstances occur that induce a severe form of inflammation of the vagina. The one most potent is long deten- tion of the fetal head in the pelvis. The pressure thus exercised upon the vaginal walls interrupts the circulation more or less completely; and if continued for a number of hours, violent reaction in the parts PUERPERAL VAGINITIS. 79 results when the pressure is removed. This pressure does not affect the mucous membrane of the vagina so deleteriously as the deeper- seated tissues. The fibro-celkdar part of the vaginal walls is the seat of the inflammation. I do not think the use of instruments, however awkwardly, does so much damage as the long-continued pressure. It must not be denied, however, that instruments do give origin to this form of inflammation. When they do so, the inflammation is more circumscribed ; it does not extend to all parts of the vagina, as is apt to be the case when pressure by the child's head has been the cause. On account of the nature of the causes, this form of vaginitis runs its course rapidly, and is most sure to end in structural lesions. It is in intense forms of this sort of vaccinal inflammation that slouo^hs and deep ulcerations are met with, which open the bladder and cause vesico-vaginal fistula, recto-vaginal fistula, and cicatrices, which re- sult in contractions and even occlusions of the vagina. It is aston- ishing how much destruction sometimes is effected by intense post- partum inflammation. I remember being called to a case, in consul- tation, where the child's head had been pressing down sufficient to bulge the perinseum and labia for sixty hours without any motion. I delivered her with the short forceps in a few moments, without any violence to the parts. The patient was then unavoidably left in the hands of the same careless practitioner that had so outrageously neglected her before the delivery. I saw her three months after- wards, and found the whole septum between the bladder and vagina gone, the urethra terminating abruptly, as though it had been cut straight across, in a great irregular cavity, that was bounded by the pubis before and the uterus behind, and without any defined sides to it. In still a worse case, where shoulder presentation had prevented the passage of the child, the woman was in the second stage of labor six days. The woman arose from her bed with a large un definable cavity, — without any bladder, apparently, but the very top portion, — and the loss of two inches of rectum, into which the urine and faeces were poured involuntarily. In more than one instance I have seen the whole vagina sealed up, from the fourchette to the urethra, and, — as far as I can judge, — to the os uteri, as the effect of intense and neglected puerperal vaginitis, arising from unaided difficult labor. Every practitioner must meet with cases in which the cavity of the vagina is misshaped, and partially closed, from the cicatrices resultinor from it. Xow, much of these direful effects mav be averted by the rational management of inflammation after it hns been in- itiated. 80 AFFECTIONS OF THE VAGINA. Symptoms. When injurious pressure has awakened inflammation in the vagina, the labia and walls become swollen, hot, and very tender. The patient does not generally complain of much severe pain, but there is a sense of soreness and heat. There is almost always fever, chilli- ness, and other evidences of disturbance of the circulation ; the tongue is coated, ordinarily white, sometimes yellow, or even brown, from the beginning. As the disease advances, two or three days from the beginning, the discharge from the vagina becomes more than ordi- narily fetid, the labia excoriated, while the heat of the vagina is still verv great, and there is much mucus and some pus issuing from it ; and later, shreds of decomposed substances, and sometimes consider- able sloughs, are mingled with the discharge, increasing the fetor. The pulse is more accelerated, and sometimes becomes quite rapid ; the patient is much prostrated ; the tongue brown and dry, and the teeth foul with a dark clammy mucus, while the skin is bathed in a copious perspiration. In from two to six or eight days, to these symptoms is added an evacuation of urine through the vagina, at first small quantities, and afterwards more considerable, until, in a short time, the contents of the bladder are passed through this way ; the parts around are excoriated by the urine and other acrid dis- charges, and a slow, uncertain convalescence succeeds, with a per- manent vesico-vaginal fistula. Occasionally, though not so frequently, the faeces pass through the vagina a few days after the beginning of the inflammation, and we have a recto- vaginal fistula. If neither of these evils occur, there is extensive ulceration, not so deep, but extending over a large surface of the vagina; thus pus and acrid ichor are poured out in copious quantities, for a long time, gradually decreasing as the surface heals. As these ulcerations heal up, the tissue becomes condensed and contracted, until such strictures or oc- clusions result as are above mentioned. The practitioner should be wide awake to this frequent course of post-partum vaginitis. Treatment. As most damage from this form of vaginitis usually accrues to the bladder and rectum, our first and most solicitous care should be be- stowed upon them. The bladder should be frequently emptied with the catheter ; at least every few hours the urine must be drawn oif. To appreciate this direction, we have but to remember that this organ may be considerably distended in that time, and as the septum URINARY FISTULA. 81 between the vagina and bladder is in a state of intense inflammation, it is softened, and therefore is easily ruptured. My impression is that fifty per cent, of the vesico-vaginal fistulae which now occur might be avoided by following this rule. Its importance cannot be overestimated. In very bad cases the catheter might be used even more frequently, or kept in the urethra. The rectum should be kept free from any accumulation of fseces by frequent injections of tepid water. In addition to this prevention of fistula, the utmost cleanliness must be observed. The vaorina should be washed out with soapsuds or other bland detergent fluid, from four to six times a day. For the first four or five days the parts may be kept lubri- cated thoroughly by the injection, after the water, of very bland sweet oil, or almond oil. AVheh the slough begins to be thrown oiF, or pus and sanies become copious, an injection of half a pint of tepid water, containing six or eight drops of creasote, twice a day, will serve to cleanse and stimulate the parts better than soap and water alone, which should be used between times. After the lapse of a week or ten days, if the ulceration is not healing, an injection of ten grains of nitrate of silver to the ounce of water may be used quite advantageously. This solution should be injected from a hard rubber or glass syringe, directed to the ulcerated part by the finger. As the case still further advances, a solution of tannin, alum, sulphate of zinc, or other astringents, with the detergents, may be used. As the parts begin to contract by the advanced healing of the ulceration, the closure, paitial or entire, should be anticipated by the introduction, daily or oftener, of wax, rubber, or other sort of bougies. It is well, when this last expedient is necessary, to smear them with oint- ment that may exert a healing influence on the ulceration. The physician cannot be too attentive to these cases. He should see to it personally that his directions are carried out, and feel himself respon- sible for any serious permanent injury that can result from want of diligence. Women or their nurses cannot undei^stand, and it is feared that physicians do not properly appreciate, these means of averting^ the awful accidents which result from slouo^hino^ and ulcer- ation in these cases. Urinary Fistula. Although generally resulting from puerperal vaginitis, fistula is sometimes produced by other causes. Extensive ulcerations from pessaries sometimes penetrate the septum between the vagina and bladder. Stone or other foreign bodies in the bladder may act as 82 AFFECTIONS OF THE VAGINA causes of ulcerative processes of sufficient gravity to do the sarue. Malignant diseases, as cancer of the uterus, vagina, or bladder, not unfrequently lay open these cavities; and, in some rare instances, perforations by the unskilful use of instruments have been observed. Urinary fistula may be: first, urethro-vaginal ; second, vesico- vaginal; third, vesico-uterine; and, fourth, vesico-utero vaginal. In the first variety the opening is through the urethra; In the second through the septum between the vagina and bladder; in the third the vesical wall of the cervix uteri is perforated ; in the fourth, two cases of which I have seen, the anterior and posterior portions of the Fig. 10. Fig. 11. cervix are both laid open. The cervix is sometimes involved with the vaginal septum, being torn up from the extremity through the anterior lip into the vaginal cavity. The whole urethra sometimes sloughs off, leaving the pubic arch unoccupied by that canal. In one case I have recently seen, the urethra aud neck of the bladder were lost, leaving the remainder of the vesico- vaginal septum healthy and entire. In certain other instances the whole lower portion of the bladder is wanting, and the uterus more or less mutilated. To make the condition more deplorable, in some rare examples of the terrible destruction of the parts, the rectum is involved in the common URINARY FISTULA. 83 ruin. The size of the opening in the urethra or vasico-vaginal septum is sometimes so small as scarcely to be perceptible, and from this it may vary through all grades of dimension to the irreparable loss of tissue above described. The direction may be lengthwise, diagonal, tortuous, or crosswise. The fistula, when established, is usually associated with other effects of the disease from which it is produced. Cicatrices and contractions of the vaginal walls are very common accompaniments. These, when extensive, embarrass examinations and operations very much. They also change the size, shape, and direction of the vaginal cavity. Diagnosis. The constant flow of urine throuo^h the vasrina, instead of the urethra, is a sufficient symptom to decide the existence of fistula; but we meet with cases where the flow of urine is not constant, the patient being able to retain for some time and then discharge her urine nat- urally. This circumstance is due to the plugging of a small opening by mucus, or the prolapse of some part of the bladder into the fistula. In all instances it is proper and necessary to make a clear diagnosis of the existence, size, shape, position, and complications of the fistula. This is usually easily done by the fingers and probe. The patient should lie on her back with her hips near the edge of the bed, and her legs flexed so that we may have free use of both hands. The fingers will readily pass through a large fistula into the bladder, and, by moderate care, be made to thoroughly survey it and the surround- ing parts. But the fistula may be so small or situated so as to entirely escape detection by the finger. We shall be aided in such cases by introducing a probe, slightly bent, through the urethra with one hand, while the fingers of the other are in the vagina. The bent extremity of the probe is turned toward the septum, pressed gently upon and passed over every part of it until it is made to pass through the opening, when it may be recognized by the finger in the vagina. When the perforation is very small, or vesico-uterine, this kind of examination will fail to find it. In such cases the vagina should be dilated as for operation, and exposed in a good light so that every portion may be seen. When thus exposed, the cavity should be sponged out and all the urine thus removed. After this perforation, usually we have but to watch a few moments when we shall perceive the fluid making its appearance through a minute pore, which, per- haps, is hidden in an ulcer in some remote part, or we may observe it coming through the os uteri. If, however, no urine makes through 84 AFFECTIONS OF THE VAGINA. in such quantity as to indicate the place of injury, we may inject the bladder with tepid water in such amount as to distend the organ somewhat. Soon the obstacle is overcome and the water will escape copiously into the vagina. If it comes through the mouth of the uterus, the fistula is situated in the cervical cavity. This may be made more conclusive by plugging the os with cotton and again in- jecting the bladder. The fluid will not escape, of course, until the cotton is removed, when it will pass in such abundance as to leave no doubt of its place of exit. German physicians, Yeit especially, recommend the use of water colored so as to make its flow through the opening more obvious. Prognosis. Having found the fistula, ascertained its size, position, shape, direc- tion, etc., we ought to survey the vagina, to find strictures or other deformity, and ascertain the distensibility of this tube. We do this in part to determine the prognosis of the case. Can the fistula be cured ? is a pertinent and important question, which will be decided by this kind of examination. Fortunately, now, thanks to Dr. Sims, almost anything short of loss of the whole septum may be cured. If the fistula consists of a defined opening, it matters little how large, we are justified in expecting success. If, as is sometimes the case, there are no sides, edges, or ends to it, but the vagina and bladder are one cavity, smooth, and continuous, we cannot reason- ably undertake an operation unless it be to close the vulva, as has been suggested and practiced. Some circumstances, indepen- dent of the character and size of the fistula, are necessary to insure success. The vagina should be healthy. If the walls of this cavity are in a state of inflammation or congestion, the prospects of a cure are more remote. Great nervous susceptibility is sometimes difficult to overcome, and should be a reason to defer the operation. The general health of the patient is also a matter of the first importance. A highly nervous condition of the system, with an abundance of lithates in the urine, is a condition in which there are many chances of failure. Treatment Naturally divides itself into palliative and curative. The palliative treatment is of great importance, and he would be a benefactor who should devise means of preventing the great suffer- ing which results from these inevitable circumstances. The greatest amount of pain and suffering in such cases is caused by the flow of URINARY FISTULA. 85 urine over the cutaneous surftxce. The salts held in solution by the urine, and the compounds resulting from their chemical decomposition inflame and excoriate the skin of the thighs, perinseum, and external genital organs. Relief can be perfect only by preventing the contact of the urine with the skin. I think there would be no difficulty in making an instrument that would collect the urine, in most cases, before being discharged from the vagina. But the difficulty consists in getting one that would be tolerated in the parts. What we want is a sac that may be introduced and retained in the vagina with an opening in the upper wall opposite the fistula, large enough to permit the urine to flow in it. The sac should have a tube leading out of the vaginal orifice in order to convey the urine into a reservoir outside, which should be attached to the person of the patient. The sac should be of india-rubber or other impervious material, and so soft and smooth as not to irritate the mucous membrane of the vagina, and so small as not to distend the vagina painfully. But the urine would not flow into and through this tube unless the sac was dis- tended so that the opening would be applied to the fistula. The dis- tension may be effected after the sac is introduced, by passing cotton up through the tube until sufficiently distended. In order to make the urine drain through the tube something like cancellarige should extend from the cotton in the sac outside through the tube. The drain- age will be started by wetting the contained material. The capillary attraction of the cotton will absorb the urine until it becomes satu- rated, while the loose cord will carry it off* like a siphon through the tube. If an instrument of this kind can be made that will be tol- erated by the vagina, I think it will act well. In the absence of anything to prevent the urine from flowing on the person, the patient must depend upon frequent ablution with warm water externally, and upon warm injections in the vagina. After washing externally, the skin should be kept covered with simple ointment. The injections should be made four or five times in the twenty-four hours, and the external ablutions as often as the napkins become sufficiently saturated to replace by others. Another item in the palliative management of the first importance is one mentioned by Dr. Emmet, viz., never to use a napkin twice without washing. Sometimes to avoid labor patients Avill simply dry the napkins and then use them again, thus using a napkin sev- eral times without washing. In this way the salts of the urine are applied to the skin in double strength, and the mischief greatly in- creased. 86 AFFECTIONS OF THE VAGINA. The curative treatment consists ia the closure of the fistula. It is hardly necessary to mention any other method than the closure of the fistula by suture in some form or other. Cauterization was often resorted to before the present safe and sure plans of operation by Drs. Sims and Bozemau, but is now scarcely thought of. To Dr. Marion Sims we are indebted for the cure of vesico-vaginal fistula ; for although others had succeeded in making cures by the use of nearly the same means, his ingenuity and jDersevering industry gave such positiveness and intelligent definiteness to the different steps to be followed in order to succeed, as to convert the operation from one of great uucertaint}^, confined to experts and experienced operators, to an easy, almost invariably successful one, which any surgeon of ordinary skill may venture upon without fear of failure. The pix)fession is also indebted to Dr. Emmet, for a ver}' lucid demon- stration of the principles upon which the operation is founded, in his work on that subject. In describing the very simple operation of Dr. Sims one can scarcely do otherwise than follow, if not copy, the graphic description given by Dr. Emmet. Very much depends upon proper preparation of the system of the patient and the parts concerned, in order to in- sure successful adhesion of the two edges of the fistula. The patient should be in the best possible general health. I think there is great propriety in the distinction insisted upon by some surgeons between the plastic and aplastic diathesis in patients subjected to surgical opera- tions, and am anxious that my patients, for some weeks before the operation, be subjected to the best hygienic condition for their general health. In the country, if possible, plenty of exercise in the open air, good nutritious diet, a contented and happy state of mind are all that are required to effect the desired preparatory condition. In patients whose blood is impoverished from nursing, hemorrhages or other debilitating circumstances, the ferruginous and bitter tonics should be administered. If the general health is well established and maintained for a little time, the vagina will scarcely be other- wise than firm and sound in texture, and free from the troublesome urinary concretions that sometimes adhere to the mucous membrane of the vagina, the vulva, and even the greater labia. During the preparatory constitutional treatment, where that is necessary, the local preparation may be attended to — by frequent cleansing by copious in- jections of warm water, stimulating the parts in the vagina that are red or excoriated with a weak solution of nitrate of silver every four or five days. The solution may be of the strength of 5i to f^iv of distilled water. Dr. Emmet savs that : URINARY FISTULA. 87 " It is frequently necessary to pursue the same general course for many weeks before the parts can be brought into a perfectly healthy condition. This point is not reached until not only the vaginal wall, but also the hypertrophied and indurated edges of the fistula have at- tained a natural color and density. This is the secret of success, but the necessity is rarely appreciated ; without which the most skilfully performed operation is almost certain to fail." The only other preparatory step will be the administration of a cathartic to evacuate the bowels. The catharsis ought to be entirely Fig. 12. Fig. 13. Fig. 14. Fig. 12. — Tenaculum, with which to hold the edge of Fistula while being pared. Fig. 13.— Curved Scissors, for paring edge of Fistula. Fig. 14.— Wire Adjuster. over at least twelve hours before the operation. With these prelimi- naries accomplished, we should have a large window on the sunny side of the house, a sun-shining day, four assistants, a table of conve- nient height, five feet long and two wide, and the necessary instru- AFFECTIONS OF TUE VAGINA, ments. The table, covered with one or two quilts, is to be placed with the end toward the window, from four to six feet distant. The Fig. 15. Fig. 15.— -Speculum for dilating Vagina. Fig. 16.— F()rcei)s for twisting the Wires. Fig. 17.— The Catheter. Fig. 18.— Needle Forceps. Fig. 19,— Sponge-holder. The instruments are represented half size. patient lies on her leftside, the limbs drawn up, the right rather most with the left arm behind her, so that she rests full on the front of the URINARY FISTULA 89 chest. One of the four assistants uses the anaesthetic, another the speculum, a third the sponges, and the fourth attends to the instru- ments. On a tray, within easy reach of the operator, the instruments should be placed. They are the speculum, two tenacula, scissors, Emmet knife, two long sponge-holders, forceps for carrying the needles, one wire adjuster, a blunt hook, forceps to twist the wire, half a dozen needles, slightly curved, about one inch long, armed with silk ligature, doubled so that the silver wire may be placed in Fig. 20. Fig. 21. Method of passing the Needle. Method of paring the edges. the loop and thus drawn through the wound, an elastic male catheter, or one of Sims's S-shaped instruments, with an india-rubber tube, a little larger than the catheter, to carry the urine clear of the bed. The surgeon takes his seat at the end of the table next the window, near the breech of the patient, introduces the speculum, dilates the vagina, and thus brings the parts thoroughly in view, and then gives the instrument to the assistant to keep in that position. If the posi- tion of the patient prevents the parts from being thoroughly exposed and lighted, it should be changed until this difficulty is obviated, 90 AFFECTIONS OF TfiE VAGINA. when the operator may proceed as follows : With the tenaculum in the left hand, the edge of the fistula is transfixed and held up to view, and, with the scissors, bevelled from the mucous membrane of the bladder outward. Dr. Emmet says the point of the tenaculum should be in- troduced toward the fistula, as shown in the figure. As much should be removed in this way, without changing the place of the tenacu- lum, as practicable. Another place on the edge of the fistula is then seized and trimmed in the same manner, and so on, until the whole circle is denuded completely of the cicatricial tissue. We may some- times succeed after a little practice in removing a complete ring of the edge of the fistula. This will of course insure to us a more perfect operation than if the parts are removed in pieces. As this part of the operation is being accomplished, the assistance of the sponge will Fig. 22. Method of using the Tenaculum in giving aid to the Needle, be called into use on account of the bleeding. I do not see the neces- sity of removing as much substance from the edge of the fistula as is directed by some authors. The main object, I think, is to have the edges evenly and thoroughly denuded of the mucous membrane. This much should be done with a completeness that admits of no doubt, and if we have a good light, there need be no doul)t, as we can see and examine the part suffi- ciently well to be positive. After the bleeding has ceased, we may insert the sutures. We commence at the angle of the wound most remote and difficult to reach. The needle is to be introduced first into the lip of the wound nearest to the operator, by starting it in URIN-ARY FISTULA. 91 about half an inch from the freshened edge, dipping it down, so as to make the point come out iu the denuded portion, just at the junc- tion of it and the vesical mucous membrane. The needle being: brought through at this point, is again inserted in the opposite edge, corresponding as near as possible with that part whence it emerged, and carried forward far enoui^h to emergre half an inch bevond the edge of the wound, and drawn through ; the wire is then hooked in the double end of the silk and drawn through the wound, and de- tached from the silk and given to the assistant in charge of the speculum to retain in its place. The next suture is to correspond with and be placed within two lines of the first. They are thus placed in sufficient numbei-s to close the opening completely (see Fig. 23). Having all the sutures introduced, the one nearest the operator Fig. 23, ^ihiP" The Fistula witti edge p>ared and the Sutures placed. must be isolated and twisted by the forceps made for that purpose, until the angle of the wound is evenly coaptated. The next is to be managed in the same way, and so of the remainder in order. Great care must be taken to see, as the closure is effected, that the lips of the wound are drawn evenly and smoothly together (see Fig. 24). 92 AFFECTIONS OF THE VAGINA. If we are not particular, the edge of one side or the other rolls slightly in, and unfreshened mucous membrane is brought up to the denuded surface. This, I think, is a circumstance that is very liable to occur in the hands of an inexperienced operator. Both the inser- tion of the sutures and bringing together the edges may be facilitated by the skilful use of the tenaculum and the adjuster. The tenacu- lum will enable us to disengage and straighten the edges, in adjust- ing them, and in inserting the needles keep them firm. The adjuster will place the twist of the wire in any position with reference to the junction of the wound we may desire. In twisting the wire there are two things to be avoided, — one is tightening it too much, and the other leaving it too lax. Experience will fix these items after a few Fig. 24. Wire Adjuster. operations, but I think that^the operator may venture to tighten the twist of the wire until it fixes but does not strangulate the part in- cluded in the stitch. After the twist is completed, we ought to be able to pass an ordinary probe through the circle of the stitch with- out much force, and yet, upon its removal, there should be no apparent space. If the stitch is drawn too tightly, the parts will be strangulated and early cut through by ulceration ; if too loose, the urine will pass through as the bladder becomes filled and prevent adhesion. As each wire is adjusted and twisted it should be bent over the tenaculum, so as to lie flat upon the surface of the mucous membrane URINARY FISTULA. 93 of the vagina. The operation finished, the catheter may be inserted, the patient placed carefully in bed, on either side, and a grain of opium administered. The catheter will sometimes become foul with deposits, and require cleaning every twelve or eighteen hours, but as a rule, while the urine is running freely, it may remain in place. Great watchfulness will alone prevent this instrument from being misplaced. The great desiderata of the after-treatment, are to pre- vent an accumulation of urine in the bladder, and the bowels from being evacuated. The former can be certainly accomplished in no other way than by having a competent assistant by the patient, or very near her all the time, who, when the catheter docs not deliver Fig. 25. Fia 26. Closins the Wounds and Twisting the Wire Sutures Eemoving the Sutures. the water freely, will remove it and replace a clean one, however frequently that may be required. Dr. Emmet directs that the patient be placed upon her back and so remain during the after-treatment. He causes a double inclined plane to be made by the bedding, so that the legs may be bent and the head and shoulders elevated. AVe may keep the bowels quiet by administering a grain of opium twice or three times a day. If the patient is very restless, we ought to give as much more as is necessary to quiet this. The only other impor- tant item of treatment as a general thiuo^ is cleanliness, and for this purpose vaginal injections of tepid water, with fine toilet soap, twice 94 AFFECTIONS OF THE VAGINA. or three times a day, will suffice. The vagina will thus be kept clean with much certainty. The diet should not be too sparing. The or- dinary diet of the patient, in half or two-thirds of the quantity, I am convinced is better than any considerable change in quality. The patient must remain quiet as practicable for nine or ten days. There will be no good in leaving the sutures in place longer than ten days, perhaps, but there can no harm result from their presence longer. The removal of them is easily accomplished, by passing one blade of the scissors within the circle of the stitch, and dividing it, when the w^ire may be withdrawn by the forceps. The patient should keep Fig. 27. her position and wear the catheter for five or six days, after the sutures are removed, to allow the consolidation of the cicatrices and the closure, by contraction, of any minute opening that may have been left. Although the experience of Drs. Sims and Emmet has proven the propriety and efficacy of this kind of after-treatment for vesico- vaginal fistula, all of it is not absolutely necessary to success. In two instances operated on by the author, the patients were not con- fined to any position, and were permitted to rise from the bed and sit up part of the time each day, from the time of the operation until URINARY FISTULA, 95 the sutures were removed. The catheter was not worn in eilher case, but it was used for the first four days, every two liours, to evacuate the bladder. At the end of four days, the patients were })ermitted and instructed to evacuate the bladder as often as once in two hours voluntarily. Both the patients were cured, and the comfort they enjoyed con- trasted very favorably with that of such as were confined to the position on the side or back, and were obliged to wear the catheter for ten or fifteen days. I have, from time to time, seen suggestions in medical journals, which I cannot now command, that led me to conduct the after-treatment in these two cases as above stated. Simon^s Ilethod. In Continental Europe the late Professor Gustav Simon, at the time greatly distinguished himself in plastic operations. His opera- FiG. 28. tion for vesico-vaginal fistula is, in many respects, different from that above detailed. 96 AFFECTIONS OF THE VAGINA He places his patient on her back with the breech very much ele- vated. In cases where the fistula is near the orifice of the vagina, the limbs are placed in the position usual in lithotomy. If the fistula is deep, however, the limbs are brought up and extended over the sides of the abdomen and breast, as shown in Fig. 27. If the uterus is sufficiently mobile, Simon draws it down to the external Fir 9q organs of generation, and thus places the fistula immediately under the hand of the operator. In order to ascertain the mobility of the organ, he seizes the cervix with Museux's forceps, and draws upon it until the vagina is inverted, or until it is evident that the forcible traction required will do violence to some of the tissues. When the cervix is drawn down sufficiently, two strong threads are passed through it by which it is held in place. Fig. 28 represents this stage of procedure; the sides of the vulva being held out of the way by levers made for the purpose. URINARY FISTULA, 97 When the uterus cannot be thus drawn down, Simon uses two specula, and the levers in the sides of the vulva, if necessary. This method of exposure is very pkiinly illustrated by Fig. 29. One large speculum draws back the perina?um, and another, somewhat differently constructed, is placed under the symphysis pubis. Fig. 30. The margin of the fistula is prepared by cutting away all the cica- tricial tissue, and the paring is done almost perpendicular to the sur- face of the vaginal mucous membrane. There is some slight inclina- tion or declivity in the cut edges, but they are very much less bevelled than in Dr. Sims's operation. Fig. 30 will give a correct idea of 98 AFFECTIONS OF THE VAGINA. this part of the operation. A comparison with Fig. 30 will give the reader an idea of the liberality with which Dr. Simon considers it necessary to pare away the tissue. The wound is closed with fine white silk, about the size of a large horsehair. Each stitch is placed a little more than a line distant Fig. 31. from the one next to it. The needle is carried entirely through the lips of the wound, so as to penetrate the vaginal and vesical mucous membrane. In large fistulse, every alternate stitch is placed further from the edge of the wound. Fig. 31 also shows this method of in- troducing the stitches. The threads are carefully tied in a knot and the operation is completed. The closed fistula is well represented by Fig. 32. URINARY FISTULiE. 99 Yesico-uterine fistulse are operated upon in the same manner. Figs. 33 and 34 show how such fistulse are pared, the stitches in- troduced, and tlie wound closed. Fig. 32. In the after-treatment, Dr. Simon thinks it superfluous, if not in- jurious, to leave the catheter in the bladder. He directs us to draw off the urine once in two or three hours, until the patient can volun- tarily discharge it, which she can usually do in the second or third day. He allows the patient to lie in any position, and on the eighth or ninth day she can rise from the bed. All straining at stool, before the eighth or ninth day, should be avoided, if necessary, by the ad- ministration of opium. On the fourth or fifth day the physician should examine the wound with a view to the removal of the stitches, and if they are cutting their way through the tissues they should be cut and drawn out. 100 AFFECTIONS OF THE VAGINA. Of 43 fistula? in 40 women operated upon by Professor Simo'i, 35 were perfectly cured, 2 of the women died, 5 more of the fistulse were nearly cured, and 1 was not benefited. Fig. 33. Kolpokleisis. Cases of urinary fistula occur which cannot be cured by an opera- tion like the foregoing. Occasionally we meet with instances in which the damage is more serious, where the septum between the bladder and vagina is nearly or completely destroyed, not enough of this structure being left to enable us to restore it. Surgery has successfully met these cases by closing the vaginal ori- fice or lower part of the vaginal canal, thus making a common receptacle of the posterior and lateral walls of the vagina, and the remaining portion of the bladder, into which the renal secretions and the uterine discharges are received and from which they find their way out through the urethral canal. The vagina may be closed by unit- ing the inner edges of the labia or the anterior and posterior walls of the vagina quite inside the orifice. The operation for uniting the labia will be necessitated in some instances. We occasionally meet URINARY FISTULA. 101 with cases where the anterior wall of the vagina is entirely removed from the pubis, and nothing is left behind that bone to which the posterior wall of the vagina may be united. So completely is this removal of tissue that the posterior face of the pubis is covered with nothino^ but a thin cicatricial substance. The labial closure of the vagina is the only resort in this class of extreme cases. The operation consists in removing a ring of mucous membrane from the inner margin of the labia, just behind the orifice of the FiCx. 34. urethra, three-quarters of an inch deep, and then by means of deep silver sutures making perfect apposition of the denuded surface. The sutures should be passed deep enough to include the whole of the raw portion of the parts, and extend on the outside three-quar- ters of an inch in the substance of the labia beyond their margin. The sutures, to insure union, should be not more than three lines 102 AFFECTIONS OF THE VAGINA. apart. The parts should be carefully adjusted while the wires' are being twisted, so as to make an even adaptation. When there is sufficient of the vesico-vaginal septum behind the pubis to permit its coaptation to the posterior wall, the operation performed and proposed about the same time by Simon and Bozeman is preferable to the foregoing. Simon's method is simple and efiPec- tual in closing the vagina thoroughly. He denominates the opera- tion Kolpokleisis. The vagina is held open by the instruments and by the method described for operating on fistulse^ and a ring of mu- cous membrane is removed as represented in Fig. 34, and then united by the sutures. Silver wire is probably the best suture for this op- eration. Dr. Simon operates as high up in the vagina as the disease will permit, and instead of confining the operation to the urethral portion of the cavity, he sometimes operates so near the os uteri as to preserve almost the entire length of the anterior wall of the vagina. After either operation the treatment will consist in perfect quietude, the use of opium to relieve pain, and the fixed catheter to prevent an accumulation of urine until the parts are healed. Bozeman' s Method. Dr. Bozeman, whose operations have attracted attention in Europe as well as in this country, claims to have made improvements upon Fig. 35. Bozeman's Apparatus for Retaining the Patient in Position. the operation for vesico-vaginal fistula as well as in the means and methods of performing it. As now employed his operation has for URINARY FISTULA. 103 its •distinctive characters the button suture, the position of the pa- tient, and a self-retaining specuhim. The figure which is here intro- duced will serve to illustrate the position of the patient and the self-retaining speculum. In paring the edges of the fistula Dr. Bozeman makes the extent of denuded surface rather greater than is recommended in the foregoing pages, and does not place his sutures as near together. After having prepared the parts for coaptation he passes the two ends of each suture respectively through the opening in his adjuster, as represented in figures taken from page 24 of M, Andrade essai sur le traitement de fistules veslco-vaginales par le procede Americain modeae par 31. Bozeman. Thus adjusted the wound is ready for the button, which should be made at the time and in accordance with the shape and size of the wound. The button Fig. 36. is cut out of a thin sheet of lead, about one line in thickness, long enough to project about one-fourth of an inch beyond the sutures at either end of the wound, and a very little more than half an inch wide. If the wound is straight after it is closed with the suture, the button should be the same ; but if the wound is curved the button should be made to suit the curvatures. Then with the ^^button-forming forceps,'' the groove along the centre may be formed by clamping across the sides from one end to the other. Thus formed the button is slightly concave on the side that goes next the closed wound, and has a groove of almost a line in depth along the centre, from one end to the other, and is ready to be perforated for the sutures, which, after measuring off the distances 104 AFFECTIONS OF THE VAGINA. Fig. 37. accurately, is done by an instrument for the purpose. The operator should then assure himself that all the spiculse caused by the perfo- rating process are removed, and proceed to adjust the button. Fig. 36 shows the sutures through the button as it approximates its future site on the wound. The button is pressed down evenly upon the wound by means of the blunt hook, and each suture, one after the other, passed through perforated shot, and fixed by clamp- ing the shot with strong forceps for the pur- pose. Each suture should be carefully fixed in this way separately. In adjusting the sutures the wire should be tightened by being drawn through the opening at the time the shot is compressed. Only so much traction should be made as will bring the lips of the wound well up into the groove, but not strangulate them. The button thus applied is well represented by Fig. 37. Dr. Bozeman claims for this suture : ** 1. Separate and independent action of the sutures. " 2. Perfect coaptation of the edges of the fistula, and power to hold them in a certain relationship during the reparative process. " 3. Perfect steadiness and support of the edges of the fistula. "4. Protection of the denuded edges of the fistula from the vaginal and uterine discharges, and from the urine, when there happens to be more than one opening, and it is not conveuieut or desirable to close both at the same sitting." We are indebted to Dr. Bozeman for a very ingenious and effectual method of diagnosing minute and otherwise indistinguishable fistulse. He calls it the linen test, and describes it as follows : " Pus and mucus in small quantities adhere to and spread upon the surface of a piece of linen without being absorbed by it, while water or urine, on the contrary, even in the miuutest quantity, when brought into contact with the same material, penetrates almost instantly the entire thickness of the fabric. The presence of these fluids, if the flow is continuous, is evidenced by increasing saturation of the spot acted upon, and the spreading of the moisture in every direction. Thus is presented a most valuable and reliable means of determining the presence of urine in the vaginal or uterine canal when the quantity is so small as to escape observation ; not only this, but the precise situation of its URINARY FISTULiE. 105 escape from the bladder can be made with the greatest certainty when it would be impossible to detect it by the ordinary means, owing to the minuteness of the orifice or its concealment by a fold of mucous mem- brane. *' In using the test nothing more is necessary than to fill the bladder with water, and then wipe thoroughly dry the anterior wall of the vagina, A piece of old linen is now rapidly spread out upon the latter, aud pressed down smoothly, the patient being in the angular position, upon the knees. In a few moments the effect of the fluid upon the linen will be seen at the place of escape from the bladder, should the orifice be even no larger than a pin's point or a fine bristle. When the patient is placed in the dorsal position it is seldom necessary to inject the bladder; the natural flow of the urine from the kidneys will be found quite sufficient to mark the situation of its unnatural escape into the vagina." With regard to the success of his method of operation, as now practiced by hira, he givas the following data : *'For the period from 1867 to 1870, 17 cases, having 23 fistula?, got 24 operations, with the following results : " 21 fistul^e completely closed. " 1 fistula completely closed in a syphilitic subject and afterwards reproduced. " 1 death, caused by intense heat of the weather and consequent exhaustion of the patient. "88 per cent, of permanent cures. " 87^ per cent, successful operations. "The syphilitic case was cured as regards the result of the operation. and the death did not result from causes connected with the operation. It will be seen, therefore, that the percentage of permanent cures and of successful operations is not far below the maximum limit. Of these 23 fistulse 8 were vesico-uterine, 1 vesico-utero-vagiual, 1 utero-vaginal, 1 laceration of the urethra, 1 urethro-vaginal and recto-vaginal, the latter admitting easily three fingers into the bowel; all of which were com- pletely closed, with preservation of the functions of all the organs in- volved." In a recent letter he says, with reference to his operations: "By examination of my reported cases, treated by this form of suture, you will fiud the inauguration of several new procedures in the following affections : " 1st. Urethral lacerations extending from the meatus backwards, a part or the whole length of the canal. By a peculiar modification of ray button, the catheter in these cases is supported and the closure of i06 AFFECTIONS OF THE VAGINA. the rent made complete to the meatus. (See North. Am. Med.-Chir. Re- view, July and November, 1857.) " 2d. Vesico-uterine fistulse. A mode of treatment to close the fistula and preserve the functions of all the organs intact. The operation con- sists in dividing posteriorly the anterior lip of the cervix uteri down to the sinus, then paring the sides of the latter and closing the wound. (See Case V, op. cit.) This was my first case, and here I got the idea. I have since performed successfully this operation in three other cases. In one case the sinus opened so high up in the cervical canal that the utero-vesical fold of peritoneum was implicated in the operation. "The great value of this procedure cannot be overestimated. The procedure of Jobert, which consists in paring the two lips of the cervix and uniting them by suture, is almost universally adopted by surgeons in this class of cases. If the operation proves successful, the men- strual fluid is left with no other outlet than through the small sinus (usually no larger than the most delicate probe) into the bladder, there commingling with the urine and finally escaping with it through the urethra. In the journals I have seen the operation is claimed as a great triumph. The operation is frequently performed by leading surgeons. " With regard to this practice I unhesitatingly condemn it. It is un- surgical and unjustifiable, and should never be performed. " 3d. Vesico-utero-vaginal fistula. An original procedure for its cure. (See Case VIII, op. cit., 1857.) "4th. Incarceration of the cervix uteri in the bladder. An original procedure for the disengagement of the cervix from its confined position and the closure of the fistula, with preservation of all the functions. (See Case XV, op. cit., and Cases XXVIII and XXXVIII, New Orleans Med. and Surg. Jour., January, March, and May, 1860.) " I would add here that my cases are the only ones to be found upon record, and I venture the assertion, without the fear of contradiction, that no cure will ever be effected by any other form of suture than the button. The mechanism of this suture is peculiarly adapted to the suc- cessful treatment of this rare lesion." I am not aware that Dr. Bozeman's operation has been objected to on account of want of success, for when skilfully performed all acknowledge its success. The chief and perhaps only objection that has had any effect in preventing it from general favor and practice is complication and consequent difficulty. This need be no objection if the surgeon is prepared with all the instruments now used by Dr. Bozeman; with them the different steps in the operation are easily accomplished. He requires no assistance during the operation, a con- sideration of no small importance. RECTO-VAGINAL FISTULA. 107 JEntero-vesical Fistula. Occasional instances occur in which from cancerous degeneration of the tissues of the bladder and intestinal canal lying in contact they become adherent, and afterwards perforated in such manner as to permit tlie discharge of the excretions of one organ into the other, thus making an entero-vesical fistula, with the urine passing into the intestine and out at the anus, and causing what urine passed from the urethra to be mixed with foeces. The author had for several months under his care a recto-utero-vaginal fistula. This condition was caused by perimetritic inflammation. The abscess perforated the bladder, uterus, and rectum, and the escape of faeces as well as urine was observed from all these cavities. The fistulous openings were small and must have been tortuous, as these excretions escaped in very small quantities. The patient, a young girl, died of tubercular consumption after having lived in this miserable state eighteen months. Entero-vaginal Fistula. This is of two kinds, colono-vaginal and recto-vaginal. The former is very rare, and is caused by malignant ulceration or grave perime- tritis. The inflammation, when sufficiently severe to cause commu- nication between the vagina and colon, usually extends up into the abdomen and involves the viscera in that cavity to a very serious extent. The suppurating cavity in this case is also large, and opens in one place into the intestinal canal, ^nd at another point of ulcera- tion into the vagina, and as the cavity of suppuration is slowly filled by granulations a tortuous canal is left, leading from the bowel down into the vaginal cavity. If the opening into the vagina can be found, I see no objection to closing it with the silver suture. After a long time these openings would probably close spontaneouly, as artificial will sometimes do. Hecto-vaginal Fistula. This accident does not so frequently as vesico-vaginal fistula re- sult from puerperal vaginitis. Stricture of the rectum, abscess of the recto-vaginal septum rupturing into both cavities, and accidents with instruments, perhaps, as often cause it. It is not so common or fre- quent as vesico-vaginal fistula, nor so distressing. The passage of the faeces, if proper cleanliness is observed, although disgusting, is not so productive of inflammation and excoriation as urine, and their dis- charge may be controlled by appropriate fixtures. A cure is also 108 AFFECTIONS OF THE VAGINA. more easily accomplished ; indeed, it is often spontaneous. As the contents of the bowels pass intermittingly, and. when in coatact with the raw surface, do not irritate it considerably, the ulcer has time to contract, and healthy granulations, in a good state of the general health, is the result. The symptoms and diagnosis of this fistula are so obvious that I need not dwell upon them ; but we sometimes meet with cases where the opening is so small and tortuous, that great patience in the use of the probe will be required to satisfy ourselves as to its position and direction. The injection of water into the rectum while the parts are under inspection will generally clear up all doubts. Treatment. If we are associated with these cases during the ulcerative condi- tion, we mav conduct them to a cure with some ceitainty. and. per- haps, more readilv than after the edges of the opening have cicatrized. The important items of treatment at such times are : 1st. Proper at- tention to the bowels ; 2d, Great cleanliness ; and 3d, ^Maintenance of healthy granulations until the contraction obliterates the opening. The bowels should be kept quiet as much of the time as possible. To accomplish this, the diet should be concsntrated. and nourishing in character; beef essence, milk, eggi^, crackers, coffee, or tea, and if necessary on account of debility, wane, or medicinal tonics ; and if the bowels have a tendency to move, opium in such quantities as will restrain them. Every four or five days a gentle alterative, say three grains of blue pill, followed by a saline cathartic : after the bowels have moved from this, the opium may be given to restrain them for four or five days again, and so on until the opening is closed. During this treatment there should be frequent injections of water into the vagina. The part should be examined with the speculum everv dav, to see that the edges remain raw. ^'here there is any tendency to cicatrize, the edges may be freely touched with pure nitric acid. If the cure is protracted, the acid should give place to the actual cautery. Toward the last, as the opening becomes small, especi- ally if it is tortuous, a piece of twine, or what is perhaps better, a silver or iron wire, may be passed through it, and the ends brou2:ht out through the anus and vagina. If the case is chronic and the opening small, the application of the acid may be made everv day until the edges are denuded, and then the same course followed as above directed. Of course, these applications must be made through the vagina with a speculum that completely exposes the part touched. RECTO-VAGINAL FISTULA. 109 If the place Is large and chronic, we shall very nuich shorten the process of cure by an operation similar to that for vesico- vaginal fistula. After having thoroughly evacuated the bowels, the patient may be placed in the lithotomy position, and exposing the parts to a strong light, the perinseum may be retracted by the rectangular speculum blade of Sims, while the vulva is held open by assistants. The edges are then to be pared thoroughly, and the aperture closed with silver sutures. The bowels will require the use of from two to four grains of opium daily to keep them quiet. They should not be allowed to move for ten days, when a saline cathartic should be given, and after it has operated well, the stitches removed. During the time be- tween the operation and the removal of the stitches, the patient is to remain quiet in bed, and have injections, per vaginam, of tepid water with soap, twice a day. If by this operation there is imperfect closure of any part, the treatment recommended for recent cases will suffice to complete the cure. Even these larger-sized fistulas are sometimes cured by the caustic acids, the actual cautery, or tinct. lyttse ; but it takes a longer time, and is attended with more pain and annoyance. The operations on these fistulfe will be greatly facilitated by having the breech of the patient projecting somewhat over the end of the table. CHAPTER VI. MENSTRUATION AND ITS DISORDERS. Several conditions are necessary to the healthy performance of the functions of menstruation. 1st. The ovaries must be present, and sufficiently healthy to pro- duce ova. 2d. The uterus must be sufficiently perfect, anatomically and physiologically, to be the medium of elimination. 3d. A certain, but not as yet very well-defined, state of the blood and nervous system must exist. These are, probably, not all the conditions necessary to perfect menstruation ; but they are the obvious and undoubted ones. The uterus, by virtue of the conditions upon which menstruation depends, is naturally a hgemorrhagic organ ; and it is in consequence of its anatomical and physiological peculiarities that the ordinary and frequently acting causes of uterine haemorrhage are rendered so potent and effective. The more obvious phenomena of menstruation are doubtless the result of a definite reflex nervous influence exerted by the ovaries upon the uterus. Although this influence is more distinctly mani- fested in the great hypersemia which precedes the occurrence of the cata menial discharge, and the changes in the utricular glands and mucous membrane of the womb, yet it is unquestionably constant in its action and parallel to that which presides over the motions of the heart, the arteries, and the alimentary canal. Generated in the nerv- ous apparatus of the ovaries, and contemporaneous with the changes called ovulation in those organs, this influence is probably conveyed by afferent nerves to the genito-spinal centre (the existence of which was first established by Budge, of Greifswalde),* or to some other reflecting ganglion, whence it is sent back to the uterus, giving rise to a wonderful series of tissue changes during the month. Some of these changes have been lucidly described by Dr. John Williams, in the Obstetrical Journal of Great Britain and Ireland, and by our own talented young countryman. Dr. Engelman, in his recent essay * Ueber das Centrum genito-spinales des N. syrapatheticus. Virchow's Archiv f. Path. Anat. und Klin. Med., Band xv, S. 115-126. PUBERTY. Ill upon the subject, published in the American Journal of Obstetrics. These changes are aptly termed by Aveling, nidation and denidation. A few days before the menstrual flow makes its appearance, the whole uterus, and especially its mucous membrane, becomes greatly hypertrophied and very vascular; when the discharge begins, the membrane is invaded by fatty degeneration. This process is so rapid that, in four or five days, the entire mucous membrane disappears, leaving the muscular structure of the inside of the uterus exposed, while some remnants of the utricular glands are left, and found en- tangled among the denuded fibres. As soon as the monthly flow ceases, a reproduction of the membrane is commenced, and it con- tinues to grow until at the end of twenty-eight days its menstrual maturity is attained. Accompanying these changes in the cavity of the uterus are others equally remarkable, affecting all the other tissues of the organ. The bloodvessels become enlarged, and circulate an increased amount of blood ; the fibrous tissue is developed beyond its intermenstrual condition ; while hypersesthesia indicates extraordi- nary nervous endowment. In fact a true hypertrophy of the uterus occurs. During the discharge, the process of involution reduces the organ to its sniallest dimensions, and the haemorrhage ceases. The culmination of this hypertrophy in the discharge of blood from the uterus is doubtless not merely an accompaniment, but a consequence of the breach of capillaries in the mucous membrane. These of course are physiological phenomena, but they strongly resemble pathological conditions, and would be so considered in any other organ in the human economy. Moreover, the dividing line between health and disease in uterine haemorrhage is as difficult to trace as that between sanity and lunacy.* Puberty. Puberty is the period at which the development of the human female renders her capable of childbearing. " An immense revolution takes place in the organization of the young girl. To her thin slender form succeeds a round and graceful contour. Her step, uncertain and hesitating, becomes firm and animated. The sweet and vivacious expression of her eyes evince the ardor with which she is endowed. Changes no less remarkable take place in the system. The chest, narrow and compressed, becomes expanded and full. The lungs act more freely, the heart, more developed, throws the blood with * The Causes and Treatment of Non-puerperal Haemorrhage of the Womb, Inter- national Medical Congress, Philadelphia, September, 1876. 112 MENSTRUATION AXD ITS DISORDERS. more energy to the remotest parts of the vascular system. The areolar tissue is increased in quantity, fills up depressions and rounds out angles, making those graceful curves in the form that constitute female beauty. Of all the organs that feel the influence of puberty the uterus and its appendages are the most aflected by it. In girlhood of small volume, at this period, the uterus, the ovaries, Fallopian tubes, and the breasts become greatly developed. The bones and muscles partake in the gen- eral development. The moral qualities of the girl are no less the subjects of change. The young girl, before a mere child in her tastes, inclina- tions, and desires, experiences a complete metamorphosis. Restless and pensive, she does not know whence come the novel thoughts that agitate her mind ; all her impressions are pleasurable ; she is penetrated by a glowing fervor ; an unaccustomed pruriency pervades the organs of generation. The most important phenomenon of puberty, its indispen- sable accompaniment, that which transforms the young girl into a woman, the first menstrual flow, manifests itself." This is a translation of the description given by Brierre de Bois- mont in his Treatise on Menstruation. It is a true contrast between girlhood and womanhood. This change is not attained in an instant, but is the work of years, and the development, instead of always being regular, steady, and equable, is in many instances quite irregu- lar, unsteady, and unequal. Imperceptibly (comparing short periods) the lithe, muscular, bony, and angular form of the girl is lost. The bones of the pelvis, the lower extremities, and chest expand and grow, but no faster than during some other periods of girlhood; and the uterus, ovaries, and Fallopian tubes assume their places and acquire their size gradually. At ten years, perhaps, down is observed on the pubis, but does not become well-grown hair until seventeen or eio^hteen. In from four to eio'ht vears usuallv these chancres are complete. Xor does the form assume the becoming loveliness of a mature maiden immediately at the time the menses are first produced. The general and even the genital development is not complete for years after the first effusion of blood. A description which portrays anything but this gradual change is fanciful and misleads the student. TJje sentiments and mental habits of the o-irl when she first becrins to menstruate are still childish and imperfect compared with what they become after the completion of her first change of life. Xor do I think it any more correct to say that the changes in the genital organs bring about all the attributes that accompany their development; they are merely contemporaneous with the other and part of the whole. The development of the body generally, and of the sexual svstem to a perfect state, usually proceeds together, and ought to be com- PUBERTY. 113 plete at the same time and in the same degree. But these conditions do not always obtain. Occasionally the frame and all the organs but those belonging to the genital system are developed into vigorous womanhood, while the latter do not assume the size and energy neces- sary for the establishment of the sexual functions ; or what is per- haps a more frequent condition, the individual is physically undevel- oped otherwise, but possesses great sexual activity if not vigor. In these, the general organization is feeble and imperfect, and incapable of meeting the requirements of womanhood, while the functions of ruenstruation and childbearing exist in perfection. The physiologist will have no difficulty in predicting in instances of this kind, the in- fluences that will be exerted by the dominant sexual organs. He will see in advance the wreck that wdll be made of the mind, heart, lungs, stomach, nerves, and other organs by the overwhelming sympathies that must arise from the undue development of the ovaries and uterus. When this latter system is subordinate in development and func- tion to the system at large, then the full health and vigor of the indi- vidual wall not be disturbed by the discharge of the sexual functions. The circumstances by which the girl is surrounded during the time when these puberal changes are going on, have a great influ- ence upon the future health of the woman. This is the turning period in the life of the w^oman. She is perfected or ruined in that time. According to her development and surrounding circumstances "svill be her future pathological tendencies. The development required for efficiency and health, is strength of muscle and heart, and large capacity of stomach and lungs. And it will require but a few moments' reflection to remind the intelligent physiologist that the conditions by w-hich girls at puberty are usually surrounded are not the best adapted to this development. The girl is generally allowed to exercise in the open air in the same unrestrained manner that her little brothers are. She exercises her muscles as much as her brain, and this expands her lungs and causes her heart to grow vigorous, and her stomach to digest w^ell. She has no ner- vous ailments while such freedom lasts. She is, however, not more than ten or twelve years old before she is restrained in her childish sports. She is instructed that it will be- come her more to deport herself like a little lady. Which means that her step must be quiet, her speech less loud and energetic. She must appear in the street only when w^ell dressed, and must conduct herself as becomes a woman. She must learn to sew and draw, w4iich means that she sit still in a stooping posture ; or she must go to school to 8 114 MENSTRUATION AND ITS DISORDERS. sit and study in a close room with many others^ breathing foul air for from four to six hours a day, and when she comes home get her lessons or " tasks " as they are properly called. If she has any more time she spends it in practicing on the piano or receiving company in the parlor. In this round of confining duties the lungs are not expanded to their full extent for many days together; the circulation is slow because there is not action enough to require quickness and energy in the distribution of the blood ; the muscles become weak and flabby from inactivity; the nervous system is taxed by study at school and at home, while all the rest of the body is kept in great re- straint. The consequences are that debility and excitability are pre- dominant qualities, and the development of the lungs, heart, and muscles does not keep pace with the growth of the brain. If exer- cise is required, dancing or calisthenics is resorted to, because more ladylike than playing ball or running races in the open air. The amusements of this period of life are not less injudicious. These chil- dren go to see the minstrels, go to theatres, ballrooms, card parties, and other places, where they meet the opposite sex in such manner as will excite their emotional nature, thus encouraging early sexual dev^elopment. About this time, between twelve and sixteen, the lungs are confined by corsets that fit "snugly" about the chest, pre- venting free expansion and the easy play of the diaphragm. Other effects of tight lacing in early as well as later life, is to press the con- tents of the abdomen down into the pelvis, and prevent a free return of venous blood from the lower part of the body. This downward pressure causes an accumulation of blood in the pelvic viscera, the rectum, ovaries, uterus, vagina, etc., and encourages congestions and inflammations. These influences, and a long train of others similar in their effects, are kept up from this time forward until the girl is married, and if she is never married always afterwards. What is usually termed education is commenced too early, and falls short of its objects be- cause it is commenced too early. Mental culture is obtained too often at the sacrifice of the general health, and still more frequently at an expense of physical development that forever mars the usefulness of the woman. Physical culture should be more assiduous than mental, during physical growth. The mind does not mature as soon as the body, and mental culture should be behind physical growth instead of before it. Six hours' study and t\vo hours' play should be re- versed; it should rather be eight hours unrestrained exercise and two PUBERTY. 115 hours' study. In writing the above I have very feebly portrayed the evils that usually surround girls at the time when the puberal changes are going forward. I^et any one visit our schools for girls of this age, public or private, seminaries or boarding-schools, and see the requirements, restraints, and confinements of the day; let him go home with them and witness their want of appetite, languor, and res- tiveness, and then see the training from mothers and fathers, who, in honesty of affection, prevent them from going out for fear of exposure or improprieties, and encourage them to learn their lesson or music to the complete neglect of their bodies, and he will be astonished that as many survive the ordeal as now do. More time is necessary for physical development than mental, and until this truth is acted upon our women will become steadily less capable of bearing the hardships of life. In addition to the want of balance in the development of the physical organization above mentioned, the circumstances of society often cause premature and undue development of the sexual organs. Girls of different ages are congregated in large schools ; the younger learn from the older practices and imbibe sentiments beyond their age, which stimulate their passions and encourage too early and too vigorous sexual desires. The dress, the free and easy association of very young people, taught to imitate their seniors, the literature easily accessible and eagerly sought after by them, and many other cir- cumstances incident to children raised in populous cities, are calcu- lated to bring out prematurely and cultivate the amorous sentiments of young people of both sexes. Opportunity is frequently offered to medical men of large experience to see lamentable suffering in young girls, the result of some of these causes. Some of the most intractable cases of uterine disease I have ever seen have occurred in girls under- going puberal development, traceable to undue excitement of the sexual oro^ns while attendinoj laro-e schools or seminaries for vouno^ ladies. During the few years in which the girl is being developed into the woman, she is more susceptible to morbid influences operat- ing upon the uterus and ovaries than at any other time in life, and consequently these organs should be kept as free as possible from the effects of all conditions which excite and stimulate them. During this time her education ought to be one that will keep her muscles occupied in the discharge of useful duties. This very brief summary of puberal pathology will do for a start- ing-point in the consideration of the disorders of menstruation. 116 AMENORRHOEA. I shall consider the disorders of menstruation under four different divisions : 1st. Amenorrhoea. 2d. Menorrhagia. 3d. Dysmenorrhoea. 4th. Misplaced menstruation (Metatithmenia). Under these four heads may be included all the deviations met with in ordinary practice. It is usual with authors to make only three distinct divisions. My fourth division is spoken of by those who have described it as uterine hsematocele, hsematoma, etc. ; but I shall give what I consider good reasons for classing it under the general head of menstrual disorders. In the march of pathological science it will not be surprising if, before long, these terms are entirely dropped from the category of disease, and these derangements mentioned as symptoms or errors of function under the circumstances in which they occur. All patholo- gists agree that they are only symptoms, and teach students to look to the diseases whence they emanate as the proper objects of treatment. The subject is not sufficiently clear, however, to do this now, and it is convenient yet to employ these terms as proper heads under which to group the various phenomena attending them. AMENOEKHCEA. Amenorrhoea means simply the absence of menstruation, and may appear under several different circumstances. 1st. Menstruation may never make its appearance. 2d. After having occurred it may cease, or, as the terra is, be "suppressed;'^ and, again, this suppression may be suddenly brought about and attended with 'acute symptoms, and hence properly be de- nominated acute suppression ; or it may not be attended with acute symptoms, and may last long enough to be called chronic. 3d. I think it right to consider deficient menstruation as suppres- sion, although but partial. This partial suppression assumes two forms, viz., infrequency, when the intervals are uncommonly long; and scantiness, the return being regular, but the quantity of the dis- charge much less than it should be. Or there may be both scanti- ness and infrequency. 4th. The menses may be retained in the cavities of the uterus or vagina, or both, after having been effused. This retention is very different in many respects from the suppression, giving rise to quite CAUSES — SYMPTOMS. 117 a different set of symptoms, and requiring a separate sort of treat- ment, agreeing with it only in the non-appearance of the blood externally. Pathology and Ilorbid Anatomy, The pathological states upon which the symptom amenorrhoea is based are very numerous, and sometiuies inscrutable. The more obvious are the following: Congenital absence of the uterus or ova- ries, or both; congenital or acquired atrophy of these organs; acute or chronic disease of the uterus and ovaries. The general conditions causing it are ancemia, cachexia^ pregnancy, and nursing, serious dis- eases of any of the vital organs or nervous system, and occlusion of some part of the genital passage. Symptoms. The local symptoms wdiich attend the absence of the menses will differ according to the conditions which give rise to it. In acute suppression w^e shall have signs of great congestion, or inflammation of the uterus. The patient, after commencing to menstruate, being subjected to the causes necessary to suppression, such as the partial or general application of cold, is seized w^th pain in the back, hypo- gastric region, and hips, attended with a sense of chilliness more or less intense. These symptoms are usually succeeded by febrile reac- tion, headache, pain in the limbs, general languor, white tongue, and a persistent pain of varied severity in the region of the uterus. There is, in this state of things, as there seems to be, inflammation of the uterus and ovaries. The symptoms may subside, and generally do in a very few days, leaving more or less local discomfort in the pelvis and neighborhood. At the next menstrual period, if the uterus is not much diseased, and the system not greatly deranged, the blood is effused, but seldom with the same naturalness in quantity, quality, and painlessness as before; there is often more or less pain, which is manifested henceforth at each successive period. At other times the discharge fails to show itself after having been thus suppressed, and the case becomes chronic, lasting an uncertain length of time. When this is the case, the non-appearance is likely to be attended by chronic inflammation of the uterus and ovaries, as the result of the acute attack, and the morbid effects brought about by uterine sympathies derange the stomach, bowels, liver, in fact all the chylopoetic organs, to such a degree as to render chymification or chylification imperfect. Sanguification will be thus vitiated, anae- 118 AMENORRH(EA. mia or cachexia results, and the patient becomes broken down and "miserable." We cannot but see in this catenation of circumstances the complicated effects resulting from inflammation of the uterus. Should the suppression be primary, — by this I mean to say, should the menses never have made their appearance, — the girl, if old enough and sufficiently developed, will suffer differently. And there is very nearly, if not quite, the same set of'symptoms present in cases where they have made their appearance imperfectly in quantity and quality, or for a few times, and then ceased. The patient suffers under the symptoms of imperfect sanguification : inability to exercise, palpita- tion of the heart, shortness of breath, torpid liver and bowels, want of appetite, or an appetite for improper food at improper times, de- spondency, great apathy, and timidity. The surface is pale, and either white and translucent, or more commonly of a greenish hue. The sufferings are often very great and protracted, and not unfrequently merge into those of tuberculosis, insanity, or other serious organic diseases. It is not unusual, even in cases where menstruation has never been perfectly established, to find the patient afflicted, also, with symptoms of inflammation of the uterus. The general symptoms accompanying scanty menstruation, when the scantiness is the result of imperfect establishment, are very much of the above character, viz., those connected with ansemia, etc. But the scantiness and infrequency, as also the entire suppression of men- struation, usually depend upon organic changes in the uterus gradu- ally brought about by chronic inflammation. What these are we cannot always determine. Sometimes, however, we find the fibrous structure condensed until the bulk of the ora^an is smaller and harder than natural; at other times it is greatly enlarged, as I have verified by examination. The most common alteration is condensation and atrophy. In such instances there will, of course, be quite a different set of symptoms, in fact many if not all the symptoms found described in connection with chronic inflammation of the substance of the cervix and body of the uterus. I need not enumerate them here, but refer the reader to the article in which the general symptoms of these con- ditions are given. Chronic amenorrhoea, or scanty or infrequent men- struation, is in this way associated with the most miserable states of general health. We are not to believe, however, that the absence of the menses is the cause of such nervous suffering as we often see associated with it, but that it is caused by the condition of the uterus and other organs ■H SYMPTOMS. 119 upon which the irregularity depends. The non-appearance of the menses on account of the absence of the uterus is not usually attended with the chronic suffering I have here alluded to; ordinarily, and indeed in all the cases of this kind to which my attention has been called the patients appeared to be perfectly well. One of these pa- tients was thirty-three years of age, another twenty-seven, and a third twenty-two, ard all of them were in perfectly good health. This is an argument, I think, in favor of the opinion just expressed, that the serious and annoying symptoms arise from the pathological condition of the uterus, or general conditions giving rise to it. The only symp- toms these patients complained of at any time that seemed to be at- tributable to amenorrhoea were the backache, weight about the hips, etc., which denote the presence of the menstrual molimen. In the cases where amenorrhoea exists before the organs are sufficiently de- veloped to assume the function of menstruation, w^e often observe a good state of health, even after the person has attained to an age when the menses are expected. I have had occasion to see, examine, and watch for several years two cases of chronic amenorrhoea from deficient development of the uterus, and perhaps of the ovaries. They were both married. One of them is twenty-eight years of age, has been married nine years, has never menstruated, has no sexual desires, but lives happily with her husband, and desires to be like other women merely to have a child for him. There are no distressing symptoms in her case. Her breasts and uterus are developed to about the size in a girl of thirteen years of age. There is hair upon the pubes, the mons is well developed, as is also the clitoris. The other has been married three years, is twenty-five years old, and resembles the first completely. When tuberculosis or other serious diseases cause amenorrhoea they are usually well manifested before the suppression occurs, but sometimes this symptom shows itself so early in the case that it is regarded as the cause of the disease instead of the effect. From what is said above, the reader will see that suppression is a symptom of the absence, imperfection, or disease of some of the organs of generation, or is due to some grave deterioration of the blood or nervous energies, and that we are to look into all the circumstances which attend upon it, with a view to learn the causing conditions. We shall not always be fortunate enough to ascertain this, and w-e must then content ourselves with conjecture, and a necessary uncer- tainty in the treatment we adopt. 120 AMENORRH(EA. Amenorrhoea from Retention. If the retention dates from puberty the patient at the proper time began to experience the symptoms of menstruation. In instances where the retaining condition is acquired, the symptoms will be found to have followed close upon a severe inflammatory or ulcerated state of the uterus or vagina. After the retention is thus established by accident, the symptoms do not differ materially from those manifested where the occlusion is congenital. At first there are very moderate pains in the region of the uterus at each menstrual period. From month to month the pains increase in severity until they become excruciatingly severe. The pains at each menstrual epoch resemble those of labor, and cause the patient quite as much suffering. They are doubtless caused by the presence of the blood in the uterine cavity, and have for their object the ex- pulsion of that fluid. Soon after the establishment of this train of symptoms there ensues interparoxysmal suffering, much greater in some instances than others. There is a sense of weight in the pelvis and about the hips, weakness and pain in the back, dysuria, difficulty in evacuating the bowels on account of pressure upon the rectum, etc. There is, after the first few months, enlargement of the abdomen, which increases more slowly than in pregnancy. The tumor is of the shape and in the position of the uterus, and fluctuates obversely upon percussion. Diagnosis. It is not usually difficult to determine positively when there is amenorrhoea, and yet there may be good reason to doubt in some instances. It is not necessary that there should be an effusion of blood to constitute menstruation, for there are periodical discharges from the genital organs which indicate the process of ovulation, and, under certain conditions of the system, are more appropriate than an effusion of blood. I allude to a periodical discharge of mucus or sero-mucus. The uterine congestion is not sufficient in quantity or force to give rise to haemorrhage, but causes effusion of the thinner portions of the blood. We are often obliged to treat patients for a time without having more than their statements as a basis for our diagnosis, but fortu- nately, in most cases, this is sufficient. We are not justified, how- ever, in continuing the care of an obstinate case for any length of time without making an effort to verify or ascertain the fallacy of ■n DIAGNOSIS. 121 the groimds for our opinion. And, if need be, we must resort to physical examination. The fact of our patient being a virgin should cause deference, but not forbid an examination indispensable to a cor- rect understanding; of the cause of a condition that is destrovino; her life. I need only mention that suppression, attended witli acute in- flammation of the uterus and ovaries, will be attended with marked and almost invariably unmistakable symptoms. The pain, fever, tenderness, and sympathetic symptoms will leave no room for doubt. Anaemia, cachexia, nursing, etc., are obvious conditions, and will be easily made out by very little attention. Correctness in diagnosis may be attained with great certainty when there is physical defect in the genital organs, by proper direct exami- nations of them, and they should be instituted when other means fail to satisfy us. The presence or absence of the uterus, in most in- stances, can be satisfactorily determined by introducing the finger into the rectum and a catheter into the bladder, and approximat- ing them. If it is present, its thickness interposed between the two will prevent the finger from defining the shape of the instru- ment ; if it is absent, they may be mnde to touch with the interven- tion of the walls of the rectum and bladder. The catheter, in this examination, should be introduced deep into the bladder, and the finger as fiir up the rectum as possible. "With this precaution, there can hardly be a mistake. I have met with several instances of con- genital absence of the uterus, and in all the vaginae were absent, but each case presented all the external evidence of womanhood. The mons veneris- was perfect and covered with hair, and the clitoris, labia majora, and breasts were well developed. The patients had the demeanor of women, and assured me that their desire for the society of men was as great as usual, and that they experienced strong sexual feelino;. One of them had married, and was defendino; herself in a suit for divorce, upon the ground of her entire ignorance of any an- atomical defect in organization ; another was about twenty-two years of age, and submitted to an examination with the hope of having a correction of the physical defect, preparatory to entering matrimony. It is possible that the vagina may be absent while the uterus is per- fect in formation — the same examination will furnish us Avith proof — or the vagina may be occluded from defect of formation. This can be determined in the manner I shall presently describe. Ab- sence of the ovaries cannot always be determined by physical ex- amination, but there is generally such a complete absence of the signs of womanhood in these cases that we cannot long hesitate. The I 122 AMENORRHCEA. mamm?e are not prominent, the manners peculiar to the sex, desire for the society of males, and sexual propensity, are absent. There is no hair on the pudenda, and the whole external organs are not developed. The signs are the same at any age. The patient at ma- ture age presents no more eyidence of sexuality than the little girl. I have very recently met with an instance of congenital atrophy of the uterus. The patient, although now twenty-eight years of age, has not menstruated, unless, as she doubtfully said, twice very scan- tily when about seventeen years of age. She is rather above me- dium size, and possesses all the characteristic appearances of woman- hood. She has enjoyed fair health until the last twelve months. For the past year she has suffered from distressing palpitation of the heart, which almost incapacitates her for business. She has been married nine years, during which time she has enjoyed sexual inter- course indifferently. She has no monthly pains, the signs of men- strual congestion, and nothing by which to know when to expect that function. Her mammae are about the size in a girl of thirteen or fourteen years, the diameter being about two inches and a half, with a thickness at the nipple of about three-quarters of an inch. The nipples are very small. The labia and mons veneris are unde- veloped and the vaginal orifice is narrow. The uterus coald be felt in its usual position or rather higher up in the pelvis, but was very light and small. AVhen the fingers were placed under it in the va- gina, and it was pressed down from above, it gave the sensation of diminutiveness, apparently not exceeding half its natural size. The ordinary uterine sound would not enter it more than half an inch. A probe, with an extremity about the twelfth of an inch in diameter, freely passed up one inch and a half. From all this, it was plain that the uterus was in a state of atrophy ; and I infer that the ovaries were so, from the absence of the nervous signs of menstruation. The size of the organs, as measured by the plan above indicated, determines, together with the history of the case, that it is congenital atrophy. Acquired atrophy is confined generally to the uterus, while congenital atrophy generally involves all the genital organs, including the breasts and nipples. I have met with a number of instances of acquired atrophy, which by carefully tracing their history, I could attribute to early miscar- riage, which it seemed to follow. And this atrophied condition, doubtless, was hyperinvolution of the organ after abortion. In looking over the menstrual history of these sufferers, there was a time when they menstruated normally, and the function was disturbed after having been thus established. DIAGNOSIS — PROGNOSIS. 123 When amenorrhcea is attended by chronic inflammation of the uterus, a not unfrequent occurrence, the speculum and probe will re- veal the condition beyond the probability of making a mistake. I have seen the worst forms of indigestion, and very great emaciation, attend this conditic«i ; in fact, I have seen no other benign disease of the uterus produce so much emaciation as this. The patient is sometimes bedridden for months. In two instances recently cured by local treatment and proper dietetics and hygienic regulations, the patients had been reduced to two-thirds of their ordinary weight. Diagnosis of Retention. Upon examining the genital canal it will be found occluded at some point between the external labia and the internal os uteri. If the hymen is imperforate the vagina cannot be penetrated. If the occlusion is higher up, it may be found by the finger and probe. By introducina; the fino^er into the rectum and a catheter into the urethra, the bladder and rectum will be found widely separated, the catheter passing up close behind the pubis, and the finger being pressed strongly against the sacrum. The finger in the rectum will easily determine how near the external organs the obstruction is. The history, the non-appearance of the menstrual fluid, the slow enlargement of the abdomen, periodic jKiinfid j^CL^oxysms^ and the occlusion of some part of the vagina or uterine cervix, are quite enough to distinguish it in most cases. Auscultation and palpation will establish the diagnosis between retention and pregnancy. Prognosis: The curability of amenorrhcea will depend on the causing con- ditions. When occlusion of some portion of the genital canal pre- vents the discharge of the menses, Ave can usually, by surgical means, evacuate it, and establish an outlet for the future. Although simple and easy of accomplishment, the evacuation of a long-retained and considerable accumulation is always attended with hazard. In the first place, inflammation may foil our efforts to establish a permanent viaduct for the blood which may be discharged from the uterine ves- sels ; and in the second, this process may be so great and extend to the peritoneum in sufficient intensity as to cause the death of the pa- tient. Amenorrhcea from anaemia may be pretty surely cured; it is the curable variety compared with those occurring from other causes. When arising from inflammation, it will also generally yield to ap- 124 AMENORRHCEA. propriate treatment, as the cure wholly depends upon the removal of the causing conditions. The cachexia which may produce amenor- rhoea is often entirely incurable, and, therefore, our prognosis must be unfavorable when they are associated. In cases of absence of the ovaries or uterus, ire can expect to do no good by treatment. Where there is only atrophy of the organs, we may hope that some of the ingenious contrivances to increase their development which our profession of the present day affords (they have almost all emanated from, or been perfected by, the fertile genius of Professor Simpson, of Edinburgh), may enable us to succeed. It cannot be concealed, however, that these causing conditions will often resist every means within our reach. To sum up, then, according to my observation, when suppression arises from any other causing condition than general anaemia, or inflammation of the uterus or ovaries, the prognosis is not very promising, and we should be cautious in promising a permanent and speedy cure. Failure in the function of menstruation is pretty sure to be accompanied with an inability for conception ; imperfection of it is, likewise^ very fre- quently an evidence of barrenness. This is particularly the case with scantiness. When menstruation is infrequent, but the function is otherwise perfect, the patient is often prolific. I have known a woman for several years, who does not menstruate more tlian three times in a year, and then not at regular intervals, and yet in the last six years she has had two children, conception following immediately after one of these irregular menstrual discharges. Treatment. We should always bear in mind the fact that amenorrhrea is but a symptom, and endeavor to amend the condition or disease upon which it depends. This rational mode of procedure, however, is not always practicable, for unfortunately, as has been more than once stated, we cannot in every instance ascertain precisely the condition. In such cases we make use of remedies, or plans of treatment, which, from the success that has occasionally followed their use, have gained the title of eramenagogues. This term signifies promoter of menstrua- tion. Are there any direct emmenagogues? I think, in the nature of things, there cannot be. To cause a flow of the menses proper, which depends upon ovulation for its existence, they must produce or promote the evolution of ova. That there are remedies and plans of treatment which indirectly promote the menstrual discharge I think there is very little doubt. In a general way we ought to con- TREATMENT. 125 sider this class of remedies as producing their effects in t^YO different modes, one by causing the growth and production of ova, and the other the discharge of blood as a haemorrhage. It would be better, then, to say that they are oviferous in their nature in the first case and hsemorrhagic in the second. To the first order belong the prepa- rations of irofi and other mineral and vegetable tonics, nutritious diet, exercise in the open air, diversion of mind, travel, sea-bathing, and, in fact, everything wliich, by correcting derangement of the vital organs and generating good blood and plenty of it, is promotive of healthy functional action generally. To the second belong aloes, savin, cantharides, and any hygienic measures which determine blood to the pelvic organs, as foot, hip, and leg baths, sinapisms to the feet or legs, etc. In many instances they may very properly be combined. ^Vhen amenorrhoea results from cold applied to the surface or lower extremities, or from any cause suddenly acting to suppress the flow, the uterus and ovaries are bordering on, if not in, a state of acute inflammation, and the remedies for it should be directed to the relief of the diseased organ or organs. The question very naturally arises, can we, or ought we to, do anything to cause the return of the flow immediately upon its suppression, and if so, what? Experience teaches us that if the flow can be reproduced in a very few hours after its suppression, before general reaction occurs, the turgid and phlogosed condition of the sexual apparatus may subside into a con- dition of health, and that this can sometimes be done by judiciously managed stimulation; but if the flow is not re-established in a few hours, we need not expect it to recur until the next period, if then, and it is injudicious to continue stimulation beyond a very short period. Then what is the proper course of stimulation? If our attention is called to the case within a few hours, and there is not much febrile reaction, we may very properly direct a hot bath to the whole person of the patient below the waist for half an hour. The patient should then be put in bed, and large sinapisms placed upon the inner portion of the thighs and hypogastrium, and allowed to remain until a strong rubefacient effect is produced, when they may be removed, and the whole replaced by a hot linseed-meal poultice. While these measures are being accomplished, we should administer copious draughts of some kind of warm tea. I cannot approve of the gin-slings or toddies given so freely under these circumstances; thev often do harm bv their excessive stimulation, reuderincr the in- flammation a fixed evil. Should the flux not return in twenty-four hours from the time of I 126 AMENORRHCEA. suppression, it would be unreasonable to expect and injudicious to continue treatment to cause it to do so. It then remains for us, if possible, to remove the phlogosed condition of the organs, so that thev mav be in a state to resume their functions at the return of the next ensuing menstrual period. It will be found, I think, that for the first month, m case of an acute suppression, especially in plethoric patients, the most successful course of treatment will consist in moderate antiphlogistic and altera- tive means, kept ap steadily. The one I have ordinarily followed consists of counter-irritants to the hypogastric region ; the hip-bath twice a day of tepid water; six to ten grains of blue mass every third night, to be followed in the morning by a seidlitz powder; and ab- stinence from all stimulants and highly seasoned food. If, however, the suppression continue beyond the second period after the suppres- sion, it may be attended with chronic inflammation, with or without general anaemia, etc.," and will come under some of the conditions hereafter to be considered. Ameuorrhoea connected with chronic inflammation of the uterus or ovaries may be treated as I have elsewhere directed those affections to be managed. I think that it is not very common for suppression, in the chronic form, to depend upon inflammation alone. More fre- quently the causes of ameuorrhoea exist in the condition of these organs that remains after inflammation, such as condensation of fibrous tissue, either with or without atrophy. The same treatment, with little variation, is applicable to both. I shall have occasion to detail the treatment in speaking of atrophy and want of development. Another condition which succeeds inflammation of the uterus and ovaries, after an acute suppression, is anaemia. For there certainly are cases in which an impoverished state of the blood succeeds an acute suppression, and in turn prevents the re-establishment of the flow. A tonic, roborant treatment, applicable to anaemia arising from other causes, may be instituted, if need be, even before the inflammatory condition of these orgaas has entirely subsided. Perhaps a little more attention to alteratives, in connection with the tonics, is necessary in this class of cases. When anaemia is the primary condition upon which ameuorrhoea depends, it will almost always be found depen- dent upon some preceding affection. Indigestion, connected with a slow or depraved state of the secretions of the alimentary canal, often, by preventing the introduction of nutritious elements into the blood, induces anaemia. This condition arises, for the most part, in one of two ways, — either the nervous energy necessary to the sustenance of TREATMENT. 127 tliP functions is diverted to other objects, as mental training in the school-girl, or tlie circulation in the abdominal organs is too sluggish on account of sedentary habits, as with the sewing-girl. Sometimes want of exercise and too great a tax upon the brain from studies, anxiety, etc., co-operate in the same individual. Anaemia may be produced by a great variety of causes besides those above-mentioned, but, according to my experience, these are far the most frequent. I would not hav^e the reader believe, because I have given the school- girl and the sewing-girl as instances of amenorrhoea, that they are the only persons in whom the same character of causes operate in the same way. Very many fashionable young ladies, who might enjoy the blessings of relaxed, diverted, or healthily employed minds, and appropriate and enlivening exercise, become anaemic from sheer lazi- ness and the nervous anxiety connected with envy. Bearing in mind, then, the causes of indigestion and anaemia, we must, first of all, thoroughly revolutionize the habits and circumstances of the patient, making plenty of outdoor exercise one of the main conditions. Riding in a carriage is not outdoor exercise for these patients; they must ride on horseback, or, what is very well, walk, run, and romp. An excellent sort of diversion for the mind is occu- pation in domestic duties, making beds, sweeping, cooking, washing, caring for and attending children, etc. The mind and body are both employed in a varied and diverse manner in these household duties, and it will be found that exercise both of body and mind is most profitable as it is most diverse and varied. While it is true that some kinds of exercise, as walking or riding, may be made to call into play a great many muscles, yet the whole routine of duties pre- senting themselves in the business of housekeeping, by personally doing the work, is more beneficial than all others devised. This lesson is taught by the contrast between the young mistress and her servant. In addition to the adoption of a more rational course of habits for the patient, much may be done by the judicious use of medicines. Almost invariably the tonics must be preceded by, or accompanied with, alteratives and laxatives. The stomach will no more recognize and respond properly to a tonic that is intrduced into it until pre- pared by correcting the secretions, quickening the gastric circulation, and unloading the bowels, than it will digest food under similar cir- cumstances. The alteratives suitable, generally, are mercury in some form, taraxacum, and turpentine. When the bowels are torpid, the stools dry and of unnatural color, particularly if the color is light, 128 AMENORRHEA. from three to six grains of blue mass, given every third night, and followed next morning by a seidlitz powder, or sufficient sulphate of magnesia to cause one or two evacuations, is an admirable alterative. Ten grains of good extract of taraxacum, with a minute quantity, say the twentieth of a grain, of bicliloride or biniodide of mercury, three times a day for two or three days, generally does very well. The mercury should not be given with tlie taraxacum longer than three days, and then intermitted for a week, but the taraxacum may be given steadily for weeks. An excellent alterative for the stomach is Venice turpentine. Ten grains three times a day after eating, on sugar, alternated or given with some of the mercurial preparations, proves often of great service. I cannot but mention the compound confection of black pepper, made in imitation of Ward^s paste, as having frequently an excellent laxative and corrective effect on a weak state of the stomach accompanied w^th constipation. I have known it to cure some of the most obstinate cases of constipation attended with anaemia. If there is not scantiness of secretions, but slowness of peristaltic movement, we ought to depend on rhubarb and aloes. The com- pound aloetic pill is a good preparation. In the selection of tonics we should bear in mind the difference between the stomachic and blood tonics. Iron is, perhaps, the only direct blood tonic, while there are a great many articles that act as stomachics. Almost all the bitter vegetables ranged under that head in the books are useful under certain circumstances. The stomach tonics, by improving di- gestion, are indirectly blood tonics, so that they are sometimes all that are necessary. In many instances, too, the stomach must be prompted by the bitters, or other stomachics, before it will absorb or assimilate iron. The bitter may precede the iron, or be administered simultaneously with it. It is sometimes convenient and profitable to combine the alterative and stomach tonic. A mixture of this kind, often used, is the compound tincture of cinchona, with bichlo- ride of mercury dissolved in it. The tincture of gentian, or colomba, answers very well compounded with mercury. Extract of gentian and Quevenne's iron compounded in a pill produce good results on the anaemic patient. If we understand the principle that governs the treatment in such cases we may readily find the means to accomplish our ends, by alteratives, stomach tonics, and blood tonics. The cachexise, several of which interfere with the regularity of the function of menstruation, must be treated as if the menses were present in their normal quantity, and in these cases the amenorrhoeal TREATMENT. 129 complication is of no importance, hence special efforts to restore the flow are injudicious, and in most cases injurious. In cases of defective nervous energy we may expect benefit from the direct application of electricity to the uterus, or to the nerves that supply it. In a paper, recently read before the New York State Medical Society, by A. D. Rockwell, M.D.,* I find the following statement : " Araenorrhcea is a symptom that yields, perhaps, more readily to some one of the many forms of electrization than to any or all other methods of treatment. In cases dependent on, or associated with, general debility general electrization is of course indicated ; but where all external efforts have been fruitless, internal electrization is not infrequently followed by an immediate and satisfactory flow." He gives a case as illustrative of the efficacy of his method of performing local electrization : "I introduced a cup-shaped metallic electrode to the uterus, so that the OS was completely surrounded, and applied the positive pole firmly against the abdomen immediately above the pubes. The current, which was of considerable strength, I reversed rapidly a number of times during the seance, and on the following day repeated the application. In less than six hours after making the second attempt, slight signs of returning menstruation were manifest, and steadily increased until, as regards quantity, the flow was quite natural. The patient was immediately re- lieved of all her distressing spasmodic symptoms, and at the present time (three weeks having elapsed since the treatment) still remains free from them." Query. Was this menstruation or metrorrhagia? Dr. Parvin, in the same journal, says : " The positive electrode passed into the uterine cavity, the negative applied to the hypogastrium, gives oftentimes a very prompt success in inducing a sanguineous discharge from the uterus; but in order that such result should follow, this means should be used only at a time when the other phenomena of menstruation manifest themselves, the flow only wanting." The faradic is the form of electrization recommended by both these gentlemen. In patients well developed in most respects, whose genital system ■^ American Practitioner, May, 1872. 130 AMENORRHCEA. is deficient, the menses cannot be produced unless these organs grow and become more active. Anything that will stimulate these organs will occasionally bring this result about. Wedlock is a remedy some- times. The indulgence in society, and the recreations of it, in com- pany with men, sometimes, through the moral faculties, stimulate the genital organs towards development. The stimulus thus afforded by society is one of the beneficial effects resulting from the change of habits in young girls who go to boarding-schools until sexually dwarfed by confinement to the uninteresting society of their own sex. Professor Simpson has recommended an instrument, which he calls an "intrauterine pessary," to bring about this development. It is equally applicable to cases of atrophy of the uterus arising after the menses have been established. I have had occasion to use it, and am now employing it in the interesting case to which I have alluded above. It is theoret'wally better, I am afraid, than it will be found pradicaUy; yet there is no doubt much good may be done by it. The object of the intrauterine pessary is to be the medium, or gene- rator^ rather, of galvanism, to stimulate the nerves of the uterus. Both of these effects are promotive of uterine haemorrhage, if not of correct menstruation. They are necessary to the development of an atrophied uterus, whether congenital or acquired. But this in- strument is recommended and used in obstinate cases of amenorrhoea, where there is- no apparent deficiency in the size and development of the organs concerned. It is in this class of cases that most may be effected by it, and yet it sometimes entirely fails to produce any effect. To do good in the cases of atrophy and want of development it should be used continuously. Where the development is good, I am inclined to think that the pessar}^ will do more good by using it intermittingly. In these cases we may introduce the instrument and allow it to re- main one week before the time of the expected period, and then, after the time is passed, remove it, and again introduce it at the proper time. We should remember that we cannot use an instrument of the same size in all cases. In the uterus that is much atrophied it would be violence to use an instrument that is applicable to a fully developed organ. In the former we must have an instrument that will pass into it easily, and in a couple of months use one larger; and after the lapse of a similar time make another one still larger, etc., until development is complete. The instrument is made of cop- per and zinc, and consists of a stem and bulb. Tlie bulb is hollow, in order to be light as possible, flattened, and oval in shape, one inch long, three-quarters of an inch wide, and half an inch thick. It TREATMENT. 131 should be perforated through its thinnest diameter by a hole two- twelfths of an inch in diameter. Into this perforation the stem is to be inserted. The stem should be two inches long for a uterus not atrophied, and as much less as is necessary, in the judgment of the attendant, when atrophy has taken place. It should be hollow and light like the bulb. The bulb, and one inch of the stem next the bulb, is made of copper, the extremity of the stem of zinc. This completes the instrument as made and used by Professor Simpson. I find, in some instances, great difficulty, if not an entire impracti- cability, in wearing it, on account of its tendency to fall out. Some- times, too, the galvanic stimulus is not sufficient. On these accounts I have made an addition to it, which, I think, adds to its efficiency as well as security of position. This consists of a zinc ball, about an inch in diameter, attached to a copper rod four inches long. The ball is introduced into the vagina after the intrauterine pessary has been introduced, while the stem is attached to a framework outside the pelvis to keep the whole in position. As will be seen by a study of this apparatus we have quite a galvanic battery, the copper rod reaching from the framework of zinc outside to the zinc ball inside, this last lying in contact with the copper bulb of the pessary, etc. If we do not desire any galvanism in the case the whole apparatus can be made of copper. Made in this w^ay the instrument is quite efficient. The young physician or student may be embarrassed in his attempts to introduce the pessary without a little consideration. The plan I have found most convenient is, to expose the os uteri by means of the quadrivalve speculum; secondly, to secure the pessary by inserting a piece of whalebone, properly shaped, in the perforation in the bulb; thirdly, thus raounterl, to insert the stem, and w^ith great gentleness urge it forward to its full length, or until it is arrested by the contracted internal os uteri or the end touching the fundus. If this arrest occurs the instrument is either too large or too long, and must be replaced by one more suitable in this respect. After the pessary is inserted we may withdraw the speculum, and, if necessary, apply the ball and external framework above described to keep it in position. All this direction does not include a fact which should ever be borne in mind by the student, viz., that sometimes the instrument is utterly intolerable; and, at others, a good deal of address and pa- tience is required to habituate the parts to it. The patient should be forewarned that pain and inflammation are the possible effi^cts, and that she must inform us should they be considerable. There is always some pain, sometimes a great deal. When the irritation is too severe 132 AMENORRn(EA. the instrument must be removed, quietude observed, and, if necessary, anodynes, and even antiphlogistic treatment must be resorted to, to remove the symptoms. After all these have subsided it may be again introduced. A little perseverance and care will render most cases tolerant of its presence. During the time the instrument is used the vagina must be thoroughly cleansed, at least twice a day, with tepid, warm, or cold water, and fine soap, used as injections. CHAPTEE VII. MENOEKHAGIA AND METRORRHAGIA. H.EMORKHAGE Occurring at the time of menstruation beyond the usual quantity is menorrhagia. Haemorrhages occurring at other times do not belong to this denomination, but are called metror- rhagia. Often both metrorrhagia and menorrhagia occur in the same individual, which depend upon the same conditions of the system or reproductive organs, and are alike symptomatic of some local or general disease. It is not difficult to understand that an exaggeration of the hyper- semia, or an unusually rapid disintegration of the uterine mucous membrane, would cause more than a normal amount of flow, nor that a want of accordance in time might be followed by the same result. Indeed most cases of uterine haemorrhage are traceable to conditions which disturb the equilibrium of these phenomena. The causes which thus act are varied and numerous. Morbid nervous influences, which increase the discharge of blood from the uterus, sometimes emanate from the nervous centres, and hence may be properly termed centric; much more frequently, how- ever, they are reflected through the nervous centres from other and sometimes distant organs, and these last are entitled to the denomina- tion of reflex or eccentric nervous influences. Mental and emotional excitement emanating directly from the brain, and cerebral and spinal excitement originating in inflammation or functional exhaustion of the brain or spinal cord, are examples of centric etiological influences. Many years ago I witnessed the rav- ages of an epidemic of cerebro-spinal inflammation, in which uterine haemorrhage was of almost universal occurrence among those adult females who fell under its influences. Morbid reflex nervous influences afford a more numerous class of causes. First among them, both in frequency and importance, are those arising from abnormal conditions of the ovaries, such as con- gestion, inflammation, displacement, and erotic excitement. Next to the influence of these bodies is that exerted by the mammary glands. Menstruation is generally more profuse when it occurs during lacta- tion. The effect of mammary irritation in causing congestion of the 134 MENORRHAGIA AND METRORRHAGIA. uterus, and thus promoting haemorrhage from it, is well illustrated by the familiar fact that sinapisms or blisters applied to the breasts will often cause metrorrhagia. Vesical irritation, or inflammation, which gives rise to tenesmus, rectal irritation, as from the presence of haemorrhoids or ascarides, and dysenteric inflammation, through the reflex influence which they exert upon the uterus, are generally recognized causes of uterine haemorrhage. Among other reflex causes may be mentioned certain forms of indigestion, hepatic con- p-estion and inflammation, and some of the disturbances of the small intestines, as may also strong impressions upon the cutaneous surface, as from cold, or from the long-continued application of heat in warm climates and seasons. All of these last-mentioned causes I think act through the reflex system of spinal nerves, and perhaps also through the agency of the sympathetic ganglia, which perform a reflex function between the viscera. The morbid effects of the various reflex nervous impressions are rendered more effective and intense by the presence of such uterine diseases as predispose to haemorrhage by increasing the vascu- larity of the uterus. Many pathological conditions which conduce to the production of uterine hsemorrliage, independently of direct nervous influence, act by increasing the hypersemia of the uterus. When the mucous mem- brane is granulated, or is the seat of inflammation, of fibrous polypus, or of malignant fungus, the circulation of the uterus is increased, and harmony in the process of nidation disturbed ; and these con- ditions will be accompanied by an unusual and long-continued flow of blood. Subinvolution, congestion and inflammation, hyperplasia, tuberculosis, cancerous and fibrous deposits in the muscular structure, and chronic and acute endometritis, in addition to preventing the normal deciduous changes in the mucous membrane of the uterus, maintain a permanent hypersemia, and thus render the womb prone to large losses at each return of the menstrual period. We have, in fact, abundant reasons for assuming that chronic hypersemia, no matter how produced, will, by virtue of the malnutrition connected with it, prevent menstrual changes from being effected in an orderly manner, and thus render the mucous membrane more frail in or- ganization, and consequently incapable of resisting the force of vascu- lar pressure to which it is periodically subjected. Besides the causes of uterine hypersemia last alluded to, and exist- ing within the tissues of the womb, there are many other outside 'pathological conditions acting in a different way. Some of these cause CAUSES OF MENORRHAGIA. 135 venous liypertemla by mechanical retardation of the circulation, Avhile others give rise to both arterial and venous hypersemia by nutritional attraction, and others again cause arterial hyperismia alone, by forcing unusual amounts of blood into the organ. Among the most frequent and important causes of venous retardation are displacements and flexions of the uterus — procidentia, retroversion, and retroflexion — the former by stretching the veins and rendering their course more tortuous, the latter by twisting them, and thus lessening their calibre; exudations into the cellular tissue and peri- toneal pouch, from cellulitis and local peritonitis, and effusions of blood in the cul-de-sac of Douglas, in retro-uterine hsematocele, by pressing upon the veins, prevent a free return of blood from the uterus, and thus cause venous hypersemia. Retardation of move- ment in the uterine veins may also be caused by obstruction to the venous circulation quite remote from the womb, as by the pressure of a tumor upon the ascending vena cava, by a loaded condition of the large intestine, by dislocation or enlargement of the liver, by obstruction to the free passage of blood through the heart from val- vular disease, and even by certain pulmonary affections. In the class of causes giving rise to both arterial and venous hyper- 8emia may be mentioned fibrous, fibrocystic, polypoid, and fungous growths of the fibrous structure of tlie uterus. These all increase the flow of blood to and through the vessels of the uterus, both arteries and veins are increased in capacity, and to these changes is added general hypertrophy. In these cases the hypersemia of all the tissues is sometimes enormously great, and the losses of blood are proportionally large and dangerous; the haemorrhage, unlike that from venous, obstruction, is not checked by the emptying of the vessels, but continues until the arterial and cardiac vis-a-tergo is Aveakened by approaching syncope. Causes producing arterial hyperaemia alone are hypertrophy of the heart, general plethora, febrile excitement, and violent exercise. The uterine hyperajmia in these cases is caused by unusual arterial and cardiac pressure alone. When not attended by local pathological conditions, the haemorrhage in these cases is not apt to be serious. Other not uncommon causes of haemorrhage from the womb are various diseases of the blood. Among these may be mentioned scurvy, leucocythsemia, chlorosis, albuminuria, and syphilis. It is not likely that the vice in the composition of the blood is the sole causative influence operating in the above-named conditions. In scurvy, for instance, we know that the solid tissues, whether as a 136 MENORRHAGIA AND METRORRHAGIA. primary condition or as an effect of the blood-changes, are diseased, the capillaries more fragile than natural, and, consequently, less capable of resisting the cardiac impulse. As evidence that the vicious condition of both blood and solid tissues is the cause of uterine hsem- orrhage in scurvy, the well-known fact may be added that bleeding is very easily provoked in other mucous membranes. It is the more likely to take place from the mucous membrane of the uterus, because of the great normal fluctuations in tlie circulation of that organ, and also because the vitiated state of the blood would nat- urally cause disturbance in other conditions attendant upon menstru- ation, especially the decidual changes. It will be seen therefore that the peculiarity in the operation of this variety of cause is not due to the presence of local or general hypersemia from retardation of the venous circulation, or from arterial and cardiac pressure, but is due to the tendency of the blood to escape through the walls of the vessels, and to the inability of the capillary tubes to resist the circu- latory force ordinarily applied to them. As another cause of haemorrhage from the womb, must be men- tioned the well-known law of the human system, to continue a long- established habit after the original cause is removed. This is prob- ably the only rational explanation of those rare uterine losses which are sometimes observed in pregnancy and in cases where both ovaries have been removed. The habit of bleeding continues after the ovarian reflex nervous influence has been withdrawn from the uterus. Still another rare yet very dangerous cause of uterine haemorrhage is that known to surgeons as the hcemorrhagic diathesis. The writer has seen one case in which he believes that the bleeding was clearly attributable to this mysterious condition, and which proved fatal. It was that of a young girl who died with her second menstrual flow. The wide range of causative conditions found connected with uterine haemorrhage is but an inverse exhibition of the sympathetic relations of the uterus. When diseased, it exercises an almost uni- versal pathological influence upon other organs, and, as a conse- quence, it is susceptible of being impressed to the same degree by certain morbid conditions of all important viscera. It will not be regarded as making an undue claim to say that the practice of gynae- cology requires a more thorough theoretical and practical familiarity with the details of all the branches of medicine than any other of the so-called specialties, ^ye are not prepared to treat the most common of female diseases without being able to scan with scientific scrutiny TREATMENT OF MENORRHAGIA. 137 every organ and function of the body. Xor until we can com])ete successfully with the general practitioner, the surgeon, the alienist, and the neurologist in the therapeutic processes of their respective departments may we hope to exercise in the highest sense the office of the gynaecologist. These remarks apply with force to the comp-e- hension of the causes and treatuient of haemorrhages of the unimpreg- nated and non-puerperal uterus. Treatment of Menorrhagia. I find it quite impossible to satisfy myself as to the best order in which to bring forward the various measures proposed for treating uterine haemorrhage. Those which have for their object the removal of the causing conditions, properly fall under the head of curative means ; while those which we employ to stop the bleeding tempo- rarily, until the remedies of the first order have accomplished their purpose, seem as naturally to belong to the category of paUiative measures. We find in each of these divisions, however, remedies which act in both ways, and the palliative means are often radical and energetic. Notwithstanding the many obvious deficiencies in this arrangement, it seems to me to be the best that I can adopt. Palliative Treatment. Before entering into a detailed description of the more essential remedial methods of curing the various forms of hseraorrhage it will be profitable to consider some of the important minor measures which are applicable in almost all instances. As the great majority of haemorrhages occur at the menstrual periods, we often have oppor- tunities of adopting measures in anticipation of them. These meas- ures are sometimes calculated to entirely prevent an exaggerated flow, and at others to very much modify it; and in all to greatly promote the action of more direct remedies. The patient should ab- stain from all causes of local or general vascular or nervous excite- ment. Among these causes are mental and bodily fatigue, emotional excitement arising from certain social relations, sensational books, and the contemplation of erotic objects. The patient should also ab- stain from stimulating drinks and highly seasoned food; her clothing should be loose and cool, so that no part of the bod}" may be con- stricted, and the genital organs should not be too warmly covered. Her bowels ought to be kept regular, or rather free. The secretions from the skin, liver, and kidneys should be maintained as nearly as 13S MENORRHAGIA AND METRORRHAGIA. possible in a normal condition, and tonics, such as arsenic, strychnia, and quinia, with digestible, nourishing, and unstlniulating diet, should be given in quantities sufficient to keep the health up to the normal standard. Other things which will contribute very greatly to good results are plenty of pure air, night and day, and moderate muscular exercise. Many other general directions will suggest themselves, which I cannot stop now to mention. When the time for the paroxysm has arrived, and the haemor- rhage has commenced, isolation, quietude, and recumbency are very important precautions to be enjoined. Position, indeed, may be made to do much good of itself. If the haemorrhage is not severe, mere recumbency will be sufficient; but if it is protracted, the hips should be elevated, and sometimes it will be beneficial to raise them so high as to cause the blood to gravitate to the fundus uteri, and to fill the whole genital canal before any of it passes out. To a con- siderable extent this may be made to act as a tampon. The position chosen to effect this object may be on the back, or upon the knees and chest. If the latter position can be commanded, it is much the best, as the reversal of gravitation is more complete. Cold and acid drinks, cold applications to the hypogastric and sacral regions, hips, and vulva, and in the vagina, are also among the remedies applicable to almost all cases. Many practitioners value astringents, adminis- tered internally, in uterine haemorrhage, but I have found so little benefit from them when not given with oj)ium or belladonna, that I seldom resort to them. Where there is much pain in the pelvis, and a dry state of the skin, opium and ipecacuanha are often very ser- viceable. Lobelia, gelsemium, digitalis, aconite, and veratrum \iride, may also be mentioned as very frequently applicable where there is vascular and nervous excitement. Perhaps the medicine most generally applicable in paroxysms of uterine haemorrhage, is ergot. In all cases of local arterial hypersemia, as in tumors, hyperinvolution, etc., we may expect good from its em- ployment. But it will generally fail to be useful when the uterine hyperaemia is venous, as in retroversion, pelvic infarction from peri- uterine effusion, abdominal tumors, etc. It will not act efficiently in cases of carcinomatous deposit, granulations of the mucous membrane, or tuberculous degeneration of the fibrous texture of the uterus. In the more dangerous instances of haemorrhage, these moderate palliative measure are not sufficient. In some, the amount of loss is so great, and occurs so suddenly, as to threaten the life of the patient. Or, if life is not in danger, the discharge may be sufficient to lead to TREATMENT OF MENORRHAGIA. 139 other verv serious remote consequences. These emergencies are to be met bv such means as will promptly arrest the flow, and keep it in check until curative processes can be instituted. Fortunately this may be done with great certainty by mechanical and chemical ap- pliances generally at our command. The genital canal, practically closed at its upper extremity, and conveniently open at its lower ter- mination, admits of being impacted to an impermeable degree, and allows of topical applications to its whole extent. In u-ing either form of these topical measures, the effort should be made to a|)p]y the remedy as near to the bleeding point as possible. AVhen practicable, we may secure the best effects by employing the mechanical and chemical means conjointly. The mechanical means embrace the different forms of the tampon. Plugging arrests the haemorrhage by forcibly opposing the evacuation of the blood, and by thus imprisoning it in the smallest cavity. The blood so confined, coagulates, and fills the space between the tampon and the bleeding surface with a fibrinous clot, which also closes the mouths of the vessels. When plugging is skilfully perforn^ied, the relief is temporarily perfect, and gives us valuable time for other treatment, or allows the cyclical period to pass, when the hypersemia subsides. The chemical means consist in the use of powerful htemostatics. By their chemical action upon the solid constituents of the blood, they produce a much firmer coagulum than results from mere stasis, and, if applied to the ruptured vessels, seal them up with coagulated plastic material, while if further away the coagulum forms a chemical tam- pon which opposes the flow toward the vulva. Used with the me- chanical tampon they may be made to fill the interstices of the ma- terial of which it is formed, and thus solidify the whole mass. In the greater number of dangerous cases of the kind of uterine haemorrhage, the mouth of the womb is sufficiently patent to permit the introduction of the plugging material saturated with a htemostatic preparation into the cavity of the uterus. Dr. Sims's method of preparing the material and performing the operation of plugging the womb is admirable in its simplicity and efficiency. The substance used is the finest article of cotton-wool, saturated with a liquid com- posed of one part of the strong solution of the subsulphate of iron and two of water. After the cotton has been perfectly saturated, it is de- prived of the major part of its fluid by pressure, and is then allowed to dry until ready for use. The application is made by wrapping a sufficient quantity of the dried iron-cotton around a long, small piece of whalebone, and introducing it into the cavity of the uterus, 140 MENORRHAGIA AND METRORRHAGIA. Avhen the cotton is detaclied and left there. If the hsemorrhage is comparatively moderate, one of these pieces may be sufficient ; if severe, it will be necessary to stuff the uterine cavity full. This can be best accomplished by having the patient placed on her side, and the uterus exposed by Sims's speculum. To facilitate the removal of this ferruginous tampon, the suggestion of Dr. J. R. Chadwick, of Boston, is, I think, a valuable one, viz., to wrap strong thread loosely around the cotton as it surrounds the whalebone. I prefer this method of using the haemostatic to its injection, because the shock from the application is much less. If the mouth and cervical cavity of the womb are not sufficiently open to permit of the introduction of this haemostatic preparation, we may plug the cervix with prepared sponge. The first sponge should be pushed through the cervix into the cavity, and up to the fundus uteri, so that when it expands its upper end may possibly reach and press upon the bleeding: point. If large enough, the cervical cavity will be completely filled and the bleeding effectually checked. The sponge should be carboHzed, and well secured, before it is introduced, by passing a strong piece of twine through it, from one end to the other. Neither the cotton nor sponge should be allowed to remain longer than twenty-four hours, and half of that time is usually long enough. After removal, the vagina may be cleansed, and the appli- cation repeated if necessary. I have sometimes been obliged to renew the sponge tampon several times in the same case, though this is not usually required. If these means are not at hand, or if the case is not sufficiently urgent to require plugging of the uterus, we may resort to the vaginal tampon. This may be made of cotton, of which pieces as large as pullet's eggs may be used, rolled somewhat solidly, and each secured with thread and lubricated with oil or lard. A sufficient number to perfectly fill the vagina should be prepared. The pa- tient should be placed on her left side, with the limbs flexed, and the upper one thrown forward over the other. The operator, standing at the back of the patient, inserts into the vagina two fingers of the left hand, with wdiich he draws the perinaeum well backward. This will open the canal so that the clots may be easily removed with the fingers, when, with the right hand, the cotton may be placed with great facility in the vagina. At first several on the OS and around it, and then the whole vagina may be packed solidly under the eye of the operator. If Sims's speculum be at hand, it should be used instead of the two fingers to hold back the perinseum. CURATIVE TREATMENT OF MENORRHAGIA. 141 Or we may vary this according to the process described by Dr. Thomas iu the American Journal of the Medical Sciences for July, 1876, page 147. After dilating the vagina, " pieces of cotton, soaked in ^Yater, pressed and flattened out by the fingers, each about the size of a very small biscuit, are pressed into tlie vaginal cul-de-sac by means of forceps till this is filled. Then other pieces are packed firmly around the cervix until only the os is visible; a smaller pad is then pressed firmly against or introduced within the cervical canal, and the whole vagina is then filled to its lowest portion." An ordi- nary surgeon's roller answers admirably for a plug, and may be in- troduced by first inserting one end, and then passing it up in short folds until enough has been placed in the vaginal cavity to fill it up compactly. In most cases, where we desire to leave the patient, the tampon should be retained by a compress and '^ T '^ bandage. When we have reason to anticipate a sudden occurrence of severe haemorrhage in our absence, we may instruct the patient or nurse how to make and apply a very safe vaginal plug. A sponge, large enough to fill the vagina closely, may be prepared by wetting it in a strong so- lution of alum, or in a weak solution of subsulphate of iron, passing a piece of strong twine or tape through the centre, and then wrapping it with tape in an elongated shape to its smallest dimensions. It may then be laid aside to dry. When the necessity for its use arises the tape is removed, and the sponge thus compressed may be passed without any resistance entirely into the vagina. It is soon expanded by the blood, and the vaginal cavity thoroughly filled. A few of these sponges prepared ready for instant use will enable the patient to pre- vent any material loss until the practitioner arrives. The plug may be removed by the tape or. twine whenever desired. The })lug may be allowed to remain from eighteen to twenty-four hours, when it should be withdrawn, and the vagina having been thoroughly cleansed w^ith carbolized water, replaced if necessary. Curative Treatment. The central nervous disorders which cause uterine haemorrhage will, Avhen recognized, require the treatment set forth in the various works upon these subjects. I need not, therefore, dwell here upon' the management of the spinal and cerebral inflammations and irrita- tions, nor upon the numerous forms of emotional excitement which lead to metrorrhagia. The treatment of the reflex, morbid, nervous influences belongs more particularly to gynaecology, and will call for 142 MENORRHAGIA AXD METRORRHAGIA. all the ingenuity and varied knoTvledge taught in thnt branch of practical medicine. The ovarian derangements, being the more ob- vious and common of these may be noticed first. Oar means for re- placing and retaining in position displaced ovaries are verv meagre. The patient mtist be confined to the horizontal position, with the pelvis elevated as much as practicable. The knee-chest position is the best, and may often be maintained for a considerable part of the twenty-four hours. Generally the displacement is accompanied by congestion or inflammation of the ovary, which increases its size and weight. T\'hen this is the case, the treatment, in addition to position and quietude, recommended during the intermenstrual period, will consist in the use of counter-irritants, hip-baths, hot-water vaginal injections, and alteratives, administered internally, or applied exter- nally in the form of ointments, or per vaginara as suppositories, in- jections, etc. Among the alteratives, the muriate of ammonia will be found very valuable. When there is much debility, the bichlo- ride of mercury, dissolved in the compound tincture of cinchona, is among the very best. Iodine, iodide of potassium, and iodide of iron should also be named as efficient alteratives in these conditions of the ovaries. One derivative measure which I desire to mention as espe- cially beneficial in these cases is dry cupping over the sacrum, often repeated. To be effectual the cups should be large and allowed to remain for a long time, say an hour or more. AYhen there is much pain in the ovarian regions, suppositories of the extract of belladonna and ergot, once or twice daily, will not only relieve the pain, but will do much towards allaying the inflammation. When haemorrhage occurs in a nursing woman, if it is of sufficient gravity, the child should be weaned. At the time of the paroxysm, if the breasts are tumid and tender, cold may be applied to them to relieve both the uterine haemorrhage and the mammary congestion. These patients require invigorating measures in connection with the local treatment of the breasts. The vesical or rectal tenesmus which gives rise to haemorrhage must be treated bv the remedies found necessary after investio-atino; the cause. So, also, with diseases of the stomach, bowels, and liver, as well as with the effect of cold or of long-continued heat. Subinvolution and chronic congestion of the whole uterus require to be treated very much alike, by the application of such remedies as condense the uterine tissues, — ergot, belladonna, quinia, electricity, cold injections, compresses, and sitz-baths. When there is no tender- CURATIVE TREATMENT OF MENORRHAGIA. 143 ness, ergot will be found a very efficient remedy, if administered for a sufficient length of time — several months, for instance. If there is considerable tenderness and pain, belladonna and quinia will be best adapted to the case. Ergot in some instances induces sensitiveness and heat in the pelvic organs, and then it should be used very cautiously. This effiect of ergot is especially noticeable when there is chronic local peritonitis or cellulitis. If there is a high degree of sensitiveness, a mercurial alterative may very properly be given in connection with the belladonna and quinia,^and a good form for administering it is the bichloride of mercury dissolved in the compound tincture of cinchona; or we may use mercurial inunction, or mercury in suppositories. I have not been able to do much good in these cases with iodine in any form. If given with iron, as the iodide of iron, it has occasionally a good tonic and alterative influence. These conditions of the uterus are very obstinate, and require a continuous treataient, oftentimes for many months. The treatment of endometritis, described elsewhere, consists mainly in a persev^ering continuance of stimulating applications to the dis- eased mucous membrane. I do not like the term caustic, for even the strongest remedies used for this purpose are applied so sparingly that their effects are little more than strongly stimulative. In the light of our present knowledge of the processes of menstruation, Fig The Dull Curette. these remedies, as suggested by Dr. Atthill, should be resorted to immediately after the monthly flow has ceased. By common consent of the profession, in this country, the treatment of granulations of the uterine mucous membrane consists in scraping them offi If the mouth of the uterus is sufficiently patent to admit a small-sized curette, the scraping may be done eflectually without dilatation; if not, a cupelo or sea-tangle tent may precede it. The curette should be passed over every point in the uterine cavity Avith firmness enough to detach the soft excrescences, and yet there should not be force enough employed to wound the natural tissue. Success will generally be announced by the discharge of the soft elon- gated growths. These are sometimes very abundant. The scraping 144 MENORRHAGIA AND METRORRHAGIA. shoiilcl be done during the flow. It is not necessary to wait for a protracted paroxysm to pass by. Although not curative, tlie same treatment may be mentioned as most efficacious in arresting the haemorrhages resulting from cancer- ous granulations. In a discussion of Dr. Hanks's recent paper, Dr. Peaslee gives the very judicious advice not to cut into the sound tissue in the process. In cases of malignant fungus, we may often arrest the tendency to haemorrhage by injecting alcohol, by means of a hypodermic syringe, deeply into the substance of the part. This process frequently repeated sometimes retards the growth very mate- rially. The tincture of the chloride of iron, similarly used, will often have the same effect. The various conditions which give rise to retardation of the venous circulation require to be treated according to the improved methods now so well understood by the profession. The displacements of the uterus, which are arranged among these conditions, must be corrected by the various ingenious appliances designed for this purpose. And this may be done during the time of the preternatural flow with the expectation of moderating it at once. Dr. T. D. Fitch, of Chicago, has recently proven this last assertion in the management of a case occurring in a patient who had just passed the menopause. The uterus was retroverted, and all the means resorted to did not even moderate the metrorrhagia until the organ was elevated and retained in position by an appropriate pessary, when in a short time the bleeding ceased. After the subsidence of the flow, the patient removed the instrument, on account of some slight incon- venience which it gave her, but the flooding began again in a very few hours, and continued, notwithstanding repeated efforts to arrest it, until the pessary was once more introduced, when the haemorrhage again subsidal, and has not returned. The patient was still wearing the pessary when I heard of her case. The extreme danger from lisemorrhage connected with fibrous tumors of the uterus is not so often encountered since the profession has become acquainted with the great influence exerted upon certain conditions of the unimpregnated uterus by ergot. It is now under- stood that fully seventy-five per cent, of haemorrhagic cases of fibrous tumor of the uterus mav be rendered free from danger, as far as the haemorrhage is concerned, by an intelligent and persevering use of ergot, and that in twenty per cent, the tumors may be removed. In using ergot, in these cases, the mode of administering it cannot be uniform. Some patients cannot take it in any sufficient doses to TREATMENT OF MENORRHAGIA. 145 answer the purpose; some cannot take it in the form of fluid extract, or wine, but can take the solid extract in the form of pills; others can take it in any form. When the stomach will not tolerate the er^ot, it may be given hypodermically, or per rectum in suppositories, and I believe that it can be made to act efficiently when given in any of these ways. Whatever method or form ^ve may adopt in the administration of ergot, we should give it in sufficient quantities to produce a sensible effect by causing contractions and pain, and there is no better rule to guide us, so far as I can judge, than to give it in increasing doses until that result follows. Twenty minims of the fluid extract, three times a day, will sometimes be sufficient, while some patients, on the other hand, will require twice or three times as much to produce the effect. The length of time required to obtain the ultimate effects of the ergot in these doses varies as much as the quantity required. The tumor will sometimes diminish very rapidly, but generally the de- crease in size is quite slow. From one month to over a year may be required to accomplish a cure when it can be accomplished at all. Ergot is sometimes very violent in its action, but by withdrawing it temporarily, lessening the dose, or combining and alternating it with anodynes, it may be safely managed. Although I have given it ex- tensively, and for a long time together, I have not seen anything worse than inconvenience arising from its use. 10 CHAPTEE VIII. DYSMENOEEHCEA. This is a general term for painful and difficult nienstruation, and includes conditions widely different in their nature. In some cases no appreciable morbid changes are discoverable in the organs which seem to be the seat of pain, either during or between the times of the menstrual flow, and these are called neuralgic dysmenorrhoea. They depend upon a general state of the system, which is sup- posed by some to be rheumatic and by others purely neuralgic. It would be difficult to define with any accuracy either of these condi- tions, the rheumatic or the neuralgic diathesis, and yet we know enough about their manifestations to be able to detect their presence. The character of the symptoms of this form of dysmenorrhoea is determined by the conditions of the system. It generally occurs in patients who are manifestly subjects of one of these diatheses, and who in the intervals between the periods ex- perience neuralgic symptoms, or symptoms referable to rheumatism. These features of the cases are sometimes so marked as to be easily detected, while at other times they are not well defined. Whether there is some permanent morbid condition of the nervous apparatus of the pelvic organs that is perpetuated from month to month, and thus constitutes the disease, or whether in neuralgic patients the vas- cular and nervous disturbance of the menstrual period is sufficient to excite and localize the morbific energ-ies of this diathesis, we do not know. I have been in the habit of teaching the latter. The par- oxysm of suffering is more irregular with reference to the com- mencement of the flow than in any other form of dysmenorrhoea. More frequently than otherwise the pain begins one, two, or even three days before the time of the flow, and continues in a subdued degree during a great part of the time of the flow. It is sharp and paroxysmal, but not generally accompanied with tenesmus. The pains do not seem to be influenced much by the flow. The intensity of the symptoms vary from slight and very tolerable pains in some patients to the greatest agony in others. This kind of dysmenorrhoea occurs in that class of patients of DIAGNOSIS — PROGNOSIS — TREATMENT. 147 whom it is often said, ^' They suffer more than any one else from the same cause." They are very nervous patients. The seat of the pain is not always the same; sometimes it is referred to the uterus exclu- sively, but generally the pain radiates to the ovaries, the back, in the region of the genito-spinal centre, and down the limbs. Diagnosis. A physical examination of the pelvic organs enables us to declare that there is none of the morbid conditions we usually find in the other forms. This, with th^ diathetic manifestations, is the only means of arriving at definite conclusions. Prognosis. This affection, although it is obstinate and resists treatment of al- most every kind, and is apt to return after it was supposed to be cured, yet the effects of judicious treatment upon it are quite marked. Treatment. Change of climate, scenery, and modes of living are among the most promising remedies. I have known patients to be entirely free from dysmenorrhoeal paroxysms during a long tour in Europe, and others to be relieved by moving from a northern to a southern cli- mate. There is probably no better way to produce a decidedly salu- tary and lasting effect upon the nervous system of these patients than to revolutionize their surroundings by change of climate. A sum- mer residence by the seaside, the bathing and exercise connected with it will often suffice to interrupt, if not cure, the recurrence of these paroxysms. If we cannot remove the patient from the circumstances under which her disease originated, we may do a great deal to get rid of the diathesis by outdoor exercise on horseback, or on foot, and, if neither of these is possible, in a carriage. The diet should be reo^ulated with a view to an exalted state of nu- trition. Medicines may also be made to exercise a powerful influence upon the diathetic condition. In cases where we can trace a rheumatic taint we should give med- icines with a view to relieve it; among^ which are Dewees's tincture of guaiac. in drachm doses, three or four times a day, the tincture of ascle- pias tuberosa, or viburnum prunifolium. In the more purely neu- ralgic cases, tonics containing iron, strychnia, quinine, and 2)hosphorus 148 DYSMENORRHCEA. are serviceable. The phosphide of zinc or the oxide of zinc will also be found very useful remedies for this general condition. The manner of treatment of the paroxysm is also of great impor- tance. As we can calculate with some definiteness the time when the paroxysm will come, we may anticipate it with such remedies as will produce a strong impression on the nervous system. The late Dr. M. B. Wright taught his students that large doses of quinine given one or two days before the expected paroxysm, with a view to having the patient pass into it in a state of cinchonism, often mitigated her sufferings very greatly, and sometimes entirely prevented it. If, as he supposed, many cases were due to malarial influences we might expect great good from this treatment. Arsenic is another remedy that will sometimes mitigate the suffering if given so as to exert its full influence at the time of the paroxysm. To do this its administration must be commenced at least a week before the return, and continued from small to increasing doses until characteristic effects appear. In giving remedies for the relief of pain during the paroxysms we should have in mind that patients afflicted with this form of dysmenorrhoea are easily fascinated with the effects of ano- dynes and give them up with great reluctance, and that there is there- fore great danger of making opium-eaters of them. I could point out a number of patients who have abused the pre- scriptions given them for this purpose to their great sorrow. We should feel a proper sense of responsibility in these cases, use anodynes as sparingly as possible, and place them beyond the reach of the patient when the urgency of the symptoms has passed. Chloral, chloroform, and morphia are the anodynes upon which we will be obliged to rely in the extreme agony of a paroxysm. The Inflammatory Form of Dysmenorrhoea. In this variety of dysmenorrhoea the condition giving rise to the paroxysm is inflammation in some of the pelvic organs, generally the uterus, the ovaries, or both. Whether there is a pure ovarian dys- menorrhoea of this nature or not, I am not prepared to positively assert, but I think it very probable that there is. In most cases of inflammatory dysmenorrhoea, however, I believe the morbid condition exists in both the ovaries and uterus. In exceptional instances the inflammation may be located in the cellular tissue, and perhaps in other pelvic structures. THE INFLAMMATORY FORM OF D YSMENORRUCE A . 119 Si/mjjtoms. Patients laboring under this form of the affection are generally the subjects of intramenstrual syniptonis of sufficient intensity to mark the nature of the causing conditions. They are the usual symptoms of uterine or ovarian disease. It is in this form that intramenstrual paroxysms occur midway between the menstrual periods. These intra- menstrual paroxysms are sometimes very severe, but probably are not so intense as those occurring during the periods. The paroxysms usually commence some hours, and, occasionally, a day or two before the flow, and partially or completely cease as soon as the flow is established and becomes free. The pain is gen- erally of a somewhat steady aching character, not so intense, but more continuous than the neuralgic form. The paroxysm is usually attended with febrile phenomena. Sometimes there is a sharp attack of fever, preceded by chilliness, and accompanied with furred tongue, headache, and pain in the limbs. The pain is not always confined to the pelvis, but radiates upward and downward. The paroxysm is usually accounted for by supposing that the pain due to the existing inflammation is very much aggravated by the hypersemia and hyper- esthesia attendant upon the occurrence of menstruation. However this may be, they are distinguished by this similarity to the pains of inflammation. Diagnosis. A thorough physical examination, for which I will refer the reader to the diagnosis of uterine disease, will enable us to discover the lo- cality, character, and grade of the morbid process. Prognosis. The prognosis of this form of dysmenorrhoea I believe to be more favorable than any of the others, because more amenable to treat- ment. It does not cause that intensity of suffering which we witness in some of the other varieties. It may not be irrelevant to state here that while we do meet with pure examples of neuralgic and inflammatory dysmenorrhoea tliere is often an obvious neuralgic element in the inflammatory form — a complication of the two varieties. Sometimes one of these morbid conditions predominates, and sometimes the other. Treatment. For the special treatment of the inflammation as the controlling element in this afiection I must refer the reader to the methods of 150 DYSMENORRHCEA. treatment elsewhere given. The progress of the cure of that element will be marked by the subsidence of the intensity of the paroxysms until they fail to return. In this form we may often anticipate the paroxysms, and allay them by appropriate treatment. The patient should be directed to take her bed before it comes on, and remain quiet until the paroxysm is over. Particular attention should be directed to her bowels, and it will often be best to give her a small mercurial — two or three grains of calomel, and follow it in seven or eight hours by a saline cathartic. After this diaphoresis should be encouraged by the ace- tate of potash, and, as the pains begin, Dover's powder. The antici- patory local treatment consists in bloodletting by leeches or scarifi- cation the day before the expected paroxysm. Hot-water injections, continued through the attack as often as three or four times in twenty- four hours, hot fomentations over the hypogastrium, and tepid sitz- baths. These will often do away with the necessity of using ano- dynes. When the pain is not relieved by these measures anodynes in sufficient quantities to mitigate it are permissible. Membranous Dysmenorrlioea. The particular feature of this form of dysmenorrhoca is the dis- charge of a membranous cast of the cavity of the uterus. Some- times the membrane comes away without losing its shape or integrity ; very much more frequently it is discharged in a broken condition, and appears in shreds or large pieces, representing in shape and size the anterior or posterior wall of the cavity of the uterus. " The microscope shows that the discharges at times consist simply of fibrinous clots, which are with difficulty passed through the os uteri, when it is very small, as is frequently the case in females who have never borne children ; at other times the fibrin is in a fibrillated state, inclosing in its reticulum numerous lymph and epithelial cells. In other cases there are found irregular shreds, containing capillary vessels with embryonic walls, in the midst of connective tissue, infil- trated with lymph-cells. There are also frequently seen fragments of uterine glands. This is a genuine discharge of exfoliated mucous membrane. The mucous membrane maybe expelled entire; this, however, is not of frequent occurrence."* Numerous theories have been proi)agated to explain the formation * Cornil and Kanvier's Pathological Histology, translated by Shakespeare and Simes, p. 685. MEMBRANOUS DYSMENORRHCE A. 151 of this membrane. It would seem that the ideas prevailing with reference to the formation of the deciduous membrane have influenced the profession in their opinions as to the conditions giving rise to this membranous formation. In the theory adopted by Dewees, Montgomery, and others, that it was a layer of plastic lymph spread upon the uterine wall, we see something of the Hunterian explanation of the formation of the de- cidua. In another theory, adv^anced by Oldham and others, we see the results of the researches of Coste, who considers the decidua nothing more than the mucous membrane of the uterus, changed by impregnation. According to this theory it is the menstrual decidua which does not undergo disintegration as completely as in health; in other words the membrane is the result of hyperuidation. In the natural condition of the uterus the mucous membrane under2:oes changes that render it suitable to become the nidus for and to em- brace and fix the ovum in its development. When conception does not take place the disintegration of the membrane and the flow are contemporaneous. If the membrane is overdeveloped by reason of a preternatural amount of connective tissue, then the membrane re- tains its integrity to a certain degree, and instead of flowing out as debris it is expelled as a whole or in large shreds. I believe with Scanzoni that the uterus in which the formation of this membrane occurs is in a state of hypersemia. Sometimes this hypersemia is trophic, and then the membrane will contain capillary bloodvessels and utricular glands, while in others it is inflammatory, and the discharge will contain fibrinous clots and false or fibrinous membrane, inclosing in its reticulum lymph and epithelial cells. This view of the subject will enable us to explain the microscopic appearances noticed in different cases. Clinical observation will also sustain the position that inflammation is the main factor in a portion of these cases at least. In the cases in which there is trophic hyperemia, the initial or actuating condition is probably nervous, and the influence reflected through the ovaries, as in the production of normal menstrual con- gestion or the hypersemia of pregnancy. Symptoms. The paroxysm is sometimes ushered in by nausea, vomiting, rapid pulse, furred tongue, headache, and increased temperature, and in many respects resembles inflammatory dysmenorrhoea ; at other times 152 DYSMENORRHCEA. there are no febrile symptoms; but in most cases of membranous dysmenorrhoea the stomach sympathizes with the pelvic trouble. The pains usually begin after the commencement of the flow and continue until the membrane passes. They are at first sharp, and dart from the pelvis in every direction, afterward cramping, and finally tenesmic or expulsive. The pains have for their object the separation and expulsion of the membrane, and subside as soon as this is accomplished. The more complete the formation of the membrane, the more urgent and painful the efforts to get rid of it. The most distressing part of the suffering depends upon the effort to overcome the resist- ance of the OS uteri to the evacuation of the membrane. Without this resistance it is uncertain whether there would be much pain, as I have known two cases in which the membrane was repeatedly evacuated without pain. In both cases the internal os uteri was patulous. I have never seen the membrane expelled by parous women. Diagnosis. This depends upon the discovery of the membrane either in pieces or as a whole. While my observation has not been sufficiently ex- tensive to enable me to establish a rule even for my own guidance, I believe it will be found that in cases attended with febrile symptoms the membrane will be of a plasmic character wholly, and that in those unattended by these symptoms the membrane will partake more of the deciduous character. The prognosis of membranous dysmenorrhoea is not very encour- aging, as it is very difficult to overcome the disposition to the forma- tion of the membrane. Treatment. The paroxysm of membranous dysmenorrhoea, especially the more febrile form, should be treated with a view to removing the obstruction. The cervix should be dilated by Hunter^s or some other dilator as soon as the pains become severe and ex[)ulsive in character; this will generally very materially shorten the duration, as it facilitates the discharge of the membrane. In connection with the dilatation, or without, an efficient dose of ergot will sometimes aid the process of expulsion very materially. Sometimes we may prevent or mitigate the severity of a paroxysm by using a fasciculus of slippery elm tents a day or two before it occurs, especially in the febrile form. OBSTRUCTIVE DYSMENORRnOE A. Ic3 If the paroxysm is attended with vomiting and fever, we should anticipate it by giving a cathartic the day before its occurrence and administer large doses of quinine. The administration of ergot between the paroxysms in the trophic variety will aid very materially in overcoming the hypersemic con- dition of the uterus, and produce a favorable influence upon the nerve-centres that preside over the process of ovulation. Mercurial and iodine alteratives should take its place in the inflammatory va- riety. The ammoniated tincture of guaiac. may be given with great propriety when a rheumatic diathesis is suspected. The local treat- ment of the two is very nearly the same, viz., dilatation and appli- cations to the mucous membrane of the cavity of the body of the uterus, as in cases of chronic inflammation and congestion of that organ. Obstructive Dysmenorrhcea. The clinical study of dysmenorrhcea will force upon the observer the conviction that, in the majority of cases, this symptom is the result of uterine contractions, and that the contractions are efforts made by the uterus to expel its contents. As I have already shown, this is the case in the membranous va- riety, the real cause of the expulsive pains being obstruction, not because there is contraction of the os uteri or cervical canal, but be- cause the substance expelled required more room for its passage than was affordeed by the os of normal size. In the inflammatory variety the same kind of pains are often no- ticed. Doubtless the cause of the expulsive efforts in this variety is the temporary stenosis of the internal os uteri, caused by the tume- faction of the mucous membrane at tl at point at the time of the menstrual congestion. This explanation presupposes endometritis with the greatest intensity of the inflammation at that point. Be- tween the menstrual periods the tumefaction subsides, and the os presents no evidence of stenosis. This is one form of temporary stenosis causing dysmenorrhcea. Another is spasm of the circular fibres surrounding the internal os uteri at the time of menstruation. We are prepared to understand how this may take place in patients of irritable fibre, when we remember the hypereesthesia that accom- panies chronic inflammation of the uterus and the congestion preced- ing the eruption of the menstrual discharge. 1 have no doubt that the cause of temporary stenosis, even in the inflammatory form, is often spasmodic closure, as blepharospasm is caused by conjunctival inflammation. 154 DYSMENORRHCEA. I think this spasmodic action is much more likely to occur in the inflammatory than in the neuralgic variety. There is one condition in which the expulsive pains of dysmenorrhoea manifest themselves with great severity where no stenosis exists. When there is a great degree of retroversion or retroflexion the cavity of the body is lower than the Internal os uteri. In such cases the extravasated blood, instead of flowing toward the mouth of the uterus, gravitates into the fundal portion of the cavity and there accumulates until its presence excites uterine contractions. It would seem from these considerations that much of the suffer- ing connected with retroflexion, and even anteflexion, with or with- out stenosis, is fairly attributable to the gravitation of the blood into instead of out of the uterus. I w^ould call attention to the figure of retroflexion, here introduced, to demonstrate this proposition : Would it be possible, even if there Fig. 39. Strong Retroflexion favoring Gravitation to the Fundus. was no stenosis, for the blood to flow out of a uterus in the position there represented? And would not the accumulation of the blood in the dependent cavity, and perhaps coagulating there, as certainly produce eflbrts at expulsion as any other foreign body? Since my attention has been directed, especially to this item, in the pathology of dysmenorrhoea, I have been convinced that too much importance has been attached to simple stenosis. Nearly all cases of obstructive dysmenorrhoea are associated with displacement or flexional deformity of the uterus. When gravity favors the outflow of the menstrual blood it requires only a very small passage through which to escape. I have repeatedly examined patients, in whom the external os uteri was not larger than a pin- OBSTRUCTIVE DYSMENORRHCE A. 155 hole, whose menstrual flow was easy and copious. AVliile thus ex- pressing myself with reference to the importance of malposition and flexion.d deformity of the uterus as offering a sufficient impediment to the discharge of the blood to induce the most distressing form of dysmenorrhoea, I would not ignore stenosis as one of the causes of it. Any cause that will give rise to retention of the menstrual flow will cause uterine contractions and pain. A typical case, in which dysmenorrhceal symptoms from forcible retention of the menstrual fluid are manifested, is congenital occlusion of some portion of the genital canal. If the obstruction is at the orifice of the vagina, the pains will not be of this character until the vagina is filled an(> a portion of the blood is retained in the uterus; but if the occlusion is at the uterus, the symptoms will begiu with the first menstrual effort. To witness a case of this kind will convince the observer that obstruction to the flow will give rise to dysmenorrhceal symp- toms. If there is a great degree of stenosis in a part of the genital canal symptoms of a similar character will occur. Symptoms, The main symptom of obstructive or retentive dysmenorrhoea is excruciating pain of an expulsive character. The pains are compared to colic, and the term uterine colic is c^uite appropriate. They generally come on before the commencement of the flow, and continue until the discharge is well established, when they gradually subside, and the flow continues from that time on without pain. In many instances the great congestion accompanying the effort at dis- charge, causing a sort of erection of the uterus, not only overcomes the stenosis, but it temporarily, to a great extent, corrects the position or deformity; without this correction the relief would not be com- plete. If the attendant will take the trouble to examine patients carefully during the flow — which by the way is very seldom done — he can easily convince himself of the truth of this statement. Diagnosis. The diagnosis may be established by physical examination. Ob- struction of the vaginal orifice by the hymen, morbid adhesions, or congenital deformity may be detected by ocular, digital, and instru- mental examination with the sound during the presence of the symp- toms. Malposition or flexions will be detected by physical examina- tion. 156 DYSMENORRHCEA. Prognosis, Like the other forms of dysnienorrhoei, the obstructive variety is apt to be very obstinate and difficalt to manage satisfactorily ; but as the corrective treatment is almost wholly mechanical or surgical, we may hope for good results. Treatment In cases where there is retroflexion with dependent fundus, the first and most important corrective measure is to elevate the organ so that the blood will flow into the cervix, and thus escape from the os uteri. This may be done before or at the time of the paroxysm. If we see the patient for the first time during a paroxysm, we should place her in the knee-chest position, and lift the fundus uteri up with one Fig. 40. Retroflexed Uterus with the Fundtls raised by a Pessary, finger. By this means we straighten out the cervix, and thus dilate the contractions and give the blood an inclined plane over which to flow and escape. This I am assured from repeated observation will often relieve a paroxysm. If this is not sufficient, with the patient still in the genu- pectoral position, we should introduce a sound to the fundus. In some cases elevating the womb, with or without the introduction of the sound, will relieve the patient for a few hours only; but if the pain returns, it may be relieved in the same way until the paroxysm subsides. Between the paroxysms a suitable retroversion pessary should be worn, and, if properly placed and watched, will go a great way toward effecting a cure. Rf» OBSTRUCTIVE DYSMENORRHCEA. 157 AVheii there is stenosis, we may often relieve the paroxysm by dilating the contracted point with a slippery-elm tent. There are two principal methods of relieving stenosis, viz. : 1st. By incision. 2d. By dilatation or stretching the parts, by instru- ments made for the purpose, and tents. Dr. Sims in his work on Uterine Surgery propounds the following opinions as to the causes of dysmenorrhooa, and bases his treatment on them. lie says (page 142): *' It (dys'raenorrhoea) is only a symptom of disease, which may be caused by inflammation of the cervical mucous membrane, retroflexion, anteflexion, flbroid tumor in one wall of the uterus or the other, con- traction of the OS externum, flexures of the canal of the cervix, either acute or greatly curved, either at the os internum, at the insertion of the vagina, or extending throughout the whole length of the canal, all of which are but so many mechanical causes of obstruction which must be recognized and remedied if we expect to cure the dysmenorrhoea." The following table is on page 132 : f OS was normal in but OS was contracted in Of 100 cases of painful menstruation, ....-{ cervix was flexed in congested in . . . [there were polypi in f OS was normal in OS was contracted in Of 29 cases of excessively painful menstruation, \ cervix was flexed in had polypi in [was congested in 6 90 61 7 2 26 23 2 1 This tabular testimony of 129 cases is a strong argument in favor of Dr. Sims's theory, that dysmenorrhoea is almost always caused by obstruction. As I have given the opinion of Dr. Sims as to the causes of dys- menorrhoea, I cannot complete this article without giving the reader an idea of the mode of treatment found most successful by him, viz., that of dilating and strengthening the canal of the cervix. He ex- poses the mouth of the uterus by placing the patient in the same position, and using the same instrument as for vesico-vaginal fistula. AVith a tenaculum he seizes and firmly holds the cervix, and draws it into the most convenient position. If the cervix is not flexed but merely narrow, he introduces one blade of the scissors into the canal 158 DYSMENORRHCEA, of the cervix far enough to divide it on one side up to the junction with the vagina, and then closes them. The other side of the cervix Fig. 41. rig. 41 represents the operation for dividing tlie straiglit cervix when too narrow. The dark part is the portion cut. On one side the knife is shown in the act of dividing the tissues. This is Dr. Sims's plan. is divided to the same extent in like manner, then, by means of the knife represented in figure, he divides the cervix up as high as the internal os. Fig. 42. Emmet's Knife for dividing the Cervix. From a cut in the June Number, 1864, Xeiv York Journal of Medicine. If the cervix is flexed, the lip of the uterus on the convex side is divided to the same height, and then the cervix opened with the knife. In this way the cervical canal is rendered rectilinear. RMt PEASLEE S METHOD. 159 This is represented by Fig. 43, taken from page 169 of Dr. Sims's work on Uterine Surgery. It shows the posterior lip already divided by the scissors, the tenaculum fastened into the anterior lip, and the knife being inserted as high as necessary. Fig. 43. " The representation in the cut is taken from the perfected instrument made by Wade & Ford, of New York city. To their ingenuity is due the application of the principle. The representation is half the size of the instrument, but the blade at full size is out of proportion, as it should be represented both longer and narrower." After Laving thus completed the operation Dr. Sims places in the wound of the lip of the cervix some cotton saturated with glycerin, and then proceeds to fill the vagina with cotton to guard against h^emorrhao^e, which he reo;ards as alwavs imminent. If there be but slight bleeding, it is not necessary to use more cotton than will keep the dressing in place. The patient should keep the recumbent pos- ture for several days. The cotton in the vagina may be removed in twenty-four hours after the operation ; that in the wound remains from two to three days. Dr. Emmet recommends that the sound be passed through the cervix every other day until the discharge ceases to prevent the parts from adhering. The sound need not be used for this purpose until the tampon is dispensed with. The following are the conclusions in practice of the late Dr. E. R. Peaslee :* " From the preceding facts I deduce the following conclusions : " I. The deep incision of the cervix throughout, and complete bilateral discission of the vaginal portion with deep incision above, are alike fre- * A paper read before the Kew York Academy of Medicine, 1876. 160 DYSMENORRHCEA. quentl J attended by certain immediate dangers, and not seldom produc- tive of certain serious remote consequences, viz., profuse and sometimes fatal haemorrhage, pelvic cellulitis, septic peritonitis (usually fatal), sterility, if not previously existing, and a tendency to miscarriage. "II. Those risks and effects are all due to the extensive division of the walls of the cervix, and to the consequent enlargement of the cer- vical canal ; and the sole compensation for all of them which can be calculated upon is the relief, and very often the cure, of stenotic dys- menorrhoea. "It therefore becomes a question of very great practical importance whether the amount of cutting may not be so far diminished as to avoid all these risks, and at the same time be sufficient for the cure of stenotic sterility and dysmeuorrhcea. But another inquiry antecedent to this is, how large a calibre of the cervical canal is actually required for the re- lief of these two conditions ; and a reply sufficiently definite for all prac- tical purposes is not so difficult as might appear. "In the imparous woman, the narrowest point of the cervical canal, viz., the internal os, is, when opened by the passage of the menstrual fluid, an ellipse, whose conjugate and transverse diameters average re- spectively one sixth and one-eighth of an inch ; its area corresponding very nearly* with that of a circle one-seventh of an inch in diameter. The external os, also elliptical when moderately dilated, has diameters averaging one-fourth and one-sixth of an inch. It thus has an area ex- actly twice that of the internal os, and equalling that of a circle one- fifth inch in diameter.f The larger size of the external os doubtless has a special reference to conception, and favors the entrance of the spermatic fluid into the cervical canal. It has no special influence against dysmenorrhoea, since the menstrual fluid, after having passed through the internal os into the cervical canal, would pass just as easily from the latter through an opening of the same dimensions into the vagina. Hence, we not very seldom see imparous women with the ex- ternal OS no larger than a ' pin-hole,' and who, nevertheless, do not suffer from dysmenorrhoea, though, as a rule, they are sterile. But if the lining membrane of the canal becomes thicker from congestion, or some other cause, such patients suffer at once from stenosis at the ex- ternal OS. " In the parous woman, the size of the external os varies within quite extensive limits, since it is exposed to so many of the accidents of par- turition, while the internal os is more nearly uniform. " I have deemed it desirable to ascertain the lowest average diameter of the two ora uteri in parous women, who are neither sterile nor have dysmenorrhoea, as a rational standard for determining the extent of in- * Tlie circle i« smaller than the ellipse, in the proportion of 144 to 147. f Circle to ellipse as 72 to 75. ■B peaslee's method. 161 cision actually required for the removal of these two conditions when stenotic. And, after a good deal of observation in this direction, I find that the inner os presents nearly twice the area of that of the imparous woman ; in the majority of cases admitting a sound one-fifth of an inch in diameter, though, in a large minority, one from one-fifth to one-sixth of an inch only can be easily passed. I therefore regard a diameter of one-fifth of an inch as ample for the removal of sterility and dysmen- orrhoea. I find the external os admits a dilator one-fifth of an inch in diameter and upward — in some cases as high as one-fourth or even three- tenths of an inch — but, as a rule, I think one-fourth of an inch sufficient for the purpose. It is of course to be understood that no narrowing of the canal exists between the two ora. Since, however, there may be some deo^ree of stenosis for the menstrual fluid, while not for the sound, it is sometimes judicious (and especially if congestion of the cervical lining membrane coexists) to increase the dimensions just named, by the use of a dilator of the next larger size. I do not assert that the pre- ceding dimensions are always required in the treatment of stenotic ster- ility and dysmenorrhoea, for they are not, nor that they are never to be exceeded, but that in almost all cases they will be found sufficient. "Should this precise specification of dimensions seem too minute for practical purposes, we must remember that dimension cannot here have a less important relation to function than elsewhere; and that enlarging the internal os to the diameter of half an inch, as is often done by the deep incision, is, as has been seen, like permanently dilating the urethra (if it could be done) to the size of the small intestine. And the impor- tance of making an incision of the internal os, with a precise intention and a precise knowledge of the mode of accomplishing what is intended, may be understood when I state that if the circle representing its area in the imparous woman be increased equivalently to surrounding it by a ring only one thirty-fifth of an inch wide, its area is increased as forty- nine to twenty-five, or almost exactly doubled. Or if an incision be made on each side of it to the extent of half a line (one twenty-fourth of an inch), and it then be dilated to a circle, it is increased two and a half times. And if the cut should extend one line to the right and the left, or the added ring were one-twelfth of an inch wide, the area would be increased more than four times and a half. This last increase is far more, in my experience, than is ever required in stenotic sterility and dysmenorrhoea. Superficial Trachelotomy — My oivn Operation. " III. Desiring to restrict the operation of trachelotomy in the treat- ment of stenotic sterility and dysmenorrhoea within the limits actually required, I, some ten years ago, devised and brought before the New 11 162 DYSMENORRHCEA. York Obstetrical Society* a series of five steel cervical dilators, to be used instead of incision, where the stenosis is slight and the cervix is normally soft and pliable. These, in shape and size, have a precise reference to the dimensions of the cervical canal, and especially of the two ora uteri, as already specified ; and each is guarded by a bulb, so as to project through the internal os into the uterine cavity only about one- quarter of an inch. " But finding that almost all cases of stenosis of the cervical canal are relieved more promptly, more permanently, and also with less pain, by incision, or this together with dilatation, than by any form of dilatation alone, I next endeavored to restrict the extent of the incision within the absolutely necessary limits, having determined them approximately by the preceding facts and calculations. To this end I devised a new method, and an instrument for executing it, which I also laid before the New York Obstetrical Society about eight years since ; but the former was so simple, bloodless, and unpretending, in comparison with the pro- cedures of Simpson and Sims, that it excited but little interest. Mean- while, however, it has been sufi&ciently tested, I think, by myself and my pupils in diflferent parts of the country, to entitle it to a more general notice. "Since the superficial incision, as suggested by myself, has for its direct object merely the removal of stenosis of the cervical canal, and is therefore proposed for the treatment of stenotic dysmenorrhoea and sterility only, it is previously to be decided whether stenosis actually exists. And the following propositions will aid in settling this question, it being understood that the exploration is to be made at least four days after, and at least three days before, the catamenial flow. A. Respecting Stenosis of the Internal Os. "1. If a sound one-fifth of an inch in diameter passes easily through the cervical canal, there is no stenosis at the internal os, and no incision is there required. This is the size, therefore, of my large sound. " 2. If a sound one-sixth of an inch in diameter be easily j^assed, as above, there is no absolute, though there may be relative stenosis of the internal os; i. e., there may be stenosis for the passage of a fluid, though not of the sound; and an incision to make it one-fifth of an inch may be required, but not unless the symptoms indicate it. "3. If the sound easily passed be but one-seventh of an inch in diam- eter, and there are no symptoms of stenosis, no incision of the internal OS is required. This is the normal size in the imparous woman, and the average size of Simpson's sound. "4. If a sound but one-eighth of an inch in diameter cannot be passed * Also described in the New York Medical Journal, July, 1870, p. 478. peaslee's method. 163 tbrougli the intei'Dal- os, there is either stenosis or, what is very much more probable, one of the flexions. Prove, therefore, that there is no flexion in this and every case in which a sound of any size does not traverse the internal os before operating for stenosis. I consider an in- ternal OS of one-eighth of an inch or less to be stenotic. Chrobak's high- est limit for stenosis of the internal os is one-tenth of an inch (two and a half millimeters). B. Respecting Stenosis of the External Os. '" 5. On the other hand, there is no stenosis of the external os if a sound one-fifth of an inch in diameter easily traverses it. If there be conges- tion of the lining membrane, however, there may be stenosis, practically, in respect to conception ; and the operation somewhat enlarging it (to one-quarter of an inch or more) may be required. "6. If the external os will not easily admit a sound one-sixth of an inch in diameter, there is probably stenosis in respect to conception, and the operation is required. If not more than one-seventh of an inch, the operation w411 also probably be required for dysmenorrhoea. " 7. In case of operation, the whole cervical canal must be made still to retain the normal fusiform shape as far as possible. "I. My metJiod consists in incising the internal os, if the stenosis exist at that part, — and the external, if at the latter, — to such an extent as to give to each its precise average dimensions in the parous woman, neither more nor less, and, of course, also overcoming any other point of stenosis existing anywhere else in the cervical canal. In cases compli- cated with congestion, however, I have shown that a slightly larger opening may be required, and, therefore, that the limits may extend be- yond one-fifth of an inch to nearly a quarter of an inch in the case of the internal os, and to three-tenths of an inch, and possibly more, of the external. "I do not, therefore, incise the internal or the external os to a given depth in all cases, but, taking them as I find them, cut just enough to give them their average normal size in the parous uterus. This is sel- dom one-half of a line and often not more than one-third of a line for the internal os, and not more than a line for the external. But, of course, there is far more variation in the latter. If the internal os admits a sound of but one-eighth of an inch in diameter, a cut on each side of nearly half a line (but three-eightieths of an inch) is required; and if but one-tenth of an inch in diameter, it must be one-twentieth of an inch deep on each side. The incisions are of precisely the same depth on each of the two sides. "Since the lining membrane at the internal os is at most one twenty- fifth of an inch thick, it is seen that I generally do not cut nearly through it. Indeed, when the os is but one-eighth of an inch wide, I 164 DYSMENORRHCEA. cut almost through the membrane; and when one-tenth of an inch, I divide it and one-hundredth of an inch of the tissue beneath it."^ "II. The instrument devised to secure this effect consists of a flattened tube, containing a blade. The former is eight inches long and seven- sixteenths of an inch wide, except its terminal one inch and three-quarters, which has a width of but one-eighth of an inch, as shown in Fig. 44. This portion is made curved by some instrument-makers, which is not an im- provement. The blade is of such a width as to slide accurately within the tube, having a nut and a screw attached to its proximal extremity to gauge the extent of its passage into the cervical canal, and a blunt point and lat- eral cutting edges for an inch and five-eighths at the distal end. There are two blades for each instrument, the cutting portion of one being a quarter Fig. 44. Dr. Peaslee's Metrotome, half size. of an inch wide, and of the other three-sixteenths of an inch. If the steno- sis is confined to the internal os, the narrower blade alone is used. If both ora are contracted, the wider instrument is passed through the external os, and the other blade then introduced and the inner os incised by it ; and in cases of decided congestion, the wider blade alone is sometimes used for both ora. In this case, a sound one-fifth of an inch in diameter is easily passed through the inner os; while, if the smaller blade had been used, considerable force would be required to carry it through. "In hospital practice I place the patient upon the side, use the duck- bill speculum, hold the cervix by means of a uterine tenaculum, pass the tube into the canal up to the shoulder, and, therefore, one-quarter of an inch into the uterine cavity through the internal os, when the blade, previously gauged, is introduced into the tube and carried up the cervical canal as far as is required to overcome the stenosis. My large sound (No, 10, American scale), or, still better, the conical dilator of the proper size, is then passed up the canal, and the operation is com- pleted. In private practice I generally place the patient on the back, and pass the tube into the cervical canal precisely as I would Simpson's sound, and then pass the blade through it, as just described. " If the external os is too narrow for the admission of the extremity of ray instrument, it may be enlarged by the introduction — generally one-eighth to one-quarter of an inch is far enough — of a narrow-pointed * The details of all the preceding calculations are properly omitted here, as a slight acquaintance with mathematics will enable the reader to verify them. peaslee's method. 165 bistoury. I have not found the internal os too narrow to receive it, except in cases of flexion, or previous traumatic injury of the cervix. " The changes in the whole uterine cavity from this operation are shown by Fig. 46. Respecting its dangers I have but little to communi- cate. The hi^morrhage following it seldom exceeds one or two drachms, and never requires any special attention. The pain is very slight and momentary, and no anaesthetic is ever required. The medullary struc- ture of the cervix never being cut into, pelvic cellulitis and peritonitis do not ensue. The only exceptions to this statement in nearly three hundred cases are: one case in private practice, in which some febrile reaction and uterine tenderness ensued, which subsided entirely, without cellulitis, in four days; and two cases, in the Woman's Hospital, of slight cellulitis. But both the latter were patients who were known to have had cellulitis a short time previously, and I was obliged, by some peculiar circumstances, to operate sooner than I otherwise would have done. The final results were precisely as desired in each of these three cases. Otherwise I have never had any unpleasant symptoms follow the operation ; and the only precautions taken are to keep the patient two days, and sometimes three days, in bed, and not allow her to walk out under a week. I use the dilator every second day after the operation for a week, and two or three times more once a week. I have very often performed the operation at my office on residents of the city, and sent the patient home to bed after half an hour's rest, and have never had to regret it. I decline to operate within four days after or six days be- fore the catamenial period. "I claim for the method just described the following recommendations in the treatment of stenotic sterility and dysmenorrhoea : " I. It aims to restore the normal dimensions as existing in the parous woman throughout the cervical canal, nothing more and nothing less, unless where a slight exaggeration of size is required on account of co- existing congestion. *^ II. It effects this object definitely and with certainty, and with inci- sions exactly symmetrical, or equal on the two sides. "III. It gives no danger from haemorrhage, since the arteries nearest the internal os, if that is to be divided, are never reached, and the whole thickness of the lining membrane even is generally not divided ; and there are no arteries within the portion divided at the external os. " IV. There is no danger of pelvic cellulitis, except in those patients in whom the least operative interference with the cervix, or the use of the sound or of a sponge-tent, will produce it. I consider the opera- tion less dangerous in this respect than the last mentioned. " V. There is no danger of septic peritonitis, since the medullary sub- stance is not reached'by the incision. " VI. It does not produce sterility or tendency to abortion by mutila- 166 DYSMENORRHGEA. ting the cervical canal. The changes it produces in the latter, as com- pared with those from the operations of Simpson and Sims, are shown by Fiss. 45, 46. 47. and 48. r:c.. Xonnal I terine Cavitr. Ditto, as modined by Peaslee's Method. Fig. 47. Fi.: rterine Cavity after Sims's Operation. Ditto, after Simpson's Operation. " YIII. It removes stenosis perfectly, and in most cases permanently, since there is verv little teudencv to closure of the slight incision made. HH DILATATION. 1G7 I have bad to repeat the operation only twice in my practice, except in cases in which there was cicatricial tissue to be divided, as after imper- fect and partial closure following rupture of the cervix in parturition, or ensuing after Simpson's or Sims's operations. Here the operation will usually have to be repeated in a year or two, unless pregnancy should occur, an event not to be expected in such cases, as we have seen. " Finally, then, since my experience has shown that a diameter of one-fifth of an inch for the internal os, and of one-quarter to three- tenths of an inch for the external os, is sufficient in the treatment of stenotic sterility and dysmenorrhoea, I suggest the disuse of Simpson's and Sims's operations in the treatment of these conditions, and the sub- stitution of a milder, safer, and more efficacious method, of which, per- haps, my own is, however, only the forerunner. At least, further experi- ence in the line I have indicated will doubtless afford still more accurate conclusions." Dilatation. Dilatation, properly conducted, often accomplishes the removal of contractions by expansion, and straightens a flexed uterus sufficiently to render the flexion innoxious. It is done by instruments which can be introduced, closed, and, while in the cavity, opened so as to cause distension. Notable among these are Hunter's and Nelson's. Fig. 49. Himter's Dilator. When the obstruction is not very great these will frequently be suf- ficient, but if there is much constriction they should give place to other means which bear more uniformly on the w^iole inner circum- FlG. 50. Dr. Nelson's Uterine Dilator. ference of the cavity. I doubt if much improvement has been made on those introduced by Dr. Mackintosh, fifty years ago. He em- ployed metallic sounds of different sizes. His method of employing them was to introduce one large enough 168 DYSMENORRHCEA. to produce some distension^ let it remain a few moments, and then one a little larger, and in the same waj succeed this by one still larger, until the dilatation is complete. This manner of dilating was repeated until the obstruction was removed. The introduction of the various forms of tents since the time of Mackintosh has di- verted the attention of the profession from this very effective method of dilating: the cervical canal. For the mode of usino- tents I would refer the reader to the subject Dilatation in another part of this work. Hank's hard-rubber dilators are elegant instruments, and may be used in the same manner as Mackintosh's. To use these dilators in the most effective manner the patient should be anaesthetized, placed in Sims's position, and the uterus exposed by his speculum. In the American Journal of Medical Science for January, 1867, I find the following summary, which I present to the reader without apology : ^'Comparative Merits of Incision and Dilatation of the Mouth of the Womb in Cases of Dysmenorrhcea. — Professor D. Humphreys Storer read a highly interesting paper on this subject before the Boston Society of Medical Improvement. The large experience and sound judgment of Professor Storer not only entitle his opinions to a respectful considera- tion, but his conclusions to entire confidence. He says : ' From a some- what extensive employment of sponge-tents during the ten past years for the treatment of dysmenorrhcea and sterility, I have formed conclu- sions different from those of the gentlemen of whom I have spoken (Drs. Barnes, Baker Brown, Greenhalgh, and Sims). I have not uufre- quently been disappointed in the result hoped for. The local obstruc- tion has almost always been overcome by the long-continued, persevering employment of the dilator, but the opened canal does not always re- move the condition thought to depend upon its closure, — dysmenorrhcea and sterility still remain. I have, however, never seen the ill effects spoken of from the employment of tents. I cannot recall a single in- stance where more than a few hours' inconvenience has been produced; and in such cases the expanded sponge, when removed, has proved to have been originally much larger than it was supposed to be — showing that he who employs these tents should be acquainted with their un- compressed dimensions. My experience has taught me, then, that these contractions, however firm they may be, may almost invariably be over- come. The physician need not feel that the part is undilatable because the application of three, or five, or half a dozen tents does not overcome it ; in a case occurring in my practice, about a year since, eighteen sponge-tents were introduced at intervals of two and three days before the canal was opened. My perseverance was rewarded by the perfect 169 relief of the patient. I could point, were it necessary, to several cases where, after years of sterility, the sufferer has been relieved and borne children, and in the intervals of their childbearing have suffered nodys- menorrhoea. I have repeatedly seen cases of dysmenorrhcea remain re- lieved for years, and known no return. In a word, I have relied upon dilatation to relieve these affections, and whatever opinions may be ad- vanced by others, so long as I feel we have a remedy from which we can confidently expect relief, and very rarely observe any injurious effects, I shall feel it my duty to employ it.' " That cases do occur where the difficulty cannot be removed by dila- tation, there can be no question ; but ' that incision is the only efficient and permanent remedy (in most cases) for dysmenorrhcea,' I unhesitat- ingly deny. " Let us for a moment look at the method proposed. Those who ad- vocate it should of course be satisfied that it has superior claims over the means now employed. I have thought the ill effects produced by distension might be occasioned by want of care ; but those arising from incision may follow the operation of the most skilful surgeon who advises it, when the metrotome cuts through the walls of the inner os ; and Dr. Barnes states, to employ his own language. ' there is no doubt that the surgeon has actually cut through the substance of the uterus, and wounded the plexus of vessels outside ; hence severe and dangerous haemorrhage has ensued, and inflammation of the periuterine tissues.' And even supposing the operation should be successfully performed, it is acknowledged by Dr. Routh, one of its advocates, ' that such an amount of contraction frequently exists as to render it necessary to have a di- lating substance worn for a considerable length of time to prevent its perfect occlusion ;' and Dr. Williams observes that ' oftentimes no relief is afforded. He had seen a patient whose cervix uteri had been slit up on both sides, forming two large protruding lips, without affording any relief to the sufferer.' Where the external os has been almost cartilagin- ous to the feel, I have overcome the obstruction with the hysterotome ; but I have never attempted to divide the internal os. I cannot, how- ever, recall the instance where it was required." — Boston Medical and Surgical Journal, September 2d, 1666. CHAPTEE IX. METATITHMENIA (3hzaTcdr;fj.i [rrf/) ; OR, MISPLACED MENSTRUATION AND PERIUTERINE HEMATOCELE. The accident to whicli I apply the above terms is an effusion of blood in tissues around and above the uterus, the effusion being sometimes very extensive, at others limited to a small space. The effusion may take place in the vaginal wall, between the vagina and rectum, tearing up their connecting tissue, or in the posterior wall of the uterus, beneath the peritoneum, or between the peritoneal layers of the broad ligament beside the uterus, or in the peritoneal cavity. The mode of the accident varies somewhat, owing to the locality in which this blood is found. The blood is effused in interspaces beneath the peritoneum and elsewhere, as the effect of a rupture of some vessel ; but while the effusion may be, and, perhaps, generally is, the result of a ruptured vessel of the ovary, the blood sometimes also arrives in the peritoneal cavity from the uterus through the Fallopian tubes. We are not yet able to decide which of these cir- cumstances is the more common. This accident happens most frequently at the time of menstrua- tion, or very near it. As an accompaniment of menstrual congestion, the bloodvessels of the whole genital organs are greatly distended, and in certain cases this turgidity becomes too great for their capacity, and a rupture is caused at some particular place ; or, the cavity of the uterus being filled with a profuse flow into it, the blood regurgi- tates through the tubes into the peritoneum. It is not likely, how- ever, that any considerable effusions are thus caused, so that t^e sudden and copious collections sometimes observed must be accounted for upon the supposition that a small arterial twig has given way in the ruptured ovisac at the time of the escape of the ovum, and poured the fluid rapidly into the sac formed behind the uterus by the descent of the peritoneum. The instances I have observed were more fre- quently connected with cases of disordered menstruation, but I have also seen the accident in patients whose menses seemed normal. Dysmenorrhoea may be regarded as the most common deviation accompanying misplaced menstruation. There can be no doubt but that effusions of blood, in every respect MENSTRUATION AND ITS DISORDERS. 171 similar to misplaced menstruation, are caused by the condition of the uterus and appendages in abortion after labor, and as the result of other causes of intense congestion ; but when so the modus in quo is precisely the same, the congestion being caused, not by the menstrual molimen, but by the congestion of pregnancy and morbid excitement which sometimes attend these two states, — rupture of a small vessel or reo-uro^itation beincr the immediate condition. Sanguineous collections arising in this way may be minute in size, but sometimes the quantity of blood is dangerously and even fatally large. The small collections are forced into places where distension is most difficult, as in the cellular tissue, while the large effiasions are met with in the peritoneal cavity. Immediately after the blood is extravasated changes begin to take place in it and the tissues occu- pied by it. Inflammation to a greater or less degree almost always is the result. In a mild o^rade the inflammation causes an effusion of serum, which augments the bulk of the accumulation and gives the appearance of much blood, when in reality there is but a small quantity. When this is the state of things, the disappearance of the tumor by absorption may be expected in a comparatively short time, and we often see it removed by absorption in a very few weeks. Dr. G. Bernutz has lately studied the pathology of uterine hsema- tocele, and presents his views in a series of interesting articles {Arch, de TocoL, March, April, and May, 1880). The most important con- clusions of this study are summarized by Bernutz as follows: " 1. Intraperitoneal uterine hsematocele may arise in two entirely dis- tinct and different ways. "2. In one case, which may be termed 'classic' hsemotocele, hsemor- rhage takes place from rupture of the products of extrauterine gestation, or from rupture of some of the internal organs of generation, or the escape of the blood which had distended the oviducts into the abdominal cavity, where a secondary peritonitis is set up by its presence, this inflammation leading to incapsulation of the bloody collection. " 3. In other cases the h^ematocele is the result of a primary pelvi- peritonitis, the haemorrhage occurring at a period more or less remote from the incipience of the serous inflammation. In this case the disease is a secondary manifestation of inflammatory action, and its true origin is found in the newly-formed membranes lining the pelvic peritoneum. "4. These neomembranous hseraatoceles may be symptomatic of various conditions. Thus they may indicate an acute pelviperitonitis in a woman who was previously attacked by a more or less severe inflammation of the pelvic peritoneum, or they may point to a repe- tition of former subacute inflammations, or, in fine, to a chronic pelvic 172 METATITHMENIA. peritonitis of a particular kind. There are, therefore, two varieties of hsematocele symptomatic of pelvi-peritouitis, each of which has a patho- genesis of its own. "5. In the h^ematoceles denoting an acute or subacute peritonitis, the haemorrhage arising in the newly-formed membrane is from the outset rather profuse, being commonly determined by menstrual congestion. For this reason an intraperitoneal hsematoma becomes at once manifest. Frequently it becomes a matter of difficulty to distinguish between the two kinds of hsematocele unless the period of incipiency has been ob- served by the physician. Fortunately the practical importance of this fact is not very great, since the treatment is essentially similar in both varieties of the disease. In the second form of hsematoceles, which alone exactly corresponds to Virchow's description, the hsematoma is the result of scarcely suspected morbid action, which is very well indicated by the name of hoemorrhagic pachypelviperitonitis. Under the influ- ence of this chronic process the pelvic peritoneum is occupied by strati- fied patches of new-formed membrane. In this way it becomes thick- ened as it were, and slight haemorrhage takes place between the super- imposed lamelke, thus forming interstitial blood-cysts. These hsemato- celes are strictly analogous to similar tumors of the tunica vaginalis."'^ The intensity of the inflammation is frequently much greater, pro- ceeding through the stage of serous effusion to the production of fibrinous deposit. A hard tumor is the result. This again may remain for a longer or shorter time, and then very slowly disappear, or only be partially taken away, leaving a permanent hardness, or, what is not unfrequently the case, proceed to suppuration and dis- charge in some way. I have seen as many as two cases terminate fatally by the exhaus- tion of suppurative fever without the discharge of the contents of the tumor. When suppuration is fairly established by the inflammation thus arising, exulceration and evacuation follow as a general rule. The vagina is most frequently perforated by the ulcerative process, but the rectum, bladder, or uterus may serve as the conduit of dis- charge. If the inflammation is of an acute character, and the steps in the process of evacuation rapidly succeed each other, the character of the discharge will partake largely of a bloody quality; but should the time required by exulceration be considerable, pus will prevail in the composition. In any case, however, the discharge is a mixture of pus and changed blood. This last is sometimes very greatly changed, sometimes but slightly. In rare instances the peritoneum ^ January, 1881, number of the American Journal of Obstetrics. SYMPTOMS. 173 is inundated by rupture into its cavity of this mixture of pus and blood, and overwhelmed witli a general inflammation, soon resulting in death. I have seen cases of this kind, which were verified by post-mortem examination. After absorption in cases attended with the milder grade of inflam- mation, very slight traces, if any, can be found by examination of the patient. AVhen effusion of fibrin takes place, displacements, per- manent adhesions of the uterus and other parts, and deformity, will be left behind, slight or considerable, as the amount of deposit was small or great. These changes will, of course, be greater after the process of suppuration and discharge has been reached by the inflam- mation. Fistulous and tortuous openings may also embarrass the convalescence of the patient, or even by their long continuance ex- haust her. Symptoms. The symptoms vary in different instances. The attack is generally sudden and well marked. During the menstrual flow, or it may be just before or after, the patient is seized with severe pain in the hypo- gastrium or one of the iliac regions. Frequently there is also a sense of faintness, som'etimes slight, but often it amounts to complete syn- cope. In place of the faintness there are sometimes coldness and tremors. The pain becomes persistent, and, perhaps, less severe, but not unfrequently it increases for a considerable time and then gradu- ally diminishes. After the inception the pain usually spreads over the abdomen to the back and hips, and sometimes down the thigh and leg. As the pain becomes greater or extends over a greater space, febrile reaction is developed, generally moderate in grade, but occa- sionally excessive; the pulse becomes rapid, the heat considerable, and the patient complains of great depression and thirst. The abdo- men increases in size and becomes tympanitic, while there may be a distinct tumidity and hardness felt in one of the iliac regions; some- times the hardness extends over the hypogastric to the other ilium. This hardness and swelling may scarcely rise above the pelvic brim, but it not unfrequently is perceived extending as high as the umbili- cus. It is not much, if at all, tender to the touch. It is irregular in its outline also. In very rare instances the effusion takes place slowly, the symptoms are developed quite gradually, and the time of the beginning is not so definite, but the subsequent course is apt to be the same. After the symptoms are fully manifested, they pursue a course 174 METATITHMENIA. corresponding to the grade of inflammation which is awakened by the effusion. In some cases the inflammation around the effusion is active and intense, and continues with severity until suppuration and exulceration end the process. Of course the fever is corresponding in grade and persistence, pass- ing through the high grade to hectic, attended with all its exhausting discharges. If the inflammation is less acute, the fever may be per- sistent for weeks, and sometimes for months, but of more moderate grade, until it gradually subsides, or slowly ends in suppuration and discharge. Fortunately, in the large majority of cases, the amount of the effusion is small, the grade of inflammation slight, and the duration but a few days or weeks. There are two ways in which individuals are rendered miserable by the frequent recurrence of this trouble. One is, when all the symptoms subside entirely for months, and then return. The tumor entirely disappears, the inflammation is wholly gone, and the patient feels that she has fully recovered her health, when, suddenly, during a menstrual flow, she is again seized with pain, swelling, fever, etc., which again subsides to be repeated more or less frequently. I have a patient who has suffered attacks of this sort perhaps twenty times in the last six or seven years, in whom the tumors have at different times been mistaken for ovarian or uterine tumors. In the other way the subsidence is only partial; there is all the time some tumidity, some inflammation, and more or less sympathetic suffering, with occa- sional severe returns. More blood is effused, the tumor is increased in size, and the inflammation intensified, and all subside to a partial extent and return again. When the tumor is much inflamed and suppurates, it may suddenly discharge through the vagina ; all the urgent symptoms readily sub- sides, and the patient becomes convalescent. Again, the discharge is sometimes slow and difficult, the relief is imperfect, and a pro- tracted convalescence the result. But sometimes, after a course corre- sponding to the above description, sudden and general peritonitis is lighted up by extension of inflammation from the sac, or a discharge of some of its contents into the peritoneal cavity. The discharge is generally fetid and highly irritating, consisting of partially decomposed blood, pus, and ichor. It is always offensive compared with discharges from an ordinary abscess. I have seen one or two instances in which the general symptoms were not manifested at all, nor did the pain amount to anything more than an inconveni- ence, not very difficult to bear. DIAGNOSIS. 175 It is iuteresting to observe the effects of tin's misplaced menstrua- tion upon the flow per vlas naturales. Occasionally no effect seems to be produced, the flow being natural in quantity and duration ; in fact, it is just at the time of the cessation of the discharge that effu- sion into the tissues takes place, but at other times there continues for many weeks a constant stillicidium of blood. Or, occasionally, — when the menses occur during the course of the symptoms, — the amount of discharge is very much increased. I knew one patient that had a constant slight sanguineous discharge from the vagina for six months, and at the regular menstrual periods copious haemor- rhages. In some cases the flow is more scanty than usual. Diagnosis. There are several conditions with which this sanguineous effusion may be confounded, if some caution is not observed. Inflammation of pelvic cellular tissue, or pelvic abscess, is the one most likely to be mistaken for metatithmenia, or this last for the first. And as I have already shown abscess is sometimes the result of misplaced menstruation, the effusion in the tissues exciting intense inflamma- tion, which proceeds to the stage of suppuration. In cellulitis the inflammation is not ordinarily ushered in by the same suddenly occurring acute pain and faintness. Chilliness and fever are more marked from the beginning, the pain usually com- mencing after the fever has begun, or, at least, increasing after the fever is established. The tumor above the linea ilio-pectinea is not perceptible for many hours, oftener one or two days ; it is extremely tender, and even in its outline. In metatithmenia the tumor is observed in a few hours, and is not so very tender to the touch. It may be handled and pressed upon much more freely than the tumor of simple inflammatory origin. If examined per vaginam the inflammatory hardness and swelling is very firm. It is usually lower down and more to one side. The tumor from sanguineous effusion is quite elastic at first, and presents an edgelike projection down behind the uterus, entirely below the os and cervix. The finger may be pushed up between the cervix and the tumor, and the thick convex edge of the latter reminds one of a thick cake. There is very little tenderness, and vessels may almost always be felt pulsating over this projection. I need not say that this is never the case in the early stages of cellulitis. The vessels in this last are obliterated by fibrinous and serous effusion. If inflammation of a high grade speedily follows the effusion of 176 METATITHMENIA. blood in the tissues, the symptoms of the two may be so intimately blended as to make it doubtful how the tumor began, and, in fact, it may be converted into pelvic abscess. Tumors of the uterus, under certain circumstances, may be con- founded with the tumor of sanguineous eifusion ; but their firmness, the want of conformity to the shape usually assumed by this last, the enlargement of the uterine cavity, our ability to isolate them by the fingers and probe, their gradual, unperceived growth, and their mo- bility, will almost always suffice to make the distinction manifest. From ovarian tumors it may be distinguished by the more regular outline, fluctuation on percussion, less grave symptoms, gradual de- velopment, absence of the projecting edge behind the uterus, the want of the beating vessels, etc., in ovarian growths. Displacements of the uterus may always be made out with great certainty by introducing the probe into its cavity to ascertain the di- rection of the fundus, and correcting its deviations. Hence the diag- nosis need not be long embarrassed by any question in reference to them. Retroversion of the impregnated uterus is constantly attended with great urinary distress, while metatithmenia seldom is. Extrauterine pregnancy, perhaps, in some instances, more nearly resembles it than any other, but the enlarged and flaccid cervix, open OS, dark color, and enlarged cavity, in this sort of pregnancy, and their absence in the accident we are considering, will suffice to dis- tinguish between them. Prognosis. The dangers to be apprehended in uterine hsematocele arise from : 1st, the shock of the effusion in the peritoneal cavity, which, however, is not generally considerable; 2d, fatal exhaustion from the amount of effusion in the abdominal cavity; and, 3d, inflammation and its effects. From inflammation we may fear death, permanent damage to the organs about the pelvis, and great suffering. Very few pa- tients escape without protracted suffering, often for weeks, and some- times months. Damage to a greater or less degree frequently follows the displace- ments, adhesions, perforations, and thickening of the uterus, vagina, rectum, and bladder. The exhaustion of protracted febrile excite- ment; the perspiration, diarrhoea, and vigils not very seldom wear out the vital resistance of the patient, who is often of a very delicate constitution; or sudden and violent inflammation of the peritoneum overwhelms and destroys her. TREATMENT. 177 The prognosis iu any given case will be governed by the intensity of the symptoms and the comparative strength of the patient. If the amount of the effusion be never so large, and there be but little inflammation, the prognosis is more favorable than if the effusion be small and the inflammation great. In fact, we may with great pro- priety form our prognosis by the amount and intensity of the inflam- mation alone, as it is almost the only source of danger. As before observed, a cause of death, though not frequent, should nevertheless be mentioned as influencing the general subject of prog- nosis in misplaced menstruation, viz., a fatal amount of extravasation of blood in the peritoneal cavity. More than one case is recorded in which there was fatal prostration, coming on and pursuing its course in a few hours, which, when examined, revealed, as the source of an extensive and copious haemorrhage, the ruptured twig of an artery on the ovary. Of the many cases that come within our observation, however, the number that thus prove fatal are extremely few. Treatment. The three great facts of this accident — haemorrhage, pain, and in- flammation — afford us sufficiently plain indications for treatment. It is very seldom that we are sent for, or in any way see these cases, until after the haemorrhage has exhausted itself or been stopped by backward pressure, after filling up the space into which the bleeding takes place. Should we, however, meet with an instance during the haemorrhagic stage, it would be very proper to make use of ice to the pelvic region, perfect quiet, and astringents internally, until the effu- sion ceased; but, as I said before, such opportunities seldom offer themselves. The cases as we ordinarily see them have proceeded through this stage ; the effusion, in fact, is generally accomplished in a few moments, or at most in very few hours. When we see the patient, she is either suffering with pain and prostration or coldness, the primary effects of the haemorrhage; or pain, fever, and inflam- mation, and our treatment will be conducted according to the con- ditions in these respects. Our resources in the first condition will lie in the use of opium or other anodyne, to relieve the pain as much as may be necessary, and if the prostration or chilliness is considerable, to stimulate sufficiently to establish equilibrium in the circulation, but not febrile reaction. In very many cases it will be sufficient to keep our patient quiet, and place her upon moderate anodyne treat- ment, good nourishing diet, and perhaps, after the first week or two, 12 178 METATITHMENIA. tonics, and she will slowly rally from the first shock, absorption of the blood will result, and she soon will recover her health. In these moderate cases we cannot be too careful not to overdo the treatment. The patients will generally recover spontaneously in a few days or weeks. But another class of cases occur, as I have already said, in which inflammation very soon succeeds the sanguineous effusion. A knowl- edge of the mischief which this inflammation brings about should make us prompt in meeting it with appropriate remedies. If the inflammation runs high, adequate antiphlogistic measures will be indispensable to a favorable course. An active cathartic of calomel and jalap or some other alterative cathartic should begin at once, while at the same time, if deemed advisable on account of the force of reaction, we may apply a dozen or twenty leeches. These may be followed by the tincture of veratrum viride, in doses of two drops every hour, until the pulse is brought down to its natural frequency and volume, if not below these conditions, and then continue its use in less doses, or the same less frequently repeated, for some time. According to my observations, the most of adults will be held at this point by taking as little as one drop an hour ; some will require more and some less. The energy of this antiphlogistic course must be graduated by the force of inflammation ; but few cases will require as much as is described here. Should the inflammation advance to suppuration, the remedies required will be supporting; at first, sulphuric acid and quinine, and afterwards these with wine or other stimulants, nourishing diet, etc. These cases are often so protracted, the patients are so much prostrated, and suffer so much pain, that great skill will be called for to adapt the anodynes, tonics, and nutri- ents to the various conditions of the patient for so long a time. A question associated with the progress of inflammation, and one of great importance, is the propriety of evacuating the fluid. To evacuate the blood soon after its extravasation would seem to remove the cause of inflammation, and thus avoid it. To say that an early evacuation of the effusion would never be proper is perhaps to assume an extreme position, and there may be cases where such evacuation ,is advisable, but I think the number requiring it must be very few. Indeed, I should fear inflammation, from the sudden discharge of a large amount of blood from the peritoneal cavity, almost as much as if it were allowed to remain in it. There is another condition in which an operation for discharge of the contents of the tumescence is less a question of doubt, viz., when pus has become mixed with CHRONIC RETROUTERINE HEMATOCELE. 179 the blood, on account of inflammation. It is very important in some instances to puncture and discharge the fluid. When the patient is being worn out by the protracted course of the disease, and the per- spirations and diarrhoea which so often attend it, we must interfere surgically for her relief. And again, when the fluid is increasing, and the tumor rising in the abdominal cavity, without showing any disposition to "point" in the pelvis, or any other place where it is desirable to have it do so, there is danger of the discharge of the pus and blood in the peritoneal cavity by rupturing the sac above, and we must anticipate it by choosing the place and mode. When we have determined to relieve the distension by puncture, we ought to use an exploring-needle or trocar to ascertain the contents before evacuating them. After being satisfied by this corroboration of our diagnosis, we may plunge a large trocar, or even a knife, into the most dependent part of the tumor. This point will almost invaria- bly be immediately behind the uterus, but occasionally it will be at the side of the pelvis. After free puncture, either with the trocar or knife, the discharge readily takes place, and the patient immediately experiences great relief If the puncture is made to remove the blood before inflam- mation has begun, the evacuation may be more difficult, as it is often coagulated ; in that case the opening must be made large with a knife, and if the blood does not easily flow, the finger may be introduced to break up the clots aud facilitate their expulsion. After the con- tents are thus expelled as near as can be, they sometimes reaccumu- late and are again discharged, and repetitions of these processes lead to still more chronic suffering, until the patient becomes a perma- nent invalid, or dies from such long-standing exhaustion. We may, with a good deal of certainty, cause contraction, granulation, and obliteration of the cavity, by injecting it with iodine, wine, or other irritant. The best way to secure efficiency in injections is to intro- duce through the fistulous opening, or one made for the purpose, a small flexible catheter, so as to reach the bottom of the cavity and throw the fluid through this tube. We thus place the fluid used in full strength in contact with the walls of the cavity, while the injec- tion thrown out of a common syringe will mix it up with the con- tents of the sac, and thus dilute it. Chronic Retrouterine Hcematocele. I have met with a considerable number of hsematoceles that did not terminate by absorption on suppuration, but remained in a latent 180 METATITHMENIA. condition, sometimes for years, and then became the subjects of change in their contents Tvhich rendered radical treatment indispensable. In the history of many of these cases the essential facts necessary to lead to a rational diagnosis are lost. The time when the eifusion occurred is so remote that many of the svmptoms have been forgotten, or taking place contemporaneously with an abortion, or paroxysm of dysmenorrhcea, the symptoms of haematocele were so blended with those of the other condition that thev escaped notice. Xot unfrec[ueutly our attention is called to these cases in the hands of inexperienced practitioners without being recog- nized, for a long time passing for retroversion of the uterus. After a greater or less length of time some of them undergo rapid increase of size, from an accumulation of serum, while others grow more slowly, but still become decidedly inconvenient tumors. One of the former kind has quite recently come under my notice. The patient was twenty-four years of age, the mother of two children, enjoyed good health until two years since, when she had, without any assignable cause, severe flooding, and was thereafter confined to bed for several weeks. She gradually recovered sufficiently to very poorly attend to her household duties. She did not have the advice of an experienced practitioner until three or four months before she came under my notice. Her physician at that time discovered a retrouterine tumor that extended above the brim of the pelvis, with the most prominent elevation on the right side, where it arose one and a half inches above the pubis. A^'hen first observed the lower portion of the tumor extended about an inch below the cervix uteri. From that time the tumor grew perceptibly until, at the time she came to me. the posterior cul-de-sac was very tensely distended. The lower end of the tumor was elastic, but too tense for undoubted fluctuation. The upper part of the tumor remained as above de- scribed. Dr. D. T. Xelson examined the patient on the same day, Thursday, the 24th of February, 1881. We requested her to call again on the 27th of the same month, or three days later. When she came again for examination we were both astonished at the rapid increase in size manifested at the lower end of the tumor. The lower end of the tumor was so much larger and descended so far down as to begin to separate the external labia. The question with us was between a fungus or malignant tumor, behind and attached to the uterus, or an old haematocele. She was at once admitted into the Woman's Hospital, and the next day a small trocar was thrust into the tumor for exploratory purposes. CHRONIC RETROUTERINE HEMATOCELE. 181 A large amount of reddish serum was ejected with great force through the canula. I then made a small incision by the side of the trocar, through which I introduced my finger, and enlarged it so that I conld introduce two fingers into the cavity. The fingers at once en- countered large deposits of macerated fibrin clinging to the wall of the cyst. These were separated as far as practicable, the cavity thor- oughly washed out, and several pledgets of cotton saturated with tinc- ture of iron introduced. The serum contained albumen and the coloring matter of blood. A very remarkable case, with the commencement of which I was cognizant, is recorded in the first volume of the Transactions of the Americam Gynaecological Society, by George H. Bixby, M.D., of Boston. I saw the patient and attended her for three or four months after the eflPusion occurred and diao;nosed retrouterine hsematocele. Duriuo^ the time I attended her the tumor decreased decidedly, and I fully expected it to be entirely absorbed. The patient, as Dr. Bixby ob- serves, passed out of my care, but remained in Chicago, where I could know somewhat of her condition. She was an invalid during the whole seven years intervening be- tween my attendance and the time she went to Boston. As she was leaving Chicago for Boston she desired me to make an examination. The tumor was easily recognized at that time, but was not large. I subjoin Dr. Bixby 's description of the case after she went to Boston : "Mrs. H , aged thirty-nine, a resident of Boston, consulted Dr. Mack, of St. Catharine's, Ontario, for an obscure pelvic tumor. On the following day I was called in consultation. The patient was of dark com- plexion and nervous temperament. Menstruation, which first appeared at eighteen and recurred at intervals of three weeks, was scanty and painless. In her youth she was unusually fond of outdoor sports, and later in life indulged in horseback exercise. She was married at twenty- one, and supposed she miscarried two years later. Seven years pre- viously, while under the care of Professor Byford for uterine disease, she became the subject of hsematocele, but shortly after passed out of his hands. For two years Mrs. H. had been suffering from a peculiar pain in the left ovarian region, and also from renal and vesical derangements. She described the pain as occurring in paroxysms, at first light, gradu- ally increasing in intensity until almost insupportable, then as gradually subsiding. Soon after the occurrence of the above symptoms her attention was directed to a tumor the size of a small orange at the seat of pain. In the dorsal position, with the limbs flexed, percussion gave evidence 182 METATITHMENIA. of a well-defined dulness in the left ovarian and siiperpubic regions ; by bimanual palpation unmistakable fluctuation. The uterus was fixed, and lateroverted to the right ; its cavity two and one-half inches in depth. Exploratory puncture (through Douglas's fossa), with a small trocar by Dr. Mack, confirmed the existence of fluid. Three pints of a light straw-colored serum were withdrawn by aspiration, which completely emptied the cyst. The result of an analysis by Dr. Fitz, of Boston, was as follows : ' A clear, light reddish-brown, odorless, slightly alkaline fluid, sp. gr. 1020; absence of sediment ; abundance of albumen, it becoming solid by boiling ; abundant chlorides and sulphates. Microscope reveals numerous oil-globules, a few round cells with large nuclei and a small amount of granular protoplasm ; an occasional granular corpuscle. If it be a question between ascitic or ovarian, the latter is probable.' Notwith- standing this result we were disposed to consider this case one of encysted dropsy of the peritoneum following hsematocele. Being now intrusted to my care she was ordered rest in bed, no treatment. Not the slightest reaction followed the operation, and in the course of three weeks she resumed her ordinary duties. Dr. Mack was disposed to attribute much of the pain as well as the renal derangement to pressure upon the nervous filaments of the tissues in the vicinity of the cyst. The description of the pain and the renal and vesical symptoms were at least suggestive of some interference with the functions of the ureter by pressure from the cyst. " The following letter from Dr. Byford, received since the operation, tends to confirm the diagnosis : '' ' Dear Doctor : I can emphatically indorse your diagnosis and proposed treat- ment. In my own practice I have met with but two cases of serous accumulation after hematocele. One was cured by a single tapping with the aspirator, the other by establishing a permanent drain from the cavity. In the last case reaccumulation took place. I then punctured with a large trocar, and passed through the canula a flexible catheter, and left it in position. The cure was effected in about three weeks.' " Diagnosis. The diagnosis of these old hsenaatoceles is not always easy. The history, if the patient can intelligently trace it, will often lead to a strong suspicion of the character of the tumor. The primary attack may date back several months, and sometimes as many years, and may have been distinguished by symptoms arising from the continued presence and occasional augmentation of the tumor, indicative of some form of pelvic disease. Not unfrequently, however, the commence- ment is so obscured by attendant circumstances as to evade the most diligent inquiry, when we shall be obliged to depend upon recent developments and physical examination for a diagnosis. TREATMENT. 183 In many cases the patient will have suffered a long time from pelvic symptoms, and be aware of the existence of a tumor. The tumor is often mistaken for grow^ths, as ovarian or uterine tumors, and even extrauterine pregnancy. In hematocele the tumor is situated behind and adherent to the uterus. The uterus is pressed strongly forw^ard and upward, and generally to the right side, so that the fundus may be felt above the right ramus, itself simulating a tumor. Generally the top of the hsematocele may be recognized by pressing the hand down into the brim of the ])elvis, while the lower end will be found to fill up the cul-de-sac of Douglas, and distend it very greatly. The distension is especially downward, reaching occasionally as low as the external organs. I should regard the forcible downward distension of the cul-de-sac with fluid as a very important, if not a distinctive sign of chronic hsematocele. The upper part, or fibrinous covering of the hsemato- cele, is inelastic and does not permit of distension in that direction, while the w^alls of the retrouterine pouch is elastic and permits dis- tension. An ovarian tumor, a tumor of the lateral ligament, or an extrauterine pregnancy develops upward instead of downward. While any or all of these may be felt to occupy the cul-de-sac they do not forcibly distend it downward. Instead of displacing the uterus upward as well as forward, they displace it forward at first, and afterwards downward. The hardness and more globular shape of a fibroid tumor, situated in the retrouterine space, will generally enable us to distinguish it from an old hsematocele. An abscess is seldom situated immediately behind the uterus, and when it is there is generally so much hardness around the presenting fluid as to make the distension irregular, aside from the usual tenderness. When the diagnosis cannot be made in any other way the tumor may be aspirated. The fluid drawn from an old hsematocele is well described in Dr. Bixby's case. The coloring matter of the blood is always noticeable. Treatment. The proper treatment of the chronic hsematocele consists in evacu- ating it, draining the cavity, and frequent injections of some disin- fectant solution, — the carbolic acid or permanganate of potash. When a sufiicient amount of fluid is removed for diagnostic purposes the trocar or aspirator needle may be taken as a guide for the incision. The incision should be made in the most prominent part of the tumor 184 METATITHMENIA. large enough to admit the finger. The index finger should be intro- duced through it, and be made to tear a large opening into the sac. The opening must be large enough to admit two fingers freely into the cavity. Large deposits of the fibrin of the blood will be found adhering to the inner wall of the sac. The removal of these coagula of fibrin is very important, for if allowed to remain they will undergo decomposition, and thus be the source of sepsis. The large opening I have recommended has the advantage of per- mitting the free use of the fingers for this purpose and the efficient cleansing of the cavity by injections. When carefully performed this operation causes little or no shock, and the patient usually recovers in two or three weeks from the effects of the evacuation. It requires several months for the sac itself to be removed by absorption. Eventually, however, it disappears to such an extent as not to be recognizable by an ordinary vaginal examination, and with proper care the patient speedily recovers her usual health. I CHAPTER X. CHANGE OF LIFE— MENOPAUSE AND SENILITY. At the period when woman ceases to menstruate various changes in her system occur, which constitute what is termed " change of life." •The peculiar anatomical feature noticeable is progressive atrophy of the ovaries, uterus, and usually of all the other female organs, in- cluding the mammary glands. Dr. Tilt, in his excellent work on the Change of Life, says: '^Pu- berty and the change of life are caused by anatomical changes, the one by ovarian evolution, the other by ovarian involution.'^ I should say these two conditions were accompanied by, instead of caused by, the ovarian evolution and involution. The change of life is an important epoch in a woman's existence, for if not, as Dr. Tilt thinks, the cause of many diseases, it is con- temporaneous with a number of the most dangerous affections, and certainly modifies very materially the course of others. When not accompanied by disease it is normal, and usually leaves the Avoman, to say the least, in no worse condition than before it occurred. Gen- erally she becomes more vigorous after it, and her prospects for life and health are increased. The change of life is gradual, requiring from one to^eight, or even ten years for the processes of involution and changes in all the body to take place. The average of the menopause is forty-five years. "While it may not always be the case I think a very early or very late men- opause is abnormal in other respects than time. The cases that come about very early in life are much more frequently than otherwise caused by pathological conditions. Peculiarity of organization is the only way to account for the remainder. Such instances as have fallen under my observation were without exception preceded by diseases of the uterus and probably of the ovaries. I say probably, because the ovarian affection cannot always be diagnosticated with certainty. The late menopause I have not met with as often, and I have not been so clearly convinced of the condition of the patients as in the former. In such cases as I have noticed most of the women seemed to be peculiarly vigorous, though sometimes I have thought the long- 186 CHANGE OF LIFE — MENOPAUSE AND SENILITY. continued functional activity of the genital system appeared to depend upon chronic hypersemia, caused by tumors, congestion, or inflamma- tion. Simple cessation of the menstrual return is not the change of life. When the menses cease from a failure of the general j)Owers, the term will not apply. The cessation of the menses does not always take place in the same way. Sometimes it occurs suddenly, with no change in the quantity, quality, or periodicity up to the last return, and with no premonitory symptoms. At other times a change in the periodicity of the men- strual flow occurs as a premonitory symptom of its cessation, the* intervals in some cases being irregular, in others steadily decreasing in time until complete cessation occurs. Not unfrequently the menstrual discharges grow progressively less for ten or twelve years before they completely cease. By this method the change of life becomes an accomplished fact only after a compara- tively protracted transitional period. Sometimes a severe hsemorrhage is succeeded by the menopause. IN^umerous other methods exist by which this important change is brought about ; those which I have mentioned are the more common ones. There are probably no reliable symptoms, not immediately con- nected with the cessation of the menses, to indicate the approach or even the progress of the change of life if the woman is in a perfectly healthy condition. The change, when a healthy one, is so gradual that the various organs and the nervous and vascular systems have ample time to accommodate themselves to the difference in the func- tions of the sexual system. Does the change of life give origin to the diseases, or to any of them, occurring at that time? My opinion is that it does not. I believe them to be merely coincident. Fibroid tumors of the uterus and cancer of various organs do frequently occur about the time of the menopause, but they also are often met with both before and after that period. The long list of diseases and symptoms enumerated by Dr. Tilt are only evidence that the woman was diseased before, or became so at the time, from other causes, instead of indicating the change of life as the cause of them. Yet there is little doubt that the progress of existing disease is modified by the changes in the circulation, nutrition, and nervous energies which occur at the change of life. In different parts of the present work I have alluded to this in describing the diseases in per- CHANGE OF LIFE — MENOPAUSE AND SENILITY. 187 sons of different ages. Women undergoing the change of life who are not tlie subject of disease require no special management or treat- ment. It is well to have them as nearly as possible cured of the inflammations, congestions, and displacements which afflict them, as that will cause the process to be more easily and naturally accom- plished. However, I think we need not fear that the change of life will be disastrous either as a cause of disease or by injuriously modi- fying those already existing. As elsewhere stated, we usually expect chronic inflammation and its consequences to be benefited, if not en- tirely cured, by senile involution of the organs of generation, and we also often find the fibroid degeneration and growths of the uterus arrested in their progress by the same change. In all respects, when not complicated, we may expect the menopause to be a favorable crisis in woman's life; and even when contemporaneous with dis- eases, it is much more likely to beneficially influence their course than cause them to be aggravated. In all my expressions on the subject I have steadily kept in mind the fact that the menopause is but an incident among the processes whicli go to constitute the change of life. Senility in woman, after a complete change of life, is a state in which she is free from the embarrassments connected with the active sympathies of the genital organs. Her diseases are more sim- ple and less liable to become complicated. They are no longer female in their nature but fall into the category of common diseases. Ex- ceptions occur to this statement. We do, though rarely, find some of the diseases, such as metritis, and even ovaritis, etc., commencing in old age. When they do originate in this stage of life, as the genital organs are in a state of feeble vitality, and the general system is in- capable of exerting the same recuperative force as in earlier life, we may expect them to be both more obstinate in their resistance to treat- ment and more disastrous in their course. CHAPTEK XL ACUTE INFLAMMATION OF THE UNIMPKEGNATED UTEEUS. Causes. Acute inflammation, not arising from specific causes, generally affects the fibrous portion or substance of the walls of the uterus. It almost always, if not quite, pervades the whole of the organ, the fundus, body, and cervix. Exposure to cold is the most frequent cause. The cold may be applied to the general surface when the uterus is in a state of turgescence from menstrual congestion, sexual excitement, or incomplete involution after labor or abortion. The same agent acting upon a portion of the surface, as the feet and legs, under a similar condition of the organ, may give rise to the same disease. It is not likely that cold, however applied, would be a suf- ficient cause, but for the predisposing condition I have mentioned. The excitement of excessive sexual indulgence may be carried so far as to cause a moderately acute inflammation of the substance of the uterus, as also blows upon the abdomen, etc. It is not a very frequent disease, and yet I do not think it can be regarded as an infrequent affection. Symptoms. In speaking of the symptoms of the dispase, I wish the reader to bear in mind that their intensity will vary from a mildness that will scarcely confine the patient to her couch to a very severe and grave disease, almost overwhelming the nervous system, with delirium and convulsions, and calling the stomach into excruciating sympathy with it. In considering the subject, I wish to be understood as attaching more importance to the suddenness than to the intensity of the attack in determining the nomenclature. It is somewhat owing to the exciting cause, as to the symptom which is likely to usher in the attack. If the cause is a moderate one, as excessive sexual indulgence, pain will generally begin some time before the general symptoms. If the cause is cold suddenly and extensively applied to a menstruating patient, chills and rigors may precede the pain. However that may be, when the case is fairly PROGNOSIS — DIAGNOSIS. 189 developed there is fever, aching in the back, pain in the head and ex- tremities, flushed face, and furred tongue. In addition to these general manifestations there is local pain, indicating the organ affected. This pain may be confined almost entirely to the sacrum and the lumbar region if the inflammation is moderate, but generally there is pain in the pelvis behind the pubis, or in one or both iliac regions. Some- times the pain radiates in several directions up the abdomen, down the thighs, and around the body. The pain is usually of a dull aching, but sometimes of a sharp character. In addition to these symptoms indicating inflammation in some of the pelvic organs, the nervous system is often affected with hysterical symptoms, convul- sions, coma, laughing, crying, or unreasonableness of some kind. I should have mentioned among the local symptoms dysuria and dif- ficult and painful defecation. Should the peritoneal covering become involved there is swelling and greater or less tenderness of the ab- domen. Xausea and even vomiting are not infrequent symptoms. After a week or more of this kind of suffering the symptoms gradu- ally subside, and the patient slowly recovers her usual health ; or sometimes the subsidence of the pains is not complete, and she con- tinues to suffer with a chronic form of inflammation. The termina- tion is almost always in resolution or the chronic form of the disease. Possibly, in some exceedingly rare instances, the force of inflammation is spent in some circumscribed locality, and it proceeds to suppura- tion. I have lately seen an instance of this kind where the suppura- tion was in the anterior lip of the cervix. Prognosis. The termination is so frequently in resolution or a moderate form of chronic inflammation, that w^e may almost always expect complete or partial recovery. Death probably never results in uncomplicated cases of acute metritis, but unfortunately we occasionally meet with grave and even fatal peritonitis, apparently resulting from extension of the disease from the uterus. It has been my misfortune to have lately met, in consultation, with two instances of this sort. Although the prognosis is favorable, as a general rule, so far as the recovery of the patient from the attack is concerned, it is not so favorable for the complete re-establishment of health, as the patient is likely to be affected with chronic inflammation in the body or cervix. Not un- frequently we trace chronic inflammation back to a moderate attack of the acute. 190 ACUTE INFLAMMATION OF THE UNIMPREaNATED UTERUS. Diagnosis. Inflammation of the cellular tissue beside the uterus, metatithmenia, rectitis, or cystitis, cause symptoms which may be mistaken for me- tritis. When doubt exists it may be easily and certainly solved by a dio^ital examination. If the bladder is the seat of disease, the ten- derness complained of by pressing it between fingers in the vagina and others above the pubis will be sufficient proof ; pressure may be made upon the rectum by including it between the introduced fingers and the sacrum. The inflammation at the side of the uterus, or cellulitis, causes tenderness and hardness close to the iliac bones on the side, and the hardness seems to be continuous with the bones. The greatest tenderness is therefore close to the side of the pelvis. In all these cases the uterus may be touched, provided it is not moved so as to press upon the inflamed part or organ without causing pain. If it is the seat of inflammation the tenderness will be con- fined to that organ, while all the rest are free from it, and may be handled freely. We should not forget that all these organs may be implicated in one great mass of acute inflammation, and all the pelvic contents be intolerably tender to the touch. In an examination to diagnosticate inflammation of the uterus, I need hardly say that a resort to instruments is unnecessary. Treatment. The intensity of the inflammation will govern us in the activity of treatment. If it is not attended with great pain or febrile reaction, although our remedies must be the same, there is no need of using them with the same energy. We should, however, bear in mind the great likelihood of leaving the chronic form behind, and be diligent in our medicinal and hygienic appliances, until every vestige is gone, when practicable. If the attack is moderate, it may sometimes be interrupted in the beginning, by measures to induce a copious per- spiration, more particularly if caused by an exposure to cold. Even a smart attack may sometimes be relieved by a large dose of opium and a steam-bath, used within a few hours after the commencement of the symptoms. After the symptoms have become fairly established and have lasted for twenty-four hours, we must not expect to find immediate relief, and should begin the systematic use of antiphlogistic treatment. In the subacute form, a brisk cathartic, foot-bath, and fomentations over the uterus, should be followed by tart, antimony, muriate of ammonia, and calomel. INFLAMMATION OF MUCOUS MEMBRANE OF THE UTERUS. 191 Perfect quietude should be enjoined also, and rest at night may be insured by giving one grain of calomel, with twice the amount of opium, in a pill at bedtime. Continued for five or six days this will generally induce slight mercurial eifect, when the pain and other symptoms will pretty surely subside. If it does not do so, a blister over or a little above the pubis will aid in banishing them. If the attack is severe, we ought to add to the above remedies the more immediately depressing. The patient may be bled from the arm until a decided impression upon the pulse is produced, or we may apply from ten to twenty leeches to the vulva and groins, as the depletant measure. In the country, where leeches cannot be had, scarification and cupping can be profitably substituted for them. Should arterial excitement be high after the depletory measure, the tinct. of verat. viride in doses from four to six drops every four hours, with the ammon. mixture, will be an efficient adjunct to our remedial measures. The calomel should be withheld as soon as its specific effects are produced. I should not discharge the obligation I feel to the student in the treatment of this disease were I not again to caution him against an imperfect cure of it. Very often it becomes chronic, and renders the patient miserable for years. We should try to avoid this conse- quence. Too early a resumption of duties and active exercise should be especially prevented. When practicable, a continuation of treat- ment and avoidance of the causes which produced the inflammation are of equal importance. As a means of perfecting the cure which the more active treatment has brought about, the sedative effect of water affords us valuable aid. The sitz-bath and vaginal injections are the modes of using it. The sitz-bath ought to be used as much as the time and patience of the patient can be made to allow. An hour is short enough time, and two hours is better, twice or thrice in twenty-four hours. The injections should be copious, and may be used in the bath and of the same water. From two to four gallons of water ought to be passed through the vagina in this way each time the bath is used, by means of the perpetual rubber syringe. Acute Inflammation of the Mucous Membrane of the Uterus. — I do not know that I have ever met with an uncomplicated case of acute inflammation of the mucous membrane of the uterus. Cases that I have seen have been connected with inflammation of the vagina, and have arisen as the effect of some poison directly applied to the mem- brane. Most of them were gonorrhoeal, but in some I have been 192 ACUTE INFLAMMATION OF THE UNIMPREaNATED UTERUS. puzzled to determine whether the poison of this affection was the cause or not. Probably this poison gets into families, where and in ways it ought not, and thus deceives us. However this may be, I think one of the worst features of gonorrhoeal inflammation is the frequency with which it invades the mucous membrane of the uterus and the difficulty of completely eradicating it. It is very apt to lurk in the uterus after the acute symptoms are removed and the inflam- mation gone entirely from the vagina, and thus require treatment as chronic endometritis. If I am not deceived by my observation, acute endometritis, of a non-specific character, is a very rare affection ; and as I have not seen it, and doubt its existence, I do not feel justified in compiling a description of it. CHAPTER XII. GENERAL CONSIDER ITIOXS ON "UTERINE DISEASE" OR HYSTEROPATHY. There is a long list of symptoms, called nervous, or sympathetic, which, although not exclusively confined to women, are more fre- quently found to manifest themselves in them. They were formerly regarded either as independent affections, or as having various sources of origin ; and although hysterical was the term usually applied to them, it was not definitely known in what manner they originated. Patient investigation has given us more definite and correct notions of them, and we have come to regard them as nearly always depen- dent on trouble of some kind in the sexual system. Medical men, however, are not united in the opinion that the symptoms alluded to are thus caused, but are divided into two well-defined parties with respect to uterine pathology. 1st. There are those who believe that the uterus has very little sympathetic influence on the system ; that the diseases of that organ are more frequently the result of diseases in other organs than of independent origin ; that the symptoms accompanying and almost always found in connection with actual lesion of the uterus do not at all depend upon this organ ; that these symptoms may be cured without any attention to the condition of the uterus, and, in fact, whatever cures them, almost always cures the affections of that organ. 2d. The other party holds the opinion that the sexual system of the female, in a state of disease, exercises a very morbid influence over nearly the whole organization ; that this morbid influence is particularly exerted over the spinal and cerebral nervous systems ; and that the only sure and permanent relief is found in the cure of the disordered condition of the uterus. Those who adhere to the latter view may be classified under two subdivisions, one of which holds that the sympathetic influence of the uterus is only manifested when that organ is inflamed or ulcer- ated, and that the cure of the inflammation and ulceration relieves the symptoms. The other maintains that inflammation and ulcera- tion are only of slight, if indeed of any, importance ; while the cause of all the difficulty is some sort of displacement. 13 194 ''UTERINE disease'" OR H YST ER P A T HT. It will probably surprise the student when he is told that all of these diverse and various opinions are held bv gynieeologists of equal emi- nence, inresrrlty. and opportunity for observation. There is reason for surpri-e in this consideration, and yet this same diversity of opinion exists in all departments of medicine ; for example, as to the nature and treatment of inflammatioD, as to the essential nature of typhoid fever and its treatment, as to the local or general origin of cancer, and the propriety of extirpation. How can this discrepancy be accounted for? It is not my purpose to answer this question at length, but merely to indicate a few obvious considerations, of which one is that the attention of medical men has been too recently directed with suf- ficient intensity to the points involved to enable them to make an induction full enough to convince by its results all the members of the profession of the correctness of any one view. This, therefore, is just the time when we meet with conservatism in the views of tem- perate and judicious investigators, as well as wdth the less laudable conservatism of those who have lived too long to improve. Another consideration is, that while judicious practitioners hold antag^onistic opinions as to the nature of diseases, they pursue so nearly the same line of practice as to lead to similar results in the treatment of them. A third consideration relates to the power of prejudice, which forms in very many minds an invincible barrier against the acquisition of truth : and the opinions imbibed in early education are those which are maintained the most persistently, sometimes in consequence of an unwillingness to learn, and sometimes even against the light of reason itself. From the pernicious influences of association and prejudice neither learned nor unlearned are exempt. Those who deny to the uterus much sympathetic importance in a state of disease are compelleri.jQNi the bolboos tennination shoold be ?«" / Jennison e, H. SARQENT & CO., CHICAGO. 's Exploring and Indicating Sound. and indicating sound is also useful for indicating the depth and direc- tion of the uterine cavity. Fig. 62. Fitch's Measuring Sound. Accidents of serious character sometimes occur in using the probe in the uterus. Dr. Engleman, in the St. Louis Medical and Surgi- cal Journal, says that he was present when Professor Carl Braun, of Vienna, pushed the uterine probe through the tissues of the uterus into the peritoneal cavity. Dr. Noeggerath, of New York, mentions a case where the sound had been passed five inches, going through the fundus uteri, as shown by the discovery of a cicatrix at a post- mortem examination made several months afterwards. Other unquestionable instances of this accident are on record. Of these cases I have heard of none in which any untoward consequences followed what would seem to be at least a serious occurrence. As all the cases published were in the care of skilful and careful practi- tioners their occurrence must therefore be attributed to some other circumstance than rashness. The probability is that on account of disease the uterine structure had become too frail from attenuation or softening to resist the slight force used to introduce the probe. It is interesting as well as surprising that so little effect followed the vio- lence done by the forcible passage and entry of the probe to the uter- ine wall or the contents of the peritoneal cavity. The Fallopian tube is sometimes so patulous from disease as to per- mit the sound to pass through it into the cavity of the peritoneum. Where the whole of the uterus is enlarged, as it is found for many days and sometimes weeks after parturition, the uterine orifice of the 256 DIAGNOSIS. tube is large enough to admit the probe. This may be the case also from the enlargement caused by uterine catarrh. When the opening to the tube is thus enlarged it requires but a slight inclination of the uterus to one side of the pelvis to bring the Fallopian orifice in a direction to be easily entered by the instrument. When once it has entered the tube the probe will find no resistance to its farther progress. In a discussion before the Obstetrical Society of New York, Jan- uary 17th, 1871, reported in the Journal of Obstetrics of August, Fig, 63. 1871, Drs. Budd, Thomas, and Noeggerath, all speak of cases in which the sound would seem to have entered the peritoneal cavity to a long distance through fhe Fallopian tube. Dr. Kosa Engert was kind enough to show me a case quite recently in which she repeatedly passed the sound through the Fallopian tube. When the end of the instrument had reached the fundus it required but little inclination to the left to cause it to enter the tube. The patient experienced no inconvenience from the examination. Another accident, and one of more importance because of its almost invariably fatal effects upon the embryo, and also because of LENGTH OF THE CERVICAL AND UTERINE CAVITIES. 257 its more frequent occurrence, is the damage done probing an impreg- nated uterus. Too orreat caution cannot be observed in makino^ investigation of the condition of the uterus before passing the probe into its cavity. I have known two instances, however, in which the impregnated uterus was probed to a depth of several inches without interrupting gestation. AVhen a suspicion of pregnancy exists there can hardly be a circumstance so grave as to justify the use of the probe. In such cases we should unhesitatingly wait until time solves the question of pregnancy. Jlode of Using. After oiling the instrument, and introducing the index finger of the right hand, and placing it upon the os uteri, the probe may be carried along the palmar surface of the finger until the point arrives at the mouth of the uterus, when, by elevating the point, it may be carried forward into the cavity of the cervix. In order to insure its passage through the cavity of the cervix, into the cavity of the body, the probe must be bent to the same degree as the male catheter. Great gentleness must be observed in the use of this instrument, because it is an easy matter to do violence to the mucous membrane by a very little rudeness of management. After the probe has passed to the os internum, a sense of constriction is felt through the instrument, which feeling soon gives way, and the probe then goes to the fundus without further resistance. Length of the Cervical and Uterine Cavities. The cervical cavity in the virgin is about an inch and a quarter in depth, and the cavity of the body from a half to three-quarters of an inch ; the former in the multipara is one and a half inches, and the latter an inch deep. In old age both are nearly or whollj^ oblit- erated. I do not often use the probe in this way for the examina- tion of the uterus in cases of inflammation and ulceration, but have adopted the suggestion of Professor Miller, of Louisville, and use it through the speculum, and shall consequently have more to say about it in connection with the use of that instrument. It often happens, with the present means, that there is great diffi- culty in determining the thickness of the uterine walls, and even the presence of a small growth iu the anterior or posterior parietes. For the purpose of enabling the inexperienced to arrive at what, in many instances, is valuable information in this respect, I have devised what may be called the hysterometer, a cut of which is here given. 17 258 DIAGNOSIS. It consists in the adaptation of two uterine probes to each other, with handles and scale for measurement, in such a way that one may be introduced into the bladder, and the other into the rectum. Thus riG. 64. The Hysterometer. approximated on the uterus, as represented in Fig. 65, the handles and scale may be so arranged as to make the measurement. When this is done the instrument may be detached, withdrawn, and the exact thickness of the uterus is ascertained. If we wish to measure the posterior wall, one probe is introduced into the cavity of the uterus, and the other into the rectum, and the scale and handles ad- justed, the measurement taken, and the instrument withdrawn. When the anterior wall is to be measured, one is introduced into the LENGTH OF THE CERVICAL AND UTERINE CAVITIES. 259 uterine cavity, and the other into the Wackier. In this way, the leno:th of the uterus and the thickness of the walls may be easily measured. This instrument will enable us to be much more accurate in our es- timate of the shape of the uterus than any other means we can employ. The handles of the probes are adapted to each other by means of a Fig. 65. The Method of Apph-ing the Hysterometer for Measuring the Thickness of the Uterus, slot, running from one end to the other, in one of the handles, while the other is of a size to fit into this slot closely and accurately. The scale is made movable, and may be easily adjusted after the probe portions of the instrument are in their proper place. In cases of distortion of the cavity of the uterus, or when there is a tumor to measure, the probes will be bent in different directions, until they adapt themselves to the shape of the parts. In consequence of the necessity of variance in the curvature of the probes in making such measurements, the scale can serve only as an index to the rela- tive position of the two probes, and cannot be relied on for the exact size of any growth or other cause of thickness of the walls. After having adjusted the scale, therefore, and observing the figures, we 260 DIAGNOSIS. must withdraw the instrument and readjust by the scale, and then measure the distance between the points of the probes. This will give us the true measure. Often the instrument may be withdrawn with loosening it, which fact will facilitate the process very much. In cases of retroversion or retroflexion, when we wish to diagnos- ticate these displacements from a small tumor, which they sometimes very closely simulate, one of the probes in the bladder, so curved as to follow downward and backward the anterior wall, the other in the uterine cavity, will clearly make out the difference. In like manner, only with reversed curves, and one probe in the rectum, the tumor may be diagnosticated to be present or absent. Speculum. Since the speculum has come into such general use, it has assumed a variety of shapes, and been composed of quite a number of different sorts of materials. For different purposes it is conve- nient, if not necessary, to be provided with different shapes, sizes, etc. ; but for ordinary use we ought to have three dif- ferent sizes : one small, one large, and the other of medium size. The bivalve, trivalve, and Sims's speculum and its modifications are the most useful forms. Fig. 67. Higby's Speculum. Nott'i Nelson's, Nott's, and different sizes of Higby's. POSITION OF PATIENT FOR SPECULUM. 261 To aid us in getting a good view of the cervix, we may draw it into view, and, if necessary, depress it somewhat by the single or double tenaculum. Fig. 68. Fig. 69. Nelson's Tenaculum. Kelson's (open). Position of Patient for Speculum, To be prepared to use this instrument to the best advantage, our patient should be placed in the position I have heretofore described, Fig. 71. Double Tenaculum Forceps. viz., before a large window, through which as much daylight should be freely admitted as possible. The better light the better view, and unless we have plenty, we cannot be certain of correct results in our Fig. 72. Tenaculum Forceps. examinations. The bed and patient should be so placed that the light may fall straight through the instrument, and full upon the parts at its internal extremity. We should also have some cotton-wool, sweet oil, and a couple of napkins, together with the dressing forceps I have before spoken of. 262 DIAGNOSIS. Mode of Using the Speculum. In comaienciDg the examinatioD, we should oil our speculum, and our middle and index fingers. Kneeling before the patient, we should introduce the index finger, and, if need be, the middle one also, to ascertain the position of the cervix uteri. This precaution will enable us to know in what direction, and how far, to introduce the specu- lum. After this preliminary examination, the forefinger and thumb of the left hand should be placed upon the edge of the labia, one upon each side, with which they should be gently separated ; and holding the speculum in the right hand, somewhat like a pen, we may intro- duce it by the guidance of the thumb and finger placed as above. In introducing it, we should push it forward sufficiently to reach the cervix, and direct it upward, doAvnward, or to one side, as we may have ascertained, by digital examination, to be the position of the os and cervix. How to Find the Os Uteri. If this is not the case, we may use our probe, and gently push the parts from one side to the other, turning the speculum in different directions until it is found. If the neck is too large to enter the speculum, we may spread the blades still more until it is brought into full view. Most frequently the parts are covered with some sort of secretion, and we should always, with cotton-wool or lint, with the dressing forceps, remove all of it, so that the naked mucous membrane HOW TO FIND THE OS UTERI. 263 alone presents itself to our view. Without this precaution, we may overlook an obvious and extensive ulceration ; for as the parts are covered over with this thick, opaque secretion, it either completely hides them from view or much modifies their appearance. I have often met with cases which I have observed attentively, for the pur- pose, if possible, of detecting ulcerations without this step, but failed, until the cotton was used, when extensive ulceration appeared. In- deed, I never think of coming to a conclusion of any kind by the use Fig. 7^. Bj'ford's Dressing Forceps. of the speculum without this precautionary measure. By this means we can see the color, size, shape, and some other conditions of the parts, and the color, consistence, and derivation of the secretions. When the mucus, pus, or blood, comes from the mouth of the uterus, we can see it issuing from it. The shape and size of the neck and OS of the uterus difPer in different individuals, according as they have been impregnated or not. Dr. J. Marion Sims has instructed us in a different method of making examinations. He prefers a table. The patient is placed Fig. 75. on the left side, the left arm under and behind her, the legs strongly flexed upon the thighs, and these again upon the abdomen, while the right knee is thrown forward, and over the left one on the table; this turns the patient over on the chest and partly on the abdomen. In this position his speculum is introduced by placing the forefinger 264 DIAGNOSIS. of the right hand in the concavity of the extremity to be used, and the finger and instrument introduced together. When well inserted, the perinaeum is drawn backward and the instrument is given to an assistant to retain in place. This will generally Fig. Fig. 7( Sims' s Depressor. expose the cervix uteri completely ; but if it does not, the de- pressor is placed upon the anterior wall, and this latter is pressed out of the way, as represented in Fig. 83. Great Tenacu- lum. Dr. Emmet's Speculum. freedom of examination is thus obtained in most cases. Still, if the OS uteri is not seen plainly, it is seized with a tenacu- lum and drawn toward the external orifice. Many practitioners prefer this method of exposing the organ for all ordinary purposes of inspection and application. Dr. Emmet has im- proved upon the speculum of Dr. Sims by constructing it in a fashion that renders it self-retaining, and thus does away with the necessity of having an assistant. Many other self- retaining instruments have been invented, that answer an ad- mirable purpose, among which I mention those of Dr. Fallen, of St. Louis, Dr. Nott, of New York, and Dr. Thomas. Of Fig. 7S ^ Xott's Tenaculum Forceps. course it is necessary to have the patient so placed that the light HOW TO FIND THE OS UTERI. 265 will fall full into the dilated vagina and on the cervix. Dr. Sims draws the cervix down, when necessary, by means of a tenaculuai; Fig. so. Simon's Speculum, different sizes. this often facilitates the examination, and enables the practitioner to make applications or operations upon it with much certainty. 266 DIAGNOSIS. Appearance of the Os and Cervix in the Virgin. The virgin uteras is small ; the cervical end is nearly round, and terminates in a truncated extremity. Through the speculum it does not present the appearance of labial projections, and the os is either a small slit, about a quarter of an inch long, or a round opening into the middle of the truncated extremity. It is about large enough to Fig. 81. Fig. 82. Simon's Retractors. Lever for Dilating the Vagina from the Side. admit with facility the end of a female catheter, and the neck projects, in relief, from the bottom of the parts exposed by the speculum, somethino; like half an inch. Appearance of the 31idtiparous Uterus. The appearance of the multiparous uterus is quite different from this; the cervix terminates in labial projections, which divide its APPEARANCE OF THE MULTIPAROUS UTERUS — COLOR. 267 extremities into an anterior and posterior half, and it does not pro- ject with so much prominence into the specuhim. The os is repre- sented by the cleft between these labial projections, and is large enough, in many instances, to admit the tip of the index finger. Fig. This figure represents the Action of the Instruments in Sims's metliod of Examining the Uterus. Ajppearance in the Aged, In the aged the labial projections seem to have atrophied to oblit- eration, and the speculum shows a round opening in a funnel-shaped depression, surrounded by the walls of the vagina. Exceptions to these Appearances. Although the above is an accurate description of these appearances under the different circumstances, there are many natural deviations from it. Color. The color of the mucous membrane covering the cervix, and enter- ing the OS uteri, may be compared to that of the inside of the lips of the mouth, a pale rose-red. Appearance of Secretion. The parts are merely lubricated, not smeared or inundated, with mucus. Tliere is just enough of this secretion to keep the membrane 268 DIAGNOSIS. moist, but not enough to hide the surface from view. I speak now of the cervix uteri. Indication of Mucus in Abundance. An abundance of mucus must be regarded as an evidence of ex- citement ; its constant and persistent abundance as an evidence of disease. ^' Remember, that in spite of their name, it is not the busi- ness of mucous membi*anes to secrete mucus; the more perfect their condition, the more favorable the surrounding circimistances, the less they do so. . . . The greater the diminution of their life, the greater the secretion." The more disease, the greater the secretion, ootil their integrity is desti'oyed, when the secretion becomes modified. The source whence this mncos is derived will show the point of dis- ease ; if it comes from the os uteri, the disease is in the cavity of the cervix or body of the uteras. Indication jrom Pus. It is extremely doubtful whether pus can be produced by a mucous membrane without destruction of the epithelium at least. Temporary congestion often increases the amount of mucus to be found in the vagina, but gives origin to no pus. The color of the mucous mem- brane, in cases of congestion, is a livid or a dark purple-red, instead of the scarlet of abrasive inflammation. Probe and Speculum Conjointly. When the neck of the uterus is exposed in the speculum, it will often be profitable to use the probe. If proj^er attention is paid to appearances under the use of the probe, much information may be gained. When the mucous membrane of the cavity of the cervix or body is inflamed, it is generally much more fragile than natural, so that it bleeds upon slight contact with the end of the probe. In cases where the inflammation extends to the cavity of the uterus, the probe j^asses the os internum without obstruction, and passes farther up than natural from the increased size of the cavity. Dilatation. By properly dilating it, we may subject the cavity of the uterus to a digital examination. Sufficient dilatation may be efiected by the use of tents and dilating instruments made for the purpose. The DILATATION. 269 compressed sponge, laminaria, tupelo, and slippery elm tents are all employed as means of dilatation. The sponge tents, as prepared and sold by instrument makers, are of various sizes and lengths. They are, or ought to be, perforated lengthwise, carbolized, and covered with a lubricant to facilitate their introduction. The sea-tangle or laminaria and the tupelo tents should also be of different sizes and lengths, smoothly polished, and very slightly taper- FlG. S4. Sponge Tents. flexed ing. All of these materials are susceptible of being made in form to suit the curves of the uterus. When any of these tents are introduced in a dry state into the uterus, they absorb the moisture of its cavity and increase in size, and as they do so they dilate it. Fig, 85. Laminaria Tent. The sponge expands more rapidly than the lupelo or laminaria tents, and is less powerful in its dilating influence. There is not much difference in these respects between the tupelo and laminaria tents. Perhaps the latter expand more strongly and act more powerfully. As the sponge dilates, it presents a rough surface to the mucous 270 DIAGNOSIS. membrane^ and to a considerable extent impairs its epithelial cover- ing. The surface of the tupelo and laminaria tents do not become rough as they expand, and consequently are not so likely to be fol- lowed by injury to the mucous membrane. As the laminaria becomes moist, it exudes a mucilage that serves as a protection to the mucous membrane. All of these tents should be well secured by having a strong thread attached to them. The thread should be passed through the whole length of the sponge and tied in a loop. This thread enables the Fig. 86. Tupelo Dilators (hollow). practitioner to remove the tent by simple traction, and does away with the necessity of the introduction of an instrument for that pur- pose. Tents intended to dilate the cervix, of whatever kind, should be introduced at the home of the patient, because perfect quietude in bed is one of the best measures to prevent the untoward effects some- times caused by the use of them. Sims's position is the most convenient for the introduction of the tent. In this position the cervix may be exposed by Sims's specu- lum, drawn slightly forward, and fixed by the uterine tenaculum or a small vulsellum (Fig. 87). The tent, mounted on a tent-holcler, or seized by the dressing forceps, is passed in until the inner end has entered to the os internum. The upper part of the vagina must be packed with cotton placed against the end of the tent, upon which it is made to rest. This will secure it in position, otherwise it might be more or less completely dislodged and thus fall short of its fullest effects. The first tent should be of a size that will permit it to pass easily into, and yet snugly fit the cervical cavity. If sponge, it will generally require about twelve hours to fully expand, and should the dilatation not be sufficient to admit the finger, the vagina and cervical cavity should be thoroughly cleansed with carbolized water, and a second sponge introduced in the same manner as the first. The second tent must be large enough to fill up the expanded cavity, and DILATATION, 271 secured in the same way as the first. A somewhat hunger time must be allowed if we use either of the other kinds, but the management of them is the same as that of the sponge. The wounded condition of the cervical mucous membrane caused by the sponge tent renders it very susceptible to inflammation, and calls for the strictest quiet and the avoidance of all co-operating morbific causes. The same Fig. 87 Iklolesworth's Dilator. condition favors the absorption of septic material, and thus exposes the patient to the danger of septicsemia. This can only be avoided by strict cleanliness. In using the tupelo and laminaria tents, the main danger consists in the liability to produce inflammation of the uterus, which may be propagated to the surrounding tissue, because of their very unyield- ing pressure upon the submucous structures of the organ. From these considerations the student will learn that the use of tents is fraught with much danger, and should not be resorted to except under such circumstances as seem to render them indispensable to correct diagnosis and a perfect course of treatment. 272 DIAGNOSIS. There are otlier means of dilating the uterine cavitj, tliat in some cases may be resorted to with much advantage, especially when it is an object to perform dilatation in a short time. Molesworth's dilator is one of the most simple and effective instru- ments for this purpose. The small-sized dilator may be made to enter the unimpregnated uterus, and when expanded by filling it with water, under strong and gradually increasing pressure of the cylinder, - will, in favorable instances, open the cervical cavities sufficient to admit the second size. By succeeding one size with another I have, in less than an hour, been able to pass my finger into the cavity of the body. The uterus can also be dilated rapidly by hard rubber instruments, a very con- venient form of which is Hank's rapid dilator. This consists of olive-shaped bulbs mounted on a handle. The smallest size may be passed into the cervix by slow and gradu- ally increasing pressure. It may be succeeded by the second, and that by the third, and so on until the cavity will admit the finger. When the uterus is especially hard and undilatable, the gradual method, consisting of the use of tents, is the proper one to employ. When, however, the mouth of the cervix is softer and more yielding, the rapid method is preferable, and in most cases Molesworth's is the instrument to be used. I would remind the student that great care is necessary to avoid damage from the use of any of these instruments or processes. • The object in dilating is to expose the uterine cavity to the sense of touch, and thus discover its contents and condition. Sometimes, with the patient in the dorsal position, we may depress the uterus, by placing one hand above the symphysis, sufficiently to bring its cavity within reach of the finger; but usually it will be necessary to draw it down by a tenaculum or vulsellum until the finger will pass up to the fundus. Polypoid or submucous tumors, excrescences, and cancerous ulcer- ation may be discovered in this way when they could not be diag- nosed with precision by any other method of examination. Characteristic Signs of Inflammation. The signs of inflammation of the submucous tissue or substance of the neck of the uterus are, increase of size, tenderness, and generally hardness; of the mucous membrane, increased color and secretion; of ulceration, still more intense redness, purulent discharge, tenderness, and not much enlargement. The former conditions may be ascer- DIAGNOSIS OF ENDOCER VICITIS. 273 tained by tlie touch, the latter by the sight, and when they are min- gled, by both combined. Open external abrasion or ulceration of the uterine cervix, after the parts are well exposed, and cleared of mucus and pus by wiping, cannot be well mistaken or overlooked; and the practitioner must not be led to believe the case one of no importance because the ulceration is not very extensive. This raw scarlet surface is always indicative of mischief, and we should expect any amount of suffering from even a small patch of it. Diagnosis of Endocervicitis. There are cases where the appearances are not so obvious, where, in fact, all the parts exposed by the speculum and within reach of our vision have a natural appearance. Xo redness, rawness, or other discoloration can be detected on the neck, in the mouth of the uterus, nor on the vaginal surfaces; they are quite healthy in appearance and reality, but there is an obvious and, in many instances, a copi- ous secretion of tenacious mucus flowing from and lying in the os uteri; wipe this away and all looks right. This is a case of endo- cervicitis. In some instances this mucus is colored with streaks of yellow by the presence of pus, or it is wholly yellow; here there is loss of integrity in the epithelium of the cervical cavity. The mu- cous membrane in the cervical cavity is ulcerated. If we remember that the mucous membrane secretes only enough mucus for lubricat- ing purposes, in the natural condition, we can arrive at no other conclusion than that the membrane is in a state of hyperexcitement when its secretion is abundant or altered, or both. When we see mucus in even small, yet perceptible quantities, issuing from the anus, what is the inference? If this is abundant, persistent, and col- ored yellow, however healthy the anus might appear externally, we could not believe that the rectum was in a healthy condition. Why not then positively determine that the mucous membrane is inflamed, which floods the os uteri with mucus or pus, or with both ? If we introduce the probe into the cavity of the cervix thus abundantly secreting, the patient will nearly always complain that we touch a "sore place, a tender spot," that it hurts her in her back, etc. And very often blood will immediately follow the withdrawal of the in- strument. This, however is not invariably the case. Another diag- nostic evidence of endocervicitis is the increase of the pain ordinarily experienced by the patient when the probe or nitrate of silver is introduced. The hypersecretion, or perverted secretion of the mucous mem- 18 274 DIAGNOSIS. brane, must then be regarded as an indication of disease of that membrane. If we have these facts fixed in our mind, and if we act upon them, Vv'e may discover and cure disease that would otherwise escape our attention and thwart our skill. But there is another ob- vious and common-sense sign of inflammation which has not been applied in our investigations of diseases of the uterus, viz., tender- ness. Tenderness or sensitiveness to the touch anywhere else leads us to susj^ect inflammation, but in the uterus it is unaccountably set down as indicating an irritable uterus and not an inflamed one. Diagnosis of Submucous Inflammation. I think when I touch the uterus with the finger or an instrument, and the patient shrinks from the contact and says " she is sore,^' or "it is sore," that there is inflammation there. Tenderness is not an evidence of mucous inflammation, but of submucous or fibrous in- flammation of the uterus. Complication of 3Iucous with Submucous Inflammation. The uterus should be examined by the same diagnostic rules that govern our investigations of disease in other organs. Some authors tell us that ulceration results from inflammation of the submucous tissue, and others that the inflammation begins in the mucous mem- brane. However this ^may be, I am sure that inflammation some- times exists in both these tissues at the same time. In this case we shall have tenderness and hypersecretion. At other times there is submucous without mucous inflammation; then we shall have ten- derness without hypersecretion. Again, we may have mucous with- out submucous inflammation, when hypersecretion without tender- ness will indicate it. These remarks will fix the importance of these two symptoms as indicating the seat of the disease. Size of tJie Uterus ordinarily Increased — Exceptions. The size of the organ is one indication of the presence or absence of inflammation; but this may vary very much under what would appear to be the same form of disease. In endocervicitis it is usual to find the cervical canal increased in calibre ; but this is certainly not always the case, as I have met with unmistakable instances in Avhich this cavity was decreased in size and the os uteri almost closed, it being so small as to admit only a very small probe. Where there is mucous inflammation of the cervix extending toward the cavity of ATROPHY AS THE RESULT OF INFLAMMATION. 'llO the body, and more particularly where the disease extends into the cavity of the body, the whole organ is likely to be enlarged. So much enlargement sometimes takes place that the fundus may be felt considerably above the pubis. Xeither is this always the case, how- ever; often there is no enlargement. The hypertrophy, or general enlargement of the organ, is more frequently indicative of mucous than submucous or fibrous inflammation. Atrophy as the Result of Inflammation. In fact, I think that long-continued inflammation of the substance of the body and cervix often brings about atrophy or shrinking of the uterus. Permanent increase of size or hardness of the cervix must be the result of submucous inflammation, and generally co- exists with it. Almost the only disease with which chronic inflammation and ulceration of the cervix uteri are likely to be confounded, is cancer in some of its stages. The many well-marked symptoms and physi- cal conditions which accompany this last disease are now, however, so well understood and so thoroughly described, that the novice need not be embarrassed in his diagnosis of it. I find in BecquerePs Traite Clinique des Maladies de Uterus, pp. 320-323, vol. i, so complete and faithful a diagnostic summary be- tween cancer and the diflerent conditions of chronic inflammation of the cervix, that I have translated and given its substance for the con- cluding portion of this chapter. It is subjoined : Cancer in the Scirrhous Condition. Cervix hard, unequal, nodulated ; os not always open, sometimes wrinkled or furrowed. Scirrbus of the neck often implicates the vagina. Hereditary influence is often traceable. Touch is painless. Discharge sometimes absent ; in certain cases very abundant, and consisting, for the most part, of albuminous serum. Menstruation increased, being neither more nor less painful, and passing often into the state of real haemor- rhage. Absence of special anaemia when the vagina and body of the uterus are in- volved. Cancerous cachexia. Inflammation and Ulceration. Xeck less hard, developed regularly in one of the lips; os always open. The induration of the neck never ex- tends to the vagina. Mobility of uterus complete. Xo hereditary influence. Touch painful. Discharge constant, and characterized by the presence of transparent mucus, muco-pus, or purulent mucus. Menstruation more painful, often re- tarded, almost always scantv. Special ansemia, as above described. 276 DIAGNOSIS. Cancer in the Scirrhous Condition. Progress continuous and without cessa- tion. The pain in cancer is very sharp, in- tense, and hmcinating, and not influ- enced by locomotion or movements of any kind. Ulcerated State. Developed at the critical period of life generally. Preceded and accompanied by h?emor- rhages. Severe, sharp, lancinating pain. Development essentially in sharp ir- regularities and nodosities. Adhesions to other organs as soon as ul- ceration is formed ; immobility of the uterus. The surface only slightly soft ; subjacent tissue scirrhous. Ulceration deep, unequal, essentially ir- regular, with thick, elevated, and hard edges. Always granulations. Discharges extremely abundant, consist- ing of purulent and often sanguineous serum ; nauseous and often fetid odor. Great haemorrhage from tiine to time, not necessarily at menstrual period. Cancerous Ulceration. Developed upon a hypertrophied and scirrhous surface. Ulceration deep, vast, unequal grayish surface, with thick edges, and easily bleeding. Ulcerated surface hard, presenting nu- merous lobes and tubercles, with nodos- ities and great hardness. Often great loss of substance. Cervix and corpus uteri immovable, on account of adhesions. Discharges sanious, fetid, sanguinolent, and of an insupportable and charac- teristic odor. Cancerous cachexia always present. Inflammation and Ulceration. Often stationary for a long time. Pains less severe, more dull, and percep- tibly influenced by walking and other sorts of motion. Chronic Inflammation and Softening. Occurs earlier in life almost always. 2sot preceded by haemorrhage. Pain dull and profound. Enlargement regular and rounded, or regularly lobulated. Complete absence of adhesions to other organs. Entire mobility of the neck and body of the uterus. Tissue of the cervix not hard, and easily destroyed. When ulcerations exist, less deep, with tumefied edges. Granulation often accompanies the other lesions. Discharges less abundant, consisting of muco-pus alone, or accompanied with a little blood, without odor. Always haemorrhage, but often a mere prolongation of the menstrual dis- charge. Simple Ulceration. Ulceration often on a healthy tissue, or presenting the soft or hard varieties or inflammatory injection. Ulceration more superficial, the edges less developed, and more regular at the bottom, not always easily made to bleed. Nothing of the sort in chronic inflamma- tion and ulceration. Ulceration is not always accompanied with loss of substance. Neck and body always movable. Discharge of muco-pus, or purulent mucus, always more or less abundant. Special anaemia. ATROPHY AS THE RESULT OF INFLAMMATION. 277 "Professor Otto Spielberg, speaking of the difficulty of distinguishing between simple inflammatory induration of the cervix uteri — hyper- plasia — and carcinomatous infiltration, gives the following as a certain indication of cancerous infiltration, viz. : 'A peculiar induration of the cervix, the disposition of its mucous membrane, and its reaction to the dila- tation of sponge tents' He expounds each member of this rule. "The hardness of cancerous deposit, in comparison with simple in- duration, is well known ; but the distinction is frequently impossible to make out, even by the most cultivated touch. The two other symptoms are unequivocal, and are as follows : " 'First, the mucous membrane in cancerous growth is firmly connected with the underlying induration, and immovable over it, which is not the case in mere hyperplastic thickening and induration ; and, second, while the latter, under the pressure of compressed sponge, in the cervical canal, becomes regularly even, though at times inconsiderably looser, softer, and thinner, the cancerous infiltration remains unalterably hard and rigid, and cannot be stretched.' He goes on to explain the reason for this difference between the products of the two inflammations from the locality where the cancerous inflammation originates, which is the utero- malpighii ; or, in extremely rare cases, from the glands of the cervical canal. The latter form gives rise to the alveolar or colloid form, of which he has only seen one case. As a rule, the disease is developed from the interpapillary depressions of the epithelium. According as the growth of the epithelium into the tissues below is or is not attended by a simultaneous growth of the papillae, two forms of cancer may be dis- tinguished, — the papillary velous, or cauliflower excrescence, and the simple infiltrated form." — Cincinnati Clinio (from Archiv fur Gynce- kologie). CHAPTER XVII. GENERAL TEEATMENT OF UTEEINE DISEASE. General Treatment I AM sensible of the great difficulty of properly estimating the value of any given remedy or plan of treatment for the cure of dis- ease. Xature does very much sometimes to aid imperfect means, and even to effect a cure under improper treatment, and very often we record cures and attribute great efficacy to our plan of management, when the favorable termination is due alone, and perhaps in spite of us, to the natural conservative energy of the system or the parts con- cerned; while at other times the circumstances inseparable from a case thoroughly thwart the best-directed efforts. It is often a mis- take, therefore, to be too sanguine in our expectations even with the use of a favorite course of treatment, or to depreciate everything which has not fulfilled our hopes. We should patiently, honestly, thoroughly, and judiciously try every means within our knowledge for the benefit of our patient, let him labor under whatever disease he may. The reader is, doubtless, perfectly aware of the very great differences of opinion in the profession as to the treatment most bene- ficial in inflammation of the cervix uteri and its accompanying ail- ments. In alluding to these many and diverse opinions, I must record my conviction of the honesty with which they are maintained by the principal disputants of the present day, and must exhort the junior members of the profession to cautious and thorough research on the subject. There must be a right and a wrong side to every disputed question; and, as a general thing, extremists are wrong. Remembering this general truth, we cannot always be kept in doubt by the facts in the case, if, without prejudice or party bias of any kind, we earnestly set to work to learn. Spontaneous Cures. Are there any spontaneous cures in these cases? I think there are, and I propose inquiring into the method adopted by nature, and take it as a guide to some extent, at least, for the plan of artificial treatment. Change of circumstances frequently makes robust per- L^ SUPERVENTION OF ACUTE INFLAMiM ATION. 279 sons of invalids. This change is generally from irregular, improper habits of living to such as are regular and appropriate; from the highest state of luxury and ease to one of need, or, at least, economy and industry, in which the patient must exercise her mind and mus- cles to a proper degree. The healthy tone of the stomach, muscles, and brain, thus brought about, decreases the susceptibility to slight suffering, enables the patient, apparently, entirely to recover from disease, and bear small ills without complaint. I need not specify the various circumstances and conditions of life which improve the tone and elevate the functional activity of the whole organism; they are numerous, and will suggest themselves to the reader. How many journeys are taken, how much time spent at watering-places and places of amusement for this purpose? And often they answer the purpose, and the patient is restored to health. Change of General Circumstances only Temporary in its Effect. This improvement in cases of disease of the uterus is brought about rather by diminishing the nervous susceptibility to the wearing in- fluence and pain of the local disease, and by fortifying the system against its advance by establishing excellent general health, than by actual cure of the local inflammation. As a consequence we find a return to the former mode of living, habits, and circumstances, re- produces, more or less rapidly, the same train of general symptoms, and makes it necessary to resort to a repetition of the journey, or whatever other means were previously successful for their removal. This is only an apparent, not a real cure, and is the kind which always results from an exclusive general treatment. Tonics, laxa- tives, and alteratives put the general condition of the patient on a better footing, and she suffers less from her local disease, and even considers herself well; but if we suspend" the general roborant appli- ances, the patient again sinks into her former state of valetudinarian- ism. I have often witnessed these changes as the effect of accidental mutation in the condition of the patient, intentional changes of place and circumstances, or Avell-advised general treatment. Supervention of Acute Inflammation, There is, however, another method resorted to by nature, which sometimes results in a permanent and complete cure. Chronic in- flammation has very little tendency to spontaneous subsidence ; its duration is at least indefinite. Situated in the neck of the uterus, 280 GENERAL TREATMENT OF UTERINE DISEASE. this is particularly the case. Acute inflammation, however, on the contrary, has a strong; tendeucv to terminate in resolution, to subside and leave the parts in a healthy condition. And, in cases of chronic inflammation in any of the organs, the supervention of the acute form proves sometimes salutary. It absorbs the whole chronic action and takes its place in the tissues ; and as it subsides, the diseased organ is left in a healthy condition. AYe have an opportunity of seeing this process of usurpation, displacement, or whatever else it may be termed, in diseases of the eye, and witnessing the salutary sequence. Acute Tiiflammation after Parturition or Abortion sometimes worJcs a Cure. Some of the functions of the uterus when naturally performed are followeil by acute inflammation in the neck of the organ. I allude particularly to parturition ; and while these inflammations sometimes linger and become themselves chronic, they generally, under favora- ble circumstances, subside kindly, and where the cervix had pre- viously been afPected by chronic inflammation, sometimes favorably modify if not entirely cure it. I think that very few cases of par- turition occur that do not cause sufficient violence to the cervix and OS uteri to be followed by a greater or less degree of acute inflam- mation. A great many are certainly thus followed. The acute in- flammation resulting from abortions occasionally has the same eifect. Instances have occurred in the hands of the most experienced prac- titioners, where, the uterine health of a primipara has been benefited by pregnancy and the processes of parturition. Posture, Exercise, and Pepose. The young practitioner will soon learn that posture and exercise are important considerations in the general treatment, and he will be taught by most writers that the reclining posture and strict Cjuietude must almost universallv be observed. AValkino; frenerallv causes an increase of pain, and, it is natural to suppose, an increase of inflam- mation; so that exercise on foot or in the erect position is regarded as injurious. On the other hand, confinement to the recumbent pos- ture and the observance of strict quietude is very hard upon the general health ; the patient becomes more nervous, and all her func- tions are performed in an irregular and imperfect manner. As a consequence, in very many instances, the symptoms are much aggra- vated. In the great majority of these cases, therefore, I think the POSTURE, EXERCISE, AND REPOSE. 281 patients are injured by confinement and recumbency. It would neither be scientific, sensible, nor successful, however, to lay down any absolute rule in respect to exercise and quietude. I think we may arrive at pretty accurate conclusions as to the sort of cases and the conditions under which each should be observed. More than ordinary acuteness of the symptoms, indicating a high degree of in- flammation, occurring in the beginning and continuing throughout, or arising during the progress of a case, as the effect of tempo- rary causes, will make rest indispensable to the removal of them. Haemorrhage at the time of menstruation or between the menstrual periods is also a reason for strict quiet. Where neither of these conditions are presented, I think the patient will be much benefited by judiciously directed exercise. I feel like insisting upon the en- forcement of outdoor exercise as a rule in these cases ; for I have often had an opportunity of contrasting, in the same cases, the influ- ence of quiet and exercise upon the recovery of patients of delicate nervous constitutions. One patient w^ho had been unable to sit up for even a short part of the day for several months, on account of the pain in the hips, dragging in the loins, and great nervous pros- tration, was sent to a water-cure, and in three months she returned home capable of walking several miles a day, and enjoyed compara- tively robust health. In a few weeks after returning to a home in which she enjoyed the luxuries and ease so desired by all who prize good living, she became ^^ miserable,^^ and was obliged to abandon her exercise entirely. It is encourao^ino; to state, that in less than six months of proper local treatment, she was permanently cured. This is but a type of many similar cases that have been benefited by the enforcement of exercise and other items of proper living, but, I must also add, not cured. It has been my constant, aim for many years to induce patients of this kind to take as much exercise as they can bear. Under the mistaken notion that any local pain indicates an aggravation of their disease, and that to exercise when it gives them pain, even to a moderate amount, is a great evil, they confine themselves to their room, and even their bed, to the forfeiture of that healthy tone and energy of the nervous system which shield them from the intolerable and inexpressible ennui, melancholy, and irri- tability, which are so characteristic of bedridden women. Pain and weariness, that subside after a few hours' rest, should not be re- garded ; it is only in those cases in which the pain and weariness in- crease at every effort at exertion that exercise should be abandoned, and then we should insist upon its being resumed again as soon as 282 GENERAL TREATMENT OF UTERINE DISEASE. sufficient advance in the cure has been made to justify another atte?npt. We should not tire, during the whole treatment, in our endeavors to institute a system of regular and gradually increasing exercise, on account of the consideration that it is indispensable to the enjoyment of useful and comfortable health. Selection of the kind of exercise will depend, of course, upon the condition of the patient in respect to pecuniary matters as well as the state of her dis- ease. Fortunately, the best kind is such as is within the reach of every kind of patients, not excepting those who are under the neces- sity of earning a living. The capacities and demands of our nature are formed to answer the curse pronounced against Adam. We not only earn our bread by the sweat of our brow, but the labor neces- sary to procure the bread brings almost all the conditions that insure health and happiness. It is, in fact, a great evil of the present state of society that our ladies cannot find in useful employment that healthy exercise for the body and mind which they need, and that such exercise and employment are allowable and acceptable only in amusement. There is almost no variety in mental and corporeal ex- ercise required by the highest social amusements, and it is only when we descend to the primitive sports that our demands in this respect are met. It is undignified in ladies to fish, hunt in the woods, or engage in muscular feats. They must for muscular exercise engage in the measured sameness of the quadrille, or the giddy whirl and violence of the waltz, or cramp their limbs to the steady routine of a system of calisthenics. What are all these, for variety and adapted- nes§ to their wants, compared to the washing, ironing, sweeping, milking, churning, spinning, weaving, cooking, walking, running, of household engagements, the stimulus of need ; thinking of all these things ; timing them ; proportioning them ; calculating, economizing, nursing, doctoring, advising, correcting, teaching, and conducting little minds and bodies through the physical, moral, and intellectual discipline which capacitates, unfolds, and imbues them with what is good and useful ? Woman's duties, taking them altogether, when well and appropriately performed, will do more than all the amuse- ments that can be invented to keep woman well and healthy in every particular. In fact, it is only woman thus employed that can enjoy amusements. To the woman that constantly seeks after amusements, these very amusements become an irksome and toilsome business ; they have a disagreeable sameness, and do not divert her; they simply vitiate her tastes. We all want variety, and constant employ- SEXUAL INTERCOURSE. 283 ment, with a sense of usefulness attached to it. With this view of the usefiihiess of mental and bodily labor, I encourage my patients to engage in their domestic duties and labor, gauging the amount of labor by their capacity of endurance. Attention to the homes of wealthy women, as society is now constituted, requires a great deal of anxiety and mental exercise. Without a proper variety of muscular exercise, the woman, in attending to the duties connected with it, be- comes more nervous ; but the home of the poor industrious citizen or farmer gives enough, and a healthy variety, of both muscular and mental exercise to promote health and happiness. Should there be such objection in any shape as to make this course impracticable or improper, it is an interesting question to decide what sort of physical exercise is most desirable and beneficial. I am decidedly in favor of exercise on foot, outdoors, as one of the very best kind, far prefera- ble to carriage or horseback riding. Carriage riding is not sufficient exercise for the most of such patients, and yet those who are most debilitated, and utterly unable to walk, may be much benefited by riding in an open carriage until they become vigorous enough to walk, when it should be abandoned. Convalescent patients may ride on horseback if they can have an easy-going animal ; but this sort of mo- tion is too violent ; there is too much jolting for such cases until nearly or quite cured of the local trouble. We ought to induce our patient to walk more each day than the previous one, if possible, until she has plenty of exercise. Sexual Intercourse. Young physicians have often asked me whether sexual intercourse is injurious during the time of treatment, and whether it should be permitted? I have no hesitation in insisting upon entire abstinence from this act. The recovery of our patient will be more rapid, cer- tain, and complete when this is observed, and I believe that failures are the result of carelessness in this respect. It is very common for our patients to enjoy more comfort when absent from their husbands, and come home from a journey, as they think, entirely cured, to be assured of the contrary by the first effort at coition, and become mis- erable with pain, nervousness, etc., in a short time on account of in- dulging in this conjugal act. I desire, therefore, to be explicit in warning my young friends in the profession not to omit the inter- diction of sexual intercourse, however delicate the task. A private interview should be sought with the husband for that special purpose. 284 GENERAL TREATMENT OF UTERINE DISEASE. 3Iain Objects of General Treatment. The main object to be gained by general treatment is to palliate the general condition of the system, to aid the local in effecting the cure, and to remove, when practicable, the effects left after a cure of the local disease. A cure of local chronic disease, by general treat- ment alone, is hardly to be expected, although, in some instances, it may be indispensable to such a result. When general treatment is used as a palliative or adjunct in local diseases, it is directed to the relief of general symptoms attendant upon them. It will be impos- sible for me to notice the treatment necessary in all the symptoms which attend and add to the distress of our patients In uterine dis- eases, but there are certain prominent and troublesome ones on which I cannot with propriety omit to dwell. I do so the more readily from the embarrassiiftent which I know, from experience, fills the mind of the inexperienced as to the proper value to place upon gen- eral treatment and the course to be pursued. Many of the patients laboring under chronic uterine disease come to us broken down, the subject of a multitude of symptoms resulting from inanition and depraved functions. These prostrated patients, it will be found, have passed through the primary sympathetic suffer- ing I have elsewhere described, and are in the midst of that condition we have been in the habit of calling nervous prostration, in which general treatment becomes a very important, if not an essential, means of success. This general treatment consists in the correction of the condition of the organs which were first sympathetically deranged, — the stomach and its associate organs, — introducing Into the system nutritive material enough to relieve the anaemic state of the nervous centres, and conducting the patient back to her long-lost habits of activity. I have elsewhere expressed the opinion that the primary morbid condition of these organs is functional derangement, and, perhaps, always deficiency of their secretions. One of the first and most important things to be done Is to correct this derangement, and the two medicines that have occurred to me to be the most efficient are mercury and nitro-muriatic acid. Mercury has always, and very deservedly, had the reputation of exciting the glands connected with the alimentary canal, viz., the salivary, gastric, duodenal, — liver and pancreas, — and those of the large Intestine. Administered in small doses, this excitement does not transcend the limits compatible with health ; but given In larger doses, it produces inflammatory excite- ment in all of them. We can very properly avail ourselves of this MAIN OBJECTS OF GENERAL TREATMENT. 285 quality of mercury in such a manner as to increase the action of all these glands, and thus promote the appetite and digestion and assimi- lation. It is, in this way, an efficient tonic, increasing the red blood- corpuscles and establishing a plastic habit so desirable in chronic diseases. To these broken-down patients I am in the habit of ad- ministering it in the form of blue mass or the bichloride; of the former one-fourth of a grain four times a day, or one grain at bed- time. When I give the bichloride, I generally dissolve it in the compound tincture of cinchona, one-sixteenth of a grain of the mer- cury in a tablespoonful of the tincture three times a day, after meals. These doses are too small for some patients and too large for others. When not large enough, they are not attended wdth any appreciable results, in which case a slight increase will be necessary. When the dose is too large, it usually causes diarrhoea. When it produces this last effect, it should be withdrawn and the acid substituted, which should be given in very small doses. Dr. L. F. W^arner, of Boston, wrote an article in advocacy of the use of mercury in the treatment of uterine disease for the obstetrical section of the American Medical Association. It was published in the Transactions of 1878. Dr. Warner brings forward cases to show the efficacy of this drug, and the article will repay perusal. It should be remembered, however, that medicines are but prompt- ers to nutrition, and that to reinstate the lost vigor the patient must be fed. Her anorexia should be no excuse for starvation ; food should be taken in sufficient quantities to nourish her, with as much persistence and regularity as she takes her medicine. If we wait for an appe- tite, starvation will go on ; and if we wait until digestion is com- fortable, we may often wait until inanition establishes tuberculosis, leucocythsemia, or some other equally fatal disease. AVe ought to prescribe and particularize what, in our judgment, is necessary, and insist upon its being taken. About the only reason for withholding any article of diet indicated is the rejection of it. Digestion is likely to be attended with discomfort of some kind, such as fulness, cardialgia, pyrosis, etc. ; but as the blood becomes better, by virtue of its tonic influence upon the organs, the secretions in the- stomach will improve, its muscular coats become stronger, bile be- comes normal in quantity and quality, and the digestion will be com- plete, easy, and comfortable, and the patient will regain her strength. The articles of diet which can be tolerated will not always be the same. When I say tolerated, I do not mean desired and digested with comfort, but I mean such as will not be rejected from the stom- 286 GENERAL TREATMENT OF UTERINE DISEASE. ach, for if they are not vomited np, and do not cause diarrhoea, they will be digested, and hence be the source of nutrition. As concentrated food and generally the most nourishing, are the different kinds of animal food ; beefsteak, roast beef, mutton chops, roast or boiled mutton, milk and eggs, butter, etc., constitute a good assortment from which to choose and prescribe. In prescribing meat in any form, we will generally be met with the objection: "I do not eat meat; I do not care for meat; I have no appetite for it.'^ I sometimes think, as medical men, we ought to reject the word appetite from our vocabulary. These patients usually have no appetite, and for that very reason are starved. If we do not prescribe the very articles we want them to take, the exact quantity and the time for taking them, they will generally disregard our directions. AYe may tell them to take two ounces of beefsteak or mutton chop for breakfast, the same quantity for supper, four ounces for dinner, with bread and butter, vegetables, and every such other thing as they wish, but always the meat. Then if we prescribe one pint of milk after each meal, and one at bedtime, the patient will have a good strong diet, and it will soon be apparent in her improved condition. The nurse should be responsible for the taking of this prescription as she is for the administration of medicines. Some patients cannot chew their meat, but can swallow and digest it if it is minced finely. It will digest in this form usually very per- fectly. General Symptoms requiring Special Attention. The symptoms, the treatment of which I propose to speak of in detail, are: 1st, general nervous prostration; 2dly, nervous excita- bility, exaltation of nervous excitement; 3dly, anaemia; 4thly, gen- eral plethora; 5thly, local plethora; 6thly, constipation; 7thly, in- digestion. These are generally more or less complicated with each other, and sometimes several of them coexist; but, ordinarily, some one assumes the most prominence, and occasions most distress, and consequently requires more of our attention than the others. Nervous Prostration. There is often great nervous prostration, and a sense of weakness, when, so far as we can judge, hiematosis and nutrition are usually well performed. The cause of this depression must be sought out in each case, as there is no uniformity in the functional deviations. Very frequently there is a deficiency of menstrual discharge, the NERVOUS PROSTRATION. 287 scantiness being very obvious; at other times it is too copious. We should inquire into the functions of all the important organs, and correct them, when disordered, as nearly as possible, by changing the habits and circumstances of the patient, and afterward, or in connec- tion, address remedies to the organs themselves. The stomach, liver, bowels, skin, kidneys, and uterus should furnish their discharges in the most natural manner, and if they are not doing so, should be corrected by the most gentle means. If several of these organs are in a state of functional deviation from health, we should not expect to correct them all at one time, but alternate our attention between them; first, with our remedies influencing one, and then another. I insist here, with reference to the plan to be pursued, that we should not address all these organs, or even a large part of them, with me- dicinal agents at one time. There is no question, I think, that com- plicated formulse often nullify themselves by containing ingredients intended for the liver, kidneys, and skin, which ought all to act about the same time. We should act upon each of these alternately, in quick succession, if we think best; but let each organ feel the full impression of its remedy before the blood and nervous energies are directed to another. In addition to this indirect way of increasing the tone of the nervous system, it is natural for us to look about for something that will act more directly. Our patient becomes so de- pressed, and suffers so much from terrible feelings of prostration, that her condition appeals to our sympathies for a more direct and imme- diate relief. If left to themselves, or the advice of injudicious friends, they almost always resort to stimulants, as whiskey, ether, chloro- form, ammonia, etc. In some cases only are these temporary reme- dies advisable, and when used, they nearly always leave the patient in a worse condition than before they were taken. They are allow- able only as necessary evils, and should be avoided when possible. These patients are usually depressed mentally, also, and much good may be done by operating upon their minds. A physician who enters the room with a cheerful countenance, and a pleasant and gentle bearing toward the patient, and who engages her in conversation, first about her case, and afterward about some favorite theme, will do more toward temporarily relieving the great nervous and mental depression than all the ether and ammonia the stomach can be made to bear. Earnest and kind assurances that her symptoms, though causing her a great deal of suffering, are not of a serious nature, and will soon subside, act generally as a good cordial to the spirit and nerves. In paroxysms of excessive nervous prostration, despondency, 288 GENERAL TREATMENT OF UTERINE DISEASE. etc., I have seen the tonic influence of very cold air do a great deal toward relieving thera. These paroxysms generally occur in close and overheated rooms, two conditions which should be removed. If it is cold weather, we should cover the patient to protect her, and let the frosty air — the colder the better — into the room, by opening all the windows and doors, and keep the room cleared of visitors. It will astonish anybody who has not observed the effect of a tempera- ture near to zero on those swooning hypochondriacs. A change almost immediately occurs for the better. If the air is not cold, it will still do much good to give it perfectly fresh to the patients in abundance. "When able, they may be taken outdoors. This treat- ment introduces the natural stimulants, oxygen and cold, into the lungs, and brings them in contact with the nerves, and is more en- livening than medicine. How long the room should be kept open and cold will depend upon the effect, but we should always, if pos- sible, make these patients sleep in open, cold rooms. This is a very important item, which it will often require ingenuity as well as authority to enforce. These patients should live outdoors as nearly as possible, and be as much as they can on their fe^t. Food. Their food should have reference to the condition of the abdom- inal functions entirely, and be regulated by them. There is gener- ally great intestinal torpor, which should be removed if possible. "^ Good, cheerful company, travel, — if the patient will not employ her body and mind in domestic pursuits, — temperate and reasonable di- versions, and, above all, time and patience, are requisite remedies. The affection is obstinate and chronic, and with the most judicious management will require time, if it does not vanish as the local treatment advances. Nervous Excitability. Connected with it often in some manner is great nervousness, exci- tability, irritability, or exaltation of all the nervous phenomena. This nervous irritability shows itself in great mental excitability, want of sleep, unreasonable agitation, restlessness, dissatisfaction ; in short, in almost every phase of mental, muscular, or nervous excitement. There is also excitability of the different organs, with or without general nervousness, palpitation of the heart, nervous headache, local * See remarks on treatment of constipation. NERVOUS EXCITABILITY. 289 muscular contraction, etc. Successful management of these nervous and excitable patients requires a careful scrutiny into their general condition ; the chylopoetic functions should be regulated in the most careful manner, the skin and kidneys should be attended to with great watchfulness. All that I have said as to general management in cases of nervous depression will a})ply to this kind of cases. As complete a revolution of the circumstances of the patient sliould be made as is practicable. From a life of ease, luxury, and absence of care, she should be, if possible, placed in circumstances requiring care, w^ith muscular outdoor exercise to the greatest extent she is capable of. If we cannot place our patients in situations which their cases require, we can send them on journeys that will demand exer- tion, calculation, care, and the deprivation of their usual domestic luxuries. The remark is frequently made that we must temper our remedies to the delicacy of the patients; and I am afraid that this injunction is misconstrued into the necessity of too great tendernes.s of treatment. The better rule is to make use of such means as will raise the patient from her state of delicacy to robustness. It is the delicacy of her constitution that causes her to suffer so much. This can be strengthened only by proper physical, moral, and mental training. The moral and mental condition of our patients when so very excitable should be attended to. Improper reading and society should be avoided, and social and literary habits should be reduced to great plainness and simplicity. Above all things, books and society should not interfere with regular rest, exercise, and outdoor exposure. As I have said before, this last should be as great in amount as can be borne, accompanied with active muscular exercise, as walking, and should be practiced in all weathers, sufficient pro- tection being secured by enough clothing of the right sort. With regard to the use of medicine, it is a fact, that it is an exceedingly difficult thino; to find anv remedv that does not produce exao^g^erated and in most cases disagreeable and even injurious effects. So much excitability of the nervous system nearly always modifies the effects of remedies, and we can seldom predict the operation of any of them, nor can we determine the value of any until they have been tried When tonics can be borne, they often very much relieve and sometimes entirely cure this great nervous excitability. Of the mineral tonics, probably bismuth, arsenic, and zinc agree best. Iron is not fre- quently tolerated in any shape by these very nervous patients. Qui- nine, nux vomica, cherry, and chamomile are the best vegetable tonics, but we must not be surprised if none of them are borne. Al- 19 290 GENERAL TREATMENT OF UTERINE DISEASE. coholic stimulants, In general, agree with them, and are the best cor- dials for temporary nervous excitement, but should be conscien- tiously avoided when possible, as not a few, T am sorry to say, of most estimable and intelligent women have used them too much, and engendered an appetite that could not be denied. Opium, and, in fact, the narcotics generally, fail to have any good effect, but on the contrary disagree with the patient totally. This, however, is not always the case with opium, as it acts like a charm with some. In all it should be studiously avoided as deleterious in the long run, and there is danger of creating an appetite for it. We may the more readily be persuaded to omit the use of all these medicines, as their effects are temporary, while hygienic and regiminal remedies are per- manent in their effects. The management of those cases of localized nervousness or unnatural excitability in particular organs, as palpi- tations of the heart, nervous headache, etc., is about the same as above, except that more attention to the stomach, from which they usually arise, may be necessary. Some forms of nervous excitement are very much benefited by the bromide of potassium. Severe nervous headache, watchfulness, and neuralgic pains are often greatly relieved by this remedy. It should be given in full doses. For headache, from thirty to sixty grains every hour until relief is obtained. For watchfulness, the same quantity an hour before and at bedtime will sometimes procure a good night's rest. When given in full doses it should be dissolved in a large quantity of water, to prevent it from irritating the mucous membrane of the alimentary canal. I have sometimes succeeded In averting the return of the syncopal convulsions described under the head of general symptoms. One patient now under my care had been the subject of them for twelve months, having them several times a month. They had become so frequent and violent as to induce the fear of epilepsy, and had been treated with many remedies without material benefit. She has been taking the bromide of potas- sium for six months In doses of thirty grains three times a day, and during that time has had no convulsions. She Is under treatment for endocervicltls. It remains to be seen, of course, whether this im- provement be permanent, nor can I say how mnch of the ameliora- tion may depend upon the treatment directed especially to the uterus. It Is certain, however, that the '^ paroxysms,'^ as she calls them, were improved immediately upon the commencement of the bromide treat- ment, and before I could reasonably expect benefit from the rest of the remedies. ANEMIA — LOCAL COXGESTION. 291 AVe undoiibteclly have a valuable means of relief from the pains attendant upon the condition of many of these patients in the hydrate of chloral, while it is often as prompt and positive in the relief it affords in sleeplessness and pain. So far as I am aware, it is not fol- lowed by the very disagreeable effects that result from the adminis- tration of opium and its preparations. It, too, should be dissolved in an abundance of water, to prevent it from producing local irrita- tion upon the mucous membrane of the stomach, as it often other- wise causes vomiting or decided nausea. Ancemia. Anaemia, with its disagreeable concomitants, sometimes also calls for separate treatment. It would be an unnecessary waste of time and space to enter minutely into the general treatment necessary, where anreuiia is the prominent and troublesome symptom. This condition calls for the same treatment found useful under other circumstances, and, while it may not be entirely amenable to it, it will be very much benefited by the remedies indicated by the state of the blood. Iron, cod-liver oil, quinine, bitter infusions, and nutritious diet, with out- door exercise to the extent the patient can bear, are the ef&cient remedies. Plethora. B'.t we sometimes find general plethora instead of anaemia, a state in which there is actually an unusual amount and too rich a com- position of the blood. I need not dwell upon this general state of the system, as the treatment is simple and familiar. The great fear is that, on account of the painfulness about the hips and legs, the patient may be too much inclined to an inactive life. On no account should this class of patients be allowed their ease ; they must be urged to use up their surplus blood in active exercise, and the kind of exer- cise, next to the cares and labor of a household, best adapted to them, is walking. Every muscle in their body must be brought into action ; every secretion must be kept free, and the mind ought to be taxed to continuous effort during the day by some useful occupation, while the strictest temperance, with reference to ingesta, should be their rule of living. Obesity, and the troublesome and dangerous effects of plethora, connected or unconnected with general plethora, will be thus avoided. Local Congestions. AVe sometimes meet with instances of violent, dangerous, and even fatal determinations of blood to particular organs, as the consequence 292 GENERAL TREATMENT OF UTERINE DISEASE. of the general ill-health which accompanies uterine disease, such as stupor, stertorous breathing, etc., indicating an oppressed condition of the brain, great dyspnoea, and sense of suifocation, showing congestion of the lungs. The treatment of these congestions does not differ from what would be appropriate under other circumstances of their occur- rence, and consists in revellents, alteratives, etc. The most frequent, and perhaps obstinate, of the local congestions are such as occur in the chylopoetic viscera, manifested by excessive secretion and discharges from the stomach and bowels. It is not uncommon for these patients to have suddenly recurring attacks of vomiting, cramps in the stomach and bowels, diarrhoea, and consequent great distress. Aside from the local treatment, we shall be called upon to exert our skill against the exhausting and depressing influences of these attacks. It will almost always be found that such attacks are preceded by constipation, with scanty secretions, furred tongue, and other evidence of unhealthy- secretions. By carefully correcting this condition we may avert these painful and exhausting occurrences. The plan recommended and so much prescribed by Abernethy will often palliate very much, viz., six or eight grains of blue mass, at night, worked off by some saline cathartic in the morning of every fourth or fifth day. If there is more permanent diarrhoea, great care should be exercised in the choice of diet; the use of warm baths should be recommended, very warm clothing, and not much medicine, as the cure will depend upon the appropriate treatment of the local disease, instead of the treatment of the general symptoms. All these symptoms, except the diarrhoea, are apt to be moderate, and can be borne until the diseased uterus is cured ; but there are two symptoms so very annoying, and which require so much patience in the treatment, and exercise so much unfavorable influence upon the uterine disease, that I hope I shall be pardoned by the reader for dwelling upon them more at length. Constijjation. I allude to constipation and indigestion, particularly the former. I have already spoken of the deleterious influence of constipation, and I think I am justified in saying that, if disregarded, it retards the cure of chronic diseases of the unimpregnated uterus more than any other sympathetic affection. And I wish to warn the practitioner to be very particular in attending to this symptom. There is proba- bly more tendency to costiveness in females than in males, chiefly owing to difference in habits. Sedentary life, confinement to close, badly ventilated rooms are among the circumstances that bring on CONSTIPATION. 293 this condition. Irregularity of meals, late hours, deficient sleep, con- centrated diet, imperfect masticatier place, the position should be an easy one; no inconvenient strain upon any muscle should be allowed, and the patient should be possessed with an entire sense of leisure to perform the act completely. The value of all these considerations, where faithfully followed, is incalculable, and very few cases can long resist them. AVjthout them, medicine will only temporarily relieve, instead of permanently curing, 294 GENERAL TREATMENT OF UTERINE DISEASE. obstinate cases. I should caution against severe effort, or straining, as it is called; let time, patience, and gentle effort be the plan. Another matter of great importance, when an effort is made to have an evacuation, is to have the abdomen distended by ingesta. The patient should be instructed to eat plentifully of vegetable diet, such as by its bulk is calculated to produce fulness. If the patient go to the water-closet with a sense of fulness in the abdomen, success will be much more likely. Should the regular time for making an effort be soon after breakfast, which is undoubtedly the best time, and the meal has not been sufficient to produce a sense of moderate distension, a full glass of water will complete that condition. For the purpose of giving fulness and a sense of distension, various kinds of ripe fruit may be resorted to with advantage. In prescribing fruit for consti- pation, we should bear in mind that there are three indications ful- filled by it, some kinds fulfilling all, while others fulfil only a part of them. They are, first and best, distension; secondly, increase of secretion, on account of the acids; and, thirdly, increasing peristaltic action of the bOwels by indigestible fibres, seeds, or rind. Ripe and mellow apples, without being divested of the rind, may be eaten in sufficient quantities to produce a sense of fulness, and this should always be at the conclusion of a meal, — breakfast, for instance; the acids will increase the intestinal secretion, and the rind quicken the peristaltic motion of the bowels by acting directly upon the mucous membrane, and through it on the muscular structure. Very acid fruits, as the lemon and orange, only produce their effect on account of the acids they contain. They are excellent as a part of the ingesta of patients whose stools are dry and hard and lumpy. Fruits con- taining an abundance of seeds, as figs, or of rind, as tamarind, etc., increase the peristaltic action without causing much secretion. By inquiring into the character of the stools, we shall have a good guide as to the kind or mixture of fruits to be selected. There are kinds of diet, breads particularly, that act like these last fruits, and may be used in conjunction with or independent of them. Breads in which the bran, or hull of the grain, is contained in considerable quantities are of this character. The Graham bread, as it is usually called, ordinary coarse, brown, corn bread, or wheat bread, are those mostly resorted to. When this kind of bread is used for constipation, it should be eaten at breakfast, dinner, and supper, in such quantities as the experience of the patient finds necessary. I have advised patients who could not use the coarse breads to make what may be called bran crackers. A tablespoonful of flour, oue pint of wheat CONSTIPATION. 295 bran, two tablespoon fuls of white sugar, and water enough to make them all into a pasty mixture, are the ingredients. This mixture is made into cakes, small or large, as may be wished, and baked in an oven until hard. AVhen soaked in tea, coffee, or milk, they are not unpleasant. I have known patients benefited by swallowing certain seeds, with the rind, whole. A tablespoonful of wheat grains, oats, barley, white mustard seed, etc., can all be used for this purpose, and are not more disagreeable than medicines. Another kind of diet, which may be used to produce the kind of effect here aimed at, con- sists of the various small vegetables, as celery, radishes, pepper-grass, lettuce, asparagus, cabbage, etc. These may all be taken in quanti- ties to cause distension. In speaking of fruits, I ought to mention the berries as an excel- lent means, cheap, and easily procured, to accomplish all the objects attained by other fruits. Everything should be done by habitual effort, exercise, diet, drink, etc., before resorting to the use of medicines ; because, as is well known to the patients generally, as well as to the practitioner, the more medicines taken the more will be necessary. They lose their influence, and the dose must be increased in order to produce a full effect. This is almost always the case. Xot withstanding this evil, we are often reduced to the necessity of using laxatives to overcome constijDation. To a just and intelligent application of medicines in the treatment of constipation, it is indispensably necessary to make ourselves acquainted with the condition of the alimentary canal, with reference to its secretions and muscular powers. It will be found that there are sometimes great deficiency of secretion, and torpor or want of vitality of the muscular structure, or weakness of this tissue. The want of secretion may be in the upper portion, in which case the bilious color is wanting in the stools, or the small intestines may give out less watery material, and then the stools are less fluid, or even dry. The secretions may also be deficient in the lower portion, or colon ; in which case the fteces will be scybalous, dry, and lumpy. The muscular torpor, from want of irritability-, is more frequent in the colon or rectum than in the small intestines. When in the colon, there is increase in size of the lower abdomen, sense of fulness and hardness, and the faeces are expelled with great difficulty. If there is sufficient activity of the colon, but the rectum is torpid, large accu- mulations occur there, the pelvic distress is increased, and nervous- ness, general and local, is exceedingly annoying. Sometimes all these conditions are combined to render the case one of the most 296 GENERAL TREATMENT OF UTERINE DISEASE. troublesome and difficult to manage. Mechanical obstruction by stricture of the rectum, formed by pressure of the uterus, may give rise to chronic constipation, which may become permanent and almost incurable ; or the uterus, by lying on the bowel, and pressing it against the sacrum, often gives rise to costiveness, that can be removed only bv correcting the position of that organ. It is not sufficient to know that the patient does not have regular operations from the bowels, but we must know wdiy she is thus constipated. Whether on account of want of secretion, and, if so, of what secretion ; whether it is attributable to general debility, combined with muscular weak- ness of the intestines, or to lack of irritability of the intestinal tube and consequent torpor ; and if so, whether this lack of irritability exists in the whole length of the canal, in the colon, or the rectum. AVe must also know whether there is obstruction from stricture in the rectum, piles, thickening in the mucous membrane, rigidity of the sphincter, or from the uterus bearing heavily upon it. To give a laxative merely because it ordinarily produces a fecal discharge, is always unphilosophical, and sometimes exceedingly injurious in its effects. I think it is inattention to the exact state of the alimentary canal that makes constipation so often incurable. For constipation, attended with very dry, hard stools, showing a deficiency in all the secretions from the bowels, in addition to the course of diet, includ- ing acid fruits, etc., our object should be to administer such drugs as will most effectually stimulate to secretion. The various saline med- icines are indicated. Sulphate of magnesia is a most excellent one ; and a good way of administering it is in combination with sulphuric acid. From one to two drachms, or even half an ounce, given in combination with acid enough to taste somewhat sharply, will pro- mote secretion along the whole of the small intestines, cause a large effusion of water, which will dissolve the fasces and render their evacuation easy and sure. In the morning, some time before eating, is the best time to take it. When there is reason to believe that the portal circulation is slow, and the liver furnishing less than its usual amount of secretion, some form of mercurial should be used with the salts. If the case is chronic and the constipation obstinate, we may give from six to ten grains of blue mass in pills, at bedtime, every fourth or fifth night, and follow it with Epsom salts in the morning. A continuance of this alterative cathartic from four to six weeks, seldom fails to cause a change in the alimentary secretions. Sometimes it is better to give these cathartics nearer, and sometimes farther apart. AVe must judge of this more by the susceptibility to the constitutional CONSTIPATION. 297 influence of mercury than anytliing else. It is almost always the case that this very scanty state of the secretions is accompanied with an impoverished state of the blood ; hence iron in some shape will be beneficial in most cases. If there is much debility, a long course of tonics will be indispensable. It may often happen that this scanty condition of the secretions is attended with debility of the muscular fibre of the intestinal canal. When this is the case, we must add to the above treatment that which is applicable to this kind of intestinal torpor, which I shall now consider. Before doing so, however, I will remark that several other salts will answer as well, and sometimes even better, than sulphate of magnesia. The kinds of tonics which are most effectual in debility of the muscular structure of the in- testinal canal are such as give general strength, and it is most desir- able to combine them with special tonics. The latter are rhubarb and nux vomica. These have always seemed to me to have a special tonic influence upon the intestinal tube, and, when properly given, to increase the susceptibility to their own action. The rhubarb, although an alimentary tonic, induces less susceptibility to its own influence than the nux vomica. The best way to give the rhubarb is either in the root, without pulverization, or in the extract. When given alone in the root, the patient can take a little, twice a day, by chewing, and, after mixing with the saliva, swallowing it. A little experience will enable the patient to judge of the rio^ht quantity, which she can repeat as often as it is required. When the rhubarb is taken this way, she may also take a solution of ferri. sulph. and strychnia, in water, one grain of the former to one-sixteenth of a grain of the latter. I have often succeeded in overcoming this constipation or debility by giving one grain of quin. sulph. with five grains of powdered nux vomica after each meal. Or the same amount of nux vomica, with iron by hydrogen, two grains each time, after eating. It is usual to use aloes in the constipation of uterine diseases ; but I have found very few cases with which this drug did not disagree. But there is a torpor of the intestines where general tonics cannot be borne; Avhere, in fact, there does not seem to be any general debility, there is only a want of susceptibility to the stimuli which ordinarily arouse them to action. The secretions color the faeces properly, and give them sufficient moisture ; there seems to be no fault in their appear- ance, consistence, odor, or other character whatever. They are de- ficient only. The patient may be plethoric and florid, her general muscular strength sufficient, and her blood, so far as we can judge, 298 GENERAL TREATMENT OF UTERINE DISEASE. good in composition. Special tonics and stimuli are indicated in such instances, and they alone should be used. Such measures should be adopted as will arouse the muscular action of the intestines. Nux vomica, in five-grain doses, with the rhubarb extract or without it, or the strychnia in solution, in doses from a sixteenth to a twentieth of a grain, constitute our most valuable medicinal appliances. This is the kind of constipation that is most benefited by and is most amenable to a persevering regiminal and dietetic course of manage- ment, such as I have endeavored to give. In addition to the rhubarb and nux vomica treatment, we may get some good from external appliances, and manipulations of the walls of the abdomen. The most valuable, when gently, persever- ingly, and methodically applied, is what is understood by the term kneading. The colon is the torpid portion in most cases of this sort of constipation. The process of kneading consists in handling it so as to stimulate its fibres directly. One plan is to grasp it with the hand, and squeeze it from one end to the other. We should begin at the right groin, and with a knowledge of the position and direc- tion of it, grasp it with both hands at this point, then a little higher up on the same side, and then a little higher, until we reach the right hypochondriac region. We should then follow it across the abdo- men to the left hypochondriac region, and thence down to the left iliac. Or, we may double our hands as bakers do when kneading their dough, and standing over the patient, press with the knuckles of both hands, first in the right iliac region, and imitating the pro- cess of kneading, pass slowly from this to the right hypochondriac, thence across the abdomen and down, as before directed. If we trust this process to a non-professional attendant, we should be sure to show him how to do it, as it is important that it should be done right. When this process of kneading or squeezing the colon is first insti- tuted, it should be practiced with the utmost gentleness, but the force and rapidity of motion may be increased until great freedom may be used. It should be resorted to a short time before retiring to the water-closet, say half an hour. Some patients find an efficient laxa- tive in what they sometimes call a water-compress, applied to the abdomen over night. It is made by doubling a napkin several times, so as to make a thick compress, large enough to cover the entire abdomen anteriorly. This is saturated with water, and, after beins: placed upon the abdomen, covered with a roller or bandage so as to keep it in place. It is thus allowed to remain from the time of going to bed until the time to rise in the morning. I think this CONSTIPATION. 299 Avater-compress is best adapted to cases iu which there is a deficiency of secretion in the intestinal tube. A bandage, or, what is better, a roller applied tightly enough to press the wall strongly upon the contents of the abdomen, frequently stimulates them to proper action, botli as it respects secretion and peristalic motion. When it is determined to use the roller or band- age for its stimulating influence, it ought to be applied upon rising in the morning, or, what is perhaps better, immediately after break- fast. This bandage should not be worn constantly, nor even many hours in the day. From the time of rising until two hours after breakfast, or from breakfast for three hours thereafter, will be long enough. The constant use of the bandage would but increase the evil — lax abdominal muscles — for which it is advised. Before leav- ing this part of the subject, I desire to say, with reference to the free use of nux vomica to overcome intestinal torpor, that in all cases we should remember its effects are cumulative, and quite a difference of susceptibility to its influence is manifested by different persons, in consequence of which the patient should be watched, and the dose graduated to the least quantity necessary in the case. Although I have given nux vomica and strychnia for a considerable length of time to a great variety of persons, and for several weeks together, I have never seen anything more than slight inconvenience from it in the shape of nervous startings. Very rarely we meet persons who cannot take it at all ; it disagrees with them as soon as they com- mence its use. There is another species of intestinal torpor of a very obstinate character and very distressing to the patient; I mean a lax, torpid rectum ; so torpid as to allow the fteces to accumulate in large quan- tities, and cause great inconvenience from pressure. To such an ex- tent does this collection sometimes go as to press the posterior walls of the vagina forward and protrude it between the labia. The first indication in such cases is to dissolve the fecal mass and discharge it. Various kinds of injections are useful for this purpose, warm oil, warm water, etc.; but one which I have seen do much good is com- posed of one ounce of fresh ox-gall and four ounces of warm water. This composition dissolves the fteces very readily, and the fresh bile stimulates the intestine to their expulsion. The evacuation, of course, will give only temporary relief, and there remains the most important indication, that of giving tone to the bowels, with a view of prevent- ing the accumulation in future. This is difficult, and in some in- stances of long standing quite impossible. Much good can be done 300 GENERAL TREATMENT OF UTERINE DISEASE. in Dearly all cases, however, and we do not discharge onr duty if we do not try to relieve when we cannot cure every case. Cold water thrown into the rectum once or twice a day, in small quantities — eight ounces — is always good, without some special reason ' to the contrary. There are generally two indications to be fulfilled in these cases, — relaxation of the sphincters and r^toring the tonicity of the proper rectal fibres. It is a singular fact, which I thiuk I have observed, that the sphincter muscles increase in stre: ^: - :e of age; this is one of the causes why the fsoc^ uic vii^cd . ::,^ more di&culty in old persons. To give tone to the rectal muscles, astringent injec- tions have been recommended and extensively used : but in my prac- tice they have been almost uniformly useless, r::?::^ ^!r:. = injurious, and always disigreeable. They dry up tl -:::::-. an evil not to be compensated for by any other effect ; they do not, so far as I can judjre, cause contraction of the muscular fibres, but they are very apt, if persisted in for a length of time, to cause inflammation. I have derived more benefit from tonic suppositories and injection s than from any other kind of medicinal treatment. A suppository of twenty grains of extract of gentian, or five grains quin. sulph., ten grains of extract of comus Florida, or a mucilaginous suspension of any of these introduced into the rectum every night at bedtime, and retained, if possible, until morning, are good tonics and eligible modes of using them. It will be nece^ary, to secure the retention and efficient contact of these tonics, to first empty the bowels with ox-gall and warm water, and afterward introduce them with as little irritation as po^ible. The quantity of mucilaginous material should not exceed tw: : >, The tonic treatment of this kind must l>e varied, taking - : : r : : ': and then another, in first one form and then a dilferen: t : :st be kept up for a long time to do much good. We car: ^ ^reful, in all our treatment, to avoid any- thing to which iiie rectum shows any sensitiveness. When it be- comes tender and sensitive, we should at once desist until all of this has subsided before we are justified in beginning again. It too fre- quently happens that both the physician and patient become dis- couraged, and desist before the remedies have had a fair trial. Is there anything that will relax the sphincter ani ? I am not aware that any means operate with efficiency in this direction ; but I have used, in a few instances, with apparent Ijenefit, the ointment of bella- donna, made by mixing the extract with lard. I apply it to the anus externally upon going to bed at night, and continue it, until CONSTIPATIOy. 301 the question against or in favor of its usefulness is fully deter- mined. This application certainly removes the irritability of the sphincter, which causes it sometimes to resist the extrusion of the faeces. As I have before remarked, there are cases in which this relaxation cannot be cured ; we are then compelled to resort to palliatives, and we must be careful to palliate intelligently. We are to give the weak rectum artificial support, to enable it to retain as near as may be its ordinary size. ThLs can be done only through the vagina. An air or sponge pessary introducetl into the vagina, so as to press the rectum against the sacrum, and thus diminish its capacity', will prevent the great accumulations from taking place, and in that way prevent one source of great inconvenience. Dr. Hodge recommends the globe pessary for this conditiou of the rectum, which answers very well in many cases, perhaps in the majority ; but each case must be studied, with reference to its own peculiarities, and the shape, size, and con- sistency of the pessary adapted to it. TThen our object is palliation alone, there is no objection to wear- ing the pessary all the time, but if it is used to palliate what we be- lieve to be a curable case, we ought to use it intermittingly, and the patient should not wear it at night especially. It would probably be better in a majority of the cases to introduce it l^efore rising in the morning, and allow it to remain until noon. One thing I think essential in the size and position of the pessary, and that is, that it does not compress the rectum l^elow its natural capacity ; there should be room enough for an ordinary amount of fieces in it, lest it become a source of obstruction, which it will do when larger or improperly placed. As will be noticed, I have omitted to say anything of enemata in constipation, from inactivity of the colon or up[)er portion of the alimentary canal. As an occasional means injections operate well ; but, like other laxatives, when used for a length of time they lose their influ- ence entirely. If we determine to use injections as an habitual laxative, by proper changes in kind and quantity, we may prolong their effi- cacy very much. To a person unused to them half a pint of cold water will act very well. When the bowels fail to respond to this quantity there ought to be an increase of two or three ounces, and then that amount used until its effects are not satisfactory, when a few ounces more should be added, and so on we may increase the amount until the quantity becomes intolerable. When this is the case we may order half a pint of water with a drachm or two of common salt, 302 GENERAL TREATMENT OF UTERINE DISEASE. chlorate potassa, or nitrate of soda or potassa. We should increase the quantity of water or strength of solution, or both, as the suscep- tibility of the rectum is decreased, until we cannot carry either farther. After we have thus obtained as much good from injections as we can it is sometimes expedient to use suppositories as laxatives. Supposi- tories are made of laxative medicines, or of any other material. Com- pound extract of colocynth, or some other purgative extract may be used ; or we may inclose in some of the extracts a dose of podophyl- lum, or any of the purgative resinoids or alkaloids. These should be retained until absorption takes place. The common suppositories of soap, tallow, wax, sperm, stearin, etc., are of the second kind. It not unfrequently happens that the above modes of using injections and suppositories may be alternated very profitably, the full effects of each being experienced upon their resumption after having used the other for a time. But some persons cannot use injections; the rectum is too sensitive, and attempts to do so induce so much irrita- tion that they must abandon them. In such cases suppositories are out of the question. This form of rectocele sometimes requires a resort to surgery. The operation is detailed elsewhere. I have elsewhere shown that the uterus, by its wrong position, sometimes presses upon the rectum and obstructs the passage of the faeces. This may be effected by retroversion or prolapse. The indi- cation, of course, is to restore the uterus to its proper place, and as I shall have occasion to speak elsewhere of these difficulties (malposi- tions), I do not think it necessary to more than mention them here. CHAPTER XVIII. fPECIAL TEEATMEXT. Baths. The local treatment of infl:irQCQiitiou of the cervix uteri is made lip of several therapeutic items, varying according to the intensity, quality, and seat of disease. Of these there are, however, a few that are applicable to almost all cases ; hence their descriptiou, modes of use, etc., may l^e considered before going farther. Baths, injections, and some minor remedies are of this kind. Water, when applied to the surface, is purely sedative in its effects if it is of the temperature of the part on which it is used. If the bath is partial, the sedative influence is for the most part confined or limited to the part to which the application is made. So with injections per rectum or vagiuam. They soothe the parts contained in the pelvis. If the water is warmer than the part of the surface bathed, the effect is stimulant ; if it is colder, by virtue of the physiological action brought into play, it is first sedative and then stimulant. The circulation and nervous influence of the vagina, for instance, when the cold water is first thrown into it, are depressed, but very soon after its evacuation, or withdrawal, the vessels become excited to increased circulation of blood, and in- creased heat takes place and the nerves become more sensitive. In all these respects baths and injections act alike. The injections are internal baths, by which the uterus is bathed through the vagina. But the effects of baths and injections may be modified by containing medicinal substances. They may be rendered more stimulant or more sedative, or be even made to possess other qualities by impregna- tion with medicines ; one in very common use is astringent in char- acter. Another mode of using water and applying it, either simple or impregnated with medicine, is, to wet a cloth or a sponge with it and bind it to the surface, or introduce it into the vagina. Several thicknesses of cotton cloth applied to the abdomen and impregnated with water is what is called the water compress ; and often when allowed, to remain in contact with the skin for several hours it pro- duces considerable excitement, and, if persisted in for days, will cause first a vesicular, next a pustular, and finally a phlegmonous eruption. The way to render it effective is, after applying the wet 304 5JI : 1 : z : z : cloth to cover it over with oil-silk, and then confine the whole with a bandage or roller, with a view to prevent evaporation. Sponge in- troduced into the va^^r ^ t^ : " "*rh water holding medicine in solution, is a common ^ . j : : :r : : i^ g me uterus. I do not d^ign giving an extended view of the e^cis of baths or their application and modus operandi, but so mudi aid is occasionally obtained by the use of them, that I cannot refrain fiom speaking of the application of some forms of them to disease of the uterus. The bath most applicable in inflammation of the cervix uteri and most commonly used is the sitz or hip-bath, which is intended to allay the inflammatoiy irrita- tion and pain. It is often the case that there is a great deal of suf- fering from pain without much inflammatory action in die parts ; in th^e cas^ a sitz-bath will often give great relief. In many instances the efficacy of the bath may be enhanced by having the patient in- troduce a speculum while in the water, so that it may pass up the vagina to the nes, down the thighs, and sometinies over the whole aMomen. She becomes sick at her stomach, is attacked with rigors, and her feet and hands often become cold. This pain continues, witli exacerliations and remi^ions, for several minni^ or hours, and when it subside, leaves a sense of soreness, more or 1^ considerable, corresponding with the severity of the attack. As the chilliness and rigors of the first few moments subside, there is reac- tion ; the patient becomes warm, and sometime decidedly feverish. In all cas^ in which I have witne^ed th^e symptoms the patients were using a syringe, in the end of which, within the vagina, were several perforations, some on the side of the bulb at the end, and one at the very extremity. I think that one of the perforations had been accidentally placed in apposition with the external os utferi, and as the water was forced through this perforation, it entered the cavity of the cervix, and passed through into the cavity of the body of the uterus, inducing the first shock, and the pains following it were caused by the spasmodic attempts on the part of the nterns to expel it. Al- though I have, in a large number of instance, been called upon to ^vitness and prescribe for these symptoms, I have not seen them pro- ceed to dangerous extremities. I think these are cases of injection into the womb ; and, in this resi^ect, they constitute my whole ob- servation. An opiate injection per rectum, fomentations over the pubis, and quiet, are all the remedies I have found necessary. And often the symptoms sulfide so soon that I have not been under the necessity of prescribing at all. We occasionally meet with patients who cannot use baths or injec- tions. In these cases it will be found, almost invariably, that this inability arises from their producing an exa^erated effect. If it is simple tepid water used for the bath or injection, its r^ults are too sedative. The bath debilitates the patient, instead of simply sooth- ing her. I have seen a single tepid bath prostrate a patient so that she would have to lie in l^ed for several hours before its effecte wore off. A cold bath induces chilliness and permanent eoldn^s, and re- action is not established ; the system recovers from its effects only after a number of hours, and that slowly. Hip, sitz, or general baths may produce these effects, and when they do so, should be almndoned as injurious. Other nervous symptoms, as difficultv of breathing, nausea, dysuria, etc., also occasionally seem to be the effects of baths. It is singular that some patients are so susceptible to the depressing effects of water that injections debilitate them very BATHS AND INJECTIONS IN PREGNANCY. 313 rapidlv, and they are obliged to abandon them on this account. Cold water, as an injection, not unfrequently causes general coldness. But it is the medicated injections that most frequently produce an exag- gerated effect. Alum injections, even when the solution is weak, w^ith some patients, produce such disagreeable and constant dryness, and sense of heat, as to make them quite intolerable. And the sensitive- ness of the vagina becomes so great that some patients are forced to cease the injections of alum wholly. The same objections apply to other astringents to a less degree, and the consequence is, that how- ever baths and injections may seem to be indicated, in the cases where idiosyncrasy renders them so objectionable, we must forego their use entirely. Should they be used in Pregnancy f Is pregnancy an objection to the use of local baths and injections ? I think not with proper care. A hot bath about the hips would be objectionable; a very cold bath that might cause much of a shock, or internal congestions, would not be advisable ; but plenty of tepid water, and even cool water, temperately used as baths, give the preg- nant woman great comfort, and cannot generally be followed by any bad effect. Injections may be used with less caution than baths. The caution which we would administer to all is, that they should not be copious. In pregnancy the patient ought not to use more than a quart at one time. The injections should always be tepid or cool ; not very cold nor very warm, lest they stimulate the muscular, vas- cular, or nervous system of the uterus too much, and induce haemor- rhage, or provoke contractions. Both of these effects, I think, I ha^^e known produced by such injections; the cold causing contraction and expulsion ; and the very warm haemorrhage and death of the ovum. Strong astringents should also be avoided. Much comfort may be derived from anodyne injections, when there is neuralgic suffering about the uterus or vagina, during pregnancy. Cases of superficial inflammation, and even early ulceration of the vaginal portion of the cervix, may alwavs be benefited by injections, baths, and the general treatment which I have heretofore detailed. In fact, most cases, if not all, w^here there is no idiosyncratic objection to the baths and injections, will be very much benefited by them. When, however, the disease has been of long standing, or extends between the labia of the OS uteri, or into the cavity of the cervix, these will only slightly benefit it. AVe must then seek for something that will more pro- foundly influence the nutritional changes, and the vascular and nervous tissues of the parts. 314 SPECIAL TREATMENT. The introduction of anodyne, astringent, and alterative ointments, pessaries, and powders, may be resorted to with much profit in many instances. The small instrument called the suppository syringe will enable the patient to place ointment in contact with the uterus very conveniently. Ointments made with opium, belladonna, hyoscy- amus, cicuta, tannic acid, mercury, iodine ; in fact, almost any sub- stance used to exert an influence locally, may be made into ointment and thus introduced. The powders of many of these articles may be deposited in the vagina in the same way. And the medicated pes- saries made by mixing the medicine intended to be used with cacao- butter, may be passed up to the os uteri through a glass speculum, either by the patient, her attendants, or the physician. In using the narcotics in the vagina, in the form of ointment or pessary, we can safely use double the quantity given by the stomach. The ointment is absorbed slowly, and consequently it requires some time to effect much by it. But the powders act much more readily. Morphia thus introduced will sometimes act with great promptitude, and the powder Fig. 91. of tannic acid is a very efficient astringent used in this way. The absorbing power of the vaginal mucous membrane is decidedly less than that of the rectum. It takes a longer time and more of the medicine to affect the system through this cavity. Possibly this may be to some extent on account of the more ready escape of substances from the vagina; but I think, also, the membrane does not take up substances so quickly. From this fact injections or suppositories per rectum will often do more good in allaying pain especially than when used per vaginam. A few drops of strong solution of sul. morphia in the rectum act very promptly. Dr. Greenhalgh and others use cotton pessaries medicated per vaginam. The cotton is prepared by immersing it in a strong solution of the medicinal agent to be employed, and afterward drying before using it. Still another method of making local applications to the upper part of the vagina is to envelop the medicines in a sac of thin cotton or linen goods, and pass it up to the cervix, and let it remain there until the astrin- gent, or whatever may be contained in it, is dissolved out, and exerts its influence upon the parts. The patient can use this kind of appli- cation without assistance. LOC^L TREATMENT. 315 LOCAL TEEATMENT. There are very few cases of chronic inflammation and congestion of the uterus that may not be benefited by what is known as local treat- ment. This is especially true with reference to those cases in which the intensity of the disease is sufficient to cause the loss of the epithe- lium or deeper portions of the mucous membrane, — abrasion or ulcer- ation. Local treatment is not only beneficial but indispensable to the cure of endometritis and endocervicitis. Local treatment consists in the application of certain medic'nes directly to different parts of the uterus and vagina for the relief of the various conditions connected with the inflammation. The medi- cines and the methods of their application are intended : first, to relieve pain by their anodyne influence; second, to deplete the parts of the superabundance of blood; and, third, to change the character of the capillary circulation by restoring its natural activity. When there is much pain of whatever character the anodyne ap- plications are indicated ; and many patients will bear anodynes as local applications for the relief of pain very much better than when taken internally. Even where there is no idiosyncrasy forbidding the use of anodynes, they may dflPect the stomach on account of their taste, so that they cannot be borne or will not be taken. Suppositories made by impregnating cacao-butter with a quantity of the anodyne to be made, fifty per cent, larger than when taken in the stomach, and repeated as frequently as required, is one method of making anodyne applications. The suppositories are made by the apothecary in a shape and of a size for the vagina, and also for the rectum. It requires a longer time for the anodyne to be absorbed by the vaginal membrane than by the stomach or rectum. When it is desired to use the suppositories in the rectum instead of the vagina it will require no more than the ordinary dose of the medicine, and the efi'ect is obtained more promptly. It must be re- membered also that the mucous membrane of the rectum is very much more sensitive than that of the vagina. When therefore we desire to use medicines, the primary effect of which is irritation, as chloral or bromides, it will be necessary to dilute them more than for the vagina. Topical applications of anodynes may be made in various other ways, by inclosing the medicines in a sac of thin cotton cloth, gauze, or domestic, and placing it in the upper part of the vagina, or entangling it in cotton-wool and putting it near the cervix. Sometimes the medicine may be applied in solution, the patient 316 LOCAL TREATMENT. lying on her back so that the fluid may gravitate to the cervix. Half an ounce of fluid introduced through an ordinary glass or rubber syringe will generally be retained — if the patient continues the dorsal position — until it affects the nerves of the part. Appli- cations of this kind can be made by the patient herself, or the nurse. Topical depletion in inflammation and congestion of the uterus is also a most valuable curative measure. When the uterus is very tender and sensitive to the touch, it will require but little irritation to cause intense local inflammation. We must be especially careful under such circumstances to avoid the third class of topical appli- cations. The tenderness and sensitiveness depend upon an unusual intensity of inflammation in the fibrous structure of the uterus above, which, although chronic in duration, is subacute in grade. This kind of turgidity, sensitiveness, and pain is sometimes kept up by the pres- ence of perimetric inflammation — cellulitis — local peritonitis, cystitis, etc., and they contraindicate any stimulating applications to the uterus. It is in the conditions just described that local depletion is applicable and beneficial. Common means of local depletion are leeches and scarification. Leeches may be applied directly to the uterus through the speculum, around the anus, over the sacrum, or pubic region. When we desire to apply them to the cervix, some preparation will be necessary to insure success. The vagina must be thoroughly washed by large injections of hot water to remove any offensive secretion or other contents of the vagina. The cervix may then be exposed by the speculum and sponged with sugar and milk, and it will add to the readiness with which the leeches take hold to prick the cervix until it bleeds, and then smear the surface with the blood. The leeches are first thrown into tepid water, and from it are taken out, placed in contact with the cervix, and watched until they fasten upon it. The number employed — from four to twelve — will be governed by the amount of turgescence and pain ; when the in- tensity of inflammation is very considerable the greater number. In judging of the number necessary, we must be governed by the pain, tenderness, and general condition of the patient. The pain and tenderness must be such as are caused by local hypersemia — inflam- matory or congestive — or by inflammation in the surrounding tissue, and not the pain and sensitiveness of neurotic conditions of the parts or the patient. I do not mean neuralgic pain as that term is generally understood, but hyperaesthesia unattended by any hypersemia. Scarification cannot be made to take the place of leeches, but it is LOCAL TREATMENT. 317 often followed by great improvement, and is very efficient in remov- ing congestion of the submucous tissues. It may be performed by any long pointed knife by which the cervix can be reached, but per- haps the more efficient instrument is Buttle's artificial leech. Fig. 92. Dr. Buttle's Uterine Scarificator and Leech, very efficient and convenient for abstracting blood from the engorged Cervix Uteri. It is a very small spear-shaped knife mounted upon a long shank and handle. With these instruments, the most dependent parts of the cervix may be pricked in sev^eral places. The bleeding may be encouraged by injections of tepid water in large quantities. Fig. 93. Knife for Scarifying the Cervix. In what time of the mouth is depletion the most useful ? Before the commencement of the flow as a rule there is the greater amount of hypersemia. and conseqyently is the time we might effect the most good from depletion. This is not always the case, however. There is no question that patients who have febrile excitement during the time of the antemenstrual congestion are very much benefited by local depletion at that time, but much more frequently the cases of lingering congestion will require it oftener. When the menstrual flow is deficient and the uterus is not re- lieved by it many women are relieved by leeching or scarifying the cervix. The congestion which lingers after the menstrual period and causes so much suffering, is generally, although not always, the result of a very scanty flow. In either case, when we determine to deplete, it should be done as early as the close of the flow, at latest, and if the flow is scanty during the discharge. Independent of these physiological reasons for selecting these times for depletion, and notwithstanding the fact that thus used the deple- tion is generally attended with the best results, the very best rule for our guide will be found in the symptoms. In most cases there is a particular time in the month when the symptoms are the greatest in intensity ; that is the time to deplete. In some this intensity occurs before, in others during or immediately after, the flow, while in still 318 LOCAL TREATMENT. another class of patients it is midway between the periods. Rarely there are chronic cases where the congestive or inflammatory symp- toms last all the time. When there is enough general vigor, these will be improved by depletion two or three times a month. In connection witli the measures for depletion, glycerin deserves to be mentioned. When placed in contact with the surface of the body, its strong affinity for water attracts the serum of the blood from the capillary bloodvessels very rapidly. This process is very much more active in the vaginal cavity, where the air is to a great extent excluded, as the whole capacity of the glycerin to take up moisture is exerted upon the membrane by which it is surrounded, and a large quantity of serum is rapidly abstracted from the diseased parts. The tumefaction and tension are at once removed and the pain relieved. When a glycerin tampon is placed in the upper part of the vagina, it requires but a few minutes to establish a copious watery discharge, that lasts until the glycerin, diluted w^ith several times its own weight of serum, is washed out and exhausted. The relief which follows this application of glycerin is often even more marked than after depletion by leeches. Glycerin was first used as a dressing in vaginal operations by Dr. Sims, and it required but a little time for him to discover its valuable properties as a means of relieving inflammation and congestion. Used in this way I con- sider glycerin invaluable. As a lubricant or solvent for local appli- cations I believe it to be worse than useless. To dissolve medicine in it, and then apply it to the cervix, is to insure the rapid removal of the medicine by a current of serum poured out from the surface. For this reason absorption from a glycerin solution, applied to the vaginal surface, is simply impossible. The efficacy of glycerin appli- cations depend very much upon their preparation and the method of using them. The best quality of cotton batting is the substance most appropriate with which to make glycerin applications. There is a great differ- ence in the grades of cotton batting in the market, and w^e should be careful to get the best article made. It absorbs a larger quantity of glycerin, and does not wad up into such a compact mass as an infe- rior article does. In preparing the glycerin cotton for use, it should be made into a round ball, about an inch and a quarter in diameter, when loosely pressed in the hand. This may be secured by passing a strong thread around it, having the thread long enough to bring out of the vagina, so that the patient may be able to remove it; or the cotton may be rolled into the shape of a cylinder, two inches long LOCAL ALTERATIVES. 319 and one in diameter, and secured by a thread. Every piece to be used should be thoroughly saturated with the glycerin. It is not sufficient to impregnate the surfiice of the cotton ball with the medi- cine, but every fibre should be saturated with it. This requires some time to accomplish, and it will be well for office use to submerge the cotton in a jar of glycerin and let it lie until it becomes saturated. ^Mien we use these, if they are thus saturated, they may be gently pressed until the glycerin will not flow from their surface. The speculum will be necessary to a perfect application of glycerin, and the cotton must be placed in contact with the diseased surface. One or more of these pieces may be applied according to the capacity of the vagina or the amount of congestion. Glycerin thus used may be applied every third day, and if the cotton is well saturated, allowed to remain twenty-four hours, when it should be remov^ed. Cotton treated with glycerin in this way is not fit for a support to a displaced uterus, and too frequent use of these applications is occa- sionally followed by a sensitiveness of the mucous membrane that renders them intolerable. It is not often that we rely upon glycerin applications for a cure, or even as the principal remedy. It is more commonly used as an adjuvant or a palliative measure to follow stronger applications. When we are under the necessity of making a strong application to the cervix and vagina, to follow it immediately by glycerin prevents the severe consequences that sometimes follow. Local Alteratives. The many remedies applied to the inflamed and abraded surfaces of the cervix, while they fulfil the general indication of changing the action of the nerves and vessels of the parts to which they are applied, their special eflects are not precisely the same. There is certainly a wide difference between the local effects of tannin and nitric acid, of tincture of iron and nitrate of silver. Yet we find them all, and many others, used in the same kind of cases, one or two of them re- garded as quite sufficient to cure a large majority of cases. This is the case with iodine, carbolic acid, and nitrate of silver. The prac- tice of experienced gynaecologists, in the use of these local remedies, is remarkable in the fact that a very few can agree upon the same articles. To the inexperienced this is perplexing; but it is account- able for by the consideration that anything which will excite the vasomotor nerves sufficiently to increase the sluggish capillary circu- 320 LOCAL TREATMENT. latloD, — an essential item in the process of congestion and inflamma- tion, — will induce a change in the morbid tissue to which it is applied. Astringents, stimulants, caustics, etc., have this effect, and so will the mechanical influence of friction or pressure. This consideration does not justify indifference as to the choice of local applications, for there are other differences than degrees of intensity in their action. There is, therefore, room and reason for selections, which will give quite a range in our choice. We should continually bear in mind that all irritants applied to the cervix as local applications, produce their effect upon the vasomotor nervous system primarily, and, secondarily, upon the circulatory and absorbent functions of the vascular system, and that in consequence of the unity of the vasomotor nervous appa- ratus of the cervix and body of the uterus, any impression made upon the neck is reflected upon the body, and conversely. The reflected influence is felt not only upon the vessels, but also upon the fibrous structure of the uterus. This explains the effects of therapeutical measures applied to the cervix. There are also certain remedies which, when applied to the cervix, exert an influence through the blood. Mercury and iodine are un- questionably absorbed, and they may have a double influence upon the local disease, first, by the direct stimulating eff'ect upon the nerves of the part, and, secondly, by their well-known general alterative in- fluence. I have several times seen a marked ptyalism follow a single moderate local application of the solution of pernitrate of mercury, and it is not an uncommon thing for patients to complain of a me- tallic taste in the mouth in a very short time after an application of iodine or mercury. AVhen thus they obviously enter the circulation, they may be expected to exert the same influence upon the eff*usion in the substance of the cervix and body of the uterus as if taken internally. Locally iodine, in the form of the ordinary tincture, ChurchilPs tincture, and other alcoholic solutions, is a very strong stimulant, and is scarcely caustic in any of these solutions. It is, therefore, in these forms, an excellent application when we desire to produce a strong but superficial effect upon the mucous membrane of the vagina, cervix, or cervical cavity, and should not be repeated often. A solution made by dissolving one part each of iodine and iodide of potassium in one part of alcohol makes a very efficacious application, made by a swab once in a week or ten days to the erosions of the cervix, connected or not connected with laceration. Their local effects applied in this way excite the capillary circulation of the whole uterus to recuperative LOCAL ALTERATIVES. 321 activity, and thus cure up the erosions and cause the absorption of the deposit in the areolar tissue. Iodine is again used in a different way and for another purpose ; that is, in a non-irritating form, in which it may be absorbed and expend its influence as an aherative through the circulation. It is often dissolved in glycerin and ap- plied on cotton to the cervix. The solution of iodine in glycerin for an application is almost, if not entirely, useless, so far as the iodine is concerned, for it is very soon washed out of the vagina by the serum drawn from the parts by the glycerin. The very best way to obtain the fullest alterative effects of iodine as a vaginal application is to impregnate cotton-wool with iodine by mixing the crystals of iodine with the cotton, and then placing them in a well-stoppered bottle in a moderately warm place, when the iodine will become volatilized and diffuse itself thoroughly, fully, and uniformly in the cotton. This cotton may be applied through the speculum to the cervix, and allowed to remain there for twenty- four hours. This application may be used every fourth or fifth day. It is a very common practice to combine iodine and other medicines for local applications. Iodine and carbolic acid, called iodized phenol, is combined in the proportion of one part of iodine to four parts of carbolic acid. This mixture is a favorite one with Dr. Eobert Battey, of Rome, Georgia. He has written an able paper, "^ detailing its effects in endo- metritis. His indoi^ement, as a local application in this form of dis- ease, is a sufiScient guarantee of its usefulness. The solution of pernitrate of mercury (acid nitrate of mercury), because of its valuable alterative influence, deserves particular notice. Unlike iodine it is strongly caustic, aud can be made to destroy the parts to a great depth. In this respect, perhaps, it is about equal to nitric acid. The application of these remedies, however, can be made without destroying the tissues ; and now that we know the salutary influence of our applications does not depend upon " burning off the ulcer,^' or cauterizing the abrasion, but that their efficacy depends upon the excitation they produce upon the submucous vessels, these medicines are used very differently. The acid nitrate of mercury should be applied by the cotton swab so lightly as not to cauterize. The cotton should be dipped into the mercury solution and saturated with it, and, before being applied, pressed firmly between two wooden surfaces until it is merely moist * Eead at the meeting of the British Medical Association for 1S79, held at Cork, Ireland. 21 322 LOCAL TREATMENT. witli the solution. The cotton thus prepared is a2)plied to the sur- face ; it coagulates the mucus on the surface merely. The application in a few hours is followed by local reaction in the capillaries imme- diately beneath the part, which, in a certain degree, is salutary. It is not best to use this for congestion or inflammation, attended or not with abrasion, oftener than once in two weeks or a month. The second day after the menses is the best time. Carbolic acid, in solu- tions of various strength, is a popular medicine for local application to the cervix uteri. The 95 per cent, solution is equal in stimulating influences to that of the nitrate of silver of 20 per cent, strength. If used exclusively, or as the main article, for stimulating the inflamed cervix, it may be applied once a week. Among the astringents the preparations of iron solution of the per- sulphate and the tincture of iron are frequently used. The tincture of iron, once in five or six days, is very generally used wath great benefit. The nitrate of silver, once so popular as a topical application, has fallen into disrepute, and is seldom resorted to by our best gynaecol- ogists. The main objections to it are the great pain it often produces, the intensity of the submucous capillary excitement it causes, which sometimes extends to the cellular tissue; the amount of haemorrhage it often causes, and its severe effects upon the nervous system. But the most important objections to it, perhaps, is the shrinkage and condensation it brings about in the cervix. After it has been used with anv thoroughness for a long: time the cervix, and sometimes the uterus, is diminished in size and indurated. Although haemorrhage is a common symptom immediately following the application, it is not unusual that the protracted use of it leads to suppression, more or less completely, of the menstrual flow. It must be admitted, however, that these objections apply more to what, in our present knowledge of its effects, we would consider the injudicious application of it in solid form. In solution it may be made to produce an alterative influence that is difficult to effect with any other remedy. A 50 per cent, solution, applied with the swab, is not a caustic, and is not amenable to the objections just above mentioned, and intended to apply to the solid form. Whatever the application may be, it should not be repeated if fol- lowed by evidences of serious irritation, as pain, lasting for over an hour ; tenderness in the iliac or hypogastric region ; chilliness or febrile excitement. When an application is made from which we expect any consider- TREATMENT OF ENDOMETRITIS. 323 able pain or reaction the patient should lie down and remain quiet until all sense of inconvenience has passed away. As before remarked, we may frequently secure immunity from suffering by following the application with a tampon of glycerin cotton. Treatment of Endometritis. When the disease is confined to the cervical cavity the simpler forms can be cured by the same kind of application made use of in the treatment of ordinary inflammation and abrasion of the cervix. To make these efficacious it will be necessary to remove the mucus from the cervical cavity by wiping it away with cotton, wdien that is Fig. 94. Small hard-rubber Syringe, to wash out the Vagina, or cleanse the Neck of the Uterus. practicable, and, when not, it may be removed by such a syringe as is represented in Fig. 94. With the ordinary flexible applicator, wrapped with cotton, the remedy is passed into the cervical cavity up to the internal os uteri. The same precaution should be observed in other cases in which the application is made. The treatment of these simple cases is really not more difficult than when the disease is on the outer cervical mucous membrane. And as the external cervical inflammation, with erosions, coexists with the endocervical, they should both be treated at the same time, by first making the application externally, and then passing it into the cervical cavity. We sometimes meet with an obstinate yet uncomplicated form of endocervicitis, or cervical catarrh, that resists all of the usual remedies. The cervix is filled with an extremely tenacious mucus that is re- moved with great difficulty, the cavity of the cervix is enlarged, and when the mucous membrane is exposed may be seen to be very rough, granulated, and scarlet red. The granular eminences are the en- larged muciparous glands, the glands of Naboth. Dr. Sims* reports * Transactions of the American Gynaecological Society, 1879. 324 LOCAL TREATMENT. cases of this kind cored by thoroughly scraping the cervical cavity with a sharp curette, and afterwards touching the surface lightly with the actual cautery. Dr. Isaac E. Taylor, of Xew York, says he has resorted to this treatment with great success. AYhen the inflammation extends to the cavity of the body of the uterus the treatment is more difficult of accomplishment, attended with less satisfactory' results, and sometimes followed by severe symp- toms. When it is uncomplicated, and the cervical canal at both extremi- ties are patent, the treatment is generally simple and efficacious. The applications adapted to this form of disease are the same as for endo- cervicitis and are made in the same way. The applicator charged with the remedy is carried to the fundus, and by a gentle rotary movement made to touch the whole endometrium. Ordinarily these applications are not very painful. This form of endometritis, when the cervical canal is sufficiently open, may also be successfully treated by the dull-wire curette. This instrument may generally be passed with great ease, and, after it is introduced, it is gently passed over the whole surface of the cavity. This can be re- peated once a week if necessary. I could report several cases where the curette used in this way has done more good than any other remedy I had used, and apparently completed the cure. The curette in these cases is used, not for the purpose of cutting away any portion of the living membrane, nor for removing growths or granulations, but for the pur^^ose of stimulating the circulation in the mucous membrane. When endometritis is complicated, the treatment will of course be very much modified by the complicating circumstances. Stenosis from contraction is a very inconvenient complication, because it must be overcome temporarily at least before our applications can be made complete. In this form I have frequently succeeded by using the slippery elm tent. The tent can be made to overcome the stenosis and at the same time exert a salutary influence by pressure upon the mucous mem- brane of the uterine cavity, and thus suffice to effect a cure. The slippery elm tent is made about one inch and a half, or one and three-fourths long, and the sixth of an inch in diameter at the large extremity, and small enough at the other to pass through the narrowest place. Every tent should be securely fixed by threads so that it cannot be lost in the cavity, and may be easily removed. TREATMENT OF ENDOMETRITIS. 325 When \N'e use them we thorouglily moisten them for two-thh'ds the distance from the extremity to be introduced. This moistening may be done in a moment by dipping them into water and then pinching and bending them. The part thus moistened should be soft enough to bend in any di- rection with very sb'ght force. AVhen the cervix is exposed we take Fig. 95. Slippery Elm Tent. the dry end of the tent in our dressing forceps and pass the moistened end into the uterus. The pliability of the tent enables us to pass it easily into the most tortuous canal. After having passed one, if we are not satisfied, we may intro<:luce one by the side of it, and then two, three, four* or a dozen until we have dilated the canal suffi- 326 LOCAL TREATME^'T. cientlv. These mav be allowed to remain several hoars if necessary, to cause further dilatation. Bat often they may be removed at once, and the cervix will be large enough to receive an application. I know, however, from frequent trial that no other application is nec- essarv to cure many cases of endometritis. When I introduce one or two tents, in cases where stenosis com- plicates endometritis, I instruct the patient to remove the tent by drawing upon the thread whenever it gives her decided pain, and to not let it remain more than twelve hours if it does not give her pain. Fig. 96. Slippery Elm Tent introduced. This is by far the most comfortable way of dilating, and according to my observation the most effective. The slippery elm has the ad- vantage of being inexpensive and easily procured. In ten minutes the practitioner can make a dozen with his pocket-knife, out of the dry bark found in any drug store. AVhen used in this way, and for this purpose, the dilatation is very moderate, but by repeating it be- comes jjermanent more readily than by the use of any other means. I can say further that I have had no bad results from slippery elm tents when used in this way, and in those exceptional cases alone where a mere touch of the probe is painful do I apprehend the pos- TREATMENT OF ENDOMETRITIS. 327 sibility of harm. It is the safest means to dilate the cervix now in use, and when several are introduced by the side of each other they may be made to dilate the cervical cavity in a few rainute?>. This tent also may be made to shield the cervix from the eflPects of the pressure of the more energetic dilators. If we wish to dilate the cervix largely we may pass a sea-tangle or sponge tent, and then jQll the cervical cavity around it by slippery elm tents. As the sea-tangle or sponge expands, the elm tents shield the deli- cate mucous membrane from contact with the hard tent, and when the time comes to remove it there will be no difficulty in getting it away. Complicating misplacements, especially retroversions, should Fig. 97. The rterus in a state of Anteflexion, with, the Slippery Elm Bougie introduced into it. be corrected as an indispensable item of treatment. After the cor- rection is made the treatment will not differ in any respect from the uncomplicated case. Flexions are more embarrassing, complications than displacements, because the point of greatest flexion is stenotic. Sometimes the ste- nosis is so great that it is difficult to pass a small sound. (Fig. 97.) The correction of the complication and the treatment of the inflamma- tion may both be accomplished at the same time. These are the cases ill which the slippery elm tent will be of the greatest service. They are often attended with the dysmenorrhoea of obstruction. We can dilate and, to a certain extent, correct the flexion every time we make an application, by using one or two elm tents before introducing the application. But generally the tents, if allowed to remain in the 328 LOCAL TREATMENT. cavity, as directed in the treatment of stenosis just described, will exert a salutary effect by pressure. When the practitioner finds that a pessary can be used to advantage it may be employed at the same time with the other treatment. When complicated by menorrhagia both diseases may generally be cured by the curette used as above directed. I have said nothing about intrauterine injections as a means of curing endometritis. The subject has been very thoroughly discussed by the members of the profession, and few prominent gynsecologists resort to this means in any form or at any time, except in the puerperal condition of the organ. For my own part I have never injected the uterus for endometritis, and I do not hesitate to condemn it in such cases as dangerous, and yet there are those for whose opinions I have the highest respect, who advise and employ injections, and speak of them as the most efficacious of all methods of applying medicines to the interior of the uterus. Professor James P. White,* of Buffalo, has invented a pipette of glass, bent to the shape of the uterus, with a bulb of india-rubber at the external end. He dips the end of the tube, which is very minute in size, into the fluid he desires to use, and then passes it through a speculum into the uterine cavity, and presses out in drops, or as much as he desires to leave there. The small quantity thus intro- duced he claims cannot, and does not, give rise to any grave symp- toms. In discussing the paper thus referred to, Dr. Munde, of New York, said : That he applies fluids to the cavity of the uterus through a very small flexible tube invented by Dr. Buttles, of New York. He thinks, cautiously done, this is a safe and efficacious way of treat- ing the interior of the uterus. This method of using fluids in the cavity of the uterus can hardly be classed among injections, as the term has been heretofore understood. * Paper read before the American Gynecological Society, 1879. I CHAPTER XIX. LACEKATIOXS OF THE CERVIX UTERI. The consequences of this accident are so serious, and its occur- rence so frequent, that it demands a prominent place in any text- book on gynaecology. While many observers had noted the presence of lacerations of the cervix uteri, their importance until lately has been underrated; they were thought, in fact, to give rise to no appreciable effects. This view was encouraged by the fact, that a proper treatment of their consequences generally resulted in a temporary removal of the symptoms, and sometimes the cure was so nearly complete as to pass for an entire recovery. Until Dr. Emmett made his remarkable researches upon the sub- ject, lacerations of the cervix passed for one of the forms of ulcera- tion, and was described as ulceration of the cervix uteri. Xow, how- ever, owing to the enthusiasm of the discoverer, many of his students have gone to what I consider an unjustifiable extreme in the other direction, expressing their opinions that, instead of everything being called ulceration, the proper term will be laceration of the cervix. To Dr. Emmett belongs the credit of first appreciating the im- portance and appropriately treating this accident. It very seldom occurs to any man to have the opportunity of giving to the profession so complete a description of an abnormal condition, and to perfect the process of cure, so that there is left to others no room for improvement. Yet this is the good fortune of Dr. Emmett. Causes. Laceration of the cervix occurs during labor or expulsion of the contents of the uterus in abortion. Sudden expulsion of the head in cases where the cervix is not dilated sufficiently may eventuate in its rupture. It would be foreign to my purpose at present to discuss the vari- ous causes of the rigidity which prevents the ready dilatation of the cervix. They certainly are numerous, and of frequent occurrence, as any obstetric practitioner is aware. ]Xor do I consider it necessary to criticise the early and frequent use of the forceps practiced by the 330 LACERATIONS OF THE CERVIX UTERI. accoucheur of the present day. The time has not yet come when the facts are at hand to justify such criticism. It is in order, how- ever, to inform the obstetrician that his patients come to the gynsecol- ogist with laceration of the cervix in great numbers. Dr. Emmett finds laceration in about 16 per cent, of the cases coming to him for treatment on account of uterine disease. Dr. Munde puts them down at about 17 per cent. Dr. Montrose A. Fallen at 40 per cent., and Dr. Goodell says, one in every six of his dispensary patients has laceration of the cervix. My own observation confirms the opinion that these lacerations are of very frequent occurrence. Observing the difference in virgin, as compared to the parous uteri, one must conclude that slight laceration from labor was the rule. Can extensive laceration of the cervix always be avoided? This question brings to mind the frequency with which the perinseum is torn under the management of the best practitioners, and the univer- sality with which slight laceration of that body takes place in primip- arous women. The Degree, Locality, and Direction. The degree of laceration varies from the slight, almost inappreci- able rupture to the splitting of the cervix into and above the vaginal junction. It may be confined to one side, while the other retains its integrity, or both sides may be torn, one slightly and the other largely, or both to their utmost extent. The locality of the laceration is much more frequent in a line cor- responding to the junction of the anterior and posterior halves of the cervix, but sometimes the anterior or posterior lip of the uterus is torn in the centre in the various degrees above mentioned ; in others both the anterior and posterior lips are thus lacerated. In rare in- stances we find the two lateral and the two central lesions in the same cases, making the cervix project into the vagina with four points. I have seen one case where the anterior lip was split up to the vagi- nal junction, and then torn across to the left side, the portion torn hanging down into the vagina. Dr. Emmett thinks that the anterior and posterior labia are fre- quently torn, but from the direction of the vaginal pressure they generally heal up, and consequently do not often come under our observation. It is not unlikely, as he observes, that many lateral, as well as central, lacerations close up during the term of lying in, and therefore never give rise to any inconvenience. EFFECTS ON THE BODY OF THE UTERUS. 331 Effects of the Laceration. If we were guided by what we know of traumatic lesions elsewhere, as well as what we find in the cervix itself, we would, a priori, infer that inflammation was an early consequence of the accident. The torn edges, much more frequently than otherwise, become covered with cicatricial tissue, the result of inflammatory exudation, and a large amount of this cicatricial deposit is ordinarily found in the angle of the laceration. Sometimes this last point of deposit presents a tough, hard node, that must be removed with great care to secure perfect union. This is not all the effects of the inflammatory action. Sometimes a fibrino-plastic exudation in the connective tissue of the two cervi- cal flaps takes place, and they become large, dense, and hard. The surgeon will often find the cervix indurated so greatly that it resists the instruments, especially the passage of the needles ; and he will find, as a rule, the more extensive the laceration, the greater will be this particular change, showing that they are all the seat of the most intense inflammatory action, and the converse. Another efi'ect of the laceration on the parts is, at first, an inflam- matory action in the mucous membrane of the cervical cavity. Fibrino-plastic deposits occur in the deeper portions of the mem- brane, which becomes turgid and redundant; its epithelium is shed, and it presents a scarlet, rough surface. Sometimes the redundancy of the membrane is so great that it rolls out and forms a mass, fun- giform in appearance. As another consequence of this fibrino-plastic exudation, the mouths of many of the ducts leading from the glands of Naboth are closed, and the mucus of the glands is confined within their cystic cavities, or the whole gland is surrounded by the exudation and becomes in- volved in the hardened mass. Thus, in diflerent cases, we find the glands presenting the appearance of translucent blebs or shotlike granulations. Effects on the Body of the Uterus. The inflammatory process going on in the cervix, resulting from lacerations, arrests involution, and the uterus remains large and vas- cular; in other words, in a state of subinvolution until the chronic inflammation is removed by proper treatment of the mucous mem- brane and submucous tissue, and the laceration closed by trache- lorraphy. That lacerations which do not cause and maintain this uterine 332 LACERATIONS OF THE CERVIX UTERI. hypersemia are innocent of general disturbances, is admitted by Dr. Emmett, as I have shown elsewhere by quotations from his work.* Complications. Other embarrassing complications of laceration of the cervix are displacements, prolapse, and retroflexions, and lacerations of the peri- nseum and vagina, and cellulitis and local peritonitis. These com- plications increase the hypersemia of the uterus, — retroflexion, by constriction of the cervix and consequent turgescence of that portion of the uterus with this; and prolapse, by altering the direction of the veins which carry the blood from the uterus, augmenting the previously existing hypersemia of that organ. The uterus is thereby increased in weight, fibrino-plastic changes produced in its substance, and the nutrition of the mucous membrane of its cavity disturbed in a marked degree. Symptoms. The general symptoms following laceration of the cervix are not distinctive. That lesion produces, through its effects upon the body and cervix uteri, the symptoms given in detail elsewhere, under the head of Hysteropathy, and consequently need not be repeated here. Diagnosis. This cannot be made out by subjective symptoms alone, and we must depend upon a thorough examination of the parts by the touch and use of instruments. By careful examination with the finger the notch in the side, when large, will be easily detected. The finger should pass along the vaginal wall to its junction with the cervix, and, keeping it in the cul-de-sac, passed all around so as to encircle the neck. In most instances, as the finger passes over the side, we will rec- ognize the fact that at that point the neck does not extend below the vaginal junction. The finger will sink into a depression between the labia. When the finger is educated in the vaginal touch, the lesion will be easily recognized. The sound will generally pass deeper into the body of the uterus than it will in the normal state of that organ, because the uterus is in a state of subinvolution. ■* Article on Subinvolution. PREPARATORY TREATMENT. 333 AYhen well exposed by the speculum, the cervix will generally be found covered by a muco-purulent fluid, enlarged, the labia turned out, the exposed cavity of the neck intensely red, and the surface roughened in consequence of the loss of epithelium, and an enlarge- ment of the papillae and muciparous glands. The infallible test, however, is to seize the extremities of both labia with tenacula and draw them down together, somewhat forcibly. If the cervix has been torn on the side, the notch will be plainly seen. If there is no laceration, the cervix will be truncated instead of bifid, and the points of the tips can be drawn down only a trifling distance below their lateral junction. Treatment. The treatment may be preventive, preparatory, and operative. The prevention of laceration of the cervix does not usually come "within the province of the gynaecologist. The obstetrician has charge of the patient at the time of the accident, and upon his skill will de- pend such immunity as can be secured by science. The probability is that it cannot be prevented in most instances in which it occurs, no more than laceration of the perinaeum can always be prevented. I can easily see how an early rupture of the membranes, a too early use of the forceps, or an ill-advised administration of ergot would favor laceration of the cervix. Now that their attention is called to the subject, obstetricians will no doubt soon be able to furnish the facts upon which may be based a judicious preventive treatment; at present it must be founded upon a rational view of the processes of labor. Preparatory Treatment. The treatment preparatory to an operation has been as fully devel- oped by Dr. Emmett as any part of the subject, and my experience corroborates the correctness of his teachings. The object of the preparatory treatment is to bring about a plastic condition of the parts to be united. This is accomplished by correct- ing any deviation from the normal state of general health by tonics, nutritious diet, exercise in the open air, promoting a soluble condi- tion of the bowels with appropriate laxatives, etc. A robust state of the general health is an all-important part of the preparation in this as in all plastic operations. The local preparatory treatment consists, first, in placing the uterus in such position as is necessary to secure the greatest possible freedom 334 LACERATIONS OF THE CERVIX UTERI. of circulation, for the purpose of reducing the general hypersemia of that organ ; second, ruaking use of such applications as will reduce the hyperseraia of the uterus and cervix ; and, third, where there is induration from fibrino-plastic exudation in the connective tissue of the cervical flaps to as far as possible dissolve it out and bring about a normal condition of the structure. The first indication is met by a judicious use of pessaries of cotton, lint, and the closed-lever instrument.* The second, calls for the use of glycerin, cotton tampons, local bloodletting by puncture w^ith Buttle's lancet-shaped knife, or other instrument, which will answer the same purpose, and large hot-water injections. An em- ployment of these means perseveringly for a sufficient length of time will be pretty sure to effect this object. The third will generally re- quire more time, and is of equal importance with the other two. The applications for this purpose consist in remedies that will stimu- late the absorbents to the removal of the indurating substance. Dr- Emmett relies to a great extent upon Churchill's tincture of iodine for this purpose. He applies it freely to the whole of the denuded mucous membrane about twice a week, followed by glycerin dress- ings. It is doubtless an excellent application. When the gland cysts are large and numerous he pricks them with the lancet-shaped knife to void their contents and to deplete them of blood. In many cases of long standing, and w here the pathological changes are greatest, the preparatory treatment will require to be employed for several months to secure the best results. In others of recent stand- ing, and wdiere the changes consist mostly of hypersemia a few weeks will suffice. The Operation. The day before the operation it is a common practice, and I think a good one, to move the bowels pretty thoroughly by giving a laxa- tive. At the time of the operation I usually give the patient ether. This, how^ever, is not absolutely necessary, especially in cases of mod- erate extent, as the operation is not very painful. To Dr. Dudley, of this city, is conceded the honor of first giving this operation an appropriate name, '^trachelorraphy.'^ Tw^o or three days after the menses cease to flow is the best time to operate. The patient is placed in Sims's or Simon's position, and the vagina dilated as largely as necessary to bring the cervix into view. The * See Displacement. THE OPERATION. 335 neck is then seized with a vulsellum forceps, and drawn down until the lips can be transfixed from before backward by a strong needle armed with a double thread. The threads are drawn through enough to form two loops, each through one of the labia, of sufficient length to pass several inches With these loops of thread the cervix can out of the vaginal orifice. Fig. The Cervix with the Threads passed. be very completely fixed, and its position varied as- the convenience of the operator may require. The loops of thread may be held up by an assistant, subject to the direction of the surgeon. When thus prepared the operator seizes the edge of the laceration with a tenaculum, and with scissors pares oif all the cicatricial mem- brane. The denudation should be carried up into the angle between the cervical flaps and the wedge of cicatricial deposit thoroughly re- moved. In doing this care should be taken to cut off any irregu- larity of surface on the edge of the laceration, so that the edges of 336 LACERATIONS OF THE CERVIX UTERI. the two sides may be brought into smooth coaptation. After the de- nudation is perfected, and the haemorrhage ceases, the stitches may be introduced. Beginning an eighth of an inch from the incision on Dr. Sawyer's Round Knife for Denuding Surface. the outer surface of the flap, the needle is passed perpendicularly through to a point that will include the same distance of the endo- cervical membrane. To the thread in the needle should be attached Fig. 100. Byford's Uterine Scissors. silver wire eight or ten inches long, drawn through and held by an assistant, until all of the wires are placed as in Fig. 101. Before twisting the wire the edges of the wound should be wiped clean of every small coagulum. If this precaution is not taken a clot of blood may be included between the united edges and prevent complete union, the wires may then be twisted evenly, as represented in Fig. 102. After the opera- tion the vagina should be thoroughly cleansed and the patient put to bed. This operation is a simple one, as the reader will see, under favor- able circumstances, i. e., when the laceration is lateral, and does not extend above the vaginal junction. When it is stellate, or there is much loss of tissue, the ingenuity of the surgeon will be severely taxed. I am not informed as to the average number of successes in the operation of trachelorraphy, but I know that failures are not infre- quent, and it may be well to consider what are the reasons of failure. Among these reasons is an imperfect performance of the operation, but chief among them is imperfect preparation. THE OPERATION'. 337 The after-treatment is of great importance, especially for the first few days. The patient must remain very quiet and avoid all causes Fig. 101. Tlie Mode of Passing the Sumres. Fig. 102. The SnUires Properly Placed and Sutured. 338 LACERATIONS OP THE CERVIX UTERI. of vascular and nervous derangements. After this time there can be more freedom of motion. It is desirable that the bowels be not moved before the end of this time, when a laxative may be given, and means taken thenceforward to keep them in a soluble condition. If we do not conclude to prevent the evacuation of the bowels we should administer diet and saline laxatives to soften the faeces. It has been usual to draw off the urine for the first four or five days, but this is not essential, as it is only necessary to avoid strain- ing. The diet must be light, and for the most part liquid, for the first few days. The vagina should be kept clean by warm-water injections two or three times a day from the beginning to the end of the after-treat- ment. I have been in the habit of removing the sutures about the tenth day, but in the majority of cases they might be taken out on the seventh or eighth day. CHAPTER XX. OCCASIONAL UNTOWARD EFFECTS OF UTERINE MANIPULATIONS AND OPERATIONS. For the purpose of making the student understand the necessity of great caution and gentleness in examinations and operations upon the uterus, I subjoin a summary of the researches of Dr. George J. Engleman, of St. Louis, on the subject.* Many of the cases mentioned by Dr. Engleman occurred in the hands of the most accomplished practitioners in different parts of the world. A simple digital examination of the unimpregnated uterus, in the hands of Nelaton, was followed by fatal peritonitis. Several cases of death from peritonitis were the result of the use of the uterine sound ; some because the sound perforated the uterine tissues on account of fatty degeneration rendering them soft and permeable ; others without any apparent reason. There are also cases in which untoward results followed the use of vaginal injections of warm water. A number of deaths are recorded in which peritonitis was caused by the use of sponge tents. One case is mentioned of severe peri- tonitis from replacing the uterus by the use of the sound. There is always more or less risk in this operation. Dr. J. M. Allen gives a case in which death was caused by the appplication of tincture of iodine to the cervix. Cellulitis has followed the application of various substances to the cervical and uterine canal. The danger of injections into the uterine cavity is shown by allu- sion to several cases of death in the hands of skilful gynaecologists. The most trivial operations on the uterus or other organs in the pelvic cavity are sometimes followed by fatal results. Even scarifi- cation of the cervix has been the cause of fatal peritonitis. I have known of two cases of death follow incision of the cer- vical canal, and several others are mentioned in Dr. Engleman's paper. Operations for lacerations of the cervix have been followed ■^ Paper read before the Missouri Medical Society, and published in September No., 1880, American Practitioner. 340 UTERINE MANIPULATIONS AND OPERATIONS. by deatli in several instances. The most careful removal of small polypi may be the cause of fatal peritonitis. Perineorrhaphy has, in a number of instances, been followed by similar consequences. Stem pessaries, when incautiously used, are very dangerous instruments. It therefore a2:)pears that any kind of manipulation of the uterus or its lining membrane is, under certain inscrutable circumstances, liable to start an acute peritonitis. One of these circumstances, and perhaps the most frequent one, is the existence of an inappreciable grade of inflammation in the cellular or peritoneal structures imme- diately surrounding the uterus. Dr. ^oeggerath"^ believes that latent gonorrhoea is very often the character of this lurking inflammation. It would seem that the use of sponge tents, intrauterine stem pes- saries, intrauterine injections, intrauterine applications, and cutting operations on the cervix uteri, were especially dangerous. AVe should exercise great care in all our manipulations of the pelvic organs, and leave no precautions known to gynsecology unem- ployed to avoid the dangers that occasionally present themselves when we venture upon the use of sponge tents, intrauterine injec- tions, stem pessaries, or operate on the cervix. * Gynsecological Transactions, 1876. CHAPTEE XXI. HYPERTEOPHY OF THE CEEYIX. Hypertrophy of the cervix is different from enlargement caused by fibrinous accumulation, and consists of an increase in the proper tissues of the organ. It is a real hypertrophy. Although not nearly so frequent as the enlargement from chronic inflammation, it is not of very rare occurrence. The symptoms do not differ from prolapse of the uterus sufficiently to characterize it. The patient generally experiences a sense of bearing-down or weio^ht on the perinteum, pain in the sacral region, leucorrhcea, sometimes menorrhagia, and the various sympathetic symptoms already sufficiently dwelt upon of uterine irritation. Diagnosis. Upon examination the cervix is found hypertrophied and enlarged. There are two general forms observed so well marked as to entitle them to special mention. The first is such as we usually find in the nulliparous, an elongation of the whole cervix, and some, but not generally, very great circumferential increase of size, and without much deviation from shape. This form is seen in Fig. 103. The next variety is an elongation and enlargement of the anterior or pos- terior labium, as represented in Fig. 104. I am not certain, from my own observation, whether this is always a pure hypertrophy or a mixture of this process with fibrinous infiltration ; probably the latter. The only appropriate treatment is amputation, and it is generally sufficient to remove all the disagreeable symptoms resulting from it. The plan I have usually pursued in removing this growth is by ecrasement. The chain of the ecraseur is passed around, at the place where the point marked out by the dotted line is seen in the figures, and the ratchet slowly worked until the division is complete. This operation is easily performed, and is perfectly safe when carefully done, and the parts cicatrize in a few days. An inconvenience men- tioned by Dr. J. Marion Sims is encountered, in some instances, in amputating the first variety, viz., the contraction of the opening of the cervical cavity. It is an inconvenience, however, that is of no great importance generally, and may be remedied by making a small in- 12 HYPERTROPHY OF THE CERVIX. ci^ion with a blunt-pointed bistoury immediately after the operation of amputation. Dr. Sims amputates the cervix with scissors. He exposes the organ with his speculum, cuts the parts squarely through at the dotted lines, and then draws the mucous membrane together Fig. 103. Fig. 104 Figures showing two Varieties of Hypertrophic Elongation and Enlargement of the Cervix Uteri. The Dotted Lines show the Proper Place for Amputation. over the cut surfaces with silver sutures. This lessens the size of the cut surfaces and the parts heal more readily. Elongation of the Supravaginal Cervix. This condition of the cervix so completely simulates procidentia of the uterus that upon a superficial examination it may be mistaken for that condition. The elongated vaginal cervix w'ith the vagina are protruded from the external parts. The vaginal walls are everted anteriorly and posteriorly, forming in most instances cystocele and rectocele. Sometimes the protrusion is less extensive, and the cervix alone protrudes from the external parts. The diagnosis is made by introducing the sound. That instru- ment will enter to a much greater depth than when the uterus is pro- lapsed, sometimes five or six inches. 2d. By placing the patient in the knee-chest position. In this ELONGATION OF THE SUPRAVAGINAL CERVIX. 343 posture the cervix very readily enters the pelvis and rises up to its normal position. If the sound is now introduced it will not enter the uterus to so great a depth. 3d. By introducing the finger into the rectum while the patient is standing, we can feel that the length and shape of the uterus are greatlv chano^ed from the normal. The fundus and bodv will be found in situ, and from it the attenuated and elongated supravaginal cervix can be traced downward to its attachments to the vagina. Fig. ia5. Supravaginal Elongation of the Cervix. This elono;ation of the cervix is called tensile elono-ation bv Dr. Matthews Duncan, and, doubtless, as Dr. Goodell'*' believes, is the result of hypertrophy and stretching, instead of true hypertrophy. It would seem at any rate that the elasticity of the cervical tissues was very much increased, as in the erect posture, with the slight weight of the relaxed vaginal walls and the bladder and rectum, the neck becomes elongated, and when the patient lies down retraction may soon follow. The vaginal portion of the cervix in most cases is considerably hypertrophied, and in respect to length and volume is much above the usual dimensions. There are other conditions in connection with tensile elongation of the cervix that have an important bearing upon * Gynaecological Transactions, 1879. 344 HYPERTROPHY OF THE CERVIX. the etiology and treatment. Almost all the means of siippoit in the lower part of the pelvis are in a state of great relaxation, and, instead of being retentive, they contribute to the aggravation of the ab- normal condition of the cervix. This is especially the case with the vaginal walls, the vesical ligaments, connective tissue, and fascia. The perinteum is either anatomically deficient from laceration, or destitute of that tonicity which makes it capable of resisting tlie pro- trusion of the cervix. In contrast with this the supporting apparatus in the upper part of the j>elvis retains its natural, if it is not endowed with more than normal retentive power. The treatment of this form of elongated cervix will depend some- what upon the time it has lasted, the extent of the elongation, and the relaxation of the perinseum. When the lesion is of recent origin, and the perinaeum has not been lacerated, and possesses a reasonable amount of resistance, we may hope to succeed in restoring the shape and size of the cervix by prop- erly supporting it with a pessary. In selecting an instrument for this purpose it will not often do to choose one that has its bearings wholly upon the perinseum, but one that is partially maintained in position by external means. In the hands of most practitioners, I believe Cutter's or Scott's will fulfil the purpose more certainly than any other. ^Vhile both of them rest upon the ferinseum they may be so adjusted that they will not bear upon it with much weight. If, however, the perinteum is in a lacerated or greatly relaxed state we must depend mainly upon surgical means, and as the result of my own observation, I do not hesi- tate to indorse the practice of Goodell as set forth in the paper above referred to, viz., to amputate the vaginal cervix and operate upon the perinaeum afterward if necessary. I do not consider it necessary to remove the cervix at the vaginal attachment, but think it better to leave a margin of one-fourth of an inch. Great care is necessary in removing the cervix in this condition to avoid wounding the blad- der or opening the peritoneal cavity. Whether the amputation is done with scissors, knife, galvano- cautery, or ecraseur, we should take measures to secure ourselves against this accident. The most convenient way to do this is to pass two strong steel wires through the cervix slightly below the junc- tion of the vagina and cervix. The wire or chain of the ecraseur may be applied close up to this wire; this will prevent any traction ELONGATION OF THE SUPRAVAGINAL CERVIX. 345 upon one part more than another. The scissors may be used and the cervix amputated according to the method of Dr. Sims. The patient must remain in bed several weeks to secure the best results. When the perinaeum has been lacerated perineorrhaphy should be performed before the patient attempts to exercise on foot. If the perineum does not need restoration, and there should be any tendency to continuance of supravaginal elongation after the opera- tion, Scott's pessary should be introduced, to supply the support that the perinjeum in a healthy condition would give. Success in this operation will depend very greatly upon the treat- ment and care the parts receive for some time after the patient resumes the erect posture and her usual exercise. CHAPTEE XXIL PEKIMETEITIS. I USE the term perimetritis to signify inflammation of the tissues surrounding the uterus, and include both cellulitis and local perito- nitis under this head. There is an abundance of areolar tissue in the pelvis. It is be- tween the bladder and pubis, the bladder and vagina, the vagina and rectum, but in greater amount between the sides of the vagina, uterus, and bladder, and the pelvic bones. In a loose manner it fills up the space indicated, and is covered by, and included in, the folds of the lateral or broad ligaments of the uterus. Within these folds of the peritoneum, the ovaria, the Fallopian tubes, and the round ligament are included with the cellular tissue. Inflammation attacks this areo- lar tissue not unfrequently on one side, and involves the tube, the ovary, ligament, and peritoneal covering; less frequently both sides are simultaneously inflamed, and still less often that part between some of the hollow organs of the pelvis is affected, when we have a comparatively small point of disease, as, for instance, between the bladder and vagina, or this last and the rectum. This is perimetritis. There is a strong tendency when inflammation is lighted up in any part, to spread to the space at the side of the uterus and vagina cov- ered by the broad ligament, on one or both sides. The inflammation is apt to run its course rapidly, as is usual in areolar tissue, either to resolution or suppuration, and as this tissue is abundant, and the organs in the pelvis easily moved, the effusive products are likely to be copious. In the first stage of inflammation, serum is rapidly poured out between the folds of the peritoneum by the side of the uterus and vagina; it pushes these organs to one side of the pelvis, and forms a prominent inflammatory tumefaction at the side of the pelvic cavity, within easy reach of the finger. This tumidity becomes harder in a short time, and forms a solid medium of connection be- tween the uterus and wall of the pelvis. Indicating the change from serous to fibrinous effusion. Within a week or ten days, in very acute cases, in others from two to four, or even six weeks, the areolar tissue is broken down into copious suppuration. In some instances the inflammation does not advance beyond the stage of serous effusion. CELLULITIS. 347 When, after lasting for an uncertain time, the symptoms begin to subside, the tumefaction disappears, and the patient soon recovers her health; while in others it is arrested after fibrinous infiltration has cemented the parts solidly together. Although the symptoms are moderated from their first acuteness when this is the case, some of them, as undue seusititiveness and sense of weight, and other kinds of pelvic distress, remain for a considerable time, and the patient re- covers from the attack very slowly, if ever completely. When sup- puration takes place, if it is completely and readily evacuated, the patient very soon regains her health and strength. In some patients of broken-down or damasked constitutions, slouo^hins; and extensive ulceration increase the damage to the organs. I once saw a syphilitic patient in whom extensive and rapidly spreading ulceration opened the rectum, vagina, bladder, and, finally, the peritoneal cavity. Sup- puration in this case was unhealthy and ichorous, smelling strongly, and produced excoriation of the parts over which it flowed. If the evacuation of the pus is imperfect on account of opening into the rectum or bladder, and even in the vagina, the symptoms may be prolonged for months and even years. And in some cases where the evacuation of the pus and subsidence of the inflammation seemed complete, the disease recurs usually with diminished acuteness a num- ber of times. I once had a patient in whom an attack of perimetritis was contemporaneous with incipient pregnancy for four different times while under my care. In each one of these four times, the inflam- mation commenced at about the time the menstrual flow ought to have appeared after conception. Every time there was copious sup- puration, a free discharge of the pus, and, to all appearance, a com- plete recovery from the inflammation. The intervals were about two years in duration. I have seen three instances in which the recurrence of the inflammation had occurred at irregular intervals from three months to a year for over six years, another ten, and one as much as eighteen years. In this last case, the abscess was situated at the left side of the uterus, and usually after a week or ten days of acute suf- fering, it discharged about a half ounce of fetid pus, and then disap- peared, so that nothing but a slight induration at the point mentioned indicated any tendency to its recurrence. This chronic form, I think,' is not very uncommon. I believe, also, that chronic induration in the spaces occupied by the pelvic areolar tissue, caused by fibrinous infiltration, not unfrequeutly presents itself as the effect of acute peri- metritis, producing many distressing symptoms, and rendering the patient liable to a recurrence of acute attacks. The extent of the in- 348 PERIMETRITIS. flammation and tumefaction is governed somewhat by the condition of the patient. If she be in the puerperal state, the inflammatory excitement is likely to be greater, the swelling more extensive, and the suffering more severe, than if this condition is not present. Preg- nancy increases the intensity of the disease beyond what it is in the unimpregnated condition; the fever runs higher, and the extent of the inflammation is greater. The same will be the case after abor- tions. The mildest form of perimetritis is that which occurs in the unimpregnated female. When pus is formed, it finds its way out through several different channels. First, and most frequently, through the vagina; the wall of the abscess nearest the vagina ulcerates through into this canal, and the pus escapes, first in small Cj[uantities, and finally freely, until the whole is evacuated; a number of days, and even w^eks, may elapse before the discharge ceases and the cavity is filled up. The escape through the vagina is not only the most common, but this is the most favorable outlet, as the opening is generally pretty free and permanent. Second, in frequency, as the medium of discharge is the rectum; the pus makes its way into this intestine generally at the upper end of the septum between it and the vagina. The discharge is comparatively slow and unsatisfactory, appearing with the stools in small quantities, and continuing for a length of time. The open- ing into the bowels is almost, if not invariably, valvular and tortu- ous, permitting the escape with difficulty. If there does not occur a second opening into the vagina, the abscess will generate pus almost as fast as discharged, and we may expect times of partial relief and exacerbation for months and even years. I am acquainted with an instance in which the patient has not been entirely free from suffering from this cause for the last six years, and a number of times has been prostrated for weeks. But few days pass without the patient observ- ing matter in the fecal evacuations. The pus makes its way at other times through the inguinal regions; sometimes it points in one of the labia, or burrows through the gluteal region. It also perforates the uterus or bladder, and follows the channels leading from them out- wardly. When the pus finds its way into any of these hollow organs, it causes severe irritation in them and efforts at expulsion. Dysuria, dysentery, and vaginitis are generally caused by it to a moderate de- gree, but sometimes the suffering from this cause in these organs is very great. But another mode of escape from the cavity of the ab- scess is into the peritoneal sac. This is comparatively infrequent, fortunately, but invariably fatal. I believe no instance is on record to CELLULITIS. 349 coDtradiot this statement. I have been unfortunate enough to be con- nected witli two cases in whicli this untoward circumstance occurred. One of the patients was attacked in the puerperal state, and, after suffering for eight weeks with the inflammation of the tissues around the uterus, acute general peritonitis terminated her life in about thirty-six hours from the time it commenced. Upon examining the abdominal cavity, an opening was found near the left vSacro-iliac junction, which communicated with the interior of the abscess, and several ounces of pus was in the cavity of the peritoneum, that had made its way through this opening. The usual lesions of extensive and acute peritonitis gave evidence of the cause of death. The other case was in a sterile marrieil woman, about twenty-live years of age, who had been treated three weeks for typhoid fever. Dissection revealeil a large pelvic abscess, with recent rupture into the peritoneal cavity, and extensive peritoneal lesions. This overwhelming perito- neal inflammation lasted only about eighteen hours before the death of the patient. When the peritoneal symptom supervened, it was regarded as the result of the intestinal ulceration which sometimes so suddenly terminates typhoid fever. Causes. Perimetritis occurs as a sequel to abortions, and labor at full term, and there is but little doubt but that these two conditions sometimes predispose to the disease. The menstrual congestion seems to do the same thing. Any circumstance that fills the pelvis with blood in active congestion may so predispose to it. Cold suddenly applied to the surface or to the feet and legs may excite the already congested parts into a state of inflammation. Much exercise of the limbs in walking or standing on them for a long time, when the pelvic vessels are already distended and excited, has, on some occasions, seemed to me to awaken inflammation. The incautious use of strong caustics to the cervix uteri may give rise to it. I think I saw a casein which perimetritis was brought about by severe exercise in walking imme- diately after the use of caustic potassa. Excessive venereal indul- gence predisposes to this inflammation, if it does not produce it alone. "^ Sy7nptom.s. The patient is attacked suddenly, usually with pain in the pelvis, hypogastrium, or iliac regions, which radiates to the sacrum, loins, * See Chapter XX for other cause. 350 PERIMETRITIS. and alxlomen. Sometimes it passes down one extremity, or there is pain in both legs. The pain, generally at first aching and moderate, raav become verv severe, and darting or cramping in character. In the besrinninor, or after the inflammation has lasted a little while, there is pain or difficulty in urinating; by pressiiig upon the inflamed parts, the passage of fseoes through the rectum is painful. The pa- tient usuallv experiences a sense of weight about the perinseum, and dragging in the loins and hips. All the pains are much aggravated by motion, or assuming and continuing in the erect posture. Pres- sure over the epigastric and inguinal portions of the abdomen in- creases the pain and suffering. At the commencement of the pain the patient is attacked with rigors of greater or less severity. The chilliness may be slight, but often it amounts to severe shaking and trembling : reaction propor- tionate to the intensity of the chill succeeds ; the head aches, the liml3s are pained, the skin is hot and dry. and the tongue coatetl, and the mouth dry and parchetl. These symptoms may come on very suddenly, and the case be well marked in a few hours from the time they commence, or so moderately and gradually as to be several days in assuming prominence. In puerperal patients they occur generally several days after confinement, and seem to be induced by undue exertion or exposure. In such cases the symptoms are more intense than in the non-puerperal cases. The pulse is rapid, the nervous system much disturbed, the heat great, and often there is delirium. The high febrile excitement is attended with severe pain, extending in various directions. Tumefaction and tenderness over the lower parts of the abdomen indiaite a local peritoneal inflammation in many of the more severe instances, although this is not always the case. Some of these puerperal cases so closely resemble cases of metroperitonitis — if they are not so indeed — that the cases are re- garded as attacks of puerperal fever. So intense are the symptoms as apparently to jeopardize the life of the patient immediately by the gravit\' of the general pelvic and abdominal inflammation. And when the tumefaction and tenderness of the abdomen subside, the febrile reaction is moderated or becomes more paroxysmal, we find a hard tumor generally on one side dipping down into the pelvis and extending sometimes to the ribs and across to the umbilicus; or it may be developed in the mesial portion of the abdomen and pelvis, extending upward to a greater or less degree. Tumors of this kind are tender, and may be detected in the pelvis by a vagi- nal examination. They do not always suppurate, but generally CELLULITIS. 351 disappear by absorption. At other times they produce copious quan- tities of pus. This inflammation sometimes dissects up the peri- toneum over the osseous, iliac, and lumbar muscles, to a great extent, dissolving out the areolar tissue in a large space. The distension and tenderness are quite frequently confined to one side, showing the point of greatest intensity of the disease, but we often find them extending entirely across, and sometimes considerably up the abdo- men. These symptoms appertain to the first stage, and last for from four or five days to tvv^o weeks, and in rare cases longer, when they are gradually succeeded by those that indicate the suppurativ^e stage. The pain becomes less acute, and changes ordinarily to a burning character, quite as distressing, if not more so than at first. It is worse at night, and prevents the patient from resting. The fever assumes something of a remitting type. It is more intense in the evening and night ; toward morning a moisture is observed upon the skin, the heat becomes less, and there is some amelioration in the suffering. After a little longer the paroxysms are very marked; chilliness in the afterpart of the day is succeeded by a very rapid pulse and intense heat of the surface. This fever lasts for six or eight hours, and is resolved by a copious perspiration. These perspirations are accompanied with great languor and depression. The patient is de- bilitated and much worn by the continuance of the symptoms. At length, after days of this exhausting, suppurative fever, the pus makes its way through the walls of the abscess, and is discharged through some of the outlets mentioned above. If the evacuation is free, and the discharge considerable, the relief is very great indeed, the fever subsides, the perspiration ceases, the spirits are good, the appetite becomes excellent; in fact the change in the patient is very great and gratifying. Convalescence is now established, and in a few days all the serious and distressing symptoms vanish. If the dis- charge is not free, and but a small quantity of the matter escapes, although there is relief, it is not so complete. The patient is tem- porarily better, but not convalescent. The opening is not sufficient, the pus continues to increase and imperfectly discharge, and fluctua- tions in the intensity of suffering continue to inspire hope and cause depression, until a freer opening occurs in the same place, or another one allows the pus to escape more freely. This description is intended to apply to cases of considerable in- tensity in the puerperal or non-puerperal patient. But the degrees of intensity are very different in different instances. Sometimes the symptoms are so slight as to scarcely attract attention, until the dis- 352 PERIMETRITIS. charge begins to make its appearance. At other times there is dis- tressing fever, but the local symptoms are so poorly marked that the case is misapprehended. I have known the fever to last for three or four weeks, ending in hectic, with its exhausting accompaniments, before the true nature of the case was discovered. An example of the occasional insidiousness of the non-puerperal form of this affection is exhibited in the following case : Mrs. A J aged twenty-four, married two months, has sitfiered for the last four years with moderate dysmenorrhoea, and occasional leucorrhoea- Sexual intercourse has given her much pain from the first since her marriage ; afiter three weeks the pain in the coitus became intolerable. At this time she had severe pain in the back and pelvic region constantly, but not so severe as to prevent her being about in the attention to dom^tic duties and taking a short trip by rail with her husband. She had some very slight febrile re- action, with sense of chilling, for about twenty da\?, when the par- oxysms assumed ^jmething of a hectic character, lasting from three o'clock undl seven or eight P.M., terminating with copious dia- phoresis. A little later a very severe pain in the hypogastric region was developed, attended with frequent efforts at urination. In about four days from the supervention of this pain she b^an to pass pus in large 'quantiti^ in the urine, together with marked quantities ot blood. Upon making examination at this time the pelvis on the right side and front portion was filled by a tumefaction very tender to the touch, which had crowded the uterus back upon the redtam and down so that the os was in contact with the perinseum. These ^mp- toms and the examination fully declared it a case of cellulitis. Diagnosis. Although the symptoms, in most cases, are severe and sufficiently prominent, they are not often distinctive. Several other ajlfecdons r^emble it in many symptoms. Hence, the only way to arrive at correct diagnosis is by physical examinations. The finger will be the only instrument nece^ary. It is cruel to use the speculum, while it affords us no aid in the vast majoritv of cases. I should not think it nec^essary to caution the reader against die use of this install- ment if I had not seen it resorted to more than once, to the great torture of the patient. In making examinations for this kind of case, the patient should be so placed that we may use both hands if necessary. When one or two fingers are introduced into the vagina, they will detect unusual tumidity in the pelvis. Sometimes this CELLULITIS. 353 tumidity extends to the bottom of tlie pelvis on one side, and occa- sionally apparently fills up the \vhole loNver part of the pelvic cavity ; at other times the tumidity is circumscribed and confined to one side high up, or before the uterus. The tumefied parts are generally hard, and very tender to the touch, so that a small amount of pressure causes great suffering ; the uterine neck is almost always pushed to one side, back\yard, upward, or downward; the vagina is generally hot and dry, and all the parts sensitive. If we place one hand above the pelvis while the fingers of the other are in the vagina, we will have a consciousness of a tumor between the fingers of the two hands. It is not always the case that any tumidity can be felt above the superior strait, but generally there is tumefaction in one iliac region or sometimes in both. The tumefaction may extend much above these regions, high up into the abdominal cavity, though not often. If the tumefaction is considerable, the uterus is firmly fixed in its place, but when less, this is not the case. In childbed patients we may distinguish cellulitis from peritonitis by digital examination per vagi nam. There is not the hard tumefaction in the pelvis in the last as in the first. Tenderness and general distension of the abdo- men are greater in peritonitis ; the pulse is more rapid and is pecu- liar. These may and probably are often combined in puerperal fever, when the diagnosis is of less importance than when they are separate affections. The general peritoneal inflammation supervenes after delivery much earlier — generally on the second day — than any of the localized inflammations do. Cellulitis is more likely to attack the patient when or after she begins to make exertion, or is exposed to cold several days, six to ten, and even more after delivery. (See Pelvic peritonitis.) From acute metritis in the puerperal or non-puerperal state, it may be distinguished by examination with the finger. There is not much difference in the mode of attack and history between acute metritis and perimetritis; but by a careful survey of the pelvic organs, we may separate the inflamed from the sound parts. In metritis the uterus is generally and symmetrically enlarged, and extends lower down in the pelvis, and if touched at any point is tender ; in cellulitis this organ is not generally enlarged, and if touched anywhere in such manner as not to press it against or move it on the side where the inflammation exists, is not the subject of painful impressions. The tenderness in cellulitis is generally to one side of the uterus, close to the walls of the pelvis. If the inflammation is in the bladder, we may easily ascertain this fact, by pressing this organ between the 23 354 PERIMETRITIS. fingers In the vagina and those above the symphysis pubis. From metatithmenia It is distinguishable by the tenderness and firmness of the tumor, the febrile symptoms, and the history of the two condi- tions; cellulitis being previously inflammatory, while metatithmenia, when inflammatory at all, becomes so some time after the commence- ment of the symptoms. The bloody tumor may be handled without much pain, Is soft and yielding, and commences at the time of menstru- ating with sharp pain likened often to severe colic, without chill and fever at the beginning ; sometimes with collapse more or less intense. Carcinoma filling up the lateral parts of the pelvis, Is sometimes mistaken for cellulitis, but more often the latter is mistaken for the former. Carcinoma Is insidious in its inclpiency. It has made great advance before symptoms indicate its existence, while cellulitis is heralded by inflammatory symptoms from the start. The hardness of carcinoma is greater, the tumidity more irregular and devoid of tenderness ; it is not hot as in inflammation. The discharge from carcinoma when it occurs is cadaverous in odor, thin and ichorous in character. In cellulitis the discharge is pus, and if it smells at all, the odor Is faintly fecal. I have noticed this last feature in several instances of perimetritis, when the evacuation of the pus was free and copious through the vagina. The diagnosis from chronic metritis is not always easy. AYhen cellulitis is chronic, it causes many of the symptoms which we ob- serve to be present in chronic metritis. It will require a careful consideration of the symptoms and history of the case, with physical examination. Chronic cellulitis ordinarily results from an acute attack, that was accompanied with a discharge of pus more or less copious, and par- oxysms of less intensity have succeeded, growing more mild, until the symptoms become obscure. Paroxysmal discharge of pus is a com- mon symptom of chronic cellulitis. Upon a thorough and cafeful examination of the pelvic cavity, we may find some small spot, not in contact with' the uterus, but by the side of it ordinarily, that is hard and tender to the touch. In chronic metritis there is not always tenderness. Prognosis. This is generally favorable. There is probably more danger in attacks during the puerperal condition, or after miscarriage, than in unimpregnated patients, although the very large majority of these cases terminate favorably. Of course I leave out of this considera- tion such instances as are attended by general peritonitis of simulta- LOCAL PERITONITIS. 355 neous origin, and constitute only a part of the whole puerperal fever. I do not think there is much diiference in the fatality of uncompli- cated cases occurring under these diverse circumstances. When cellu- litis proves fatal, it is generally in one of three ways: 1st. By ex- haustion, caused by excessive and long-continued febrile excitement, symptomatic of extensive inflammation. 2d. The exhausting effects of hectic fever, diarrhoea, diaphoresis, and want of nourishment. 3d. Severe complications, arising during the progress, as peritonitis, by extension of inflammation; or the more rapidly fatal form of peri- tonitis, caused by effusion of pus in its cavity. I have seen three fatal cases. Two of them resulted from rupture of the abscess, and discharge of the pus into the peritoneal cavity. One of these was puerperal, and death occurred ten weeks after confinement; the other non-puerperal, and ended in eight weeks from the attack. The one which proved fatal from exhausting hectic, without evacuation of the pus, terminated in sixty days from the commencement. A great many cases terminate in the chronic form. The cause of this sort of termination is often incomplete evacuation of the pus, and, as a consequence, imperfect obliteration of the cavity of the abscess. The pus accumulates from time to time, and fresh erup- tions, attended with a greater or less exacerbation of the symptoms, every few weeks or months, occur as this result. Or the external opening, wherever it may be, does not close, and there is a constant discharge of greater or less quantity, keeping up a kind of fistulous canal, leading generally some distance to the main seat of the diffi- culty. Or in still another sort of cases, the pus seems to be entirely evacuated, and the cavity obliterated, and there is nothing left but a small point of indurated tissue, which is the nucleus of inflammatory action under certain circumstances, as pregnancy, unusual excitement of the sexual organs, from other reasons, etc. Local Peritonitis. Post-mortem examinations, as shown especially by Goupel, demon- strate the fact that we may have peritonitis confined to the pelvis and its vicinity. Observing practitioners of long experience must have met with instances which, without any great difficulty, could be classed under this head, and I have no doubt of the practicability of gener- ally distinguishing them from those of cellulitis, w^ith which they are most likely to be confounded. Pelvic peritonitis is seldom primary and simple. More frequently it is primary, and leads to cellulitis as a complication; and in other 356 PERIMETRITIS. cases it is secondary, and a consequence of pre-existing cellulitis, and therefore complicated with it. Post-mortem examinations are not always conclusive as indicating a condition which had existed during the entire course of the disease; for while in the more acute stages there may have been coexisting inflammation of the peritoneum and cellular tissue, the inflammatory action in the cellular tissue may have subsided, and the peritonitis alone remain to be discovered at the autopsy, and vice versa. This would mislead the pathologist who depended upon the post- mortem appearances entirely. Whcvi the peritoneum is primarily attacked, and the inflammation is confined to this membrane, it becomes injected with blood, dry, and rough, and in the motion to which the viscera are subjected during respiration, etc., the surfaces rub together and cause sharp stabbing pain. Upon the subsidence of this stage of the inflamma- tion, an effusion of serum, rich in fibrin, takes place, which gravitates to the most dependent part, and usually accumulates in the cul-de- sac behind the uterus, but does not displace the organ to any marked degree. The effused fluid soon coagulates, and the liquid portion of the serum is removed by absorption, and there is a solid mass of fibrin left in the retrouterine pouch. If the uterus happens to be retroverted at the time of the coagu- lation, it is fixed in that position until absorption liberates it, or during the life of the patient. The movements of the pelvic organs — and by the way these or- gans are always in motion, in unison with the respiratory movements, and as an effect of the movements of the body — sometimes modify the form of the coagulura, drawing it out into bands, which stretch from one surface to the other. After this serous efl^usion, the inflammation may subside and leave the patient comfortable, but the subject of a fixed uterus. In some cases, however, the absorption is rapid, and the organ is left entirely free in a short time. Should the inflammation be more intense, the epithelium of the membrane is loosened and falls ofl^, leaving a pyogenic surface, from which pus is produced in greater or less quantities when there is a sero-purulent effusion confined in an irregular fibrinous capsule. If the pus is considerable in quantity, an abscess is the result, which finds its way out in a manner similar to the evacuation of pus as a result of cellulitis. In the non-puerperal moderate cases of local peritonitis the serous LOCAL PERITONITIS. 357 and purulent accumulatlous are confined to the pelvic cavity, but in the puerperal or the more intense forms of non-puerperal inflamma- tions, these accumulations reacli higher than the brim, and are often found in indurated patches in both iliac regions or over the hypo- gastrium. When these accumulations are round, or shaped like tumors, they may be mistaken for ovarian or uterine neoplasms. The Fallopian tubes are sometimes constricted by these fibrinous bands, and a portion of their cavity isolated, in which liquid accumu- lations collect, and give rise to Fallopian tumors, — hydrosalpinx. Bennett and Goupel in some instances found the ovaries involved in the inflammation, and either destroyed by suppuration or left in a state of chronic inflammation. Causes. The puerperal condition at term, or after abortion, is a very fre- quent, if not the most frequent, cause of local peritonitis. The action of cold upon the woman, when the pelvic organs are in a state of intense congestion, just prior or at the time of menstrua- tion, is also a prolific cause. Gonorrhoeal inflammation, by making its way through the cavity of the uterus and along the Fallopian tubes out upon the peritoneum, is, by common consent, taken to be another one of the causes; but inflammation may, by contiguity, also extend from the uterus to the peritoneal membrane. This is the case, doubtless, in the puerperal condition, after the violence done to the uterus by severe labor or abortion, and in non-puerperal cases where strong applications have been made to it, operations, etc. Direct violence to the retrouterine portion of the peritoneum is often done by the injudicious introduction of foreign substances by the patient herself, excessive coition, and by rude and ill-directed attempts to replace the uterus by instruments. Symptoms. Pain in the pelvis and lower abdomen is one of the most common and distressing symptoms, and this pain is generally characteristic. It is sharp, stabbing, and paroxysmal, or exacerbating. The sharp, stabbing, exacerbating pain is accounted for, as before said, by the friction of the two surfaces of the peritoneum, rendered dry and rough by the inflammation. In cause and character the pain resembles that of the early stages of pleuritis. While pain is one of the most constant symptoms, cases do occur 358 PERIMETRITIS. in which there is very little pain, probably because early effusion, or some other condition, prevents the friction. Another consideration, which will enable us to account for the absence of pain, is the great difference in the susceptibility of different persons. However we may explain it, we know from observation that pain is sometimes alaiost entirely absent, and then the disease may be mistaken for some other affection. In the commencement there is a sharp febrile reaction, with its attendant phenomena, as quick pulse, headache, delirium, nervous excitement, and derangement of the secretory functions, etc. The intensity of the excitement will depend very greatly upon the suddenness of the attack and extent of the tissue affected by the in- flammation ; greater when sudden and extensive, and less when the progress of the inflammation in the first stage is slow and the parts involved are small in extent. The febrile reaction is usually high at first, and very much moderated as the effusion occurs. The character of both pain and febrile reaction are greatly modi- fied by the conditions which give rise to suppuration. As suppura- tion is established the sharp pain gives Avay to a sense of tension, weight, and heat, while the febrile movement becomes more remittent or paroxysmal. Debility, copious perspiration, and frequent chills make up the items indicative of suppuration. These symptoms are partially or completely relieved by opening the pyogenic cavity and permitting the pus to be discharged. The points where the pus flows, as in cellulitis, are the upper part of the vagina, rectum, the bladder, inguinal or femoral canal, some place in the abdominal wall, the gluteal region, or one of the greater lips of the vaginal orifice, and rarely the peritoneal cavit}^ If suppuration does not occur, and the case terminates in con- valescence without it, the symptoms gradually subside. Upon examining the lower abdominal region we will generally find tenderness upon pressure, and often more or less tumefaction, with or without tympanitis. The uterus, if displaced, is pressed for- ward, but it often occupies its normal position. In the first stage there is generally not much tumefaction in the pelvis felt through the vagina, but great tenderness behind and by the sides of the uterus. When the fingers are pressed well upward in the stage of effusion there is tumefaction behind the uterus, and sometimes in the iliac and hypogastric regions. Dlagyiosis. AYhen free from complications, — which, I must say, judging from my own observations, I believe to be less frequent than the con- LOCAL PERITONITIS. 359 verse, — I do not see why there should be any great difficulty in dif- ferentiating local peritonitis. The affection with which it is more likely to be confounded than any other is cellulitis. The pain in the first stage of cellulitis is more steady ; is dull or aching, instead of stabbing or lancinating; and the tenderness, although considerable, is not so great as in pelvic peritonitis. In the second stage the pain in the two affections does not differ much, if at all. The tumefaction is not in the same locality; in cellulitis it is by the side or in front of the uterus, while in local peritonitis it is behind that organ. If the peritonitis extends above the pelvis, which it often does, it may be in one or both iliac cavities, or extend across the lower part of the abdomen. AVhen the effusion in peritonitis is above the pelvis in the centre percussion will elicit marked resonance, because the intestines are contained in the mass, and this resonance will enable us to distinguish it from a tumor. The history, symptoms, and physical signs enable us to decide between local peritonitis and retrouterine hsematocele. In peritonitis the history is one of inflammation, well marked in the beginning and throughout its whole progress, while that of hseraatocele does not indicate inflammation in the beo;innino; of the attack, and seldom in any of its later stages. In local peritonitis metrorrhagia is not a symptom ; in hematocele it is. Tenderness is a permanent feature in peritonitis, while it is very slight if it is present in hfeiiiatocele. This remark applies when pressure is made above the symphysis or in the vagina. The pelvic tumors in both disorders is ordinarily retrouterine, and not dissimilar in shape; but in the earlier periods the hsematocele is uniformly soft, while the inflammatory effusion is harder. The h^ematocele displaces the uterus more than the inflam- matory product. The tumors caused by both may and often do extend above the pelvic brim. The bloody tumor is generally central, and forms a somewhat level line across the lower abdomen, while the inflammatory tumor is usually irregular and hard, and is often con- fined to one iliac region. In retrouterine pregnancy the absence of acute inflammatory symp- toms, unless in exceptional cases, and the presence of the evidences of pregnancy, are strong differentiating circumstances, and will gen- erally lead to definite conclusions. In extrauterine pregnancy we can watch the case for a sufficient length of time, and the growth of the tumor will do much to solve the difficulty. The pelvic tumors formed by cancer differ from those of local peri- tonitis in the facts that they have no infl.amraatory history, in their 360 PERIMETKITIS. great hardness, and irregularity of growth. Fibrous tumors have no inflammatory history, are more or less movable, more dense and regular in outline. The fibrous tumor is generally accompanied by metrorrhagia, while the inflammation is not often attended by that symptom. Prognosis. When peritonitis is confined to the pelvis and its vicinity it is rarely tatal. One of the dangers connected with it is the probability of its extension to the whole or greater part of the abdominal peri- toneum. This is much more likely to occur in puerperal cases. The fatal termination is sometimes the result of exhaustion induced by protracted suppuration and febrile excitement. Acute pelvic peritonitis has a strong tendency to become chronic by the continuance of the inflammation in a subdued form. In this condition, by exposure, overexertion, sexual excitement, or injudi- cious treatment, it may become intensified to an acute degree. When pelvic peritonitis has resulted in collections of pus, in portions where the evacuation of the fluid is imperfect, the inflammation may be pro- tracted to an indefinite time. Fortunately, however, in the great majority of cases it passes into convalescence, which is usually slow, but complete. Before giving the treatment of local peritonitis I must again say that this disease is so frequently complicated by cellulitis tliat its occurrence in the simple form is not common. I believe, also, that simple cellulitis is as rare as uncomplicated local peritonitis. But it is very often the case that the cellulitis is comparatively intense, while the peritonitis is not severe, when the symptoms and physical signs are those of cellulitis: and again the peritonitis may assume a grave form, while the cellulitis exists in a very moderate degree, when the symptoms of peritonitis will predominate. The contiguity of the tissue implicated in these two affections, and the identity of vascular and nervous supply, are facts that hardly admit of any other conclu- sion than that inflammation does not generally invade either of them and leave the other unaffected. Treatment oj Perimetritis. From what I have seen and had to do with these affections, I am led to prescribe in a general way the same treatment for both of them. In the early days of an attack of peritonitis the object of treatment should be to abort the inflammation, and, when this is impracticable, TREATMENT OF PERIMETRITIS. 361 to limit its extent. We can seldom accomplish the first of these objects unless we see the patient and recognize the nature of the attack in the very l)eginning. It is not possible to declare just how many hours or days must elapse when we are no longer justified in trying to arrest the disease, for this will greatly depend upon the intensity, but we may always find something in the conditions to guide us. Before any considerable amount of effusion and tumefaction has taken j^lace we may hope to check the progress of the inflammation, even if this is two or three days after the commencement, or, when great swelling has occurred, we may still expect to limit its extent. The symptoms indicating the measures necessary to interrupt the inflam- mation are great pain, accompanied by tumefaction. These call for as energetic antiphlogistic treatment as the strength of the patient, will bear. If she is robust, from twelve to twenty leeches on the hypogastrium should be applied at once, and after they hav^e fallen off the haemorrhage nmst be encouraged by poultices or fomentations until, if possible, the hardness of the pulse is affected. At the same time a large dose of opium, or some of its preparations, should be administered, and repeated in such quantities as to keep the pain in complete subjection, and not merely given from time to time when the pain returns. If the patient is not robust we cannot resort to bloodletting, but we must always administer the opium in this way. As secondary measures the arterial sedatives may follow the depletion, when that is deemed advisable, or be our main reliance if we do not consider it best to deplete. Veratrum viride has gained such a reputation that it would naturally suggest itself as the most efficient of these. It may be given in doses sufficient to control the circulation, and keep it under control for the first five or six days of severe attacks. Poul- tices or fomentations to the hypogastric region should be one of the features of the treatment for the whole of the more active stao;es of the disease. They will often give marked relief. Large injections of very warm water, the patient lying on her back, should also be employed. An apparatus that will permit the water to run off with- out wetting the clothing will be indispensable to the proper manage- ment of the injections. This kind of treatment will sometimes check the force of the attack in a very short time by arresting or limiting the extent of the inflammation, and thus sav^e the patient from the protracted suffering which neglect of energetic treatment is sure to entail. After the effusion has taken place, and before the period of sup- 362 PERIMETRITIS. pnration has arrived, alteratives, such as mercury and iodide of potassium, are very important remedies. The former may be given in small and frequently repeated doses, until the slightest possible indi- cation of its general effects are noticed, when it should be displaced by the iodide. This is the period when decided saline laxatives are useful and advisable. When the symptoms indicate the commencement of suppuration we can no longer continue all of the foregoing treatment. The opiates may now be given when the pain requires it. The regimen and medication should be changed to quinine in liberal doses, two to four grains or more, as often as necessary, to keep up its in- fluence, and supporting food in as large quantities and such quality as the stomach and rectum will bear. Unfortunately we are often called upon to treat patients who have already passed the time when any other than the supporting and anodyne treatment would be entirely out of consideration, because many of these patients have been too greatly reduced by preceding influences to permit of any other than anodyne and supporting treat- ment from the beo-innins^. These are the unfortunates who lino-er for weeks, and sometimes for months, in spite of anything we can do for them. During the progress of perimetritis there is a time when counter- irritation will be of great service. After the more acute symptoms have subsided, and effusion is evident, a blister applied over the iliac region, where the pain is greatest, or over the hypogastrium, if that is the location of the most pain, will be required. The blister applied at this time will often relieve the deepseated pain, prevent the effusion from becoming purulent, and excite the absorbents to remove it. Later in the disease tincture of iodine will go far toward accom- plishing the same objects. A question arises at the suppurative stage of the affection which must be decided after a careful survey of the whole case, viz., should we evacuate the pus, or should this process be wholly left to nature? As one of the disastrous terminations is a rupture in the peritoneal cavity, as nature often selects very circuitous and unsatisfactory via- ducts, as the rectum, bladder, etc., and as a consequence of this last circumstance the recovery is very much protracted, I think we should, when practicable, furnish the pus an outlet of our own choosing, and as early as can conveniently be done. Soon as evidences of suppu- ration begin to be manifested through the general symptoms, we TREATMENT OF PERIMETRITIS. 363 should make a? thorough au examination as we can to ascertain where the collection has occurred. If we can discover the pus, we evacuate without apprehension of damage to any of the organs. If our first examination fails to satisfy us, it should be repeated as often as ev^ery twenty-four hours until the discovery is made. When this is done, we institute one or two precautionary measures, which will almost preclude the possibility of doing harm by an intelligent penetration. The first is to completely evacuate the contents of the bladder and rectum by the catheter and an injection. Vie ought to be sure that the rectum is empty of fluid and gas. I knew fluid in the rectum to so far deceive a practitioner as to cause him to make preparation for its puncture. We ought to pass the catheter into the bladder and rectum after we sit down to operate. The next precautionary measure is to introduce the exploring trocar into the tumor, and after the pus has made its appearance, open the cavity by the side of the retained canula. In this way I think there is great safety in the operation. The patient may be prepared for the puncture by being placed ou the left side before a good light, as if for operation for vesico- vaginal fistula, and anaesthetized. The part may be exposed by Sims's specu- lum. The instrument most convenient for making the incision is a tenotomy knife. The opening should be free and direct, so as to permit of a ready discharge. The opening should not be allowed to close. This may be prevented by keeping a tent in the wound until the pus ceases to be discharged. The objects of thus opening the cavity are to secure an external and safe outlet and its ready evacua- tion, and thereby attain a speedy cure and safety against peritoneal inflammation. When the chronic form consists in frequent repetitions of the inflammation, on account, perhaps, of its imperfect subsidence, much may be done by persistent counter-irritation, and among the best kind is a seton in the groin kept running for months. An issue will have equal good effect. This permanent form of counter-irri- tation is better, I think, than blistering or pustulation. When the opening into the intestine or bladder becomes fistulous, as it some- times does, and the discharge continues for months and even years if there is no vaginal opening, and the discharge is into the bowel or bladder, we should seek for a point in the tumor where it may be punctured, and the opening made free and direct through the vagina. If no such point can be found, we cannot, with propriety, interfere surgically. The openings are, however, often located so that we may easily reach them, as through the lower part of the abdominal walls, the labia, the gluteal region, the perina^um, or vagina. If the orifice 364 PERIMETRITIS. is accessible, we may generally succeed in obliterating the suppurating cavity and fistulous canal. Preparatory to making an effort to do so, we should try to ascertain the tortuosities of the fistulous duct and the depth of the pus-cavity. In some instances the canal is so crooked that the straight probe will pass but a very short distance, and it becomes necessary to send it in various ways; and sometimes an elastic or elm bougie will suit better for a probe than the ordinary metallic one. Professor Simpson recommends leaving a wire in the track of the fistula until adhesive inflammation is excited. I have not tried this means, for I have been so well pleased with injections of carbolizecl water that I have used them almost exclusively. I inject through a small-sized catheter. The smallest-sized elastic catheter, pushed to the bottom of the cavity, will convey the fluid in its concentrated strength to the bottom, and thus produce the effect at that point. We ought, after introducing the catheter, to inject the cavity with tepid soapsuds, so as completely to cleanse the internal parts of pus, and then immediately throw up the solution. Sometimes the first injection does away with the production of pus and produces adhesive inflammation. In order effectually to inaugu- rate the treatment, it sometimes, indeed generally, becomes necessary to slit up the orifice of the fistula somewhat, as it is usually smaller than any other part of the duct. CHAPTER XXIIL CHROXIC PEEIA[ETEITIS. Chronic perimetritis is a common form of disease. It is the cause of much sulferino; aDil is often misunderstood. c Causes. By far the greater number of cases can be traced to the acute form, but there is no doubt that many others have an entirely different origin. Most practitioners of extensive observation must have seen many cases of chronic perimetritis, in the history of which no evidence could be found that the patient had ever had an acute attack. We know that the acute form is often the result of an extension of inflammation from the uterus and vagina to the broad ligament and peritoneum, and I think I have seen instances where inflamma- tion of a moderate grade had been propagated from the uterus and remained thus associated for an indefinite length of time. This I think is the right way to account for those cases so fre- quently found complicating chronic uterine diseases, and in which the symptoms of perimetritis are completely masked by those attending the more prominent affection. It is indeed very seldom either in the acute or chronic form that it is not accompanied by inflammation of the uterus, and it is ecjually rare that the disease is not propagated from the uterus or vagina. In very few cases it is reasonable to suppose that the inflamma- tion may originate in the ovaries. I do not hesitate to assert, however, that I have not seen any cases of acute or chronic perimetritis, — where their history could be clearly traced, — that were not secondary in their origin and transmitted from the uterus. Vat^ieties. Chronic perimetritis presents quite a variety of appearances ; one form traceable directly to the acute attack is chronic abscess. After the process of suppuration has led to a discharge of pus, and the acute symptoms have subsided, the patient still suffers from 366 CHRONIC PERTMETRITIS. tenderness, pain, and long-continued suppuration. The pyogenic cavitv is perpetuated by the imperfect discharge of pus. AYhile the pus is being constantly discharged, the sac whence it comes is not entirely emptied, and there is enough pus generated to keep up a perpetual drain. The manner in which the original opening was affected is almost always the cause of this imperfect evacuation of the abscess. The canal or conduit leading from the cavity is tortuous, and penetrates the muscular fibres of the rectum or bladder diagonally, so as to form a valvular opening. The pus after having travelled along between the different muscular layers of the walls of one of these organs, makes an opening that is closed with every contraction and opened with each relaxation of the fibres. Still another unfor- tunate method of perforating the intestinal tube or bladder is when the level of the sac is below the opening. In all of these ways the complete evacuation may be prevented and the discharge protracted for years. We meet with another form of perimetritis in which the abscess seems to have been cured after complete evacuation. The subsidence of the symptoms is so complete as to leave the patient in the enjoyment of fair health. After a time, of greater or less dura- tion, sometimes a few weeks only, at others several months, tlie symp- toms recur in a less severe degree than in the acute form, and after a duration of several days or weeks a discharge of pus is again suc- ceeded by relief. These attacks are repeated an indefinite number of times, and if the patient recovers it is after a number of months or years. The suffering is sometimes very great and followed by large dis- charges. More frequently, however, the pain is not so excruciating and the discharge of pus is small. Again, other cases are met with in which the progress of the in- flammation from the beginning is very slow, and not attended with very severe pain, but continues until quite a large amount of pus is formed, which remains in the sac, with very little tendency to ulcerate through the tissue. Whether the pus in some of these cases would ever be discharged by spontaneous processes is a matter of great un- certainty. I have seen cases where from the history I felt assured that this indolent abscess had existed for years. I saw a case in this city with Dr. T. D. Fitch, that he informed me had been in the condition it was when I saw it for three years. That he had seen it, discovered pus, and advised its evacuation, as long as that, before I was called. I have seen others equally pro- tracted in my own practice and in consultation. ( VARIETIES. 367 Some cases are met with, the history of which includes a Dumber of recurring acute or subacute non-suppurating attacks, weeks or months apart, that finally culminate in suppuration. Patients suf- fering from this form have an attack of fever, with pain in the pelvis, pains running down the limbs, tenderness, and perhaps very slight tumefaction of the hypogastric region. This pas-es for '* in- flammation of the bowels.^' The patient more or less completely recovers from the attack, and after a time is again prostrated with similar but less pronounced symptoms, these run a course of four or six weeks and the patient again recovers. This time the fever may be called typhoid or bilious fever ; in a subsequent attack suppura- tion reveals the true character of the disease. The explanation of all these symptoms is that the patient had several attacks of moderate perimetritis, that for want of proper physical examination were mis- understood and called by different names. All gynaecologists engaged in extensive practice frequently meet with such cases. But all cases, nor even a large proportion of them, do not end in suppuration. The exudate in these cases does not break down, but continues hard, and is formed in masses of greater or less size in the broad ligament, attached to the side of the uterus, or between the uterus and bladder. Or where the disease is in the peritoneum the exudation may be above the brim of the pelvis in the iliac region. These deposits of fibrin are often mistaken for tumors. Xot uufre- quently a large part of one side of the pelvis is filled with a hard immovable mass of plastic effusion, and the uterus misplaced and fixed in its malposition. In other instances the accumulation is small and does not affect the position or mobility of that organ. Instead of the localized effusions here described, sometimes there is a diffuse moderate infiltration of fibrin in the cellular tissue that causes thickening of the ligament. The parts are less elastic than usual, the uterus less movable yet not fixed. This condition is the one most frequently present when the uterus is said to be " bound down," so that it cannot be reposited and re- tained in position without causing great suffering or awakening acute inflammation. There is also a very moderate degree of chronic inflammation — hypersemia with sensitiveness — which invades and remains in the peri- metric tissue without causino^ effusion or anv considerable deo^ree of tumefaction. Whether this degree or form of disease is one introductory or pre- 368 CEROyiC PERIMETRITIS. paratorr to the more grave acute grade, or one that may last indefi- nitely, without any great yariation in intensity, is not certain. It is probably the condition to which the term — so frequently used — *Matent inflammation '^ is applied, because under certain favoring circumstances the vascular and nervous action is developed into the acute form. I have no doubt that this low degree of iniiammation may exist a loner time, and perhaps indefinitely, in the absence of causes excit- ing it to a higher grade of action. Symptoms and Diagnosis. Generally the symptoms of chronic perimetritis are not distinctive, and arrange themselves under the general head of " Uterine Symp- toms." In those cases in which pus is formed the symptoms l)ecome more marked, and we may not be at a loss to understand them ; but even in some of these the symptoms are not decisive. We must, for the most part, therefore, depend upon physical examination. The history of those cases of frequently recurring paroxysms of pelvic inflammation, which for many months, or even years, precede sup- puration, will often indicate pretty clearly the character of the dis- ease with which we have to deal. Yet, without an examination of the pelvic organs, even these cannot be diagnosed until they have about i-un their course. There is geoerallv one element which, to one whose attention is attracted in that direction, will be found to be almost always present, viz., fever in a more or less marked d^ree. In all but the indolent abscess, and the slighter degree of its form, in which there is no exu- dation, this symptom will pretty uniformly present itself. Physical examination will uniformly develop sensitiveness. It will often happen that, during the examination^ the tenderness will be so slight as not to elicit complaint from the patient ; but. after the manipulation is ended, there will be left aching and a sense of ten- derness. Sometimes the reaction will be quite severe and last for hours, or even awaken an acute attacl:. This subsequent tenderness, however slight, is a symptom of much significance, and should teach caution in future examinations. Another important sign (yet not so important as the last) is certain positions of the uterus. When the cervix is drawn strongly to one side, and especially if it is fixed in tliat position, it indicates an ir- regularity in the length of the broad ligament. The ligament of the side toward which the traction is noticed is shortened, and, while not TREATMENT. 369 invariably so, the shortening is frequently owing to previous or present inflammation in the connective tissue of the ligament. If associated with tenderness this condition ought to complete the diag- nosis. As has been pointed out by Dr. Emraett, this condition is often present in cases of laceration of the cervix. Bimanual examination of the sides of the pelvis will generally enable us to detect even a small amount of fibrinous deposits. They may generally be diagnosed from tumors by their tenderness, fixed- ness, and locality. In most cases they will be fixed to the pelvic walls, especially when situated, as most of them are, in the connect- ive tissue of the broad ligament. Sometimes, however, they are developed at the side of the uterus, and adhere firmly to it. In such cases they move with the uterus, and cannot be made to move upon that organ. These are more likely to be mistaken for subserous fibrous tumors. The history will do something toward clearing up the diagnosis. There will always be a history of inflammation. The menses are not so likely to be profuse as in the case of fibrous tumors. Each manipulation will be attended or succeeded by tenderness. When the deposit is extensive the position of the uterus is generally affected by it also. The indurated patches at the brim of the pelvis, left by local peritonitis, are sometimes mistaken for tumors. We should give due weight to the history of inflammation, with which these are connected, and the tenderness that is developed by pressure, and other manipulations. When examining them we will generally find them flat instead of globular, and not movable. But the most remarkable, and, I think, pathognomonic sign, is resonance under percussion. However extensive these indurated masses may be, per- cussion will elicit intestinal resonance over the whole space occupied by them. The resonance is due to the fact that the effused fibrin surrounds, instead of displaces, the intestine, and in coagulating in- cludes that tube in the indurated mass. These signs are all different from those evinced by an examination of a tumor. The signs of the indolent abscess of the broad ligament are an immovable tumor, which is elastic or fluctuating, and the test is aspiration. Treatment. The treatment of these several diverse conditions must necessarily vary. The form in which sensitiveness and hypersemia are not attended w4th effusion will require great circumspection in the treat- ment. One is continually tempted by local inconvenience to depend too 24 370 CHRONIC PERIMETRITIS. much upon local treatment, whereas I think it is benefited less by local measures than any other form of the disease. It is, in fact, more frequently connected with, if not dependent upon, some dyscrasia (or dysthetica) than upon local conditions, and hence must be treated largely by general measures. One of the most efficacious of these measures is a judicious change of climate and habits. The object in making a change of climate and habits should be to revolutionize the circumstances of the patient. It is astonishing how these patients, who cannot stand upon their feet, on account of the great sensitive- ness of the pelvic organs, will improve on a long journey, which, from the symptoms, would seem impracticable. A trip to, and resi- dence in, California has done more to cure some of these patients than could have been done by medicine alone. But much good can be done by medicines, such as will improve the condition of the system. The bowels should be the subject of special care. They will more frequently than otherwise be constipated, and their secretions de- praved in quality, as well as scarce in quantity. The mercurials and bitter tonics, if perseveringly administered, will often correct the con- stipation, improve digestion, and act favorably on the depraved state of the general system. The sixteenth of a grain of the bichloride of mercury, with a full dose of the compound tincture of cinchona, or the tincture of columbo, three times a day, makes an excellent mixture for such cases. The diet should be full in quantity and nourishing in quality. Exposure to the fresh air and sunshine is also indispensable to restoration. The exercise should not be too much restricted, because confinement always aggravates the general condition, and moderate exercise is not harmful to the local trouble. The special treatment should consist in large injections of tepid water, and extensive but very moderate counter-irritation. The counter-irritant I rely upon most is the tincture of iodine, diluted with an equal quantity of alcohol. This liniment should be applied over the whole lower part of the abdomen, back, and hips. I believe, however, that the local treatment can often be dispensed with if judicious management of the general health is persevered in and diligently applied. In the cases in which fibrinous deposits are observed, special treat- ment is of more importance. And the first thing that I would insist upon is that pessaries and stimulating applications to the uterus should be abjured. Large hot or tepid water injections and sitz-baths will be of great TREATMENT. 371 service. It will sometimes be found that hot-water injections will cause discomfort, while tepid water will be followed by relief, and the effect experienced from them should guide us in our choice. Concentrated counter-irritants in the inguinal regions will also be found very beneficial. A small seton I believe to be the best form of counter-irritant, and when kept clean and shielded from the friction of the clothing it will give the patient but little inconvenience, and we must not forget the soothing influence of glycerin tampons. Diligent attention to the general health is of the greatest import- ance also, and very small doses of mercury, laxative diet, and expo- sure to pure air in a mild climate will generally suffice. In the sup- purative variety, which is but the advanced stage of the latter form, attention to the general health is of paramount importance. When the suppuration is intermitted with intervals of comparative comfort, we may generally interrupt the paroxysm by establishing and keep- ing up for a considerable period a discharge from the iliac or in- guinal region over the seat whence the discharge emanates. I know of no one remedy that does so much good as the seton. It should be larger than in the last variety, and the local irritation kept up for several weeks or even months. When the suppuration is continuous, in addition to attending to the general health, we should try to establish a more direct outlet. When the discharge is from the rectum we may sometimes pass a bent probe through the opening and bring its point down upon the roof or side of the vagina, and make it a guide to a puncture in that direction. When we cannot improve the direction of the outlet we may sometimes destroy the pyogenic character of the cavity by injec- tions of carbolized water through a flexible catheter, introduced and carried to the bottom of the cavity. In the case of the indolent abscess all that will generally be found necessary is to draw off the pus by the aspirator. In this variety the lining membrane (or wall) of the cavity has ceased to produce pus, and consequently when the sac is emptied the fluid does not reaccu- mulatc. I have seen several cases thus happily terminated. CHAPTEE XXIV. DISPLACEMENTS OF THE VAGINA, BLADDER, AND RECTUM. In every displacement of the uterus the direction of the axis and the calibre of different parts, or the whole of the vaginal canal, are changed from their normal conditions. In procidentia the vagina is in part or wholly inverted. In such cases, however, the changes are complications of the displacements of the uterus, and are described and treated as such. The more common and yet not entirely independent displacements of the vagina are known as cystocele and rectocele. Cystocele. Cystocele is a prolapse of the anterior wall of the vagina, being borne down by a prolapsed bladder, or drawing down that organ with it. The prolapses of the anterior vaginal wall and bladder may also make sufficient traction upon the uterus to cause prolapse of that viscus, and thus be complicated by it without the posterior wall of the vagina being much disturbed. Still another thing may be said in this connection. Sometimes the mucous membrane of the anterior or posterior wall of the vagina may prolapse through the vulva without displacing the fibrous sheath,- the bladder, or the rectum. Rectocele. When the posterior wall of the vagina protrudes externally it is generally attended with displacement of the anterior wall of the rec- tum, and sometimes the uterus is drawn down and displaced by trac- tion of the wall of the vagina. The symptoms of cystocele are dragging sensation or weight in the vagina, with leucorrhoea and burning pain, occasioned by the inflam- mation from the exposure or friction of the mucous membrane of the vagina, and vesical suffering. In recent cases there is simply frequent desire to micturate and unsatisfactory discharge of the urine. As the case becomes chronic the incomplete discharge_of urine leads to its decomposition, the precipitation of the salts contained in it, and the evolution of ammonia. The ammonia and salts irritate the raucous membrane of the blad- der to a greater or less degree, and in aggravated cases severe inflam- RECTOCELE. 373 mation and ulceration occur, attended with discharge of mucus, blood, and fetid gases. These local results are attended by constitutional disturbances com- mensurate with their gravity. The sufferings in rectocele are usually less severe. There is weight, leucorrhoea, and unsatisfactory defecation. The muscular coat of the rectum loses its tone and permits the faeces to collect in a large mass in it, which intrudes into and fills up the vagina. When an effort is made to expel the excrement it collects in larger quantities and remains in this passive pouch until the patient presses or scoops it out with her fingers. Diagnosis. Upon examining the vagina the anterior or posterior prolapse will be readily discovered, and may be isolated by passing the finger into the vagina. If the anterior wall is prolapsed the finger wull pass behind the tumor, and in front of the tumor if the posterior wall is the portion affected. We may demonstrate a cystocele by introducing the catheter. The instrument, instead of passing backward and upward, will go down- ward and backward, and the point may be felt occupying the tumor. In rectocele, if we introduce the finger into the rectum, it may be turned forward toward the vagina and made to enter the tumor. If the prolapse consists of the mucous membrane alone, the finger or catheter will not pass into the tumor. Causes. Loss of substance or tone in the perinaeum is one of the most im- portant conditions necessary to prolapse of the vagina. There may be loss of substance in the anterior border of that body from rupture, or loss of firmness from subinvolution, lack of general muscular vigor, — debility, — or senile atrophy. In old women we not infrequently find all the genital organs in a state of abnormal relaxation from loss of fibrous tissue. Instead of normal atrophy, in which the parts are condensed, as the fibrous tissue disappears, there is no contraction, and the uterus, vagina, and perinaeum are reduced to their membranous structures, incapable of resisting force in any form. Subinvolution of the va- gina, bladder, and rectum, on account of the vascularity and laxity attendant upon that condition, permit displacements, which are fa- vored by the weight of these and other pelvic organs. 374 DISPLACEMENTS OF THE VAGINA, BLADDER/aND RECTUM. Retention of the urine and faeces are also important factors in the displacements. They distend and weaken the walls of the viscera until they become incapable of resisting the pressure. Treatment. The same general principles govern the treatment of these two conditions. If the perinaeum is deficient^ its integrity should be restored by perinseorrhajDhy, and this will often be sufficient to eflPect a cure of either or both. When there is no loss of perinaeum, or the deficiency is slight, we may often cure cystocele by returning and retaining the prolapsed portion in position until the redundancy of tissue is reduced by the contraction and condensation which take place when the distending forces are removed or counteracted. The instrument which I have found most serviceable in cystocele is Zwanc's pessary. The points upon which it rests are the rami of the ischium, and it presents the flat surface of its expanded wings upward, affording an admirable lodging-place for the redundant tis- sue. The application of this instrument is not difficult, and when of the right size it very generally relieves the symptoms at once, especially the irritableness of the bladder. It will be necessary for the patient to wear the pessary for many months until the condensa- tion or involution is complete. Like every other pessary, this one should be removed and examined often enough to insure cleanliness and prevent damage to the vagina. If it causes ulceration it must be removed at once. Sometimes a ring, kept in position by external support, may be made to retain the procident wall quite securely. The practitioner should rely upon the pessary in most instances of this kind as far preferable to other surgical means, except the restoration of the perinaeum when deficient. When a surgical operation is required, the object to be attained by it is to remove a portion of the redundant mucous membrane over the central part and draw the edges together, and thus lessen the calibre of the vagina. To the inexperienced this operation seems a formidable one, but it is not so, and when attempted the difficulties will rapidly vanish. In the natural condition, the mucous membrane of the vagina is attached to the fibrous sheath by very loose connective tissue. In cystocele the space is much greater, hence, with a tenaculum we can RECTOCELE. 375 lift the membrane freely away from the vaginal sheath and with the scissors remove it to any extent we desire. As before remarked, the protrusion in many instances is made up of the mucous membrane alone, w^hen the operation is easy and a complete success. When the fibrous wall of the vesico-vaginal space yields, and is prolapsed with the mucous membrane, the operation is much more likely to fail, and we will at Fast be obliged to resort to a support. Judging from my own observation, I should say that rectocele is hardly curable in any other way than by operation. The perinaeum is almost, if not always, deficient, which requires an operation for its restoration. When this is the case, the two may be cured by the same operation. The more protuberant part of the rectocele is at the perinseum, and this portion may be denuded as far as necessary and closed with the perinseum, or a single ligature may be made to sur- round the part denuded like a puckering string, and the whole may be closed up and drawn down upon the perinseum. If the perinseum does not require an operation, then a similar operation to that recommended in cystocele may be performed. Dr. Gillette, of !N"ew York, performs an operation for condensing the mucous membrane without removing it, by passing silk ligatures between the membrane and the fibrous sheath and drawing it up over the most protuberant portion. Silver wire sutures are generally used for drawing the edges of the mucous membrane together over the denuded part. The manipulation will be suggested with sufficient accuracy in what is said about the use of instruments in the operation for vesico- vaginal fistula, — perinseorrhaphy and an examination of the figures. The after-treatment is of great importance. The patient should be kept quiet in bed and have opium enough to relieve pain, and in cystocele the urine should be evacuated by the catheter often enough to prevent distension. In rectocele the rectal tube must be used to prevent the accumulation of gas, and the bowels moved by saline laxatives every other day. Salines should be used because they liquefy the stools. CHAPTEE XXY. DISPLACEMENTS OF THE UTEKUS. The womb may be displaced when not pregnant, when pregnant, parturient, or puerperal. In the unimpregnated condition the more common forms of dis- placement are lapse, prolapse, protrusion, retroversion, anteversion, retroflexion, and anteflexion. Another rare form of displacement is upward. This is generally caused by attachment to tumors, with the development of which the uterus is lifted upward. It is also dis- placed by effusions and tumors forward toward the pubis, and back- ward toward the sacrum, without change of axis. These latter changes in themselves are of but little importance, and will be corrected by the removal of the tumor or effusion, when that is practicable or neces- sary. The natural position of the uterus is not precisely the same in every individual. It is generally situated very near the centre of the pelvis, with the fundus directed a little forward of the axis of the brim, and is, probably, a quarter of an inch below the plane of the superior stmit. In the virgin, more frequently than other- wise, there is slight anteflexion. The lower end of the cervix is very little below the level of the arch of the symphysis pubis, with the os turned slightly forward. Very often the fundus is turned in a small degree to one side or the other. This description has reference to the cavity of the pelvis, and not to the line representing the longitudinal axis of the body. The variation of the position ©f the pelvis in relation to the axis of the body is very great, and this variation will carry the axis of the uterus with it. In the woman who stands erect, with her shoulders thrown well backward, the axis of the uterus is almost horizontal, and nearly at right angles with the perpendicular axis of the body. On the contrary, the woman who stoops or throws the shoulders forward causes the direction of the axis of the body and superior strait of the pelvis to approach the same line. The more nearly the longitudinal axis of the bod}^ and the axis of the superior strait correspond, the 'more the abdominal organs press into the pelvis. In addition to the permanent or fixed relation of the pelvis to the trunk it must be borne in mind that the move- ) 1 NATURAL D-TERINE SUPPORTS. 377 Fig. 106. ments of the body are continually effecting temporary changes in these relations, and that some avocations keep the pelvis flexed upon the trunk from six to ten hours daily. In considering the natural position of the uterus we should not forget its great mobility — a provision of salutary importance — a cir- cumstance that serves to continually correct its position when the displacing influences are withdrawn. Xatural Uterine Supports. It is not a very easy matter to determine all the agencies concerned in retaining the uterus in its natural position. From what has been said the reader will infer that I consider the rela- tive position of the axis of the pelvis and body one of the agencies. At the brim of the pelvis the broad and the round ligaments are unmistakably supports to the uterus in keeping the fundus in proper position with reference to the pelvic circle, as well as to prevent its prolapse. The broad liga- ments are not strong, but they are elastic, and, while their power to prevent displacement is not very great, they are sufficiently elastic to replace the organ against moderate force. Their perpendicular duplicature embracing the uterus is greatly strength- ened by the considerable amount of connective tissue which they contain between their folds. This connective tissue not only connects the folds of the peritoneum, but extends from the wall of the pelvis to the sides of the uterus, and is thus a direct means of support to the organ. In the pelvic cavity the utero-sacral ligaments, formed by folds of the peri- toneum, with a large quantity of connective tissue and prolongations of pelvic fascia, are efficient ligaments. Below the uterus, the vagina, and the connective tissue binding it to the pelvic walls, at the side and in front, and further strengthened by the pelvic fascia, make decided resistance to displacing agents. In the chapter on the perin^eum I have already said sufficient in regard to its agency in supporting the uterus. All these supporting agencies are affected by physiological conditions which strongly modify their efficiency. Pregnancy, by the general hypertrophy it brings about in all the genital organs, completely disqualifies them as sup- porting agencies, and, until they are reduced to their proper firmness Xatural Position of the Bodv. 378 DISPLACEMENTS OF THE UTERUS. Fig. 107 and length by involution, their effects in this direction are nothing. From recent physiological teaching we must believe that their sup- porting power is also reduced by the congestion and trophic changes accompanying menstruation. These varying efficiencies of the natural supports of the uterus are considerations of great importance in con- nection with the etiology of displacements. Causes of Displacements. In speaking of the direction of the pelvic axis I have already intimated that women who, from disease, debility, occupation, languor, or any cause, habitually stoop, and thus bring the axis of the pelvis nearly to correspond with that of the body, place the uterus in a posi- tion to be easily displaced. The pressure of the abdominal viscera upon its fundus, increased with the percussion of coughing, sneezing, and respiration, injuriously bear upon it. In these patients ascending stairs, walking, stand- ing, etc., produce an exaggeration of these effects. The position occupied by working on the sewing-machine, or even sewing by hand, ironing, washing, etc., is more mischievous than the work itself; and, if the same things were done with the body erect, they would be comparatively innocent. Increase in size, and consequent weight of the uterus from tumors, congestion, inflamma- tion, subinvolution, and elongation of the cer- vix are causes of displacement. When the size is increased in all its proportions the tendency is to prolapse ; if the increase of weight is confined to the fundus there will be Unnatural or Stooping Posi- an inclination to antevcrsiou or anteflexion, tion of the Body. • n • retroversion or retroflexion. Sometimes the thickness or increased weio:ht is in the anterior or posterior wall, then the inclination will be in the direction of the disease. I believe that pre-existing disease is the cause of displace- ments of the uterus in the great majority of instances, and that displacement is very seldom the cause of the disease usually asso- ciated with it. Loss of tone in the ligaments, flabbiness and soft- ness of the vagina, relaxation of the attachments composed of fascia and connective tis.sue, and the want of strength in the perinseum, LAPSE. 379 except when torn, generally depend upon coexisting disease, as sub- involution, general debility, senile atrophy, etc. There is no doubt, however, in mv mind that the uterus weio^hinor an ounce more than natural, especially in a person in whom the plane of the superior strait of the pelvis is too nearly horizontal, will in time overcome the resistance of all the means of support with which the uterus is surrounded, and determine a displacement of some kind. Conditions outside the uterus, as a loaded condition of the intes- tines, which causes them to settle down upon the pelvic organs, straining at stool, especially when there is impaction of the rectum, jolts from jumping, straining from lifting or reaching, maybe causes of displacement. I think it is impossible thus to displace a uterus otherwise in a healthy condition ; but I do believe that such acts are the etiological items that complete a process already begun. I have not attempted to enumerate all the causes of displacement of the uterus. It is my design, in a general way, to merely indicate the manner of their action. In most cases many causes co-operate to bring about a displacement. Lajyse. Simple falling of the womb in the direction of the axis of the superior strait brings it into a position in which the lower end of the Fig. lOS. Lapse or Descent of the Uterus, without change of axis, and the Displacement of the Bladder and Pressure upon the Rectum. cervix is inserted behind the apex of the perineal body, while the fundus is from half an inch to an inch below the ordinar)^ level, and 380 DISPLACEMENTS OF THE UTERUS. sometimes even more. In this displacement the lower wall of the bladder is drawn dow^n in consequence of its attachment to the uterus, and occasionally a reservoir for the retention of urine is thus produced. When this is the case dysuria is oue of the symptoms. When of long standing, pressure upon the rectum gives rise to tenesmus, de- velops haemorrhoids, ulceration of the mucous membrane of that viscus, constipation, etc. This form of displacement is probably generally caused by some form of hypersemia of the uterus instead of primary relaxation of the supports. Prolapse. When the perinseum is deficient, relaxed, or overcome by long- continued pressure, the cervix turns forward and the body of the organ lies in the vaginal canal, with the fundus backward upon the Fig. 109. Prolapse of the Uterus. level, or, rather, above the level of the cervix. In this position with reference to the vaginal canal and the axis of the inferior strait, the organ may slide forward until the cervix extends to and even through the vaginal orifice. With this kind and degree of displacement there is some change in all the pelvic and lower abdominal viscera. The bladder is drawn down until the direction of the urethra is changed. The Fallopian tubes and ovaries are moved from their natural posi- tions, and the rectum is generally more or less displaced forward and downward, while the intestines sink down into the pelvis, and by their weight increase the uterine displacement. PROTRUSION. ;8l Of course the resistance of the ligaments is overcome to permit of such prolapse, and the vagina is more or less inverted. Protrusion. After the cervix has passed beyond the vaginal orifice, the direc- tion of its descent is again changed, and when the whole organ is expelled or dropped from the body, the longitudinal axis of the uterus corresponds with the perpendicular axis of the bodv. The utenis hangs down between the thighs. The extent and size Fig. 110. Protrusion of the Tterus. with attendant cliange in the position of the Bladder and Inresiinal Canal. of the protrusion is of course variable. Sometimes the whole of the uterus is thus protruded, covered with the inverted vagina, the fiindns merely clearing the external parts, while at other times the whole of the uterus depends several inches below the pelvis. With this dis- placement there is always very extensive displacement of the pelvic and abdominal viscera. The great vaginal hernia thus formed, sometimes contains the ovaries. Fallopian tubes, bladder, a large quantity of intestine, and elongated omentum. The viscera are sometimes so extensively dis- placed as to cause more or less descent of the transverse colon, stomach, and liver. In this last degree of protrusion the retentive power of the vaginal sphincter, perinseum, and all the ligaments is lost, and the 382 DISPLACEMENTS OF THE UTERUS. only support left is the greatly distended and elongated vagina, which, as a kind of sac, contains this great mass of diverse organs. Anteversions and retroversions without some flexion are not fre- quent displacements. These conditions until within a comparatively short time were all described as versions ; now, however, the distinc- tion between versions and flexions is recognized by the profession everywhere and is of great importance. In simple versions the uterus retains its figure, the fundus generally lying lower than the os, either before or behind the vagina. In anteversion the fundus falls for- w^ard upon the anterior vaginal wall, while the cervix points in the direction of the sacrum. It is a rare displacement. Retroversion is Fig. 111. Anteversion of the Uterus. the condition in which the fundus falls backward and occupies the cul-de-sac, while the cervix is turned upward and forward, more or less nearly approaching the symphysis pubis as it is longer or shorter. In both these displacements the position and calibre of the bladder and urethra are affected, as in the one the fundus is pressed down- ward upon the bladder and urethra, while in the other the cervix bears them upward. In flexions, which are always deformities, the cervix or body of the uterus is doubled upon the fundus, or expressing it differently, the fundus is bent backward or forward of the normal axis of the organ. Generally in flexions of the uterus the cervix is not much SYxMPTOMS. 383 displaced, but in some instances the fundus remains in position while the cervix is bent forward or backward. In anteflexions the fundus is bent forward and lies upon the blad- der and anterior wall of the vagina, while in retroflexions the fundus is turned backward and occupies the cul-de-sac below the vagina. There are several degrees of flexion in both varieties, some being bent very short, while in the others the flexion is slight. Some gynaecologists believe that slight anteflexion is the natural condition of the virgin uterus, and is consequently of more frequent Fig. 112 :C" ^^X""^- /• .\ H ^: «,' Vv'-?.' ^s^ Retroversion of the Uterus, showing the Fundus pressing upon the Eectum, and the Cervix encroaching upon the Bladder. occurrence and of less importance than any other displacement. I have no doubt of the correctness of this view of the subject, yet ex- treme anteflexion sometimes gives rise to great inconvenience and suf- fering. I quite agree with Dr. H. Webster Jones, of this city, when he says that *' retroflexion of the uterus is the most mischievous of all displacements and the most difl&cult to manage.^^* Symptoms. The symptoms of displacement of the uterus are not sufficiently "^ A paper read before the Chicago Gynaecological Society at the April (1880) meeting. 384 DISPLACEMENTS OF THE UTERUS. distinctive to characterize one condition fiom another or even to enable us to decide whether there is displaeement or not^ Those displacements in which the utems remains within the pelvis manifest their existence by the influence they exert opon the nervons and vascnlar apparatus. The symptoms are for the most part those spoken of elsewhere as uterine symptoms, to which the reader is referred. In fact these forms of displacement, when the utems is in a healthy condition, do not give rise to any symptoms, and it is only when the uterus or some other of the pelvic oi^ans are diseased, that the pa- tient suffers inconvenience. All experienced gynaecologists meet with displaced uteri in which uterine symptoms do not exist* But when there is uterine hyperaemia, subinvolution, ordinary con- gestion, or inflammation — and one of these conditions nsnallj ante- dates the displacement — the patient will sufler from uterine symptoms. These remarks do not apply to protrusion of the nteros, for in some respects the influence of this condition is pecnliar. More fre- quently than otherwise the symptoms are entirely local. Locomotion is often not so much affected by extensive protrusion as by some form of version of the uterus. While I believe that tlie symptoms are gen- erally caused by the hypenemia of the uterus, and that this is the antecedent state of the viscus, there is no doubt but that the uterine disease is very much aggravated by the displacement, on account of direct pressure upon the nerves passing through the pelvis, and by changing the direction of the vessels, thus lessening their calibre and embarrassing the circulation in the organ. The pressure upon the sacral plexus causes sciatica, or upon the nerves of the anterior parts of the pelvis neuralgia of the anterior fiart of the limbs. The circulation in the veins carrying the blood from the uterus is retarded^ and congestion, with all its sympath^c accompaniments, results. Diagnosis. By physical examination there is very little difficnltj in tnafeing out a correct diagnosis, unless when complicated. In lapse or simple falling of the womb a finger in the rectum will easily reach the cervix: at the point where it presses upon that int<^ine. By this method the eer\^ix will be found just i ' it will l>e easily displaced upward and to the sid- be passed behind it and along its posterior wall. E _ina the finger will pass downward and backward to reach the cervix, when DIAGNOSIS. 385 it win easily recognize the shape and size of that part of the organ. To introduce the probe it will be necessary to draw the cervix for- ward with the finger, when it will pass upward and forward. The retroversion or retroflexion will be easiest recognized by intro- ducing a flexible probe or sound. The point of course will pass in no other direction than downward and backward. When the sound is in the cavity, if we turn it, the fundus will be lifted up into its proper place. The movement of the uterus under the influence of the sound may be best observed by the finger introduced into the rec- tum. If, after the sound is inserted into the uterus to the fundus, we pass the finger into the rectum and place it upon the fundus we can accurately observe the process of replacement. AVith the sound in the uterus fixing that organ, and finger in the rectum, the diag- nosis between a small tumor and a retroverted fundus will not be difficult. The finger may be passed up over the fundus on the ante- rior wall of the uterus, and thus determine that the appearances are not caused by a small tumor which sometimes simulates the fundus. Anteversion may be diagnosed by the sound ; passing it up carefully it will pass forward and upward, and at the same time lift the fundus from its position on the anterior wall of the vagina. If there is a sharp flexion we sometimes have great difficulty in passing the sound. In retroflexion, w^hen this difficulty occurs, after passing the sound down to the flexion, the finger should be introduced into the rectum and the fundus lifted up enough to straighten the cavity so that the sound will pass. A finger in the vagina may be made to lift the fundus from the anterior wall of the vagina for the same purpose in cases of anteversion. There is generally very little difficulty in diagnosing prolapse, as the finger will easily recognize the cervix, and the sound will pass directly backward instead of upward or downward. One would suppose that protrusion would be the easiest form of displacement to recognize by physical examination, and so it is generally. Some- times, however, the shape, color, size, and consistency of the uterus are so changed by congestion, ulceration, and friction as to make it almost unrecognizable. By carefully inspecting the protruding part, however, we will always be able to find the mouth, through which the sound may be made to pass to the fundus. The catheter introduced into the bladder will generally pass downward and backward into the tumor. 25 CHAPTEE XXVI. DISPLACEMENTS OF THE UTEKUS, CONTINUED. Treatment of Displacements of the Uterus. Peeparatoey to speaking of the use of instruments for the sup- port of the uterus reposited from a state of displacement, it will be proper, in a cursory manner, to describe conditions in which they are not applicable, and to which we must direct our attention before we can succeed in their use. In cases of displacement where the vagina is sensitive, we will find any kind of pessary intolerable. Inflammation of the vagina and vaginismus are probably the most common conditions giving rise to the hypersesthesia which precludes the use of the pessary ; and when either of these morbid states are present, their removal is the first thing to be accomplished. AYe sometimes meet with undue sensitiveness of the perineum and lower portion of the rectum, rendering the use of some forms of pessaries entirely impossible. This sensitiveness is often the result of simple hypersesthesia ; but more frequently it is caused by inflammation and ulceration of the rectum, fistula, or haemorrhoids. Hypersesthesia from inflammation of the uterus, and especially in the acute and subacute forms, are incompatible with the use of pessa- ries. Simple hypersesthesia, similar to that found in vaginismus, is a not infrequent condition of the uterus, which forbids the applica- tion of direct support. Immobility of the uterus from old adhesions must be overcome, also, before we can venture upon pessaries. Perimetric inflammation in the acute, subacute, or chronic forms contraindicate the use of suj^port. It might be considered superfluous to mention these conditions as incompatible with mechanical support; but it has been my misfor- tune to witness efforts made, and persevered in, to replace a uterus that was displaced by inflammatory efiPusion, and was only a part of a great mass, all of which was supersensitive from the actual presence of subacute inflammation. Instances of this kind, of injudicious at- TREATMENT OF DISPLACEMENTS OF THE UTERUS. 387 tempts lit restoration of the displaced uterus, are not confined to the practice of wliat might be termed ignorant physicians. We occasion- ally meet with them in the hands of the general practitioner who ought to know better. We cannot emphasize too strongly the in- junction not to make attempts to restore the uterus when they are attended by pain, or when there is any abnormal increase of general temperature or a rapid pulse. Displacements which are the effects of non- inflammatory effusions, as hsematocele or peritoneal dropsy, cannot be replaced with any safety until the cause is removed. It is seldom that mechanical support is devoid of peril w^hen the uterus is displaced by tumors. For the most part, when there is a tumor situated in any part of the uterine tissue of sufficient weight to displace the organ in any direction, we ought to abstain from the use of pessaries. That there are occasional cases in Avhich the patient may be made more comfortable by supporting the uterus and tumor I have no doubt, but I believe they are exceptional, and require the exercise of unusual skill to avoid mischief. Before resorting to permanent mechanical support the uterus should be habituated to replacement by manipulation, piledgets of cotton, oakum, or other soft material. It is true that experienced gynaecolo- gists, in favorable cases, are often able to adopt a pessary that may remain for an indefinite length of time doing no harm, but generally they are obliged to proceed cautiously and watch the effects before they can be sure that their instruments are profitably borne. I would again warn the inexperienced against repositing the uterus when it causes pain, or allowing an instrument to remain in the vagina when it produces suffering; and it would probably be equally proper to say, that in all cases the instrument should not only not cause pain^ but be attended with a sense of relief. The number of mechanical devices to replace and support the uterus is so great as to excite astonishment and skepticism in the ordinary observer. Almost every conceivable material has been em- ployed in their construction ; and while there are undoubtedly many contrivances which are merely the product of the imagination of the inventor and worthless, a large majority of them have some useful application. Almost every instrument of profitable fashion has a physiological as well as mechanical basis. It should, as far as pos- sible, be made to perform its functions in imitation of the supports employed by nature. While this remark may not be applicable to 388 DISPLACEMENTS OF THE UTERUS. all kinds of mechauical supports that may be made available, it will apply to a great many of them. Another statement in reference to this formidable array of sup- porting instruments will not be out of place, and that is, a consider- able diversity of inventions will be found necessary to success. We cannot expect to succeed in all cases by any one instrument or any class of instruments; we are, therefore, fortunate in having the benefit of so much ingenuity in this direction. When the displacement is not extreme, much good may be done by frequent replacements by the hand or otherwise. Patients can often be taught to replace the uterus themselves. The knee-chest position will do a great deal toward correcting most dis- placements of the uterus. The assumption of this position is espe- cially useful in correcting lapse or falling of the organ, prolapse, and retroversion . Dr. Henry F. Campbell, of Augusta, Georgia, contributed an able paper on the genu-pectoral position as an important item in the treatment of displacements of the uterus. {Transactions of the Ameri- can Gyncecological Society, vol. i.) To make the position more effec- tive. Dr. Campbell has invented a small glass tube (figure, p. 216), which the patient can introduce into the vagina to admit the air. In this way he avails himself of the effects of gravity in removing the pressure of the abdominal viscera and of atmospheric pressure through the vagina. Patients who are taught how to effect these objects by position may sometimes relieve themselves, temporarily at least, of the pain and discomfort attending malposition. If, after having occu- pied this position for a sufficient length of time, they will carefully lie down on the side for several hours, the consequences will be more effective, if not more permanent. This position will often enable us to elevate the retroverted uterus by the fingers, which could not be replaced without the aid of instru- ments, and, in some instances, the introduction of instruments will Oe greatly facilitated by placing the patient in this position. Instruments. The instruments for sustaining the uterus in its restored position are used externally or internally, and some are partly external and partly internal. The external variety are usually termed abdominal supporters. SUPPORTERS. 381) Supporters. Their main object should be to restore and retain the pelvis in a proper relation to the spinal column. They are made by connecting two pads or disks, one for the back and one for the abdomen, by two Fig, 113. Fitch Supporter, flat metallic springs extending over the hips on each side. The disk resting on the back is sometimes double or quadruple, the divisions Fig. 114. •OO^NVTM^Ji:^ London. being about four inches apart, one above the other, and connected by springs. These disks rest on either side of the spine, and by press- ing on it give it support. The anterior part is broad and placed just 390 DISPLACEMENTS OF TEE UTERUS. above the pubis. AVben properly placed, tliis instrument has a strong tendency to keep the patient erect. Shoulder-straps, to draw the ^^??^?*^'W^^^ t3 ■5 SvYV»i^.^>-r Silk Elastic Body Belt. A^ shoulders backward, add to tbe efficiency of these instruments. The best of these external supporters are Banning's and Fitcli's (Lon- FlG. 116. Banning Supporter. don). An ela.«tic bandage properly made will, to a certain extent, perform the same service. Pessa/^ies. Instruments to be introduced into the vagina or uterus, upon which the organ may directly or indirectly rest and be thus supported in its natural position, are much more extensively useful and are adapted to a larger range of displacements. Pessaries are made of a great variety of materials and fashioned into very different shapes and sizes. The great numl^er and variety of pessaries lead to much confusion in considering the subject of their adaptation. There is so much difficultv in determiniuo' what each form of instrument mav be made PESSARIES. 391 to do that the inexperienced practitioner is often unable to see in each one tlie character of the case to which it is suited. His practice, therefore, instead of being rational, is often haphazard, an utter failure, and sometimes injurious. I have neither the time nor the desire to give an elaborate account of the different forms of pessaries, and the different cases to ^Yhicll they are adapted ; but, for the benefit of the student, I will endeavor to classify them, so that he may at least get some useful hints in the methods of using them. 1st. The first class I will mention includes those pessaries which have for their points of resistance or support the vagina and perinseum, and I will term them vagino-perineal pessaries, because their shape is such that they are held in position by resting upon the perin^eum. Fig. 117 Fig. 118. Smith's Pessary. Thomas's Modification of Smith's Pessary. and by being grasped by the vagina. They consist, for the most part, of modifications of Hodge's instruments, as the Albert Smith pessary, and those resembling it. It is large posteriorly, and narrow ante- riorly. The broad part surrounds the cervix uteri, while the narrow part lies in, and is retained in place, to some extent, by tlie anterior part of the vagina, the walls of which embrace it with some degree of firmness. But the instrument has a double curve on the flat. One curve enables the posterior part to rise behind the uterus and lift up that portion of the vaginal wall implanted in the posterior surface of the cervix, and thus draw the cervix backward and upward. The second, or perineal curve, adapts its concavity to the upper part (convexity) 392 DISPLACEMENTS OF THE UTERUS. of the perinseiim. It thus rides upon the perinseuni and supports the uterus, and rocks backward and forward with the different move- ments of the viscera above, when impressed by respiration, or other movements of the body. There are many pessaries that have these points of support. The second, or perineal curve, is a great improvement upon the earlier h Fig. 120. Gehring. Hemtt. forms of Hodge's pessary for some cases. It is admirably suited to retroversion when there is no considerable degree of laceration of the perinseum. There are some other pessaries that are retained in position by the vagina and perin^eum, as the globe, elastic disk, cradle pessary of Hewitt, and the anteversion pessary of Gehring, etc. Fig. 121. Zwank's Pessary. 2d. Belonging to the second class of pessaries are those which are supported upon the ischiatic tuberosities, or rami, and may be called the ischiatic. An example of this variety is Zwank's pes- sary. It has two branches, resembling wings, that, after the instru- PESSARIES. 393 raent is introduced, spread open, one on each side, resting upon the ischiatic bones. This instrument, expanding the vagina, lifts the uterus up, by virtue of the insertion of the vaginal walls into the cervix. It also affords a nearly flat, expanded surface, upon which the uterus may rest. It is very useful in cases of cystocele, when the anterior wall of the vagina prolapses to a moderate degree ; this pes- ary will frequently do all that can be desired for temporary relief, and not unfrequently it accomplishes a permanent cure. This instru- ment has but little support from the perinseum or vagina. 3d. The third class of instruments have their bearings on the tuberosities or plane of the ischium and pubis. These are the vari- ous forms of rings : the round, oblong, or elongated, etc. The ring that is not curved on the flat side, if small, may, and often is, re- tained by the vagina, while the anterior segment rests against the pubis ; but when large, it extends to the three points above named. The same thing may be said of the small and large disk pessaries, whether hard or elastic. Of course, when the perinseum is present in its entirety, all these different forms of pessaries find more or less support upon it. 4th. Still another class of pessaries, acting as levers, are partly suspended from behind or before, and rest upon the perinseum as a fulcrum. The intravaginal portion of some of these instruments have the retrouterine and perineal curves that belongs to the vagino- FlG. 122. Scott's Pessary. perineal class, but its anterior extremity is elongated, and to it is attached a tape or cord, that passes directly upward or backward between the thighs and upward to the waistband, to which it is at- tached. The posterior or retrouterine extremity, by pressing back- ward against the posterior wall of the vagina, elevates the whole uterus, and, carrying the cervix with it, throws the fundus forward. It is a very simple instrument, easy of application, and answers ad- 394 DISPLACEMENTS OF THE UTERUS. mirably in some cases of retroversion, lapse, and prolapse. Dr. Scott, of Woodstock, Canada, makes an instrument of iron or copper wire, and covers it with india-rubber tubing. The wire may be bent in any shape, and thus made to suit different cases. The ring part should be fashiofled to fit well behind the uterus, and the projecting part bent so as to pass down between the limbs and turn up along Fig. 123. Cutler's Instrument in Position. the sacrum ; to this end the string or tape is attached that fastens it to the waistband. Very little attention will enable the practitioner to adopt the instrument, and when once fitted the patient may remove and replace it. The two points to guard are the one behind the uterus and that SUSPENSION PESSARIES. 395 upon the periniieum. Without care there is some danger of getting too great pressure behind the uterus or on the perinreum. These may be avoided by changing the curves to fit the parts comfortably. Cutler's instrument belongs to this class, and is admirably suited to the purpose of retaining the uterus in position after it has been ele- vated from a state of retroversion. Suspension Pessaries. 5th. These instruments have their resting-points outside the pelvis by fixed attachments to an apparatus around the waist. They are made in the forms of rings, cups, and stems, mounted upon a vaginal stem, which is connected with the outside attachment. Fig. 121. Fig. 125. The Dr. Mcintosh Natural Uterine Supporter. supporter Applied. The vaginal stem is sometimes immovably fixed to some metallic support outside, and when placed is supposed to rigidly confine the uterus in position. In other instruments the vaginal stem is sup- ])orted by elastic cords, generally four in number, extending to the waistband. In cases of entire or almost complete loss of the peri- neum, this kind of support, as a temporary means, and calculated to give some relief until more radical measures can be resorted to, is sometimes useful. In very old patients, where senile atrophy has resulted in such extreme tenuity of the perineum and vaginal walls as to render them incapable of resisting the downward pressure of the superincumbent organs, these instruments may sometimes be made useful. They are not, however, the proper kind of pessary to employ when the perineum and vagina are in a condition to permit the use 396 DISPLACEMENTS OF THE UTERUS. of pessaries described io class 1st. I might pass the intrauterine stem pessaries without notice if I did not desire to condemn them as supports. I am willing to condemn them mildly, however, because they are used by a number of eminent and careful gynaecologists with Fig. 126. Fig. 127. Fig. ]28. 1 1 The Ring and Cup Attachments to Cutler's External Supporter. evident profit, and because, also, I have not had any extensive expe- rience with them. Temporary pessaries, of various shapes and sizes, are made of cot- ton and oakum. They are not often relied upon for the permanent support of the uterus. They are very convenient as a vehicle for medicinal applications to the uterus and vagina. Adaptation of Pessaries. Lapse or falling of the uterus is probably the least difficult dis- placement to treat successfully. It will frequently not be necessary to use a pessary. By relieving the hypersemia, hypersesthesia, and enlargement of the uterus, the depression will often be cured. For this purpose scarification, glycerin cotton, the local application of tincture of iodine, or iodized phenol, hot- water injections, sitz-baths, etc., persevered in for a sufficient length of time, constitute the proper course of remedies. If this is not sufficient we may resort to the Albert Smith or Emmett pessary, and keep it in the natural position until, through the freedom of circulation thus attained, the structural changes are removed, and the tissues of the uterus restored to their normal condition. Anteversion, The same remarks in reference to the removal of the hyperaemia and hyperaesthesia of the organ are applicable to this form of dis- 1 I RETROVERSION. 397 placement as in falling of tlie uterus. When not very much displaced in this direction, it will seldom be necessary to resort to supports; but when the malposition is extreme we may very properly employ Fig. 129. Thomas's Anteversion Pessary. either Geh ring's, Hewitt's, or Thomas's anteversion pessary, any one of which must be used with the precautions mentioned above. Betr aversion. There are many cases of moderate retroversion, especially when the uterus is not unusually heavy, or sensitive, in which support is not called for. Patients will often have this kind of displacement without inconvenience, and I hold it to be an absurdity to interfere with this or any other form of displacement that does not give rise to symptoms. When the uterus is enlarged, sensitive, and strongly retroverted, we may justly consider that the venous circulation is interfered with, and that the correction of the displacement is an important if not an essential measure in the treatment. Even in such conditions as are here supposed, the restoration of the position is only one of the means requisite to secure success. The other conditions must be attended to in a thorough manner, until the shape, size, and consistency of the uterus are restored. In the worst forms of this displacement the uterus and tissues upon which it has for a long time exerted injurious pressure, will not at first tolerate an instrument capable of keeping the organ in place, and it will be necessary to use soft and temporary pessaries, as cotton or soft rubber instruments, until the complicating conditions subside, or are much improved, and then they must often be employed inter- mittingly in order to avoid harm. Dr. Campbell's method of re- placement by the knee-chest position as above described, will often be tolerated and beneficial when no instrument, of whatever material composed, can be borne. Sometimes frequent restoration will be all 398 DISPLACEMENTS OF THE UTERUS. Ave need do toward restoring the uterus, while the other treatment is removing the cause or causes of the displacement. When there is no tenderness or other complication w^e can often at once introduce a permanent pessary ; but wdien Ave do this, Ave should carefully watch the case, and remove the instrument at the first warning given by pain or tenderness. Scott's, Cutter's, Albert Smith's, Emmett's, and Thomas's pessaries are all under certain circumstances useful and successful in retroA^ersion, and they afford a sufficient A'ariety from which to choose. The question of adhesions binding the uterus in a malposition scarcely comes up in relation with any other displacement, but in this it is one of A^ery great importance. Impaction is much more frequent, and is often mistaken for adhesion. It should be remem- bered that these adhesions are the result of inflammation, and gener- ally local peritonitis, and that this last-named condition is often present in a subdued degree for a long time after the effusion result- ing from it has hardened into a false membrane. This circumstance w^ill be a standing caution to the considerate practitioner. It Avill be easy by a little indiscretion, in our attempts at restoration, to arouse a more acute form of inflammation, and thus do much mischief. ^Yhen there is tenderness behind the uterus Ave cannot be too careful, indeed Ave should always wait when there is good reason to apprehend local peritonitis until CA^ery CA^idence of it has subsided. And this Avill generally require a long' time, CA^en if judicious treatment is employed. The repositor in such cases is a very mischicA^ous instrument, if it is not always a questionable one. Position and the fingers wdll nearly always be the best means to re- duce the retroA-erted uterus, as well as to make the diagnosis between impaction and adhesion. As a general rule it will be found that, AA^hen the patient is placed in the knee-chest position and tAvo fingers of one hand introduced into the vagina and two of the other into the rectum, the impacted organ can be lifted out of its false position Avithout giA'ing her much pain. When there are adhesions, hoAvever, this would be both painful and impracticable, and Ave must desist from the effort, and pursue a course of treatment calculated to cure the inflammation. Are there any circumstances under which we are justified in break- ing up these adhesions? I think not, and but few where it is advis- able to stretch them so as to permit the uterus to be replaced and kept in position by a pessary. From obserA^ations, frequently repeated, I am sure that the absorption and disappearance of them are frequent and RETROVERSIOxV. 399 may be looked for after sufficient time, and that it is better to wait an unnecessary length of time for this to occur than it is to run any risk of awakening dormant mischief in the peritoneum or cellular tissues. When we are satisfied of the removal of these bands of lymph, eiforts to raise the uterus by posture and manipulation should be con- tinued for some time before using the cotton or soft ^ubber pessary. There are several conditions of the vagina and cervix uteri not yet mentioned that are calculated to embarrass the inexperienced in the successful application of the pessary in retroversion. When the pos- terior reflexion of the vaginal wall is short, and the cervix is placed so far back as almost to seem implanted into the end of the vagina, it is sometimes difficult to make a sure lodging for the pessary behind it. In that case I believe Scott^s instrument to be the best, because it can be bent to any angle or length, and retained in position by the external branch, so as to press under and behind the cervix witli much exactness. When the intravaginal cervix is very short, so that it will easily slip over the side or back part of the instrument, I know of none better than Scott's. It is certainly more easily adapted to, and kept in proper relationship with, the contour of the posterior part of the vagina and in constant relation with the cervix than any instrument which lies wholly within the vagina. Another very embarrassing condition is a strong inclination of the retroverted fundus to one side, with the cervix lacerated. When the uterus, thus twisted, is reposited, the instrument to be effectual in its bearing must press upon the vaginal wall on the side opposite to the induration of the cervix. A pessary, like the Albert Smith or Emmett, that finds its support entirely within the vagina, is very hard to ad- just, on account of most of the weight resting on the side instead of one of the ends, as in ordinary retroversion. When, in consequence of the shortening of one of the broad liga- ments, the cervix is strongly drawn to one side, much care will be necessary in placing an instrument so as not to make too much pres- sure upon the short side, and yet give the proper support. In all such cases there is good reason to fear that there is a lurking chronic inflammation in the ligament to which the cervix is attracted, which upon slight provocation will be aggravated and become acute. In adapting the instrument pressure upon the suspicious ligament must be avoided. The instrument should be so moulded as to make mod- erate traction upon the opposite side of the vagina. I say moderate, because forcible traction will not be borne, will be likely to give pain, 400 DISPLACEMENTS OF THE UTERUS. and may possibly cause inflammation. And here again the skilful use of Scott's pessary has, in my hands, yielded the best results. Of course in this class of cases much care in moulding, placing, adapt- ing, and watching, will be indispensable to success in the use of this or any other instrument. The treatment of protrusion or procidentia is founded upon the three indications derived from the nature of the case. Eestore the perinseum, remove a portion or cause contraction of the hypertrophied vagina, and strengthen the relaxed ligaments. My own experience is decidedly favorable to the use of artificial support, and in a great many instances it will be practicable and effective. If the uterus can be kept in its proper place, the ligaments will contract and become more resistant, the vagina also diminishes in size, and if the perinseum is not partially lost it will assume its tone and relative form and po- sition. Such pessaries as may be made to sustain the organ without distension or pain are best adapted to the work. In fact the vagina ought to be distended as little as possible. They should not rest on the perinseum for support. Those supported externally are most suc- cessful when they can be tolerated. It is true that we sometimes succeed with globe pessaries, or disks, or lever, or ring pessaries. When the perinseum preserves much of its tone these instruments will fill the indications, but not otherwise. An air-bag globe of small dimensions at the upper end of a stem, will be tolerated often and prove very useful. The stem may be planted upon a shield that sets upon the external organs outside, and there retained by straps or bandages. This is a better way than to have a stiif rod reaching out and up to the top of the pelvis, or even up the abdomen. So long a rod under all movements of the body, bears with rigid fixed- ness upon the uterus. To fix the instrument at the vulva with a cord or band, places it where it is not subject to every form or great latitude of motion, while it does somewhat yield to internal pressure. The great trouble in the use of these instruments is that sometimes, after our best efforts to secure the results, they are not tolerated, too much sensitiveness of the parts preventing them from being worn. The pessary ought to be worn only when the patient is in the erect posture. It should be taken out after lying down and reintroduced before rising in the morning. Patience in selecting and modifying the shape of the pessary, with a clear view of the indications to be fulfilled, will sometimes enable us to succeed perfectly after having made a discouraging number of trials. We should study the case and learn why the instrument is not tolerated, and correct the diflfi- PROLAPSE. 401 culty by changing or correcting the qualities of the instrument. It is remarkable how the vagina and perinseum will contract and become strong, when the uterus is kept in its place for some months. An ingenious use of artificial support will cure as many if not more cases than any other one sort of treatment. Astringent injections should be pei*severingly used in connection with the artificial sup- port. Saturated or very strong solutions of sul. acid, tannin, acetate of lead, etc., and decoctions of astringent bark, as oak, are the most eligible and effective forms for them. An efficient use of astringents would appear in some cases of ex- treme prolapsus to be sufficient to effect a cure. Dr. G. P. Hackenberg, of Rochester, X. Y., reports two cases in the Medical Record cured by what he calls packing the vagina with tannic acid, and says with reference to others : " I have treated with uniform success many lady patients who were subject to prolapsus uteri." Again he says : '^ I have hardly failed to control the most obstinate cases of prolapsus by this treatment." I here give a de- scription of his plan as given in his own language : *' A glass speculum was introduced iuto the vagina so as to push the uterus into its place. Through the speculum was introduced a metallic tube or syringe, with the end containing about thirty grains of tannin. With a suitable piston the tannin was now pushed out of the cylindrical tube against the uterus. The cylindrical syringe was then withdrawn, and the packing was neatly and effectually completed with a dry probang around the mouth and neck of the womb. After the packing was com- pleted the probang was placed against the tannin in order to hold it, and the speculum was partially withdrawn. The packing was now fully se- cured. The probang was next withdrawn, closely followed by the spec- ulum. *' The application of tannin held the uterus firmly and securely in its place, not by dilatation of the walls of the vagina, as in the case of the use of a pessary, but rather by an opposite condition — by corrugating and contracting the parts. The patient was promptly relieved by the application, and to her great astonishment was able to take long walks with comparative comfort. " The happy effects of this packing continued about a week, when symptoms of a relapse began to show themselves. Another packing was resorted to, with the same good effects. As we proceeded with the treat- ment of the case we prolonged the intervals of the application. At first they were made weekly, finally but once or twice a month. In two years the cure was completed, and I understand that the lady enjoys com- paratively good health since. 26 402 DISPLACEMENTS OF THE UTERUS. " The almost constant application of tannin to the uterus not only overcomes the hypertrophy and elongation of the cervix, but I think even induces a slight atrophy of the parts. At no time did the patient suffer from this local treatment." Surgeons have generally in their operations addressed themselves to but one item in the case. One party operates upon the perinseum, Fig. 130. A. Cervix Uteri. E. Urethra. C C C C. Denuded Surface. restoring or lengthening it, more or less completely to close up the vaginal orifice, while another party lessens the diameter of the vagina itself and condensing its walls into cicatricial or undistensible tissue; and it is feared that the success of one procedure too frequently leads the operator to almost indiscriminate repetition of one kind of opera- tion, instead of acknowledging the importance of another and the necessity of meeting it with a different sort of surgery. Two, quite different in their nature, have been perfected and practiced by two PROLAPSE. 403 great representatives of female surgery, viz., Dr. J. Marion Sims and Mr. I. Baker Brown. Dr. Sims operates on the walls of the vagina. His operation consists in removing the epithelium of the mucous membrane, so as to denude the latter thoroughly, around a triangular space on the anterior wall of the vagina. The base of the triangle is at the cervix and the apex near the urethra. It is represented by Fig. 131. Showing the Uterus Entirely Protruded from the External Organs. A. Urethra. S. Os Uteri, c c cc. The Denuded Parts, with the Wire Sutures ready to approximate the Denuded Edges. Fig. 130. Dr. Sims recommends this to be done with the uterus returned into the vagina, but I cannot understand why the operation may not be more easily done with the uterus in its procident state. I have never done the operation, but I certainly would denude the 404 DISPLACEMENTS OF THE UTERUS. membrane and insert the silver wires as they are seen in Fig. 131, then return the uterus, and afterwards bring the parts in apposition, and keep them so by twisting the wires. Dr. Emmet prefers the scissors to remove the membrane to the knife; he thinks there is less bleeding. The patient is prepared for the operation by thoroughly evacuating the bowels the day before, and administering, an hour before its commencement, half a grain of morphia. Chloroform ought to be given so as to keep the patient unconscious. Then placing the patient in position on her back, with the thighs well separated, the uterus is drawn down so as completely to invert the vagina, and held by a tenaculum in the hands of an assistant. The surgeon, by means of the scissors and tenaculum, removes the membrane, as represented in Fig. 130. This being done, and the bleeding having ceased, he may proceed to the introduction of the sutures, being careful to cause the needle to enter at equal distances from the margin of the cut surface outside of the triangle, pass well into the substance of the membrane, and come out close to the margin of the cut surface inside of the triangle, and in the same manner to dip under the other limb of the triangle. At the base they should be brought out every quarter of an inch in the cut, crossing from the longer limb of the figure. Drs. Sims and Emmet pass silk sutures through with the needle, and thus bring the wires through by attaching them to the thread. After this much of the operation is completed, the patient may be turned on the left side, and the vagina distended as for the operation for vesico-vaginal fistula, the parts carefully coapted, the upper two wires requiring great care to bring the whole of the elon- gated denuded surface together. The rest of the stitches from above downward may be drawn and twisted so that the denuded surfaces lie in even contact. The patient must be kept quiet by opium for ten days, the bladder emptied with the catheter every four or six hours, to prevent the urine from running on the wound, and the vagina should be syringed twice a day after the third day. Dr. Emmet advises us to remove the sutures on the tenth day, but says they may be allowed to remain longer. The sutures should be suffi- ciently numerous — every quarter of an inch — to keep the parts thor- oughly in contact, and they must be drawn tight enough to bring them well together without strangulating them. For direction as to twisting the wires, the reader is referred to the remarks, on this subject, in the article on vesico-vaginal fistula. They should be cut and arranged after being twisted, as in the operation for that acci- dent. This operation is applicable to cases where the hypertrophy PROLAPSE. 405 of the vagina is very great, and the perineum entire but much dis- tended. Mr. I. Baker Brown's operation is applicable to those cases where there is a deficiency of perinseuni from laceration. It consists in de- nuding the posterior wall of the vagina an inch above the raphe of the perinfeum, and up the sides of the orifice two-thirds of the inner surface. The mucous membrane should be pretty thoroughly re- moved in order to give a solid substance for adhesion, deep stitches as for restoration of the ruptured perinseum passed, and the parts evenly adjusted. Fig. 132 shows the surfaces prepared and the sutures inserted. There can be no doubt but that cases might be cured by a combi- nation of these two operations, where either one alone would fnil. Fig. 132. Showing the parts, c c. Denuded and the Sutures passed. In such cases, Sims's operation should be done first, and after the patient is entirely recovered from it, the deficient perineum can be restored. In performing the operation of lessening the calibre of the vagina I have sometimes removed the mucous membrane from the whole area included in the triangle of the incision as represented in Fig. 130, and then burying the sutures in the submucous tissues across the whole face of the wound thus made. This I think forms a more solid cicatrix. Schroeder I believe does the same thing, his patch of 406 DISPLACEMENTS OF THE UTERUS. denudation, however, is oval instead of triangular. Dr. Gillette has operated successfully for protrusion by passing sutures under the mucous membrane without denuding it. His operation simply condensed the walls of the vagina. On two occasions I have imitated him so far as to pass the sutures around a sufficient area, and draw it in like a puckering string of a purse without denudation. CHAPTER XXVII. DISPLACEMENTS OF THE UTEKUS COXTIXUED. Betroversion and Retroflexion of the Uterus during Pregnancy. The uterus is sometimes found retroverted or retroflected during pregnancy. When small during the first few weeks of pregnancy, its existence is not observed because it produces no inconvenience, and it is not until it grows large enough to partly or completely fill up the pelvis that anything is known of it unless discovered by ac- cident. If it is examined at such time, the os uteri will be found against the symphysis pubis, sometimes but little above the arch, but occasionally as high as the top of that junction. If the uterus is re- troverted fully, the mouth looks upward and forward ; if retroflexion exists, the os is still at the symphysis, but its opening is directed downward and forward. In this last case the cervix is bent upon itself at a sharp angle, the lower extremity as before remarked look- ing downward and forward, and the uterine extremity turned back- ward and downward. So that the difference in these two conditions consists in the bent state of the cervix, and not in the position of the uterus. The body of this organ has its axis reversed almost com- pletely, the fundus extremity running through the lower bone of the sacrum, while the upper extremity of the axial line passes out of the abdomen above the symphysis. The body lies in the hollow of the sacrum included in the peritoneal cul-de-sac between the vagina and the rectum. Both these canals are compressed, the rectum hard against the sacrum and the vagina up against the pelvic bone. The direction of the vagina is upward and forward instead of backward, its usual course. The finger cannot be made to sink deep into the vagina except behind the pubis ; in introducing, it turns upward and forward. The urethra runs up in close contact with the symphysis pubis, and is narrowed very materially by extension and pressure, so that it very imperfectly performs the function of a viaduct from the bladder. Causes. Although pregnancy usually corrects misplacements of the uterus, such is not alwavs the case, for this condition is sometimes a mere 408 DISPLACEMENTS OF THE UTERUS. continuation of its unirapregnated position. It is well understood by accoucheurs also, that in the early months of pregnancy the normal position of the organ is depression, and that prolapse and retrover- sion are not unusual effects of recent impregnation. Under certain circumstances this last deviation is not corrected by the advance of growth in the organ. Where other causes co-operate, a distended bladder may aid in causing the uterus to assume and retain this posi- tion, as may also loaded intestines pressing upon the fundus and anterior face. These causes and perhaps others operate to bring about a gradual displacement, but there are some that cause the con- dition suddenly. It should be remembered that it is only at a cer- tain time that these sudden causes can produce the effect, and that is after the end of the third month and before the beginning of the fifth month. It is about this time that the uterus attains a bulk sufficient to partly or entirely fill up the pelvic cavity. If when it has at- tained this size a sudden impulse is imparted to the fundus and anterior face of the organ, the fundus may be crowded so low into the hollow of the sacrum as to reverse the axis. In this state the forces acting in favor of correction are feeble and may fail to bring it about. Strong abdominal pressure upon the intestines and bladder under tenesmus, falls upon the feet or breech, lifting heavy weights, and even severe sneezing and coughing, are occasionally causative. In the cases where the efficient causes are suddenly applied, the symptoms are acute and established at once. In the other cases the train of symptoms gradually make their appearance. Symptoms. When induced suddenly the patient is seized with great pain in the back, with a sense of weight upon the perinseum, constipation, retention of urine, tenesmus, dragging sensation in the loins, and often though not always, sickness of stomach and vomiting. If gradually established, the pains, constipation, and retention of urine are slowly established, requiring from seven to twenty-one days or more to render them intolerable. I knew a case caused by a woman riding all day in railroad cars without urinating. There are two important symptoms, viz., retention of the urine, and of the faeces; from these result most of the distress complained of. Great distension of the bladder and the terrible suffering thereby produced is the worst. The student should bear in mind that quite frequently this symptom is deceptive. The urine is constantly drib- bling from the meatus, and the patient thinks, and will say, she DIAGNOSIS — TERMINATION. 409 passes plenty of urine. The fact of this constant slight discharge should cause us to suspect that the bladder is distended ; it does not occur when the bladder is empty ; it is not sufficient to prevent it from beino- distended. Indeed I do not now recollect anv con- dition but overdistension that causes it. Retention of fseces is not productive of so great trouble as the other, but is attended with more or less inconvenience. Great pelvic distress, with stillicidium urince, are almost character- istic of retroflexion or retroversion, when recent pregnancy exists. Diagnosis. This is usually not difficult. The first, a very important consid- eration, is the existence of pregnancy. Upon making vaginal ex- amination immediately upon introducing the finger it comes in con- tact with a tumor. The pelvis is filled up by it in the posterior and lower part so that the finger is directed upward and forward. Very high up the vaginal cavity is quite small from pressure, at its ex- tremity; in contact with the pubis is the os fincce, very firmly held in its place. The tumor is round, elastic, and smooth ; not so hard as fibrous tumors, more central than ovarian, and more uniformly round than extrauterine pregnancy. It may be ascertained in most instances, also, that the tumor is larger toward the sacrum than the symphysis. Te)Tiiination. When left to itself retroversion may terminate in abortion, when the contents of the uterus will be expelled and the symptoms thus relieved ; or the bladder may be ruptured, the urine being discharged in the peritoneal cavity, causing painful death ; or the uterus may be ruptured, and its contents discharged in the cavity of the peri- toneum, giving rise to fatal peritonitis ; or the foetus and its mem- branes may be surrounded by fibrinous material, the patient recover, and these substances remain there enveloped ; or, inducing local sup- purative inflammation, be discharged by exulceration. Sometimes the tenesmus becomes so great as, by the violence of the eiforts, to break through the posterior walls of the vagina and uterus, and dis- charge the contents through the vulva from this artificial opening. Inflammation sometimes arises without being initiated by any of these disastrous accidents, and less suddenly causes the death of the patient. I think there can be no doubt but that there are very rarely cases of spontaneous reposition, recovery, and completion of the term of ges- tation. 410 DISPLACEMENTS OF THE UTERUS. The prognosis is unqualifiedly bad if left to nature, but equally favorable if intelligently treated at the proper time. Treatment. The main thing to be done is to replace the uterus. This can very generally be accomplished. The attempt should not be delayed, as the uterus is constantly increasing in size, and the impaction becoming more certainly greater, increasing the difficulties as well as dangers. To facilitate the replacement the bladder should be emptied by the catheter when practicable, and the fseces removed from the rectum. This takes away some of the obstacles. Sometimes the urethra is so tortuous in its course, and the walls compressed so completely to- gether, that a catheter will not enter the bladder. An elastic catheter will sometimes pass the obstruction when the metallic will not; which- ever we may use should be urged forward w^ith the utmost gentle- ness, bearing in mind the great danger of perforating the attenuated urethra. The patient should be placed upon her knees and chest, or on the left side, with the left arm behind her, the thighs strongly flexed, and the right drawn up close to the abdomen and thrown for- ward. She should be placed on a table or the edge of a bed, so that the genital organs are easily controlled by the operator. In this posi- tion we may often succeed in replacement by the hand alone. The right hand should be well lubricated, and all the fingers be intro- duced into the vagina, so that the palmar surface is turned to the sacrum. The tumor is thus pushed up very gently and slowly, with the pulps of the fingers pressed closely upon the face of the sacrum, as high as the hand may be made to reach. There are not many cases in which the fingers will fail to carry the fundus above the promon- tory of the sacrum. When thus elevated it suddenly starts up and assumes the normal position. If, however, the fingers do not reach high enough for this purpose, a collapsed gum-elastic bag or bladder may be carried up between the fingers and the uterus, and, when elevated as much as we can reach, the bag may be inflated sufficiently to raise the uterus high enough. I have succeeded in all the cases I have tried with this method, and I think, when the impaction is not so great as to preclude dislodgment, that it will almost invariably succeed. Some surgeons recommend the introduction of the empty bag into the rectum, and inflating it there, and pushing it up ; others introduce a drumstick, with the end cushioned and lubricated, into the rectum, and, pressing it against the uterus, elevating it in that way. Again, an instrument is used not unlike two drumsticks, some- TREATMENT. 411 what curved, attached together. The attachment confines the ends very near each other. The end of one of the branches goes into the rectum, and the other into the vagina. Thus arranged they pass up and carry before them the uterus. These expedients are very sure, but rough, and not a very safe means of arriving at the results. I think as much force in a proper direction can be applied by the fingers and elastic bag as it is judicious to employ in such cases. There are other methods of proceeding, but I do not think it necessary to men- tion any other, as these will suffice when reduction is practicable. In all these efforts to elevate the fundus we may fail, and then we may evacuate the uterus. This can generally be done by passing a bent probe through the mouth of the uterus far enough to rupture the membranes, and permit the escape of the liquor amnii. This being done, abortion will soon ensue, I can conscientiously only mention, for I can hardly think the operation of puncturing the uterus with a trocar through the vaginal wall ever commendable or necessary. The cervix is probably hardly ever so inaccessible but that some form of bent instrument can be made to enter it. CHAPTER XXYIIL DISPLACEMENTS OF THE UTERUS COXTIXUED. Inversion of the Uterus. I^'TERSIOX is the turning of the uterus inside out, with the fundus down and the cervix up. a reversion of its surfaces and ends. It is partial or complete. When partial, the fundus is depressed in all degrees, from a mere indentation to a considerable protrusion through the cervix and os uteri. The depression of the fundus, or partial in- version, passes into complete when the whole organ, fundus, body, and neck, have passed through the mouth, and hang down below it. It presents a recent and a chronic form. The recent may be regarded as extending through the first two weeks ; after which, the circum- stances and condition of the uterus and patient become what they re- main in the future, however long it lasts. The uterus, in that time, has becii condensed by contraction and involution to such an extent as to make the case permanent and difficult of change, except to dimi- nution and further condensation. Inversion almost invariably occurs anterior to or at the time of the removal of the placenta, but several hours, and, in very rare cases, several days may elapse before it is complete and discovered : for it is quite probable that in these in- stances partial inversion or greater or less depression of the fundus had existed from the time of delivery. It is believed by different parties that there are two modes observed in the process of inversion. Sometimes the fundus is indented or depressed in the cavity of the body like the bottom of a "junk bottle," the depression rapidly or slowly increasing until it is completely down. At others, the whole of the fundus, and, more or less, the whole of the body, are firmly contracted, while the cervix remains flabby and relaxed. In this con- dition a slight amount of abdominal tenesmus will drive the con- tracted part down through the relaxed cervix; and thus initiated, it requires but a continued action of the fibres of the organ and abdomi- nal muscles to finish the process. The causes of inversion are not always obvious, as cases have occurred under circumstances when least expected from any discoverable reasons, and inversion fails to be brought about by circumstances that are usually enumerated as sufficient. We occasionally meet with instances that have no history, SYMPTOMS. 413 and neither patient nor physician can give us a clear idea of the time or manner of the occurrence. Such a case was a subject of litigation in this city a few years since. And other cases are recorded in virgins, and consequently referred to congenital origin. In a large majority, however, we may trace the history back to accouchement. The predisposing causes are enlargements and partial or complete passiveness of a part or the whole of the muscular iibres of the uterus. These are the conditions in confinement at full term, or abortion or premature labor, also enlargement from hydatids, hydrometra, tu- mors, etc. When the uterus is thus enlarged and lax after a greater or less loss of its contents, traction on the cord or placenta, or con- tained tumor, or injudicious or accidental pressure on the fundus by the hand of some person, or the action of the abdominal muscles thrusting the contents of the abdomen downward upon that part of the organ, it may be inverted. It is possible, I think, also, that powerful, irregular action of the fibres of the uterus may cause the initiation and completion of the process of inversion. It is then said to be spontaneous. The weight of the placenta, or the contrac- tion to expel a polypus, may commence inversion, and even complete it. The irregular contractions that result in inversion may commence before the expulsion of the child. After the liquor amnii has been discharged for a long time, the uterus contracts to suit the inequali- ties of the foetal surface, the globular shape of the organ being re- placed by inequalities in a number of places. Much is yet to be learned on this subject. It would seem clear from statistics brought forward by Drs. AVest and McClintock that it is exceedingly rare, if it ever occurs, under good management of labor cases. It has not been encountered in patients confined in the London Maternity Charity, nor the Lying-in Hospital of Dublin in 140,000 cases. The student is not to consider from this that it is impossible for it to occur in the hands of the ablest of accoucheurs. Symptoms. Usually these are appalling in the extreme. Without warning the patient is seized with faintness, coldness of the extremities, sense of great prostration, rapid and very feeble pulse, oppression about the heart, copious perspiration, hurried breathing, often vomiting, ringing in the ears, and blindness. Soon these symptoms increase, until the patient lies in a profound state of collapse, indifferent to everything transpiring around her, or throwing herself in every di- rection in paroxysms of agony inexpressible. This condition of col- 414 INVERSION OF THE UTERUS. lapse is not always the result of copious haemorrhage, but seems to be of Dervous origin. A shock not unlike that caused by severe accidents, as falls, strokes, etc. But, generally mingled with this sort of impression, there is profound exhaustion from loss of blood. From this state of collapse the patient may very slowly rally, until she enters a tedious and imperfect convalescence. Or, in the cases where the exhaustion from hasmorrhage is added to the great depres- sion of the shock, the patient may be overwhelmed, and in a hour, or very few hours, her sufferings end in death. Imperfect recovery from the great effects of the first shock may enable the patient to live for several days, and at last, in five to ten days, die. In case the patient recovers from the first symptoms, after some weeks she may regain a fair degree of health, and retain it, or even improve, until lactation gives place to ovulation, or until this last function super- venes upon the first. The first menstrual discharge is preceded by copious mucous evacuation, and when the menses begin they are more than ordinarily profuse, and generally before they cease amount to prostrating haemorrhage. This haemorrhage is repeated monthly, more frequently, or is continuous, while the leucorrhoeal discharges become very profuse. Functional derangement of other and im- portant organs enters the list of morbid impressions ; the bowels are constipated, the heart palpitates, the stomach cannot digest with its former vigor and completeness, the head aches, the eyes become weak; the disposition of the patient changes; the memory fails her; she is pale, cold, and anemic ; in short, she enters a decadence that is continuous, until, after several months, or a few years, she is ex- hausted and dies. Although this is the course usually pursued by cases of inversion, it must be remembered that there is a class of them in which the patients do not suffer even much inconvenience, and their condition is discovered only by accident during their life, or on the dissecting-table. Diagnosis. When the symptoms present themselves so as to awaken suspicion, the diagnosis of recent cases may be made out quite clearly, by the descent of a tumor into or entirely through the vagina, and the ab- sence of the uterine globe above the symphysis pubis. The diagnosis, after a few days or weeks have elapsed, and the case becomes chronic, is not quite so simple and ready. The tumor is felt in the vagina, and is more sensitive than polypus. It is easily surrounded by the fingers, and by introducing two fingers in the vagina to the upper PROGNOSIS. 415 end of the tumor, the deprassion formed by the junction of the vagina and uterus may generally be easily surveyed. If this is not entirely satisfactory, the sound should be introduced into the vagina before the fingers are withdrawn, and, guided by them, be made to sink as deeply into this depression as it will go without too much force. If the uterus is inverted, the probe will not pass beyond the fingers any distance, but if the vaginal tumor be a polypus, the sound will pass up at some point some inches above the fingers into the uterine cavity. The operator may test the position of the uterus in another way, by introducing the finger high up into the rectum, so that the end may reach above the tumor, and retaining it there, he may pass a catheter or sound into the bladder, and approximate the two; if the womb is in place, its thickness will be perceived interposed be- tween the two, but if inverted, the extremity of the catheter can be brought down upon the finger, with nothing but the membranous walls of the bladder and rectum intervening. Prognosis, Xo more serious complication of labor can occur than inversion of the uterus. The danger is great and imminent ; in a considerable majority of cases proving fatal, the patient dies within a few hours. Mr. Crosse says : " In seventy-two out of one hundred and nine fatal cases, the patients died within a few hours, eight of the re- mainder within a week, and six more within four weeks; another at five months, the result of an operation which had an unsuccessful issue, one died at eight months, three at nine months, and the others at various pericnils of from one to twenty years. '^ ( West.) Death in the first place soon after delivery seems to be the result of rapid ex- haustion of the vital forces by the terrible shock to the nervous system and the profuse haemorrhage that often complicates it. Death in sub- sequent times, however remote in the chronic form, is brought about by impairment of the vital functions by the same means, operating more slowly but as surely. The patient dies from exhaustion in both forms. Accordingly, we find that while inflammation has something to do in affecting the issue in rare instances, those cases in which there is no uncommon haemorrhage or leucorrhoeal discharge last longest, and sometimes do not prove fatal at all, the patient en- joying fair health for many years. I know one patient, fifty-six years of age, whose uterus was inverted sixteen years ago, and yet remains in that condition, as I have verified by examination, who is 416 INVERSION OF THE UTERUS. in the enjoyment of as good health as the majority of women of her time of life. Treatment. The management of recent cases will be the easier the sooner after the accident it is commenced. Its reduction is generally successfully accomplished within the first hour or two if intelligently attempted. It is more difficult as time elapses, but it should never be considered impracticable until proper and persevering efforts have been made. The first item for consideration and action is to dispose of an attached placenta when the uterus has not detached it before, during, or after its descent. If the placenta is wholly adherent, its attachment should in nowise be interfered with until the uterus is returned to its former position; but if it is partially detached, it should be immediately separated by gently ^^peeling'^ it off with the fingers. This instruc- tion has reference solely to the prevention or lessening the amount of haemorrhage. If the placenta is attached throughout, the haemorrhage will be trifling; if partially separated, the condition most likely to be accompanied with fatal hsemorrhage exists, — relaxation of the uterus and partial separation of the placenta. It is well known that suffi- cient contraction of the uterus will separate the placenta, and when not contracted enough to do so, it is in too lax a state- for us to desire its detachment. If the placenta is partially separated, the completion of it by the fingers, as in the case when included in the uterus, will enable and stimulate this organ to contraction, and thus to the sup- pression of the haemorrhage. I do not think the question of conve- nience of return, or the possibility of being foiled in the reduction by the continued attachment, should be entertained. The want of con- traction enough to throw off the placenta is an evidence of such pro- found inertia as to insure easy reduction of the uterus. It being decided what course to pursue with the placenta, imme- diate efforts should be made to revert. And before beginning these efforts, we should remind ourselves of some facts in the case that are apt to be lost sight of in the hurry and confusion of such an appall- ing occasion. One fact is, that immediately after the occurrence of the accident, the uterus is in the same flaccid condition in which it was incapable of resisting the action of the cause ; another is, that it soon begins to contract, becomes firm, and, consequently, more diffi- cult to affect by counter influences; and a third, that the more the uterus is stimulated, by handling or otherwise, the sooner and more firm the contraction becomes, and, consequently, the greater difficulty in reduction. TREATMENT. 417 Xo operator has complained to us of the bulk belug too great to return, but all of the resistance caused by contraction. The experi- ence of Dr. Meigs is conclusive on this point. He found that upon attempting to reduce the size of the uterus, by squeezing it to expel the blood, he caused it to contract, and it became so hard as to resist his efforts to push it up within the os; but as soon as he pressed upon the fundus he would depress it, or rather elevate it, until, by continuing pressure, he made it ascend first into the body, and through it into the neck, and finally up to its proper place. Dr. White, of Buffalo, although he did not mention with the same dis- tinctness the effects of the two sorts of pressure, was enabled, by in- denting first and then following up the vantage, finally to push the fundus up the same way through the os and body of the uterus after he had in vain tried to reduce it by squeezing, etc. Dr. AThite's case was reduced in this way eight days after delivery. And I must be allowed to express the opinion, that it increases the difficulties in re- cent cases of inversion to try to lessen the bulk of the uterus. A great bulk indicates a flabby, reducible state, and is favorable to suc- cess instead of otherwise. Do not squeeze the uterus to lessen its size in these cases. The two cases I have referred to, of Drs. White and Meigs, so in- telligently and deliberately observed, and so clearly described, fur- nish us with more intelligible means of arrivinoj at correct ideas of the steps by which inversion of the uterus is reversed, than any I am able to find on record. They both concur in showing the usefulness of one hand in the vagina to steady the uterus, and direct the force applied to the fundus by the other hand, and the injurious effects of compressing the body of the organ. The most appropriate mode of operating in recent inversion, therefore, is to introduce the left hand into the vaoina behind the uterus, while with the fiuo^ers of the right the fundus is indented, and gently, but steadily and perseveringly, reverted entirely above the os and cervix, until it assumes the globu- lar shape and proper position above the symphysis. If the fingers of the right hand cannot be used to advantage, or are too weak to accomplish the desired elevation, we may use an instrument resorted to by Dr. White, a large elastic rectum bougie, or by Dr. Beers, shaped like the end of a walking-cane, with a round smooth head upon a staff. The indentation and elevation may be more efficiently effected by this latter instrument, perhaps. The fact cannot be too forcibly impressed upon our minds, in un- dertaking this operation, that gentle firmness is the proper expression 27 418 INVERSION OF THE UTERUS. for the force to be employed. Perseverance, instead of violence, is both more certain, successful, and secure, in overcoming the resistance of muscular fibre anywhere. This is especially true with the uterus, the strongest muscle in the body. As nearly as may be, we should act in the absence of uterine contractions. During and after the time we are attempting the return of the organ, the strength of the patient must be supported by stimulants, tonics, and nutrients. Brandy will, perhaps, serve best to restore the circulation and heat ; it may be aided by the use of the aromatic spirits of ammonia and laudanum. In addition to the stimulant and supporting influence which laudanum exerts, it allays the irritable condition, so frequently present, of the stomach, the uterus, etc. After the urgency of the symptoms has passed by, the tincture of iron, quinia, beef essence, and nutritious diet generally, will be necessary to restore the im- paired condition of the vital energies. The energy with which the stimulants are to be urged during the shock must be regulated by the urgency of the danger. Large doses of brandy, laudanum, and spirits of ammonia will not only be borne, but often be called for to meet the symptoms. The Treatment of the Chronic Form Is palliative and curative. The palliative is for the purpose, as far as possible, to check the drain which is so constantly exhausting the patient, to support the system as well as we can, and to use any other means suggested by the circumstances for the relief of distress- ing symptoms. The haemorrhage is from the mucous membrane of the uterus, its outer surface as it lies in the vagina, as also the profuse mucous dis- charge. I think much may be done to moderate, if not stop, these evacuations by astringents introduced into the vagina, so as to sur- round and lie in contact with the uterus. Pledgets of lint, saturated with the persul. of iron, passed up into the vagina, and allowed to remain on the bleeding^ surface of the uterus until the bleeding ceases, will be of great service. The tinct. ferri chlorid. on lint is an excellent application for the same purpose. Other astringents may be tried in the same manner. If these should fail, the vagina may be tamponed fully with cotton, dipped in astringents or not as the physician may think best. Severe paroxysms of haemorrhage should be carefully treated in this way until they terminate, it being desirable to save as much blood as possible. It is not necessary to suggest to the intelli- gent reader the necessity of rest in the horizontal position. Between TREATMENT OF THE CHRONIC FORM. 419 these paroxysms the patient should use astringent injections of con- centrated strength, saturated solutions of alum, acetate of lead, tan- nin, etc., with a view to condense the mucous membrane, and render it less vascular, and in this way abate the urgency of the losses. The tinct. ferri. chl., one part to four of water, twice or thrice a day, will have an efficient astringent effect upon the uterus. When the organ extends through the vulva, it is irritated by contact with the limbs and clothing, and it is very desirable to return it into the vagina, and keep it within that cavity. The gum-elastic air-pessary, supported by a T bandage, will keep it in the vagina, and may render it more easy of a radical cure, by reduction or reversion. I would urge the attendant to personal attention to this treatment, to such an extent, at least, as is necessary to have it efficiently tried. Veiy few pa- tients have the intelligence to appreciate the importance of it, or to know when proper trial of it has been made. The radical treatment has for its objects either a restoration of the organ or its amputation and removal. So far as we can judge, although both operations are attended with danger, that of amputa- tion the more. And I think it clearly the duty of the practitioner, when driven to a choice between the two, to give preference to at- tempts at restoration. We have not only greater safety as an argu- ment in favor of it, but successful restoration reinstates the patient in all her sexual capacities, while amputation, if not disastrous in other respects, renders her forever sexually neuter. It is to be hoped that before long the operation of amputation will be regarded as un- justifiable, because of the certainty of restoration. Great improve- ment in our means and the mode of effecting this must be made, however, before this conclusion can be reached. There is no longer room for doubting that restoration of the inverted uterus occurs spon- taneously. I think it is proven by the case of Dr. Hatch, published in Dr. Meigs's Obstetrics. The case of Madame Beauchardat, pub- lished by Baudelocque, is also, I think, conclusive on the point of restoration. Other cases, less clearly and circumstantially reported, may be found scattered through medical literature for the last cen- tury. There are two methods, if they may be so denominated, that have been successful in reducino^ chronic inversion of the uterus. Two representative cases are published in the American Journal of Medical Sciences for July, 1858 ; one by Professor White, of Buffalo (it was his second case), and one by Dr. Tyler Smith, of London. It will be observed, by examining the reports of these cases, that the res- toration began by the cervix passing through the os uteri first, then 420 DISPLACEMENTS OF THE UTERUS. the body, and fioally the fundus. This is different from what I think is the common mode of restoration in recent cases. The operation for reversion in Dr. White's second case was completed, we are led to suppose, in something more than an hour, and at one sitting. The uterus had been inverted five months. Dr. White operated by in- troducing the hand into the vagina while the patient was in' a state of anaesthesia from chloroform, squeezing the uterus so as to lessen the size as much as possible, and at the same time pressing the organ upwards by means of the large rectum bougie. Success followed a somewhat ])rotracted manipulation. The uterus was restored by the lips of the OS uteri beginning to fold outward, and the neck to pass up through this opening, next the body, and afterwards the fundus. There is nothing in this case said about the fundus being indented from beginning to end. This is no more than might be expected by considering the anatomical circumstances. The fundus and corpus uteri are firmer and more solid than the cervix, and hence less likely to yield to the same amount of force. The force applied to the fundus, when the organ is strongly pressed upward, acts more efficiently upon the cervix than any other part, from the fact that the vagina, attached all around the mouth, has not merely the effect of resisting the up- ward pressure of the uterus, but, being upon the outer surface, it ini- tiates and keeps up the funnel-shape expansion of the os necessary to permit the other parts to pass through it, as well as to draw it down over the part entering it from below. I believe that, in some respects, this is the best manner of operating for immediate restoration, yet one thing done seems to me to be superfluous, if not mischievous, viz., the squeezing the uterus. Dr. Sims recommends that the uterus be supported by one hand above the pubis to prevent too great extension upon the vagina. While the uterus is being pushed up from below, the cup-shaped cavity formed by the inverted cervix may be felt if we forcibly press the fingers down into the pelvis from above over the pubis. This manipulation affords us valuable aid in forming our diagnosis, while it gives the opportunity of assisting in the reversion. The great thing to be gained is the commencement. After the neck is one-half reverted the restoration proceeds with more rapidity and ease than before until complete. A better instrument than the bougie used by Dr. White would be a cup on a strong handle, large enough to safely lodge the fundus of the uterus. Dr. White now uses what he calls the re- jjositor. The figure shows its action with sufficient clearness to re- quire no extended explanation of its use. The steps in the operation TREATMENT OF THE CHRONIC FORM, 421 for immediate restoration are, first to introduce the hand into the vagina, and, embracing the uterus with it, hold the organ steady, with the fundus and cervix nearly parallel with the axis of the superior strait; second, place the fundus of the uterus in the cup of the instrument held by the other hand, and then press gently upward, increasing the firmness of it until it is as great as the parts will bear without violence, and continuing it with such force until the parts yield and f)ass up. The time required may be considerable, and it is an object to continue it for a long time, increasing the pressure so slowly as not to be perceived, except by comparing it at considerable intervals. The patient should be under the influence of chloroform to insensibility, and placed on her back, with the limbs widely sepa- rated across the bed, and with the hips very near it; or, what would Fig. 133. Fig. 1:54. be better, an operating table of convenient height, about two feet wide and five long. Greater facility would be afforded for attendants by such a table. The surgeon should kneel or seat himself in front of the patient, so as to have free use of both hands and perfect command of the parts. The second mode of restoring the inverted uterus, as practiced by Dr. Tyler Smith, is to apply the force so gradually as to require several days for the completion of it. The uieans used were, first, the frequent introduction — I think twice a day — of the hand into the vagina to squeeze the uterus; and, second, to keep a gum-elastic air- 422 DISPLACEMENTS OF THE UTERUS. bag distended in the vagina, which constantly pressed the fundus upward, certainly, however, with no great force. He succeeded in restoring a uterus that had been inverted for fifteen years. With proper apparatus I should very much prefer this gradual method, as requiring less violence, being less hazardous, and perhaps less painful. A sufficient number of cases have been successfully treated by this means to justify giving it a fair trial. Having succeeded in three cases in reducing with the elastic bag, I am more favorably impressed with its efficiency than Dr. White seems to be. The reduction was effiicted in from five to eight days, without giving the patient pain enough to interfere with her sleep, or causing her any serious incon- venience. Each day showed advances; the first, relaxation of the rigid neck ; the next, shortening of the displaced uterus ; and each day after exhibited gradual improvement until the restoration was found to be complete. I am convinced that in many, if not most, of the simple cases of chronic inversion the reposition may be accomplished by this method, and I would certainly try it before resorting to the more hazardous and more painful plan of Dr. White. Success with the elastic bag, however, requires a careful study of each case, and a watchful adaptation of the means. The kind of instrument is of much importance. The best shape, perhaps, is quadrilateral. It should be strong enough to bear considerable pressure without mate- rially altering its shape, and furnished with a tube and very tight stopcock. The instrument should be distended with water instead of air, as there are few that will not permit air to escape in greater or less quantities. The chances of success will be increased by a firm and well-shaped perinseum to support the pressure, and by its own elasticity adding to the efficiency of the instrument. When the peri- nseum is deficient, we may compensate it by well-adjusted mechani- cal support. The more firm the tissues of the vagina the better. The instrument should be introduced in an empty condition, and placed well back in the vagina, and the water forced into it until moderately distended. We must then carefuly examine the relation- ship between it and the uterus, and see that the latter is pressed up- ward in the direction of the axis of the superior strait. If this is not the case, we may be able to place the uterus in the right position by moving it with the finger. If this cannot be done, the bags should be emptied and changed until right. If the shape of the instrument is not properly adapted to the vagina, it should be replaced by another. By exercising due care in selecting and adjusting the instrument, we shall be able to get the force exerted in the right direction. When TREATMENT OF THE CHRONIC FORM. 423 satisfied that the instrument is properly adjusted, we should inject water into it, and distend it as much as the patient can bear without decided pain. It will not be necessary to remove it more than once in twenty-four hours, but it ought to be examined in reference to the degree of distension, and if it should continue tense, and the patient feels no more discomfort from it, we ought to inject more water until the patient experiences slight uneasiness from the pressure. Once in twenty-four hours the water may be allowed to escape, and the instruments be removed, the vagina cleansed, and the parts thor- oughly examined. If we are producing any impression on the rigid cervix, the relaxation will be perceptible by the facility with which the uterus will move upward. The instrument should be carefully readjusted and again distended. On the second removal of the bag I think, usually, we may expect to discover decided progress in the process of restoration. I do not believe it judicious to manipulate and squeeze the uterus, with a view to lessen the blood in it, every time we remove the elastic bag, and would sedulously abstain from anvthino^ of the kind, believino; that the reaction after the withdrawal of the hand would engorge the vessels of the organ. The daily re- moval of the instrument, cleansing of the vagina, and readjustment must be continued until the uterus resumes its proper position, or until we find we cannot succeed by this plan. Judging from my own observation, and the cases I have seen recorded, I should expect suc- cess to follow between the fifth and the eighth days. But efforts may be continued much longer than this if necessary. As soon as the fundus has passed into the cervix, it will spontaneously resume its proper position, because the resistance to its doing so is removed; but if this should not occur, a rectal bougie may be placed against it and sufficient pressure exerted to rectify it completely. The pressure of this elastic bag when properly managed is just the kind desired, and the degree may be made very considerable. When the bag is of the right size and. form the uterus is pressed upward in such a manner as to place the vaginial attachments upon the stretch, and cause them to draw open the cervical cavity, and this tension is increased by the dilatation of the upper portion of the vagina in every direction. It thus acts as a dilator as well as repositor. And although the degree of pressure upward is not so great as may be made by the repositor of Dr. White, or by the hand, its steadiness of action, and the great length of time it may be continued, more than compensates in the end for its lack of violent force. We all are acquainted with 424 DISPLACEMENTS OF THE UTERUS. the efficiency of moderate but long-continued traction upon fibrous tissue, in cases of long-standing dislocation. I will here present a case which has recently come under my ob- servation : December 24:th, 1878. — Mrs. M., Irish, aged twenty-six years, was brought to me with inversion of the uterus, which had taken place at the time of her first labor, fourteen months before. I obtained a very imperfect history of the case, but so far as I could learn nothing unusual occurred during pregnancy, and when the labor began the patient was in the enjoyment of robust health. The first and second stages of labor were normal, and together lasted six hours. During the. third stage haemorrhage was alarming, and the succeeding pros- tration very great. The patient could give me no intelligent account of the mode of delivering the placenta, or of the duration of the third stage. The only recollection of it was that she suffered from great pain and weakness. The accident was not discovered at the time, and when, after the lapse of some weeks, the attention of the prac- titioner was called to the unusual condition of the contents of the vagina, he said : " She must have a polypus or something else/' He either was not aware of what had occurred or did not wish to have the true condition known. Astringent injections were used and stimulants and tonics given. The patient gradually rallied, and during the first year was seen by a number of physicians, and many opinions were expressed and methods of cure tried. No benefit resulting from treatment, she came under the care of Dr. White, of Bloomington, who recognized the true condition of the patient, and made a very judicious and prolonged effort to reduce the uterus by the forcible method and failed. He then advised her to visit me for further treatment. When she arrived she was very anaemic and exhausted. She was. constantly discharging blood and mucus, and at the time of her menses flowed profusely. There was great tenderness and sensitive- ness of the vagina, uterus, and lower portion of the abdomen. The pulse was weak and about one hundred to the minute. She had a poor appetite and was obstinately constipated. An examination confirmed the diagnosis of Dr. White. The vagina was very capacious, and depending from its roof was a small, very firm uterus. The involution seemed to have been carried be- yond the ordinary degree. It was in a state of hyper-involution. It was completely inverted. The labia could be felt forming a thin border, completely surrounding the cervix, with the likeness of a I TREATxMEXT OF THE CHRONIC FORM. 425 fringe, the edge pointing upwards. The uterus was so firm and condensed that it resisted every effort to elevate it. It could be drawn down somewhat, bringing with it a pouch of the upper wall of the vagina. There was considerable sensitiveness of the iliac and hypogastric regions, but no tumefactions, induration, or other evi- dence of the products of inflammation. A mild cathartic was ad- ministered, followed by the tincture of iron and quinine, and on Christmas day the treatment for reduction was commenced. An elastic bag, four inches long, and when distended three inches in diameter, with a tube attached, was selected as the main instrument. When collapsed this bag presented a quadrilateral shape, larger in the centre, and slowly tapering towards the ends. I selected a sac of this shape because it filled the vagina from the vulva to the bottom of the fornix, and when introduced one of the faces reached the fundus in such a manner that the organ would not easily slide over its sides. As the bag was slowly distended the fundus produced a depression in which it was firmly retained when the sac was filled. I introduced this bag, while empty, so that it lay on the posterior wall of the vagina, and carefully adjusted the dependent fundus so that the body was in a line with the axis of the superior strait. Water was slowly injected until the distension produced a sense of discomfort. The distension was kept up for twenty-four hours, when the water was permitted to flow away. The instrument was removed and cleansed, and again replaced and filled. The first time it was removed an evident softening of the cervix was noticeable, and the body could be pressed slightly into it. From day to day the softening and dilatation became greater, and upon the removal of the instrument advance was ascertainable. Upon removing the bag, on the seventh day, I found that the uterus was in a state of complete inversion, and all progress seemingly lost. With the finger, how- ever, I could easily press the fundus entirely into the dilated cervix, thus assuring myself that the work of reduction was almost complete. A more careful adjustment and careful distension of the bag were effected, and on the removal of the instrument on the eight day it was found that the fundus had mounted to its normal position. The sound was introduced two and a half inches. This patient improved in strength and became more comfortable from the commencement of the treatment to the end. After the first three days she was up during a part of the day, and on the seventh and eighth was about her room, and, in addition to keeping her room in order, gave her child all the attention it needed. 426 DISPLACEMENTS OF THE UTERUS. I have no doubt that she was perfectly truthful in her assertion that the treatment gave her no inconvenience except at the time and for a few moments each time after the adjustment of the instrument. There was no time when I felt the least uneasiness about the effects of the pressure, or was under the necessity of giving anodynes for the relief of pain ; nor did the presence of the instrument prevent the free and comfortable evacuation of bladder and rectum. In fact, the patient improved from the time she was placed under treatment. Notwithstanding the important improvements of Dr. J. P. White, .who deserves more credit for his success and teaching in inversion than any other man, and Dr. Tyler Smith's success in the use of the gum-elastic bag, there will yet remain cases in which the uterus can- not be restored to its natural position and relations. Inversion, com- plicated with several fibrous tumors of the body or fundus, will resist ordinary methods of reduction, and, no doubt, cases in which the causes of difficulty cannot be precisely discovered will occasion- ally be found unmanageable. What shall be done with such? The necessity for any operation that involves the life of a patient, already in great danger, should be clearly determined by the circumstances of the case and with ample counsel. If the patient's health is growing worse and her strength being exhausted by great discharges or per- sistent inflammation, relief should be attempted at all hazard. If, however, the woman is enjoying fair health, or if the symptoms that usually harass her after the accident of inversion are improving, any operative procedure beyond efforts at reduction is not justifiable. In cases where restoration is proven to be impossible by proper, prolonged, and repeated efforts, or the uterus is so enlarged by morbid growths as to make it obviously useless to try reduction, and the con- ditions demand relief, amputation is the last resort. In a resume found in the American Journal of Obstetrics , xlugust, 1868, trans- lated from the German, we have fifty-eight cases reported of ampu- tation of the inverted uterus; eighteen terminated fatally, forty recovered. This is a large mortality, but probably the fatality will become proportionately less as all the conditions of the operations are improved. The methods of amputation now practiced are essen- tially three : 1. Ligating and allowing the ligature to remain until it cuts through. 2. Ligating to prevent haemorrhage, and then amputating below the ligature with the knife, scissors, or ecraseur. TREATMENT OP THE CHRONIC FORM. 427 3. Passing the ecraseur or galvano-cautery wire through the sub- stance of the cervix without ligating. The ligature, when properly applied, effectually prevents haemor- rhage, but it is very likely to cause inflammation, also a very formid- able occurrence, and one which is the frequent cause of death. Or if it remains long enough to cause sloughing even of the amputated stump, there may arise toxaemia, resulting from the absorption of the putrid substance. The ecraseur avoids this latter difficulty, but I should fear it would be an insecure guarantee against haemorrhage in all cases. Dr. Thomas Hay, of Philadelphia, reports, in the Medical and Surgical Reporter, December 2d, 1871, a case in which amputa- tion was successfully performed by the ecraseur alone. Dr. McClin- tock, of Dublin, applied the ligature for forty-eight hours, and then removed the uterus by amputating with the ecraseur in the groove formed by the ligature. Practical demonstration is the only reliable guide in important operations ; we are not supplied, however, with enough examples of success by any one procedure to justify us in making a positive choice between them. It will not be difficult to get access to the cervix for the purpose of applying the ligature or amputating. This may be done by drawing the organ down to the vulva with vulsellum forceps. The galvano-cautery is better than all the above methods of ampu- tation. The wire applied as an ecraseur, heated to a dull red color, and drawn slowly through the cervix, will do away with the dangers of haemorrhage, and leave no sloughing surface from which sepsis may be generated. CHAPTEK XXIX. DISEASED DEVIATIONS OF INVOLUTION OF THE UTEEUS. The uterus is very much hypertrophied by the processes of gesta- tion, so that after its contents are expelled by labor, the organ weighs from one and a half to two pounds. An atrophizing process, called involution, serves to reduce the organ to its original conditions in size and weight. Involution is a physiological change, as much so as evolution ; but not unfrequently disease invades the tissues and renders it abortive : 1st, causing it to be temporarily ^^ delayed ;" 2dly, to fall short of completion after it has been commenced ; or, 3dly, to proceed entirely beyond the limits compatible with the healthy functions of the uterus, reducing it below its usual weight and size. I mean by the term "delayed involution" to designate a condition of the uterus in which this process does not begin for a number of days — from ten to fourteen — after parturition. The contractions which immediately succeed and continue after labor, by interrupting the circulation in the substance of the uterus, initiate that process, and by the end of a fortnight it is half finished. Should these contractions be rendered inefficient, involution is at a stand, the uterus remains large, the circulation too great for safety to the patient, and sufficient to keep up the nutrition in the muscular fibres, which are still capable of a good degree of energetic action. For a number of days the uterus is felt to be as large as a child's head, above the pubis, and not very firm. Causes. The most common cause of this delay is inflammation attacking the substance of the uterine walls. The inflammation may be acute, and the patient's suffering such as to demand attention, or so slight as to pass without much notice. Cases of puerperal metritis, for a week or ten days immediately succeeding delivery, not unfrequently prevent this enlarged condition of the organ. Another cause which probably operates to prevent involution is atony of the uterine muscular fibres. The contractions are feeble, and so inefficient as to delay for a long time, and render very slow. SYMPTOMS — PROGNOSIS. 429 the early stages of involution. Too early assumption of the erect posture and undue exercise on foot, keeping the bloodvessels of the uterus distended unduly, and thus overcoming the muscular contrac- tion, are not unfrequently the causes of delayed involution. Si/mptoms. The symptoms of delayed involution, separate from the inflamma- tion, are not always very well marked. Weight, heat, and aching in the back are the most frequent, especially if inflammation is the cause. There is always great danger, however, of a very alarming symptom while this state of the uterus exists, and that is flooding. Where the delayed involution is dependent on atony of the muscular fibres, haemorrhage is sure to take place if the patient exerts herself considerably. As the first indication of any seriously wrong con- dition of the uterus, the patient is suddenly seized with copious haem- orrhage, which subsides under the influence of rest, cold, and astrin- gents, but suddenly and unexpectedly recurs without adequate cause. When suspected, the diagnosis is not difficult by an examination with one finger of the right hand per vaginam, w4iile with the left hand pressure is made above the pubis. The uterus, thus examined, is found to be as large as immediately after labor is ended. The soft, uncertain condition of the uterine globe will not always enable us to discover it by placing a hand upon the lower part of the abdomen alone, but by including the organ between the two there will be no danger of mistake. If the organ retains sufficient firmness to be easily distinguished above the pubis by the single hand, there w^ill be but little danger of haemorrhage. The local distress will then be the only indication of the necessity of a diagnostic examination, when the greatly enlarged condition will be easily detected by the examination above directed. The fingers may be easily made to enter the mouth of the organ and move the whole mass, while the hand above will easily recognize the movement, or the hand above may be made to press it down upon the fingers below. Prognosis. There is imminent danger of serious, if not fatal, haemorrhage. I have known as many as two cases of sudden fatality from flooding after the seventh day from the time of labor. It is always a serious condition, and should be watched diligently and treated efficiently. Even in cases where the delay is caused by acute inflammation great 430 DISEASED DEVIATIONS OF INVOLUTION OF THE UTERUS. haemorrhage may take place, although not so likely as when caused by muscular atony alone. If the delay is for a very considerable length of time the involution is pretty sure not to be completed, but the uterus remains in a state of subinvolution for an indefinite time. Very often the causes which effect delays continue to act, and finally produce subinvolution. Treatment. The treatment depends upon the causing conditions. If there is inflammation of the uterus the antiphlogistic measures necessary to combat it are demanded, with counter-irritation, fomentations, etc. Should atony, unattended with inflammation, exist, ergot in large doses is demanded imperatively until ergotism is brought about. I usually give 5ss. pulv. secale corn, in infusion, every half hour, until contractions are brought about. When this is done the effect of the drug may so subside that it will be necessary to administer it again in twelve or twenty-four hours, until all disposition to relax has passed away. When atony and the inflammatory condition coexist, which may be known by the tenderness, fever, and haemor- rhage occurring together, the ergot and other treatment should be combined. Haemorrhage is not likely to come on until after the inflammation has pretty well subsided, and aids usually in removing the last of it. I subjoin two cases as representatives of the two conditions of the uterus, and the mode of treating them : Case I. This case was furnished me by Dr. S. Wickersham, of this city. He was called to Mrs. E., an Irishwoman, aged twenty-eight, in her fourth labor. May 7th, 1863, 4 o'clock p.m. She had been in labor, attended by a midwife, for the most of the day. At 1 o'clock A.M. of the 8th pains had entirely ceased, from atony or exhaustion of the uterus. Constitutional symptoms began to show the necessity for relief. The forceps were used, and the child was delivered. The placenta was delivered in due time without difficulty, and the uterus contracted well. Haemorrhage not more than usual. The pulse was unusually frequent at and after the time of delivery. The labor was followed in two days with puerperal fever, in which the uterus and peritoneum were both involved. Up to the 20th she had improved very much, so as to be considered by the doctor as convalescent. In the early part of the day sudden and violent haemorrhage prostrated the patient to what was at the time considered a moribund condition ; but by active stimulation and external warmth to her cold extremi- ties she rallied, and appeared to be slowly recovering. At 6 o'clock TREATMENT. 431 P.M. on the 2-4th the haemorrhage returned with " terrible vio- lence," and she was thought again to be dying. Notwithstanding the most energetic use of stimulants she could hardly rally from this last attack. On the 26th, in consultation with Dr. Wickersham, I found the patient so prostrated as to leave but little hope of her re- covery. Suspecting that the uterus was in a state similar to w^hat is found immediately after delivery, I insisted upon making an exami- nation, which was resisted by the patient and friends. Through the kind perseverance of Dr. Wickersham I was permitted to do so. The uterus was so flaccid that I could not discover it above the pubis until after iutroducins^ the fing^er into the vaccina and movino^ it about, when the fundus could be felt as high as the umbilicus, with the reo^ular o^lobular form. The mouth and cervix were laro^e and flabby, and easily admitted two fingers. After this examination the indication seemed plain. Large doses of ergot were given in addi- tion to the stimulating and supporting treatment. Hemorrhage was very slight on the morning of the 27th. She continued to improve slowly until the 9th of June. At 5 o'clock a.m. the haemorrhage returned, and lasted until 10 o'clock a.m., but in so moderate a de- gree as to produce but little effect upon the patient. I was not in attendance after the first consultation, and could not trace the steps of condensation, but after the 9th of June the haemorrhage did not recur. It will be seen that on the twelfth day after confinement dangerous haemorrhage took place ; that it again returned on the sixteenth day after delivery to a very alarming extent ; and that after the liberal use of erorot the haemorrhao^e returned but slio^htlv. It should be noted, also, that the cessation of the haemorrhage was sudden, and probably resulted from faintness, and that it returned as soon as the arterial reaction amounted to any considerable degree. The faintness, doubtless, was the cause of stoppage in both attacks before ergot was given, but the haemorrhage was effectually checked by contractions caused by the ergot. Case II. Mrs. E. is the mother of nine children. She is thirty- three years of age, and a German Jewess. Of robust, almost athletic make and habits, she always enjoys excellent health. In the last three confinements she has almost lost her life from loss of blood, both before and after the delivery of the placenta. I attended her in the eighth labor, the last before this one. There was nothing peculiar in it until after the child was delivered, the labor having lasted but about four hours. The pains were ordinarily vigorous and propul- 432 DISEASED DEVIATIONS OF INVOLUTION OF THE UTERUS. sive. The liquor amnii was not evacuated until ten minutes before the head was distending the labia. After the child was expelled the uterus did not contract thoroughly. It seemed large and rather soft. This state lasted for half an hour, when a feeble contraction detached but did not expel the placenta. From this time hseraorrhage became excessive. I waited for half an hour — using friction, kneading, and pressure over the uterus, with application of ice to the vulva — for contraction of the uterus and expulsion of the placenta, but although there were occasional pains, thev were so feeble as to produce no effect u23on the haemorrhage. About this time the ergot I had sent for arrived, and I gave immediately o^s. in a little wine and water. Fearing the prostration which was rapidly coming over the patient, I introduced my hand into the uterus, grasped the placenta, and irri- tated the organ by moving the whole around in it. This brought on contractions enough to expel my hand and placenta, and deluge the bed with coagula and fluid blood. Yery soon the ergot began to act, and the haemorrhage ceased. I give this description of her eighth labor to show her predisposition to inertia uterina. As the ninth labor approached, I determined I would administer the ergot as soon as the parts were well dilated, and the head began to pass the os uteri. I was sent for at 8 o'clock p.m., June 30th, 1864, to attend her. I found the pains active and the os uteri fully dilated, and the membranes distending the labia. I at once gave her ergot 5ss. in in- fusion, making her swallow the ergot as well as the water. This was repeated in half an hour. By this time ergotism was fairly estab- lished. In three-quarters of an hour from the time I arrived the child was born, and in a few minutes the placenta was expelled from the uterus into the vagina whence it was removed. No haemorrhage followed. The uterus was well contracted. I considered her condi- tion very favorable, and at the end of another hour took my leave. Her condition for the first forty-eight hours was in no respect unusual, except that the lochial discharge was rather free. From this time I saw but little of her until the 10th of July. I returned from the country at 5 o'clock p.m., and found she had been flooding since early in the morning, not very greatly, but suflQcient to begin to pro- duce faintness. The uterus could be felt above the symphysis pubis as large as a child's head, and not very hard. I ordered cold to the pubis, and twenty drops of aromatic sul. acid in some water every four hours, expecting soon to have the haemorrhage checked ; but to my surprise, at 8 o'clock on the 11th, the haemorrhage still continued, being but slightly moderated by the means used. I now ordered two i SUBINVOLUTION OF THE UTERUS. 433 teaspoonfiils of vin. ergoti every half hour until the haemorrhage ceased. But the nurse said that the " second dose put her in so much pain and caused such large clots of blood to come from her that she dare not give it again." The haemorrhnge ceased entirely from this time until the afternoon of the 13th, when it returned with considerable violence. The ergot was again given, and from this time forward the patient had a favorable convalescence, and is now in the enjoy- ment of good health. Subinvolution of the Uterus. To understand subinvolution in its principal bearings it will be necessary to discuss more at length the subject of involution itself. I think that involution of menstruation plays a much more impor- tant part in the structural diseases of the uterus than we have been inclined to attribute to it. It will not be considered irrelevant there- fore to take a glance at the subject, as involution presents itself in menstruation as well as in pregnancy. In the healthy uterus, what may be called trophic changes are con- stantly going on, from the beginning of menstruation to the meno- pause. The circulation of the uterus is increased in quantity from the cessation of one menstrual crisis to the beffinnino- of the next. Dur- ing the days of the flow the ajfflux of blood subsides to the lowest amount. From the cessation of the monthly flow there is an increase of solid tissue in the uterus until the beginning of the next menstrual flow, during which time there is involution or an elimination of solid tissue, notably the mucous membrane of the cavity. These processes of afflux of blood and accretion of tissue may be, and often are, prolonged, and pass into what is known as congestion of the uterus. When this round of monthly changes is interrupted by pregnancy^ processes similar in character on a much larger scale are accom- plished. The afilux of blood and increment of tissue do not attain their maximum until the end of gestation. The contents of the uterus is expelled, and then begin the changes called involution, the object of which is the elimination of the superfluous circulation and solid tissues, until the uterus returns to its menstrual status. The prolongation or arrest of this is subinvolution. Post-partum involution is no doubt initiated, if it is not completed, through the agency of muscular contractions. The large fibres which have been strong enough to expel the foetus, placenta, and mem- 28 434 SUBINVOLUTION OF THE UTERUS. branes, continue to contract, and in doing so compress the vessels, and thus cut off at once a large quantity of the blood circulating in the uterus. As a result of this some of the fibres are deficiently sup- plied with nutritive elements, and undergo fatty degeneration. The granular fatty material is absorbed and the general bulk of the organ diminished. Further contraction is thus rendered possible, when more fibres disappear in the same way until the process of involution is finished. The length of time required is, I think, much longer than is generally supposed, seldom intone month, often not in three months, and sometimes morbid causes prevent it from ever being accomplished. The uterus then remains more vascular and bulky than normal, or is in a state of subinvolution. In both post-menstrual and post-partum subinvolution this simple vascular condition does not continue for any great length of time. Hypersemia is often a mischievous condition, and sooner or later causes changes in the organization of the viscus in which it exists. In subinvolution there is at first hypersemia, with hypertrophy of the fibrous, vascular, and nervous tissues. These solid portions of the organ degenerate, not into a fatty substance that may be absorbed, but into fibrous tissue of a low organization. Either as the effect of exudation from the capillaries, or the slow absorption of the more vitalized molecules of the muscular fibres, or both, there comes to be an undue amount of connective tissue. The transition from the more muscular and highly vitalized state of the uterus to this one of induration may be accomplished in a few months, or it may require the lapse of years. When it is complete many of the symptoms that indicated the state of recent subinvolution are re- placed by others of a different kind ; especially do the bloody dis- charges from the uterus become less than normal. Subinvolution is a term then which embraces different pathological conditions; or, perhaps, it would be expressing the facts better to say, that several distinct pathological conditions of the uterus result from subinvolution. This last statement will apply equally to menstrual subinvolution as to the post-partum. We ought not to lose sight of the fact that all the physiological and some of the pathological changes occurring in the uterus are to a great extent coincidental with, if not the consequences of, the changes going on in the ovaries, — the organs that dominate the whole genital system. During ovulation the menstrual hypertrophy takes place ; at the time of the discharge of the ovum menstrual involution occurs. CAUSES. 435 During the development of the ovum in the uterus, ovarian hyper- trophy is going on ; at the time of the expulsion of the ovum the processes of involution begin. It is quite probable that after the ovum is inclosed in the uterus and gestation established, the uterus is prompted bv ovarian influence to the enormous physiological and anatomical changes which go forward in it, up to the perfection of foetal life, and afterward govern the processes of labor and involution. It is certain that the ovaries do not return to the condition in which they were, before conception, until pregnancy has terminated, nor in fact during several months of lactation. While the generative functions of the ovaries are held in abey- ance by lactation, — or, if I may express it differently, while the ovaries are engaged in the reflex duties of sustaining lactation, — they do not return to their former condition. According to my obser- vation, involution of the uterus, ovaries, and vagina is not complete in persons who nurse their children until the ordinary term of lacta- tion has elapsed. Looked at in this way I think involution will present different features than when viewed from a more circum- scribed standpoint. We will attach more importance to the influence of the nervous system, exerted through the ovaries. The term and process of involution extend to the changes observed in all the genital organs, the lacteal glands, the ovaries, uterus, vagina, Fallopian tubes, uterine ligaments, and perinseum. How much more susceptible to the effects of morbid causes, therefore, must be all the contents of the pelvis in the hypersemic, hypersesthetic, and hypertrophic conditions during the time involution is going on, and how readily the affections of one pelvic organ will influence the condition of all the others. The genital organs constitute a separate and, in some respects, inde- pendent physiological system, governed by special nervous centres, all bound together and dominated by the ovaries, under all the physiological changes accompanying pregnancy, labor, and invo- lution. Causes. Any morbid causes that prolong the processes of involution may arrest the process entirely. The character of the labor may have this effect. If it has been tedious enough to produce great nervous ex- haustion, the uterine fibres will be powerless to conduct the changes necessary to a speedy and perfect involution. If the cervix is lacerated or badly contused, the consequent inflam- 436 SUBINVOLUTION OF THE UTERUS. matory reaction interrupts involution for a greater or less length of time, or perhaps for all time. Inflammation of the body of the uterus resulting from severe labor or exposure may do the same thing. General and special causes not dependent upon labor often act so as to bar the completion of involu- tion. Some of these causes are general debility ; that is an impover- ished condition of the blood, lack of nervous energy, a want of the powers of endurance, cold acting through the nervous system upon the circulation of the uterus post-partum or during menstrual con- gestion, the excitement of anger, fevers, or the depression of fear, etc. Special causes operate through the genital nervous centres upon the uterus directly, as venereal excitement from unnatural lascivious practices, coition during or just before menstruation and within the month after labor, libidinous literature, and exciting exhibitions. Diseases in the surrounding organs by keeping up nervous and vascular excitement, ulceration, fissure, and hsemorrhoids of the rectum, specific vaginal inflammation, laceration of the perinseum, urethral and vesical inflammation, displacements of the uterus, etc., all tend to produce this effect. Frequency of its OccurrenGe. Without exaggerating the importance of subinvolution, I believe it would be correct to say, that more of the chronic congestions of the uterus originate in puerperal and menstrual subinvolution as here explained than in any other one condition. By taking the puerperal and menstrual involution as a funda- mental and almost constantly present condition of the pelvic organs for a basis, I think we can better explain the mode of operation of exciting causes in producing chronic diseases than by any other hypothetical method. Certain it is, that there is no other organ in the body so prone to lesions of circulation and their consequences as the uterus, and that the reason why this is the case must reside in the anatomy and functions of the organ. It is an organ, the very nature of whose condition is one of un- ceasing fluctuation of vascularity and nervous susceptibility. Symptoms and Diagnosis. The general symptoms of subinvolution are in no respects distinc- tive. All the reflex symptoms spoken of as uterine symptoms, or symptoms of uterine disease, may exist in patients the subjects of this SYMPTOMS AND DIAGNOSIS. 437 condition ; neither do the local symptoms guide us with certainty to a correct diagnosis. In the earlier months of subinvolution, in fact for an indefinite term, metrorrhagia is a frequent symptom, and in some instances continues as long as the disease lasts. It represents what may be termed the vascular stage of subinvolution. In a great many cases of subinvolution after a certain time, which also is very indefinite, the bloody discharge from the uterus becomes less copious, and occasionally entirely ceases. This diminution of the flow indi- cates the supervention of the fl"brino-plastic stage, or a condition in which the vascularity of the uterus is diminished while the solid tissue is increased. Leucorrliosa is generally present or absent under the same conditions that govern the flow of blood. Diagnosis. The diagnosis must be made up from the history and physical examinations. If the sufferings of the patient date from an abortion, or labor at full term, and in addition to the general and local symp- toms of uterine disease there is or has been for months too copious or too frequent menstrual discharges, or haemorrhages intervening between the regular periods, the presumption is that there is subin- volution, or at least that the symptoms were at first those of that condition. One of the most constant appreciable conditions of sub- involution is the large size of the uterus. This may be ascertained by bimanual examination and the introduction of the sound. When the uterus is lifted up by the fingers in the vagina, the fundus will be more easily felt by the hand above, and the sound will pass farther beyond the normal depth into the cavity than when the organ is of a normal size. The shape of the uterus is generally still that of the post-partum organ. It is proportionately thicker through its antero-posterior diameter. The enlargement, therefore, is diiferent from enlargements from other conditions. The shape is often modified by retroflexions and lacerations of the cervix. When retroflexed without laceration, the fundus and body are much larger proportionately as compared with the cervix. When the cervix is badly lacerated, it is enlarged. The appearances in this respect are sometimes deceptive when the labia are widely separated. When examined through the speculum the color is deeper than natural, the mouth patulous, the cervix large and often ulcerated. Generally, also, there is copious albuminoid mucus hanging from the OS uteri, sometimes of an amber color, from the admixture of pus- I 438 SUBINVOLUTION OF THE UTERUS. corpuscles. When the cervix is lacerated, the mucous membrane of the cervical cavity is exposed, and presents a papillary or fungoid appearance. These are the appearances in the vascular stage of subinvolution. After this has passed, and the fibrino-plastic change has taken place, the cervix and body will feel hard to the touch; sometimes the indu- ration in such cases is very marked indeed. While the induration is generally uniform with respect to the cervical circle, and extends en- tirely around, at other times it is confined to one of the lips. Then the color is often not increased, and the surface is smooth and covered with cicatricial tissue instead of granulations or fungoid bodies. Prognosis. During the vascular stage of subinvolution, and while the hyper- trophied fibres of the uterus retain their muscular character, we may hope to succeed in restoring the normal condition of the organ. We must remember, however, that metrorrhagia, indicating great vascu- larity of the uterus, is no evidence that the fibres are not greatly changed or replaced by non-contractile tissue, and consequently the prognosis should be guarded. The longer the time the case has lasted, the greater the probabilities are that the fibres are replaced by connective tissue. After this vascular and hypertrophic condition of the muscular fibres have passed away, and there has been extensive fibrino-plastic deposit in the walls of the uterus, the probabilities of a cure are very remote. The uterus is then hard, inelastic, its tissues permeated by few vessels, and the nerves diminished, if not entirely absent. Treatment. The preventive treatment should begin during pregnancy. Every means necessary to place the patient in good health, both generally and locally, must be resorted to, — exercise in the open air on foot, if at all practicable, and domestic employment or exercise of like character. The habits of the patient should be regulated with a view to the development of the muscles of the entire body, while her diet should be abundant in quantity and of the most nutritious quality. It is not my purpose at this time to do more than to call the atten- tion of i\\Q> obstetrician to the subject of preparing patients for the great task of passing safely through labor. During labor everything TREATMENT. 439 sliould be conducted with the view of preserving the integrity of all the soft parts, because, as before intimated, damage to any of the parts concerned in labor is pretty sure to be followed by subinvolu- tion. The more physiological a labor is, and the more skilfully conducted, the less the tendency to subinvolution. After labor complete contraction should be brought about, and maintained, not by mechanical irritation, but, if need be, by the use of ergot and vaginal injections of hot water. These latter will stimu- late the pelvic nerves and prompt the uterus to contraction, and by their cleansing effects promote the repair of every damage that the soft parts may have sustained. Above all things, a sufficient amount of absolute rest must be enjoined to insure recovery of the viscera. The most assiduous attention should be especially given to control all inflammations that follow labor. From the immense number of gynaecological cases traceable to labor, it is to be feared that some of the modern innovations in the practice of midwifery are not improvements. More attention and care in conducting patients through cases of abortion and premature labor should be practiced than is usually done. Abortion is looked upon by the patients themselves as a small matter, and it is very difficult to induce them to give the necessary time and care to themselves. Physicians know that it is a more dis- astrous process than labor at full term, and they will do service, there- fore, by enforcing proper measures, whenever it is practicable, to insure good recovery from it. After the patient has passed from the hands of the accoucheur to those of the gynaecologist the treatment of subinvolution will be gov- erned by the conditions in each case. Until the muscular fibres have lost their power of contraction, ergot, strychnia, quinine, and iron, with good, nutritious diet and exercise in the open air, will be the general remedies most efficacious. Ergot, given in moderate doses, perseveringly administered, is a very powerful means of supplementing the natural contractions. It is not applicable to cases, however, where there is inflammatory ex- citement in the uterine substances, and should be withheld until, by alteratives, counter-irritants, and rest, that condition is removed. When this inflammatory condition is not present the ergot and tonics, judiciously administered, will co-operate well in the accomplishment of the general result. However, gynaecologists do not often see these cases until the contractility of the fibres has been very much im- 440 SUBINVOLUTIOX OF THE UTERUS. paired, if not entirely lost. In most cases, even thus late, the ergot and tonics will have some good effect. In chronic cases the local treatment is of prime importance ; and the first thing to be thought of is the removal of any cause- of in- creased vascularity that may be found associated with it. If there is laceration of the cervix or perin&eum it should receive attention. If there is misplacement it must be corrected, so that the outgoing cir- culation may be as free as possible. VTlien these conditions are cor- rected we may begin a system of local treatment that will remove the congestion, and cause the absorption of the fibrino-plastic deposits. The use of glycerin tampons and hot-water injections will be found applicable and beneficial in most cases. The glycerin cotton should be applied about every third day, and allowed to remain in the vagina about twenty-four hours. During this time the capillary bloodvessels will be depleted by the loss of a part of the serous portion of the blood they contain, and exosmosis from the intervascular spaces will also be excited in such a manner as to empty them of their contents. This leaves the part with which the glycerin comes in contact white, shrivelled, and les- sened in bulk, {. €., depleted. This is not all the good effect pro- duced by the glycerin applied to the cervix of the uterus, for the frequent removal of the serum from the intervascular sj^aces, which, of course, is replaced by a fresh supply from the vessels, is a very efficient means of dissolving out the fibrino-plastic material. It is, in fact, a kind of washing out of the tissue with serum derived from the mi- nute bloodvessels : it acts, therefore, both as a depletent and a solvent. Large hot-water injections constitute another valuable means of overcoming hyperaemia, and causing absorption of solid deposits. But there is another class of local remedies that I believe is more serviceable than these, and that is local stimulants applied db'ectly to the mucous membrane, such as iodine, carbolic acid, tincture of iron, acid nitrate of mercury, and many others that I might men- tion. In the teachings of twenty-five years ago the application of these remedies to the mucous memurane was supposed to exert only a very limited influence at the point to which they were applied, and we thought in applying nitrate of silver to an abraded or ulcerated surface the only effect it had was to heal up the abraded patch. Xow we know that this is a very small part of the effect of these local ap- plications. The vasomotor nerve supply of the whole uterus is so intimately connected that it may be considered a unit, and no j^art of it can be stimulated without affectingr the whole. Applications made HYPERINVOLUTION. 441 to the cervix of sufficient strength to stimulate its circulation to greater activity affiict every fibre and capillary in the organ in a sim- ilar manner. When, therefore, there is chronic engorgement of the uterus the very best way to get rid of it is to stimulate the circula- tion by local applications to the cervix. This same principle may be turned to great advantage by stimulating its internal mucous mem- brane, and one of the best ways to do this is to scrape the cavity of the uterus with a dull wire curette. This instrument may be introduced in most instances without dif- ficulty, and passed slowly but firmly over the whole surface. In some instances, where the mucous membrane is soft, small pieces may be brought out by the instrument, but generally this is not the case. When pieces of the mucous membrane are thus removed it would be too mechanical an explanation to say that the patient is cured be- cause the uterus has been partly or wholly divested of its diseased membrane. It is the excitomotor influence exerted on the nerves, and the consequent effect upon the whole circulation of the organ, that is the result of its use. It is not merely to the hsemorrhagic condition of subinvolution, but to the hypertrophic condition also, that the curette is applicable. Dilatation with compressed sponge has often accomplished good in the same kind of cases as those to which the curette is adapted, but it is a much more hazardous measure, and should only be resorted to when the other means fail. Hyperinvolution Is the state of the organ in which the involution has proceeded to such a degree as to condense the tissues beyond their ordinary density. The condensation thus accomplished renders it less vascular and erec- tile, and the fibrous structure is paler and harder than natural. As the result of this condensation and diminution in the quantity of the circulation, the uterus as a whole is smaller and lighter than common. The degree to which hyperinvolution may be carried varies greatly ; sometimes it is so slight as to require great care to distinguish it, at another the uterus is reduced to half its ordinary weight and dimensions. Causes. Inflammation seems here to be more concerned in the production of hyperinvolution than any other morbid process. From examina- tions during the progressive steps of morbid states of involution, I am inclined to think that in cases where inflammation of the mucous 442 SUBINVOLUTION OF THE UTERUS. structures exists exclusiveljj or where inflammation of the raucous membrane preponderates, the involution is arrested, and hence we have subinvolution ; but when the inflammation is mostly confined to the submucous tissue it proceeds to hyperinvolution. Symptoyns. The condensation of the tissue and reduction of the vascularity of the organ always diminish the menstrual flow ; and hence we have de- creased menstruation in a moderate degree, and obstinate amenorrhoea in the more extreme condition. The symptoms attendant upon hyper- involution are very similar to those enumerated in the description of chronic inflammation. They are sometimes very distressing, rendering the patient thoroughly miserable for many years. The worst cases of this form of diseased involution I have met with have been traced to inflammation resulting from abortions; but it likewise takes place as the effect of inflammation after ordinary or full term parturition. Diagnosis. The diagnosis is easy with the aid of the uterine sound. This in- strument will not enter the uterus as far as it does into a healthy organ. The uterus is lighter and more easily moved, also, by the finger introduced into the vagina. One of the almost invariable effects of hyperinvolution is sterility. I have met with a number of cases of sterility occurring soon after marriage, on account of abortion, in the first three or four months, being followed by inflammation and hyperinvolution, the patient ever afterwards remaining sterile. The successful treatment of these cases requires a great deal of pa- tience and well-adapted measures. If the change in the condition of the uterus is slight we may sometimes succeed by introducing a bougie of slippery elm bark, large enough to distend the cavity of the cervix as much as practicable, three or four days before the expected men- strual discharge. This seldom fails to increase the discharge, and if used perseveringly for several months will sometimes cure the case. The bougie should be cut out of the bark so as to be about an inch and three-quarters in length, for cases of moderate contraction, and secured by a thread before introducing it. It should be allowed to remain until the discharge begins, and then removed. If, however, it is of long standing, and the diminution in size very considerable, we will be under the necessity of using the stem-pessary recom- mended by Professor Simpson. It may be made of zinc and copper, in order to add the influence of galvanism. CHAPTER XXX. CANCER OF THE UTERUS. "Those growths may be termed cancerous which destroy the natural structure of all the tissues, which are constitutional from their very commencement, or become so in the natural process of their development, and which, when once they have infected the constitution, if extirpated, invariably return, and conduct the person who is affected by them to inevitable destruction/^ (Miller, as quoted by West.) This general definition of cancer will include all its varieties, which are usually divided into four: 1st, medullary; 2d]y, epithelial; 3dly, colloid ; 4thly, scirrhus. I have mentioned these varieties in the order of frequency in which they usually occur in the uterine tissues. I have not seen either a case of colloid or scirrhus in the uterus. There can be little doubt, however, that both are met with. The medullary variety is by far the most common form with which this organ is aifected, the epithelial being also quite common. Cancer of the uterus is of very frequent occurrence, and the deaths from it, compared to death from the same disease occurring elsewhere in women, predominate over all other localities. It attacks the cer- vical portion of the uterus more frequently than all other parts of the organ, yet it begins in every other portion, — in the fundus, body, or cavities of the body or cervix. In some rare instances it runs its course to fatal results without involving all these parts. When it begins in the cervix, it usually, either gradually or suddenly, passes upward to the fundus ; or if beginning in the fundus or body, it creeps downward to the os tincse. I have seen two instances where the lower portion of the cervix was but slightly, if at all, changed, while all the other parts of the organ were infiltrated by cancerous deposit. The material of cancer, particularly the medullary, is de- posited in the tissues, supplanting them more or less perfectly. The tissue most commonly attacked by all the varieties except the epithelial is the connective tissue. The parts attacked are thickened and indurated, the thickening and induration being very irregular in shape and size. If one of the lips of the os uteri is hardened from cancerous deposit, the elevated points are sharp and angular, and the 444 CANCER OF THE UTERUS. hardened parts terminate abrujuly. and in a manner unlike the in- duration from auv other cau.-e. The hardening froo3 inflammatory fibrinous de230sit is more globular than angular, and less abrupt in its termination in the sound parts. If the cancerous deposit is in the body or side, on any part of the wall, it is enlarged into an irregular shape, and there are pits and points in many places. The infiltration and induration increases for an uncertain length of time, until, perhaps, the cancerous deposit so far displaces and re- places the ordinary tissues that the nutrition of the parts is disturbed by the destruction of the bloodvessels, and sloughing takes place over a small or large space, but always over an irregular space, thus leav- ing a greater or less chasm. This is ulceration, — cancerous ulcera- tion. The absorbents do not remove the parts, and thus- cause ulceration, but there is sloughing and denudation by death of many minute parts, the absorbents having but little to do in the process. The sloughing causes the smell and putrilaginous character of the discharges. This process "widens and deepens the chasm, sometimes quite rapidly, at others very slowly. In the case of the medullary variety, after induration and enlargement have advanced to a con- siderable extent in the uterus, the nutrition of the neighborinQ: organs and tis^ues is disturbed, and the deposit is infiltrated into all the sur- rounding parts, — the bladder, the rectum, the areolar tissue by the side of the uterus, the peritoneum, in fact, into everything in the neighborhood. This general deposit is not limited by the coverings or divisions of the parts, but all become united, so that all the pelvic tissues become one agglomerated mass of cancer ; or, if it take one direction more than another, the bladder and uterus may be glued together, or the rectum may be bound thus to the uterus. This dis- position of the deposit very soon becomes sufficient to fix the uterus immovably in its place. After the ulcerative process has fairly begun, it advances more or less rapidly, until much of the surrounding parts is destroyed; the bladder and uterus become one continttous cavity, and sooner or later the rectum also is laid open, and then the pelvic viscera are involved in one confused excavation, from which the putrilage of cancerous degeneration is poured out, commingled with urine, faeces, and blood. There is quite a constant proportion between the rapidity of the destructive progress of cancer and the age of the patient. It is slower in the aged, and destroys the young patient most readily. Of three cases under observation, in which cancerous deposit began in the body SYMPTOMS. 445 or fundus of the uterus instead of the neck, two were in patients be- yond the climacteric period, one being sixty-four years of age and the other fifty-sev^en when the symptoms first attracted their attention. The other patient was forty-three. In this last patient, simultane- ously with the evidence of deposit in the body of the uterus signs of it appeared in the bladder, vagina, and clitoris, the duodenum, and in the pyloric orifice of the stomach. I always look for a more rapid degeneration of the tissues invaded by cancer in comparatively young patients. Symptoms, Discharges, pain, and fetor are the symptoms that usually attract our attention in cases of cancer of the uterus. When a patient com- plains of any of these, however, the case is generally an advanced one. Pain, perhaps, is the symptom first experienced, and is caused earlier than any other. Unfortunately, pain is so common to women — they suifer so often in the regions of the uterus and hips — that this symptom is not heeded by them until some other symptom makes its appearance. The pain is not generally intense nor troublesome until after the disease is recognized. ]N^or is it peculiar. It is described as lancinating, darting, twinging, — and very correctly, too, — but there is often nothing of this kind of pain during the whole course of uterine cancer. The discharges in cancer are of three kinds, and the mixture of them in different proportions. They are: 1st, blood; 2d, limpid serum; 3d, sloughs, generally minute. The first two are not offen- sive to the smell Avhen pure or mixed together, as they often are, and they only become so by being mingled with the last, by dissolving or holding in suspension or being merely mixed with greater or less pieces of dead tissue. In the earlier stages of cancer blood or serum may be, and generally is, effused, while the latter is reserved to the open or ulcerated stage. In this open or ulcerated stage all three kinds of discharges are almost always mixed together. In women who are still menstruating, the discharge first experienced is of blood. There is, at first, an increase in the amount of menstrual discharge; a little later, and blood is lost between the times of men- struation. The blood thus lost is derived from the same source as the menstrual blood, — the vessels of the mucous membrane of the corpus uteri. Later, when haemorrhage is so constant and attended with fetor, it is effused from eroded vessels upon the ulcerated sur- face. The blood in the former case is produced as the result of constant 446 CANCER OF THE UTERUS. turgescence; in the latter, on account of the disintegration of tissue. Limpid, unoffensive serum is almost always observed in the cases of old women, after the menstrual period of life has passed, and gener- ally coming from the os uteri, which may be for a long time un- changed, indicating that it comes from some distance up in the organ. In fact, if the same serum was effused from the surface of the vaginal portion of the cervix it would most likely be mixed with blood, be- cause the parts producing it would not be sufficiently protected to insure the integrity of such frail tissue. In two remarkable instances the copious discharge of this limpid serum was, for many months, the only sign of disease presented by the patients. One of my pa- tients, sixty-one years old, had been under the necessity of wearing napkins for six or more months before calling my attention to her condition. The discharge was so copious when I saw her for the first time that I collected about two drachms from the speculum in ten minutes. When examined it was found to resemble distilled water in appearance, it was so clear and colorless. There was no smell nor other oflPensive quality to it. When examined by the mi- croscope no solid substances were found, except a very few natural epithelial scales. In a very gradual manner this transparent liquid became colored with blood. It was sometimes clear and sometimes bloody for several months before becoming fetid, and only for a few weeks before the patient died was it constantly bloody and fetid. The cervix uteri in this case was not attacked at all, and the mouth and lips of the neck were natural. The body of the uterus, as high as the fundus, was enlarged more than double its natural size, indu- rated, and nodulated; and, when examined after death, the walls pre- sented the peculiar friable hardness of medullary cancer, but there was no excrescence in the cavity, as I had expected to find. Whether the discharge is blood or serum at first, or a mixture of both, it is generally odorless ; but after a time it becomes fetid, and remains so persistently. The fetor appears, from the testimony of most observers, to be peculiar ; but I have not been able to dis- tinguish it from the smell of putrilage of other productions. When all these symptoms unite they form a case almost unmistakable. Lancinating pain, sero-sanguineous discharge, and peculiar fetor, continuing persistently, are almost distinctive of cancer. I cannot lay much stress on either one of these symptoms ; but of the three the most importance should be attached to the fetor. Persist- ing for weeks it should cause us to suspect a cancer. Contempo- raneous with the complete establishment of these symptoms we hav^e CAUSES. 447 constitutional suffering. It is not often, I think, that general suffer- ing precedes the local symptoms of cancer, and it has always seemed to me to follow as the effect of local disease. It has not been my lot to meet with the broken-down constitution sometimes said "to be gen- erated by the cancerous diathesis. Cancerous angemia, causing the straw-colored translucency of the skin, considered characteristic of the malignant cachexia, is not distinguishable from the hsemorrhagic anaemia occurring sometimes in persons of the same age, produced by the drain upon the blood. In the fully developed condition of carcinoma the constitution suffers, and the collection of symptoms are such as arise from the embarrassment and failure of the functions in a long struggle with pain, loss of blood, anxiety, and inaction. Debility, with indigestion, palpitation, restlessness, neuralgia, constipation at first, colliquative diarrhoea and aphthae toward the end, nightsw^eats, wandering of mind, unsteadiness of purpose, succeeded by delirium and apathy; in fact, all the train of symptoms which precede dissolution when it approaches through protracted struggles, in which pain and ex- hausting discharges are the destroying agencies. Causes. But little can be said as to the causes of cancer of the uterus. The general opinion that it is hereditary in most cases is, doubtless, true ; and yet a great many instances occur that cannot be traced to such a cause. This is no reason why they may not be hereditary, because sometimes the circumstances which permit the hereditary taint to show itself do not exist for a number of generations. And, again, the taint may be so dilute as to require very favorable circumstances or co-operating causes to bring it out. If a mother dies of cancer at the age of forty-five, and impart the same morbid tendency to her daughters, the laws of cell- development would bring it about at the same age in the child. If, therefore, the daughter dies a year too soon of some other disease, the taint is inoperative, though present. Two or three generations of cancer-bearing persons cut off by other diseases lose the history of its inheritance. Or if a mother be the subject of cancer at the end of a life of active, nay, excessive, child- bearing, while her daughter leads a life of celibacy, or has but a single child, the physiological life of the two is so different that we would naturally expect some modification of consecutive cell-devel- opment to result. So that, although the hereditary taint is the same in the two, their jmthological ages may differ, and the daughter may 448 CANCER OF THE UTERUS. not have cancer until a later period, and die before that time arrives. We should, I think, allow much for influences that may modify hereditary taints, and only regard them as hereditary tendencies, to be brought out in mother and daus^hter under similar circumstances, and which may be postponed or produced earlier in the one or the other by certain conditions. Married women are affected more frequently than the single, and the fruitful than the barren. When we consider how many more married than single women there are in civilized communities, and how few married women are sterile, we ought not to attach much importance to these facts. A much more significant fact is that a very large majority occur during the menstrual years of a woman's life. It is true that there may be nothing more than a mere coinci- dence in this fact, and that, after all, the hereditary mutations in the system during these years may bring about cancerous deposit, inde- pendently of any connection with the menstrual function. But it certainly is a coincidence, if not an etiological coincidence. As to the connection of cancer with chronic inflammation and ulceration of the uterus, much has been and may be said. I cannot lay my hand on statistics upon this subject, but I have never observed the coinci- dence of inflammation and cancer, or that cancer was a consequence of inflammation. If, however, they are occasionally connected, there are but few at the present day who believe cancer to be the result of long-continued inflammation. Diagnosis. It would seem that the diagnosis of a disease so marked as cancer would be an easy matter, and so it is when all or even most of the peculiarities of the disease have been fully developed ; but in the very beginning there may be much obscurity. A patient complain- ing of nothing more than a perfectly clear, inodorous, watery dis- charge, seemingly in the enjoyment of good health, would hardly be regarded as a victim to one of the most surely fatal and loathsome diseases incident to the human race ; and yet it is almost invariably so when the patient is advanced beyond the epoch allotted to men- struation. The cancerous disease, as it usually occurs, advances be- yond the period of doubtful symptoms in a very short time, and in the majority of cases our attendance is not requested until a scruti- nizing examination will enable us to decide very positively on the nature of the case. Our attention will be attracted by the unusual amount and character of discharge, pain, and smell. DIAGNOSIS. 449 Summary of appearance in cases from Becquerel : " Cancerous Deposit. Cervix hard, unequal ; nodulated, os not always open, sometimes wrinkled or furrowed. Cancer of the neck often implicates the vagina. Hereditary influence is often traceable. Touch is painless. Discharge sometimes absent, in certain cases very abundant, and con- sisting, for the most part, of albuminous serum. Menstruation increased, being neither more nor less painful, and pass- ing often into the state of real hemorrhage. Absence of special anaemia when the vagina and body of the uterus are involved. Cancerous cachexia. Progress continuous and without cessation. The pain in cancer is very sharp, intense, and lancinating, and not influenced by locomotion or movements of any kind." ^^ Ulcerated State. Developed at the critical period of life generally. Preceded and accompanied by haemorrhages. Severe, sharp, lancinating pain. Development essentially in sharp irregularities and nodosities. Adhesions to other organs soon as ulceration is formed ; immobility of the uterus. The surface only slightly soft, subjacent tissue scirrhous. Ulceration deep, unequal, essentially irregular, with thick, elevated, and hard edges. Always granulations. Discharges extremely abundant, consisting of purulent and often san- guineous serum ; nauseous and often fetid odor. Great haemorrhage from time to time, not necessarily at menstrual period." " Cancerous Ulceration Developed upon an hypertrophied and scirrhous surface. Ulceration deep, vast, unequal, grayish surface with thick edges, and easily bleeding. Ulcerated surface hard, presenting numerous lobes and tubercles, with nodosities and great hardness. Often great loss of substance. Cervix and corpus uteri immovable, on account of adhesions. Discharges sanious, fetid, sanguinolent, and of an insupportable and characteristic odor. Cancerous cachexia always present." 29 450 CANCER OF THE UTERUS. Prognosis, The prognosis of cancer is a gloomy one. Indeed, there is no dis- ease which so uniformly terminates fatally as cancer of the uterus. Notwithstanding this fact forces itself upon our observation, there will sometimes, in the course of a large experience, occur a recovery from it spontaneously and unexpectedly. I need not enter into the dis- cussion of the causes of this fatality. Whether the disease is essen- tially a blood-disease, or whether primarily local, there are but few instances in which it is not multilocular. It exists from the begin- ning, or very soon afterwards, in more than one place. Yet again, this is not invariably the case. We very seldom meet wdth an in- stance in which the area of deposit is small and confined to one locality. If this locality is accessible, the case possibly is curable. I say possibly, because the pathology is treacherous. This gloomy picture is in part relieved by the greatly improved palliative means we now possess. Very much may be done to allay the agonizing state of body and mind under its ravages. Treatment. Both medicinal and surgical means fail to give the profession much satisfaction in the treatment of cancer of the uterus. When the disease is clearly confined to the cervical portion of the organ, amputation of that portion holds out a very faint hope of cure. It is so common for the cells constituting the main bulk of the deposit to be scattered far beyond the apparent margin of the disease, that much more frequently than otherwise an abundant crop of them is left behind to continue the w^ork of destruction. Very rare instances of cure are reported. While, then, it is our duty to give our patient even a remote chance for recovery, we cannot hold out much hope of radical cure by removing the cervix. The same is true in reference to the operation for extirpating the entire uterus. The immediate danger attending the removal of the cervix need scarcely enter into our calculation of the benefits that may arise from it. This cannot be said, however, of the operation for exsecting the whole uterus. The dangers in this operation are manifold, and the results not far from fifty per cent, of deaths, while the immunity from a return is scarcely worth counting upon. TREATMENT. 451 I do not think the operation can be sustained by success until the immediate dangers are very much diminished. For these operations see Epithelioma. Can we reasonably hope for a cure of cancer by medicine ? I think this question can be unqualifiedly answered in the negative. I fully believe that the rapidity of growth may sometimes be re- tarded, and possibly stayed for a, length of time. Many medicines have enjoyed the reputation of curing cancer, and have been used with implicit faith, but I may safely say that not one does at the present time. I need not stop to inquire how such reputation could have been acquired, except to say that until within a comparatively recent date other and curable diseases were mistaken for cancer. Quite lately we have been assured of the great powers of cundu- rango in this direction, and for a time there were very slight reasons to hope that it was a useful if not a curative means in the treatment of cancer. It has enjoyed a place in the category of cures for cancer for a shorter time than many others. Within a few months a beam of light has fallen upon the subject which has again awakened the hope that possibly we are on the eve of finding a medicine capable of influencing this destructive cell- growth. Professor John Clay,* obstetric surgeon to the Queen's Hospital, Birmingham, has had some very fortunate experience with Chian tur- pentine in uterine cancer. The statement, coming from one whose professional character, so far as I know, cannot be impeached, and published in the staid old journal, the London Lancet, must com- mand general attention. Considering our experience in the cure of cancer the results obtained by him seem marvellous, and for fear of marring the face of his report I abstain from making my own sum- mary, but will quote his case in full, together with some of his re- marks. "A woman came to the hospital as an out-patient, aged fifty-two. She was suffering from scirrhous cancer of the cervix and body of the uterus. Haemorrhage was excessive, pain of the back and abdomen agonizing, and cancerous cachexia well marked. The patient evidently had not a long time to live. The uterus was so extensively destroyed by the cancerous ulceration that its cavity readily admitted three fingers. In such a case it appeared to be justifiable to attempt to relieve the * June number, the report of London Lancet, 1880. 452 CANCER OF THE UTERUS. snfferiDgs of the patient, even if the remedy should produce unfavorable symptoms, or should prove of no avail. I therefore prescribed Chiau turpentine, six grains; flowers of sulphur, four grains; to be made into two pills, to be taken every four hours. No opiates were prescribed or lotion used. No change was to be made in her diet or occupation. On the fourth day after taking the medicine the patient reported herself greatly relieved from pain, and was in better spirits, but she complained of a large amount of discharge. It w^as feared that she referred to a discharge of a sanguineous nature. On examination, however, the va- gina was found to be filled with a dirty-white secretion, so tenacious as to be capable of being pulled out ropelike, and this although she had syringed herself three hours previously. The os was quite contracted and would now scarcely admit the finger, and the surrounding swelling or cancerous infiltration of the cervix was much reduced. On the twelfth day the thick tenacious secretion had almost disappeared, and was suc- ceeded by a somewhat copious serous fluid. The os was not so firmly contracted, but would only admit the finger. The patient's general health was improved and the medicine well tolerated. Sixth week : I ordered her a quinine mixture in conjunction with the turpentine, but sickness supervened, which ceased on omitting the quinine. Twelfth week : My notes are, — the parts feel ragged and uneven, and do not bleed on roughly touching them. The speculum shows several cicatricial spots. The turpentine has been taken regularly during the day for twelve weeks every four hours, during which time she has been almost free from pain and has had no hseraorrhage ; no glandular enlargement ; general health improved. Walks easily to the hospital, being about a mile distant. As the patient did not come again to the hospital her address was ob- tained, and it was ascertained that she had left her residence. Being a widow she could not afl^ord to keep her home, and she went to reside with her married daughter in a northern town, but left no address. The case showed that the medicine was one of great power in cancer of the uterus, and it is to be regretted that an opportunity was not offered for fully carrying out the treatment. "Another patient, aged thirty-one, suflTering from cancer of the os and cervix uteri, was treated concurrently w^ith the one just mentioned. These parts were enlarged from carcinoma to the size of a hen's egg. The OS was dilated, and the cavity of the cervix was filled with epithe- lial growths, which bled freely on examination. Sacral pain was very severe, and haemorrhage had been continuous for the previous six weeks. The Chian turpentine and sulphur were given as in the previous case. The patient again attended at the hospital on the seventh day after tak- ing the medicine. She was in excellent spirits, and expressed her grati- tude for the relief aff*orded her. The medicine entirely relieved her 4 TREATMENT. 453 paiu. She had increased white discharge. On examination the os and cervix were found to be nearly of the normal size. The os was patulous, and its surface was studded with flabby shotlike eminences, which did not bleed on roirghly rubbing them. I said to her: 'You are better; you must continue the medicine.' She answered: * I should think I must, for I could not do without the pills ;' they have eased me so very much.' She continued to improve, and on the fourth week she expressed herself as quite well. I impressed upon her the necessity of cou tinning the medicine, and told her to see me occasionally. She did not come to the hospital again for four months, when she brought another patient to consult me, believing that she was suffering from cancer. I reproved her for leaving off attendance at the hospital. She answered that she thought it unnecessary, as she had continued quite well. On this visit she submitted to an examination. The os was rough and irregular, but was of nearly the normal size ; no signs of cancerous infiltration ; the periods were regular, and not profuse, and were unattended with pain ; there was slight leucorrhoea. This case was a most remarkable one. The turpentine acted upon the growth with great vigor, literally melting it away in the brief period of four or five weeks. "The third case was one of epithelial cancer of the os, cervix, and the body of the uterus, in a woman, aged fifty-two years. The vagina was not involved. The mass was larger than a cricket-ball, almost filling the vagina. The border of the os was three-quarters of an inch in thickness, forming a ring of two and a half inches in diameter, through which pro- truded an epithelial growth, principally proceeding from the anterior wall of the uterus, and projecting about two and a half inches into the vagina. The case was sent to the hospital for my opinion by my son, Mr. Langsford Clay, who had attended the patient but a short time. The journey to the hospital fatigued her very much, and she declared that she could not come again, and that she did not wish to remain as an in-patient, believing that she could not live many days. She had re- peated haemorrhages, had much pain, and had the cancerous cachexia well pronounced. My son volunteered to attend her at home, and I agreed to see her occasionally with him. I thought it advisable, as an experiment, to vary the treatment somewhat, and ordered to be added to the pills one-sixth of a grain of the ammoniated copper, as from the large mass to be acted upon I thought that an astringent should be super- added to the turpentine. The dirty-white, tenacious discharge, appeared and continued for the first five weeks, but there was no haemorrhage after the first examination. The swollen os uteri and the cervix beyond were the first to show signs of diminution ; this was noted on the fourteenth day. The tumor, however, was rough and shrunken, and did not project so much. Sixth week: The surface of the tumor was at the level of the 454 CANCER OF THE UTERUS. OS uteri, and seemed to consist of a mass of bloodvessels, which bled moderately after examination. This condition occasioned me some sur- prise, as three weeks previously the patient was ordered a lotion made with perchloride of iron, with a view to arrest haemorrhage, since from her anaemic condition it was feared that the loss of a moderate amount of blood would be followed by serious consequences. I asked her what kind of a syringe she used with the lotion? She replied, 'I thought the lotion was merely to bathe the external parts.' This, as it happened, was very satisfactory information, as it showed that the lotion had no share in the reduction of the mass, which now was scarcely half the original size. She was supplied with a syringe for the purpose of apply- ing the lotion, and after using it three days the mass of vessels had con- siderably shrunken, and no longer bled on manipulation ; but the surface of the growth had the touch and appearance of a gangrenous mass, but there was scarcely any fetor. The patient now complained of gastro- dynia, with colicky pains in the bowels, but she had no diarrhoea or vomiting. I believed this to be due to the copper, and it was con- sequently discontinued. It also appeared to me that the turpentine might not be efficiently digested in the solid form, and that it would be better if the remedy were administered in a state of minute subdi- vision, as in the form of an emulsion. An ethereal solution of Chian turpentine was prepared by dissolving one ounce of the turpentine in two ounces of pure sulphuric ether (anaesthetic). The ether dissolved the turpentine instantly. This solution was given to our skilful dis- penser, Mr. Whinfield, with a request that he would prepare a pleasant mixture or emulsion from it; and, after a few trials, he prepared one which is not unpleasant to take, according to the following formula : Solution of Chian turpentine, half an ounce ; solution of tragacanth, four ounces; syrup, one ounce; flowers of sulphur, forty grains ; water to sixteen ounces ; one ounce three times daily. This form of mixture was given to the patient, and was much liked. She has now taken the turpen- tine for thirteen weeks uninterruptedly. The os uteri is a little more than one inch in diameter, and feels like a ring of cartilage about a quarter of an inch in thickness. The tumor has nearly disappeared, and the finger can be introduced posteriorly into the uterus for more than an inch. The general health has much improved, and she is quite free from pain and looks cheerful, and is becoming stouter. No sedative whatever has been given during the treatment. Fourteenth week : She complained of severe ' cramplike pains' in the back and lower part of the abdomen, which she attributed to the mixture, and in consequence it was discon- tinued for a few days, and an opiate given, by which she was greatly relieved. The turpentine was again resumed. Nineteenth week : She is now fairly convalescent. The growth has almost disappeared, and the TREATMENT. 455 parts beyond the os uteri are somewhat hypertrophied, yet are almost normal to the touch. " The fourth case was that of a patient aged thirty-two years, who came to the hospital after having been discharged as incurable from the Women's Hospital. She was greatly depressed, and was most desirous to be cured, for the sake of her family of young children. She has had repeated floodiugs, and suffered greatly from pain during the past five months. Constipation very troublesome, which probably arose from the opiates she had been in the habit of taking. On examination, she was found to be suffering from epithelial cancer of the os and cervix uteri, but not involving the vagina. There was a cancerous mass of the posterior parts of the OS and cervix, of the size of a goose-egg. This growth pushed the os uteri towards the pubis, almost preventing that part from being felt. The turpentine mixture was given her three times daily, and from this period a very rapid diminution of the growth took place, so that by the six- teenth day it had almost entirely disappeared. The os uteri was now in situ, admitting the finger readily, and there was the same condition of the vessels as that observed in the preceding case. The lotion with the perchloride of iron was used daily for a few days with excellent effect. In the ninth week the patient suffered from spasmodic pains in the back and abdomen, and as this was attributed to the medicine, it was discontinued, and iodide of calcium, in five-grain doses, three times daily, was administered. This was taken for about a fortnight, but, not feeling so well, the patient was admitted into the hospital. The condi- tion of the internal organs was now much the same as before, the iodide of calcium was given, but there was some thickening about the cervix, which was fixed to the vagina. The rectum was excessively loaded, and required several days to effectually relieve it. The Chian turpentine was administered simply ; but a lotion was prescribed, containing six grains of white arsenic to one pint of water, to be used daily. Under this treatment the women very rapidly improved, the pains entirely ceased, and the parts became much reduced in size, and more movable. The patient was now anxious to leave the hospital for her home, as she felt quite well ; but it was deemed advisable to send her to the Sanatorium instead. She is very active, cheerful, and happy, and may be pronounced convalescent. " Other cases are under treatment, both in the hospital and privately, all showing similar effects. The remedy is now being tried in cancer of other organs, and apparently with good results. One of the most in- teresting, perhaps, is a case of scirrhus of the breast, which has been under observation for some weeks. Among the other cases are cancer of the vulva, stomach, and abdomen, in which very remarkable benefit has been already produced. "From the results obtained by the use of Chian turpentine, it may be confidently said that the remedy does exert a powerful action on 456 CANCER OF THE UTERUS. cancer of the female generative organs in particular, and it will be of advantage to point out some of the conclusions at which I have arrived respecting the efficacy of the drug, and the manner in which it should be employed. The oil of turpentine, if it produces any effect on cancer, is inadmissible on account of the speedy production of its specific effects even when administered in small doses. The same remark applies with less force to the Venice and Strasbourg turpentines ; in my hands they have not produced the same beneficial effects on cancerous growths as the Chian turpentine has done. The maximum dose of the last-named drug which can be safely and continuously given is twenty-five grains daily. It is advisable to discontinue the remedy for a few days after ten or twelve weeks' constant administration, and then to resume it as before. The combination with sulphur was given at first, and has been continued. It is doubtful whether much benefit is derived from the combination, but the effects have been so uniformly good with it, that it was thought advisable to continue its use. There is every reason to be- lieve, from the trials made with other substances in combination with the turpentine, such as carbonate of lime, iodide of calcium, ammoniated copper, quinine, berberine, hydrastin, etc., that the turpentine is best administered simply, as the most marked and rapid effects have always been manifested when it has been given alone. " The turpentine appears to act upon the periphery of the growth with great vigor, causing the speedy disappearance of what is usually termed the cancerous infiltration, and thereby arresting the further development of the tumor. It produces equally efficient results on the whole mass, seemingly destroying its vitality, but more slowly. It appears to dis- solve all the cancer cells, leaving the vessels to become subsequently atrophied, and the firmer structures to gradually gain a comparatively normal condition. " It is a most efficient anodyne, causing an entire cessation of pain in a few days, and far more effectually than any sedative that I have ever given. In the cases I have described no sedative was employed in any instance, although in some cases where great pain had existed previously to commencing the treatment, large doses had been given. Whether this arrest of pain arises from the death of the tumor, or, as my son sug- gests, is due to there being no longer irritation of the sentient nerves (in consequence of tension being withdrawn by the removal of the cells), the fact is the same. " If, after the use of the remedy for some weeks, one of these cases were examined by a stranger for the first time, he would probably con- clude that it was one of commencing malignant disease, by reason of the irregularities of its surface. The effect of the remedy being first to remove the cellular structures, any loss of tissue produced by the inva- sion of the disease cannot be restored, and hence the irregular touch and TREATMENT. 457 appearance even after cicatrization. The arrest of the h?emorrhagic dis- charge and the remarkable freedom from glandular affections, after a lengthened use of the turpentine, are especially important factors in materially aiding the removal of the cachexia, and of improving the general condition of the patient. " Without being in position to affirm that the Chian turpentine is a positive cure for advanced cancer of the female generative organs, yet, however, the facts here adduced may be interpreted in this respect, two circumstances are indisputable — one, that all the patients after several months' treatment are living, and that the disease has not advanced as is usually the case, but has retrogressed — in fact, has all but disap- peared ; and it may at least be safely asserted that when the remedy is steadily used for some time it arrests the progress of the disease, and re- lieves the pain incidental to the morbid growth in a manner which can- not be said of any other remedy. It is probable that on an extended experience of its use and by variations of the mode of administration, it may prove an effectual cure for this intractable disorder. Patience and perseverance on the part of patient and medical adviser are absolutely required. AVe know that in some diseases, as bronchocele and syphilis, a long continuance of well-known remedies is often necessary to affect a cure of the particular disorder, and that the administration of the remedies has to be varied from time to time, according to the thera- peutic effects produced by the drugs. In cancer, as far as experience has at present indicated, the same alternating method may perhaps have to be employed. Whatever may be the ultimate results there can be no doubt that Chian turpentine in these disorders is a most valuable medicine. Judging by my experience it is no figurative expression to say that it acts as a direct poison upon the growth, probably causing its ultimate death. In advanced cancer the process of reparation is slow, but if the surrounding structures are not too much involved in the pro- cess of destruction, it will seem that a cure may be reasonably expected. It is not that the remedy has failed against the cancer, but that the vital organs are so much destroyed that their complete reconstruction and adjustment of functions are not possible, and life fails in conse- quence of their mutilated condition. Even under these circumstances, if the cancer does not recur, the efficacy of the medicine is obvious. In the early stages of cancer it may be affirmed that an undoubted cure may take place speedily, and as the contiguous structures are not ex- tensively involved, but little deformity ensues; and experience justifies the expectation that under such circumstances a recurrence of the dis- ease will not follow. " The history of the local treatment of cancer of the uterus is one of singular interest, and is highly instructive to the practical physician. The contrast between the general and local treatment is the more notable, 458 CANCER OF THE UTERUS. as Dothing can be more injurious to the welfare of the patient than an attempt to destroy the cancer by external agencies. The disease is not to be averted by this means, as the symptoms assume a more intense and threatening character, until the patient rapidly sinks. It may be ob- served that the internal treatment here recommended when used for a considerable period is borne by the patient with remarkable tolerance. As I have mentioned, in some of my experiments I determined, in order most thoroughly to test the medicine, to reply upon this alone. Recently the arsenical lotion has been superadded, and with no injurious conse- quences — it appears to act as a disinfectant, and it may produce some benefit by promoting the cicatrization of the tissues. Several sugges- tions offer themselves for inquiry as to aiding locally the detachment of the growth, after its vitality has been destroyed ; but this is not of much importance, as there seems to be no fear of the blood becoming affected by the absorption of the decaying tissues, the turpentine probably pre- venting any such calamitous occurrence. "If the practice now described should prove by future experience to be justified, then it will be incumbent upon the medical adviser to treat cancer of the generative organs at an early stage of its development, and it is reasonable to conclude that this dreaded and most fatal disease will no longer be the scourge it has hitherto proved, and that another benefit will have been conferred upon suflfering humanity by the resources of therapeutic art." Palliation. There comes a time in the progress of cancer of the uterus that the patient is prostrated by the septic effects, caused by absorption of gan- grenous products at the surface of the degenerating mass. When this is the case we may often relieve the patient more by removing all the dead and dying tissue with a sharp curette and thermo-cautery than any other way. To do this the vagina should be dilated with Sims's or Simon's speculum until the parts are thoroughly exposed. Then with the sharp curette we should gouge out and remove in detail all the diseased substance down to the solid tissue of the cervix, and then cauterize the whole surface with the thermo-cautery. In this way, for a time, get rid of the haemorrhage, the fetid discharge, and often the distressing pain. . After this the patient's general health will almost always be greatly improved, and she a happy respite from her terrible suffer- ing. This operation may be repeated once or oftener, as the conditions seem to justify. One who has never tried this method of relieving the patient would PALLIATION. 459 very naturally be deterred from resorting to it by fear that the haem- orrhage would be dangerously profuse. A trial, however, will prove to him that this apprehension is groundless. If the curetting part of the operation is done briskly there will not generally be much hsemorrhaw, and the benefits resultino^ from it will far exceed the ill effects of the loss thus incurred. I mention this as the first and most important palliative measure to which we can resort, as the comfort of the patient will be promoted to a greater extent than by a resort to any other measure. Palliation of the pain, smell, and debility, is the object of the most of our treatment. We use local remedies for pain, introduced into the vagina. Of course, the anodyne and anaesthetic remedial agents constitute our resources for combating pain. Opium, belladonna, cicuta, hyoscyamus, and Indian hemp, may all be used locally for the pain. The best form for their application locally, is that of a bolus of five grains of pul. opii. We may instruct the patient to introduce the finely powdered opium through a small glass tube, with a piston of whalebone and cotton. It is applied thus to the ulcerated part and walls of the vagina in the neighborhood, and very effectually acts as an anodyne. Ten grains of the extract of hyoscyamus may be used as a bolus, or two grains of ext. belladonna ; and so on with all the anodynes. A grain of morphia may be mixed with the ext. hyos. to great advan- tage. Medicated injections often soothe the diseased part very much also. The watery extract of opium may be thrown into the vagina by a small syringe, and allowed to remain, the patient lying on her back for a length of time. Hydrocyanic acid in solution, gtt. xx to a pint of water, passed through the vagina, has a very pleasant effect some- times. Injections of vapors of the ansesthetics are highly recom- mended, particularly by Professor Simpson. Carbonic acid gas and chloroform are those most used. The chloroform vapor may be passed through the vagina by the ordinary perpetual syringe, made by the Union Rubber Company. The chloroform should be placed in the bottom of a large bottle, while the receiving-tube of the syringe may be passed through the cork and made air-tight with wax. The other end, being inserted in the vagina, high enough to almost come in contact with the dis- ease, the pumping may be commenced. The vapor will be caused to rise in the bottle quite rapidly under the exhausting influence of the syringe. Care should be taken not to let the tube deep enough in the bottle to come in contact with the chloroform, lest this fluid, in- 460 CANCER OF THE UTERUS. stead of its vapor, pass through the instrument. The vapor thus delivered into the vagina causes a sense of heat and glow, which very soon seems to replace the pain. When properly done, patients expe- rience great relief from this gaseous injection. The same apparatus will do to convey carbonic acid gas to the parts. The gas is gener- ated by mixing in the bottle carb. soda and tart, acid, and then pour- ing a little water upon it. Although I have never yet tried the effect of great cold to the part, I have no doubt it would be very effective in relieving the pain. It should be applied through the speculum directly to the parts diseased, and no other. A small amount of the freezing mixture, of two parts pounded ice and one part common salt, in a small muslin bag, is the means used by Professor Simpson. It is thought this cold not only relieves the pain, but that it retards the advance of the disease somewhat. The contact should be con- tinued until the parts assume a pale, bloodless appearance, when this is practicable, and may be used twice or three times in twenty-four hours. With the local remedies for pain maybe mentioned the sub- cutaneous injection of morphia over the sacrum, or in the iliac region. All local remedies for pain will, after awhile, fall short of the relief demanded by our suffering patients, and we will be under the necessity of introducing them into the system in a jnore effective manner. We must resort to their internal use. I need not mention the anodynes to which we would resort in such cases ; they are well known to the profession. I would, however, caution the student not to use opium when any of the others will answer the purpose. Indian hemp will be found to do this more frequently than any of the others. They will all fail, eventually, and opium will prove the great bless- ing in such cases. And let me add the further caution : to commence Avith as small doses as will answer the purpose; and while we deal liberally enough wath the drug to get its good effects, increase it slowly as possible, for with all our precautions in this respect we will be under the necessity of giving it enormously. The anaesthetics are too evanescent to be relied upon for main remedies, but they will render the influence of opium more prompt, and perhaps lasting. The haemorrhage of cancer will sometimes require prompt inter- ference. I think, however, that although the bleeding is always ulti- mately exhausting, that it is seldom immediately dangerous from its copiousness. I have generally, when the haemorrhage required in- terference, depended upon the introduction of small pieces of ice fre- quently repeated. It is often very grateful to the patient as well as haemostatic. Dr. Simpson recommends powdered tannin introduced PALLIATION. 461 through the speculum and placed on the part; but he places more dependence on a paste made of perchloride of iron and glycerin. If the bleeding should be very alarming, notwithstanding these means, the tampon would be our last resort. The offensive odor emanating from the disease makes it very de- sirable to have some means of correcting it. I should remark, witli reference to the plans often resorted to, that they are more or less injurious to the patient and attendant, viz., the burning of sugar, myrrh, etc., in the room. This should be done very sparingly. For the air, chloride of lime and good ventilation will do better than all other expedients. We do not wish to make a stronger smell less offensive, to be sure, but we desire to remove the effluvia. Burnt sugar simply fills the room with various other less offensive gases, which we breathe with them, the original cause of the trouble. Chlorine, disengaged from the chloride of lime, probably destroys the material floating in the air that offends the sense of smell. But the emanation may be lessened by the use of carbolized water as a w^ash and injection. Frequent changes of the linen and bedding of the patient are matters of cleanliness that, of course, will readily sug- gest themselves. Septicaemia is the condition which most commonly causes the great- est suffering and hurries the patient towards a fatal issue. Any pal- liative measure, therefore, which enables us to stay or modify its course, will prove a source of great relief. The absorption of the liquid products of the necrosed and sloughing tissue eliminated from the surface of the ulcer is the cause of the septic fever; hence a most important item in the palliative treatment of cancer is to keep the surface of the ulcer as free from dead and fungous substance as pos- sible. This may, and ought to, be done by removing it with the sharp curette as often as necessary. When we operate for the re- moval of the necrosed substance and fungus, the parts should be well exposed by Sims's or Simon's retractor speculum, the vagina thor- oughly washed out, and then freely sponged with the tincture of iron. This will enable us to see the line of demarcation between the sound and dead tissue. Then with Simon\s spoon every portion of the rot- ten substance should be freely removed. During the operation fre- quent washing away of the blood will be necessary, that we may see what we are doing. When the ulceration is extensive, and making its way toward the bladder or posterior peritoneal cul-de-sac, it will require care to avoid opening one of these cavities. Although I have done this palliative operation a great many times, 462 CANCER OF THE UTERUS. I have not seen an excessive loss of blood or any other serious eon- sequence follow it. It is always better, however, to be prepared with Fig. ISo. Fig. 136. P Sharp Curette, Sietnond's C^ixette. means by which to check the bleeding, and probably the best is tne thermo'cautery. If this, or some other form of cautery, cannot be PALLIATION. 463 commended, and haemorrhage is sufficient to require an haemostatic, a tampon of cotton, saturated with a solution of the persulphate of iron, may be advantageously used. It is surprising how much relief this little operation generally aifords. The patient will often be so much improved as to indulge in the hope that she is recovering from her loathsome disease. In a greater or less time, however, the symptoms will return, and may be again relieved by the operation. When a case is advancing slowly, this process of cleansing the ulcer may be profitably and safely resorted to a number of times. We ought not to try to remove any of the tissue beneath the ulcerated surface, but confine the operation to the scraping away of the necrosed substance. This same operation is applicable to cases in which there are frequent haemorrhagic discharges. It generally puts a check, and sometimes permanently, to losses of this kind, especially if followed by the use of the actual cautery or the ther mo-cautery. The history of this terrible malady discloses many disappointments in discoveries of cancer cures. The more recent discoveries of this kind are the jaborandi and Chian turpentine. The former temporarily tempted the credence of the more sanguine of the profession, but after repeated trials has been condemned as utterly w^orthless. The Chian turpentine, which, on account of the great respectability of its early advocate, seemed to hold out a faint hope that we were on the threshold of a valuable discovery, has been found wanting also. That the progress of cancerous deposit will ever be arrested by medicine is a problem for the future. That true cancer of the uterus can be cured by any kind of surgical operation is yet to be proven. Cancerous deposit in the uterus, if not the result of blood disease, is a focus from which widespread contamination emanates in every direction, to an extent that surgery cannot reach. Such is the melancholy paucity of our resources in cancer of the uterus. Scarce as they are, however, they may afford the suiferer great comfort ; and we should fall short of our duty if we did not industriously employ them, as the best the profession can afford. CHAPTEE XXXI. EPITHELIOMA, CANCEOID, EPITHELIAL CANCEE OF THE UTEEUS. All these terms, with many others, are applied to a fungoid de- velopment in and upon the mucous membrane of the uterus. It is essentially an excessive and modified proliferation of the epithelial cells, which destroys the membrane upon which it grows, and slowly penetrates adjoining structures. Its development is not by interstitial deposit, as in other varieties of cancer, but consists of superficial accumulations and soft deposits of epithelial cells, held together by very delicate, connective tissue. Fig. 137. The shape of the deposit, or growth, varies. In some instances it is thinly spread over a large surface, while in others it grows out as a fungus from a restricted area. In the former instance the whole mucous membrane of the cavity of the uterus may be overlaid and permeated by it, from the external orifice to the fundus, and thus be EPITHELIOMA CANCROID. 465 converted into a flat, friable covering of the deeper structure ; while in the latter there may be fungi, of greater or less size, projecting from the mUcous membrane of the uterine cavity ; but much more frequently they spring from one of the cervical labia, or the whole cervical circle. The substance of the membrane thus diseased is generally hyper- trophied, but not otherwise very much changed in character, until Fig. 138. the disease has made great progress on the membrane itself When the disease is situated in the endometrium the body of the uterus may be enlarged for a long time, and never attached to the other organs. When the growth occupies the external membrane of one of the cervical labia the submucous structure is sometimes increased so that it may project into the vagina much beyond its ordinary extent. This will give the appearance of a large fungus, while it is really the hypertrophied lip covered with cancroid deposit. At other times the labium is not so much enlarged, while the fungus projects down sufficiently to partially or wholly fill the vagina. In all of these varieties, after a time, "the more superficial parts of 30 466 EPITHELIAL CANCER OF THE UTERUS. the growth undergoes a process of necrosis and sloughs off. The par- ticles thus sphacelated, together with sanguineous and mucous fluids, constitute the discharges from epitheliomatous surfaces. Disintegration of this sort is generally accompanied with further growth, so that the size of the deposit is not materially, if at all, diminished. Fig. 139. Fungus Growing from the Cervix. When the process of disintegration has fairly begun the symptoms of cancer become developed, and gradually the role of septic symp- toms supervenes, and carcinomatous dyscrasia is established. Diagnosis. The symptoms of epithelioma are the same as in other forms of cancer. They have already been described, and I need not reproduce DIAGNOSIS. 467 them here. AVe may differentiate epithelioma from other forms of cancer by examination with the finger and sound. In epithelioma there is an absence of the irreo^ular hardness caused by the submucous deposit by the presence of a soft, friable projection into the vagina, or the same kind of substance occupying the whole of the cervix, not indurated, but somewhat enlarged. When this substance exists in the mouth of the uterus we may ascertain how far it extends by passing the sound through it into the cavity. The resistance to the instrument will be slight, yet sufficient to impart that feeling of re- sistance caused by its passage through a yielding tissue. If the de- posit is confined to the cervix the slight opposition to the advance of Structure of Epithelioma. — From Cornil and Ranvier. the instrument will cease before it reaches the uterine cavity. If it extends to the fundus the resistance will continue the whole depth of the organ. I can imagine, although I have not met with such a case, that a polypus in a gangrenous condition might embarrass us somewhat ia making a diagnosis. The use of the microscope would clear up the difficulty in such a case. A very small piece pinched ofp from the mass will suffice for examination. In the disintegrated substance of the polypus we would find the debris of fibrous tissue, while the cells of epithelioma would be found in the malignant growth. If a sarcomatous polypus should occupy the vagina the microscopic test would be equally decisive. From a decaying placenta, arrested in the os uteri, we would dis- tinguish the epithelioma by means of the microscope, in case any doubt should arise. 468 EPITHELIAL CANCER OF THE UTERUS, Prognosis. The prognosis is not so hopeless as in the other varieties of cancer of the uterus, as it is usually localized — in the earlier stages at least it is occasionally amenable to treatment. Without treatment it is equally fatal, as the morbid process is progressive to an unlimited extent. Treatment, The treatment of epithelioma of the uterus, as just intimated, is much more promising than the other cancerous affections. The cura- tive treatment consists in removing the whole of the disease, and ^yhen this is practicable we may reasonably indulge a hope of success. Fig. 141. Dr. Paquelin's Thenno-cauten-. This can generally be done when the morbid deposit is confined to the vaginal portion of the cervix, and sometimes when it extends to the fundus of the uterus. The means we possess by which this may be accomplished are the knife, the scissors, the ecraseur, — wire or chain, — the galvanocautery, and the thermo-cautery, or the actual cautery. I have performed the operation for removing epithelioma by all these different instruments separately, and by using several of them in the same operation. A TREATMENT. 469 Dr. John Byrne, of Brooklyn, in a very interesting article pub- lished in the second volume of the Transactions of the American Gynaecological Society, advocates the exclusive use of the galvano- cautery. He gives a number of cases illustrated by his method of operating, and of the success following it. The results are very en- couraging, and at the time his plan was published it was regarded as most promising. He exposed the cervix by his speculum, and ampu- tated it with his cautery knife, heated by the battery to a tem- perature that made it assume a dull red color; or, surrounding the Fig. 142. Fig. 143. Byrne's Cautery Battery. Byrne's Cautery Ecraseur. cervix, or that portion to be removed by the platinum wire, and then applying the battery so as to heat it to the same temperature. In doing the operation according to the latter method the cervix is fixed by the vulsellum, and, if movable, drawn down to a convenient dis- tance from the vulva, and the wire, while cold, placed around the cervix as high as possible not to include the utero- vaginal junction. In this position the wire is tightened while cold, and then heated. 470 EPITHELIAL CANCER OF THE UTERUS. Before heating the wire the constriction should be increased slowly until the wire has fairly imbedded itself into the included tissue. Quite forcible traction^ exerted by the vulsellum, should be main- tained while the wire is slowly passing through the substance of the neck. This will cause the central portion of the amputated cervix to be divided higher than the periphery, and the cavity will be conoid in shape with the apex in the centre. If the disease is not all removed by this operation the cautery knife may be applied, as dif- FlG. 144. rn Byrne's Cautery Electrodes. ferent parts are drawn down by hooks, until the operator is assured that all the disease is removed, or that the operation is carried as far as the integrity of the bladder and peritoneal cavity will allow. The prominent dangers in performing this operation are haemor- rhage, wounding the peritoneal cavity, and opening the bladder. The first may be avoided by having the temperature of the wire low. If it is white hot it will cut the tissues, including the arteries, without closing the latter. But if of a dull red heat it will coagulate the albumen in the areolar tissue, and the blood in the arteries, some dis- tance from the wire. In this way the vessels will be sealed and primary haemorrhage avoided. To avoid wounding the bladder or TREATMENT. 471 peritoneum, I am in the habit of applying the wire with the cervix in its normal position, and making traction after the wire has been drawn tight enough to fix it firmly in its bed. If we are careful to apply the wire in this way, there is not much danger of accident. When the disease does not extend to the junction between the vagina and uterus, this is an admirable method of removing the cervix. The objections I make to the galvauo-cautery are, that it requires more skill in the management of the battery than most prac- titioners possess ; that the burnt surface is so changed we are unable to judge whether at the point of separation all of the disease has been removed or not; that it is cumbersome as a portable instrument, and that it is no better in any respect and not so manageable as the thermo- cautery. I think also that the great heat generated in the vagina is not without objection. The advantages are that it destroys the cell growth some distance above the surface of the amputated stump, and the operation is entirely bloodless. I have not employed it in my recent operations. In removing the cervix for epithelioma, it wnll be very convenient, however, to have the galvano-cautery, or the thermo-cautery, as one of the instruments, but if we intend to thoroughly remove the disease, and especially if it extends above the vagino-uterine juuction, I think we can remove it more safely with the scissors or knife, or both. If there is much of a tumor projecting into the vagina, I generally apply the ecraseur around it, and include, if possible, the whole of the vaginal neck within its grasp. I use the chain instead of the wire in the ecraseur because I find it much easier to manage. We should be very careful in the adjustment of the chain to avoid injur- ing the bladder or penetrating the peritoneal cavity. In this part of the operation the galvano-cautery may be used in place of the Ecraseur. If we use the ordinary ecraseur, there is no need of dilat- ing the vagina with any sort of speculum ; but if we use the hot wire, then the vagina should be well dilated by Sims's speculum, Simon's retractor, or Byrne's speculum. After as much as possible of the vaginal cervix has been removed in this way, the most important part of the operation is just begun, because, in most cases we will not be sure of having removed all the diseased tissue. The surface from which the neck has been thus removed should be examined thoroughly. We can do this best by seizing it with the vulsellum or single hooks and drawing it down as low as possible, where it can be thoroughly examined. It will also insure precision to examine the portion amputated from the cervix to ascertain whether any of 472 EPITHELIAL CANCER OF THE UTERUS. the diseased tissue was cut through, or whether the cut surface is all sound or not. If we can assure ourselves in this way that the disease is all re- moved, we have little else to do than secure our patient from haem- orrhage. In my own operations I have had no trouble with any of the arteries divided. They usually spirt pretty freely for a few min- utes, and then gradually cease bleeding. I do not make this state- ment to encourage carelessness as to haemorrhage, because, in excep- tional instances, in the hands of other operators, there must have been dangerous cases. Hence, as a precaution against haemorrhage, and for the purpose of destroying the cell growth deeply, we should apply the cautery at a dull red heat all over the amputated surface. If we find by the examination of both amputated surfaces that we have not removed all of the disease, or if we have any doubt upon the subject, we should seize point after point of the remaining portion of the uterus and cut it off with the scissors, and thus excavate the supra- vaginal cervix and body of the uterus as high as practicable, or until we are satisfied that all the disease is removed. By the frequent examinations as we proceed in this part of the operation, while the whole is held down, we can keep within the peritoneal covering of the uterus. In operating in this way, we should often introduce the sound to determine the direction and depth of the uterine cavity above the excavation. The sound will serve as an excellent guide to our progress. If the vagina is roomy enough, we may sometimes have the sound held there most of the time. After we have excavated to the desired extent, we should char the surface of the artificial cavity with the ther mo-cautery. Dr. H. C. P. Wilson, of Baltimore, has invented an ingenious shield, with which the cautery is surrounded, to prevent the heat from affecting the parts anywhere except at the point of contact. Wilson's shield is a very useful addition to Pa- quelin's thermo-cautery. This operation should be repeated as soon as evidence of the return of the disease is apparent. Often when the cavity of the uterus has been curetted free from the epithelial deposit, that organ contracts, and, to some extent, obliterates the cavity formed by the excavation, and the area of the disease becomes less each time. In such cases we may repeat the operation with more prospect of removing the whole of the disease than in the first; and even the third or fourth opera- tion may thus advantageously be performed. Recent experience leads me to attach much importance to the very free use of the solution of the pernitrate of mercury. Small pellets of absorbent cotton satu- I TREATMENT. 473 rated with that fluid are placed in contact with the scraped surface, supported by larger pieces of dry cotton. These large pieces we use in such position and in such quantities as to completely protect the sound parts, by absorbing the free acid. I am encouraged in this Recommendation by the fact that epithelial cancer may occupy the rivucous membrane for a long time without vitiating the substructure deeply, by high authority, and by the result of my own observation. 1 prefer this before any other medicine, because it is absorbed and acts as a local alterative upon the lymphatics and the juices surround- ing the parts. Formidable as this operation really is, I have not seen it followed by untoward symptoms of any kind. In many cases I have excavated the uterus entirely above the internal os until the walls became very thin in every direction, and many others to a less extent. Opening the peritoneal cavity and bladder is one of the dangers in the progress of this operation. This can be avoided by care. Hsemorrhage is probably the only other danger, and with Paquelin's thermo-cautery, or the galvano-cautery, at hand we can easily check it by touching the bleeding artery. The operation may be followed by dangerous shock, primary or secondary haemorrhage, metro-peritonitis, cellulitis, or septicaemia. For the treatment of all these conditions, except haemorrhage, the reader is referred to ovariotomy. Injections of carbolized water, sufficient to keep the vagina well cleansed, is all that will be found necessary to secure the patient from blood-poisoning. Ordinarily the cavity is filled up in two or three weeks, and the wounded cervix covered with a firm cicatrix. In some instances, however, the process of malignant degeneration goes on, and we are restricted to palliative measures for the rest of the patient's life. If extirpation of the uterus is justifiable in any form of malignant disease it is so in epithelioma, for that disease is often entirely local- ized in the uterus, and yet occasionally so situated that we cannot remove the whole of it by any other operation. The formidable operation proposed by Freund, and practiced by him and his followers, has not been followed by a success that would encourage me to perform it under any circumstances. We may rea- sonably hope, however, that some method of exsecting the uterus which will be less difficult of performance and less dangerous in its results may be some day invented. Indeed, a long stride in that direc- tion has already been made, and is illustrated by an operation recently 474 EPITHELIAL CANCER OF THE UTERUS. performed by L. C. Lane, M.D., Professor of Surgery in the Medical College of the Pacific. Dr. Lane terms his operation pervaginal enu- cleation of the uterus. That term alone would mislead the reader, for the uterus was not enucleated ; it was extirpated, and the opera- tion might very properly be called colpo-hysterectomy, or vaginal ex- tirpation of the uterus. The operation is very simple, and does not involve the necessity of extreme and protracted exposure and handling of the abdominal organs. The wounding of tissue is less extensive, and the whole operation is done in the lowest and least susceptible portion of the peritoneal cavity. After placing the patient on her side, in Sims's position, and dilating the vagina with Sims's speculum. Dr. Lane had the uterus drawn down with Pean's tenaculum forceps, and then made an incision through the posterior wall of the vagina. " The fundus was then seized by the forceps and the uterus made to revolve on its transverse axis, so that the Fallopian tubes and ovaries were brought down low in the pelvic excavation in such manner that the base of the tubes and accompanying arteries became accessible and easily ligated. " Ligation was done with a strong silken cord so passed through but- ton-holes (?) in the broad ligaments that they could not afterward slip off. This portion of the operation was completed in fifteen minutes, but the detachment of the organ from the bladder was long and tedious, but finally successfully done without opening that viscus. Yet so thin was the remaining vesical walls that the lustre of the catheter, which served as a guide, at times could be seen. The organ being removed the pelvic excavation was rinsed out with a one per cent, solution of carbolic acid, a Nelaton flexible catheter was placed in the bladder, the pelvic excava- tion was filled with lint, saturated with four per cent, carbolized linseed oil, and the abdomen covered with india-rubber ice-bags. A drainage- tube was so fixed alongside the carbolized lint as to allow the escape of any fluids which should be passed out from the wounded surface. " The convalescence was uninterrupted." The description of the operation is very imperfect, yet I think it will not be difficult for the reader to follow it understandingly. The steps of the operation are : 1. The dilatation of the vagina by Sims's speculum. I believe Simon's position and retractors would be better. 2. Fixing and traction of the uterus downward. 3. Incision of the posterior vaginal wall, which should be in the central line and extend from the cervix to the recto-vaginal attachment. 4. Bringing the fundus uteri down through the vaginal opening by vulsellum forceps. 5. Ligating the posterior border of the broad ligament near TREATMENT. 475 the cervix uteri, so as to include the Fallopian tubes, ovarian liga- ments, and accompanying arteries. 6. Separation of the anterior sur- face of the uterus from the bladder. The first two steps of the operation need no further description than is given in the quotation. In the third step of the operation a fold in the centre of the posterior wall of the vagina should be drawn forward by the tenaculum, and incised with scissors. The incision should be perpendicular with, instead of across, the vagina, and large enough to admit the finger, by which we should be guided in com- pleting the opening from the cervix to the attachment with the rectum. What w^e are to av^oid in making this incision is the wounding of a loop of intestine or projection of omentum, which may occupy the posterior cul-de-sac, and, while dividing low enough, not to wound the rectum. The fourth will be facilitated by traction on the cervix, which will bring the fundus downward and forward within reach of the finger, and then permit the uterus to be retroverted within reach of the forceps. Drawing the fundus forward, up well toward the pubis, will so twist and condense the posterior portion of the broad ligament as to make the fifth step easy of accomplishment. With the posterior border of the broad ligament thus brought forward we can easily pass the needle containing the ligature from the vagina backward, or from behind forward, and secure the arteries with great facility. Without some caution another danger is that of including the ureters in the ligatures. The ureters approach the neck of the uterus in passing to the bladder, and at the anterior part of the cervix are within less than three lines. The ligature, therefore, should not be more than one-quarter of an inch from the cervix. The most difficult part of the operation is the separation of the uterus from the bladder. The fibrous coat of the bladder, where it is attached to the uterus, is very thin, and great care is required in sep- arating it from the uterus not to open the bladder. The direction given by Freund should be remembered. He recommends making an incision across the anterior surface of the uterus, through the peri- toneum and connective tissue. Then by means of the finger or handle of the scalpel, strip the bladder off from the uterus. When the point of vaginal attachment to the uterus is reached it may be carefully sepa- rated with the knife or scissors. The separation of the neck from the vaginal attachment and the side will be easy after the bladder is iso- lated. It seems to me that the operation of Dr. Lane would have had a 476 EPITHELIAL CANCER OF THE UTERUS. better conclusion if he had closed the wound either with silk or wire sutures. The most of the large opening ought certainly to be closed in this way^ and if the operation is performed under carbolized spray it would be better thus to unite the whole of it. Should we desire to amputate the body from the cervix this method of bringing the uterus out of the peritoneal cavity would give us an excellent opportunity with the minimum risk. A question very naturally presents itself in this connection^ Should we leave the ovaries in the pelvis after removing the uterus ? Redner explains how the favorable results in ovariotomy led also to the removal of myoma and carcinoma of the uterus by laparotomy, and then how more recently the unfavorable results of the method of operating advocated by Freund led to a neglect of laparotomy. This change was favored also by the fact that the large number of cancers springing from the cervix uteri could only be removed imperfectly and with difficulty by this method, hence we have drifted back to the older practice of attacking the organ through the vagina. Eedner himself operated several years ago in twenty-eight cases of carcinoma uteri through the vaginal wall, with almost invariable success (only three deaths, two by Infection, one by haemorrhage), by supravaginal excision of the cervix. And once having gone so far it was but a step to remove the whole uterus through the vagina. This procedure has recently been carried out almost simultaneously by Billroth, Czerney, and Schroeder. Eedner himself has operated in this manner on six cases within the last month, and his assistant, Hofmeyer, operated successfully, in a clinic, a seventh one. Out of these seven cases only one patient died, of internal hsemorrhage from a rupture of the ligamentum laterum uteri. Schroeder gives a short description of the steps of the operation. A Museux forceps is fastened upon each lip, the vaginal wall cut through, and all connection with the bladder broken up by the finger, in order to avoid any Injury of the ureters allowing them to escape upwards; then, through an incision Into the cul-de-sac of Douglas, the posterior connections of the uterus are severed and the uterus turned out through the opening, drawn down by means of the forceps, and cut off near the ligamentum lata. The arteries, which are thereby very much stretched, must be ligated. The ovaries and tubes are not taken out by Schroeder, because otherwise the ligament-stumps (espe- cially the ligamentum infundibulopelvicum) become so short that their ligation is very difficult, and secondary haemorrhage liable to occur. He ligates the vessels of the ligaments en masse, sews the stumps to each side of the vaginal incision, and carries a drainage-tube through be- TREATMENT. 477 tween them. After the necessary cleansing the antiseptic bandage is applied. The prognosis is not only considered good by Schroeder because the mortality figure is so small, but also because the convalescence is so rapid and easy, for in the cases cited only two showed slight fever and two others mild symptoms of collapse. As to the indications for such operative measures, Schroeder advises against interference when the cellular tissue of the pelvis is already invaded by cancer, which must be determined by careful palpation. He further calls attention to the fact that the larger the diseased uterus the greater will be the difficulties by this method, and the more appropriate will Freund's procedure become, and, at the same time, that in cases of cancer of the cervix situated low down we should be more conservative in either enucleation or supravaginal excision ; yet after all, notwithstanding all of the advantages of the new procedure, the former methods would still retain their merits, according as they might be selected in particular cases. In Martin's three cases he found such difficulty that in only one case was the operation complete. 2d case : Impossible to sever all adhesions; portion of diseased tissue remained behind. 3d case : Same kind of difficulty ; conclusion that firm adhesions and brittleness or friability of the uterus contraindicate the operation. Interrogated by Meyerbeer, Schroeder says he closes the vaginal opening with curved needle and silk, but recommends ligation of ligaments by wire. Baum (of Danzig) says he formerly operated successfully by supra- vaginal incision seven times, without resulting fever, that in only two cases had he failed to find a return, but in the last few months had operated per vaginam four times, two of the cases resulting in death from shock and septic peritonitis. He operated after Billroth's manner, and in one case removed the ovarian tubes, but applied no sutures in order to allow better drainage of the secretions. A drainage-tube was introduced, through which, in case of fever, the parts were washed out. Schroeder favors sutures which do not render septicsem-ia more liable and insure against protrusion of intestines.* Baum prefers his method, and thinks protrusion of intestine can be prevented by position. * Paper read by Schroeder (Berlin) on "Total Extirpation of the Uterus per Vaginam" in the gynaecological section of the fifty-third Versammlnng der deutsche Naturforscher und Aerzte in Danzig, in September, 1880. Reported in the Archives -uer Gynaecologie Sechszehnter Band, Drittes Heft. CHAPTER XXXII. SARCOMA. AxoTHER variety of malignant disease of the uterus is sarcoma. It generally shows itself in the form of a tumor, developed at the expense of the fibrous structure of the uterus, an apparently isolated portion of which is infiltrated by an abundance of peculiar cells. While not encapsulated, like the fibrous tumors, these growths dis- place the surrounding tissue, and protrude in a submucous or sub- serous direction until they become, to a greater or less degree, pediculated. When first discovered and described these tumors were denominated recurrent fibroids, because ablation did not destroy them. Their recurrence is, doubtless, due to the fact that, while apparently isolated, the neighboring tissues are permeated by the sarcomatous cells. Instances of diffuse sarcoma are also sometimes met with when all the tissues of the entire uterus are infiltrated. The cases of diffuse sarcoma with which I have met have all belonged to the small-celled variety, and the process of degeneration has spread from the uterus to the surrounding tissues, invading es- pecially the connective tissue of the broad ligament. Sarcoma is a less frequent disease than carcinoma or epithelioma. Symptoms. Its early clinical history is very similar to that of the fibrous tumor, and is more generally mistaken for it than any other growth. Serous leucorrhoea, metrorrhagia, and enlargement are the main ones. Its course is usually rapid, less so, perhaps, than cancer, and more so than fibrous growths. In some cases it attains to a large size before any peculiar phenomena appear. After a time, especially if sub- mucous or polypoid, it begins to break down, the discharge becomes offensive and copious, and the disease proves fatal in much the same way as cancer. The general symptoms in the early periods of development are not marked, and thev onlv become so after the tumor has ^rown larg^e enough to interfere by pressure with the fecal and urinary excretions, or in breaking up furnish septic material in such quantities as to induce septicaemia, when all the disastrous symptoms of that formid- i DIAGNOSIS. 479 able fever are established. Thus diarrhoea, copious perspiration, elevated temperature, rapid pulse, failure of the assimilative func- tions, and great nervous prostration tend to a fatal issue with as much certainty as any other of the malignant affections. Diagnosis. In the commencement it is always difficult to arrive at a correct diagnosis. The symptoms are not characteristic, and until the com- mencino; dissolution of the tumor are as much like those of fibrous tumor as they are like carcinoma, and when disintegration begins they thoroughly simulate cancer or epithelioma. The only sure diag- nostic sign of sarcoma is afforded by the microscope. A portion of Fig. 145. From Coriiil and Ranvier. the tumor should be submitted to microscopic examination, when the characteristic cell may at once be discovered (Fig. 145). Mr. Butlin* makes the following histologic distinction between sarcoma and carcinoma. He says : " I should, then, define carcinoma to be a tumor of epithelial origin, having generally an alveolar structure, and sarcoma a tumor of con- nective tissue origin, formed generally of embryonic tissues, and without alveolar structure. And, for the minor differences, the cells of carci- noma generally resemble those of the epithelium from which it grows ; there is little intercellular tissue; the vessels run in the fibrous tissues, not among the cells ; and multiplications of cells is by endogenous forma- tion. On the other hand, sarcoma is composed of round or fusiform or giant cells, and these are packed, in a more or less abundant basis ; the vessels are often mere fissures between the cells, and the cells increase in * Lectures on the Relation of Sarcoma to Carcinoma, by Henry Trentham But- lin, F.R.C.S. American reprint. London Lancet, February, 1881. 480 SARCOMA. number by division. These minor characters are common, but they are not constant. One or other of them may be absent in a tumor of either class ; or, worse, may be present in a tumor of the other class. More commonly it is sarcoma, which simulates the appearance of carcinoma; but, fortunately, this feigning takes place most often in textures where there can be no question of the origin, and therefore of the nature, of the tumor. The alveolar structure, found in some sarcomas, is rarely so perfect as that of most epithelial tumors ; indeed, careful study dis- covers that the tissue which surrounds the alveoli is generally formed of spindle cells. There is, in most cases, no real difficulty in assigning each tumor to its class." Prognosis. The prognosis is no more favorable than that of cancer. While in many instances the tumor caused by the morbid growth seems to be quite isolated^ the cells penetrate the surrounding tissue to such an extent as not to be eradicable. The contamination of the surrounding tissue does not seem to take place by absorption and transmission of the cells, or debris of the sarcomatous cells, but to be due to the insinuation of the cells into the contiguous substance surrounding the growth. It is, probably, always local in its origin and progress. This consideration, if true, would encourage us to hope that, by ablation of all the morbid sub- stance, we might arrive at a cure. Treatment. To be radical the treatment should consist of the entire removal of the growth. I have seen no cases in which any operation has re- sulted in more than temporary benefit. When the disease is confined to the uterus, I think the most rational treatment would be the re- moval of that organ. Hysterectomy would seem to me to be more promising in sarcoma than in carcinoma. In addition to the general palliative treatment, detailed under the head of cancer, the removal of sloughing masses by the curette and scoop, we will often derive great benefit from the free administration of ergot. The contraction of the uterus, under the influence of ergot, will do more to clear out the softening mass from its cavity than any instrumental interference. I have in several instances removed the sarcomatous growth by ergot so thoroughly that the improvement of the patients' health led them to hope for ultimate recovery. When the growth is submucous, and of the most friable variety, I would fully expect it to be expelled by ergot. It does not, however, affect the spread of the growth, and ultimate fatal result. CHAPTEK XXXIII. TUMOKS OF THE UTERUS. Any organized growth within the substance of the uterine walls, or depending from or connected with any of its surfaces, may be called a tumor. This definition will include polypi of all varieties and sizes, from the mere granule that renders the mucous surface irregular by its protrusion, to the growth which fills up the uterine cavity. Fibrous Tumors. Fibrous tumors of the uterus are homologous growths. They are not pure hypertrophies of certain parts of the uterine tissues. As proof of this the tumor-tissue exhibits too much of the rudimentary character of fibres of the undeveloped kind, and there is not a uniform proportion of the different constituent elements. For instance, we find that sQme specimens are quite firm and resisting, while others are frail. In the firmer variety, the fibrous element is more abundant than the connective, and these ought to be denominated myomatous or muscular fibrous tumors, while the term fibroma would be better adapted to those tumors in which the fibres of the connective tissues preponderate, and the tumor is softer. The question very naturally arises : How do those tumors origi- nate ? A question that cannot be satisfactorily answered. What we know about their "habits" I will lay before the reader. They occur more frequently in persons between the age of thirty-five and fifty, and are found oftener in women of African descent than in those of European or Asiatic origin. From much observation I am also persuaded that the long continuance of great hypersemia of the uterus strongly predisposes patients to fibrous tumors. Hence, we find them connected with sterility, dysmenorrhoea and menorrhagia. I know that these conditions are often the results of fibrous degeneration, but I have had opportunity of watching many such morbid states of the uterus, which, while giving rise to other symptoms, were constantly attended with hypersemia. In some such cases after years of suffering tumors were developed. One remarkable instance is in a patient who has been under my eye for fifteen years. She is a maiden lady, now forty years of age. A few years after she commenced to menstruate, 31 482 TUMORS OF THE UTERUS. she became subject to hypersesthesia and hypersemia of the uterus. Although I saw her, and made examination of the uterus several times a year during these fifteen years, I discovered nothing which induced me to suspect fibrous growth until three years ago. Then I could easily make out a tumor, with two nuclei of development in the anterior wall of the uterus. When first noticed, the tumor was half as large as an orange. It grew to four times that size in the next twelve months. I have seen so many cases similar to this that I cannot believe hypersemia and the development of the tumor to be a mere coincidence. We know that prolonged hypersemia is one of the necessary conditions of hypertrophy, and it is hardly possible to have hypertrophy without hyperplasia. It would seem, indeed, to be the hypertrophy of the vortices or foci of muscular gyrations in the undeveloped condition of the fibrous structure which leads to the formation of these tumors. Fig, 146. All fibrous tumors of the uterus have their origin in the wail of the organ. Some arise immediately in contact with the mucous membrane, then begin to intrude themselves into the cavity of the uterus as soon as they begin to grow, and become pediculated while yet small, d. Others commence their growth beneath a very thin layer of fibres, a. These are quite near the mucous membrane, but not in immediate contact with it. They very soon overcome the resistance of the thin layer of fibres, and pushing the mucous membrane before NATURE OF TUMORS. 483 them, become pediculated later in their growth. If, however, they are deeper in the wall, but nearer the mucous than the serous surface, the larger part of their bulk encroaches gradually upon the interior of the uterus, forming broad tumors that fill the cavity. They can easily be recognized by the finger after dilating the cervical canal. All of these varieties are submucous tumors, but in common profes- sional language the first two are called polypi, while to the last the term submucous tumor is generally given. The term intramural is used to indicate the tumor that arises in the centre of the uterine wall, B ; a tumor which in its development displaces the surrounding tissues alike in every direction. In point of fact the exact central mural tumor is very rare, the great majority having their nidus ex- ternal or internal to the central layer. The subserous tumor varies in its relative distance from the peritoneal surface in the same manner as the submucous from the lining membrane of the uterus. Hence, some of them spring from the outer surface of the uterine wall, are suspended by a very slender pedicle, and covered only by the peri- toneum, E. Others are not so pendulous, but still are enveloped by only a very thin layer of fibres externally. If they are still more remote from the peritoneal surface, they merely show themselves as bulky protuberances on the outside of the uterus, c. One more state- ment with reference to position. They are usually developed in the wall of the body, and comparatively seldom have their origin in the cerv^ical portion of the uterus. This statement is true of every variety. Their Nature. A dissection of these tumors enables us to discover that they are surrounded in most instances by a well-marked capsule. It ought not to be called a cyst, for it has not a separate organization, and it is formed by the tissues surrounding the tumor, being compressed as they are displaced, until the inner surface of the cavity becomes smooth. At a number of points the capsule and surface of the growth are connected by frail fibrillae and vessels. The number and magnitude of these connecting fibres and vessels vary, but it is ex- ceedingly uncommon for vessels of considerable size to enter any of these tumors, and the vascular supply is proportionately small. From these facts the logical deductions, namely, that fibrous tumors of the uterus are of slow growth, of low vitality, and not usually reproduced from their capsule, are corroborated by observation. The source of their nutrition, or their vascular supply, is diffuse, coming through many small channels at various points in their periphery, and not, as 484 TUMORS OF THE UTERUS. in the ovarian tumors, from one great artery. Such a supply is the cause of a somewhat definite period of vitality. It is not capable of maintaining the growth to an indefinite degree, and a disturbance of its nutrition may easily occur. Thus, after they attain a certain magnitude, they are likely to stop growing, and in many instances they degenerate into a lower form of tissue, resembling cartilage, or even to descend still lower in the scale of vitality, and be partially changed into a cretaceous deposit. Again, their low vitality subjects them to the process of inflammation or eremacausis. Inflammation, resulting in gangrenous disintegration, is one of the accidents that sometimes brings about their discharge and cure. At other times it occasions the death of the patient during the complicated consequences thus arising. I have witnessed both of these terminations. The fibrous tumor of the uterus is frequently multiple. The position occupied by the growth is accompanied by a number of important effects. When situated in the centre of the wall — intra- mural — it grows more rapidly than when in the subserous portion of the fibrous structure, but probably not so vigorously as when nearer the mucous membrane, or when it belongs to the submucous variety. In fact it will generally be found that the nearer the peritoneum the nucleus of origin, the more slowly will the tumor increase in size. We also find that the intramural and submucous varieties cause the uterus to grow and become vascular with much greater cer- tainty than the subserous. Indeed, we often find very large subse- rous tumors growing from a uterus of comparatively small dimen- sions. The tumor may be not less than ten times the size of the organ to the fundus, of which it is attached. If a tumor of this size w^ere developed in the centre of the wall of the body of the uterus, the depth of the cavity would be not less than six inches. While the uterus in such cases is more than ordinarily vascular, it is not so much so as it would have been if the tumor had belonged to the in- tramural variety. Of course the polypous, or submucous tumor, de- velops the uterus with more uniformity than the intramural variety. The uterus, in the cavity of Avhich there is a polypus, grows with nearly the same symmetry as if pregnant. It logically follows from these facts that the submucous and intra- mural varieties are the most mischievous, as the more rapidly the uterus grows, the more certainly will it do mischief by pressure; and the more vascular the uterus becomes, the more haemorrhage will occur. And we find from observation that these inferences are cor- rect. NATURE OF TUMORS. 485 Again we find that developed in certain zones of the organ their behavior and effects are different. Fibrous tumors comparatively do not often originate in the cervical portion of the organ, and when they do their growth is not very rapid, nor do they cause the uterus to become very large. In the corporal zone they grow most rapidly, cause the uterus to enlarge faster, and do more mischief. Lastly, in the fundus their activity of growth is less rapid, and produce less morbid changes upon the organ. In examining uteri containing fibrous tumors, which have fallen under my observation, I have noticed that the character, as well as the degree of its development, has varied quite considerably. The growth of the fibrous structure of the uterus is not exactly the same in character and degree as in pregnancy. The fibres are cer- tainly enlarged, and they become muscular, but in very few localities do they attain to the same perfection as in pregnancy. In the subserous variety they do not anywhere attain to the per- fection of pregnancy, and are usually quite rudimentary in their character. Nor do they possess much contractile power. In the in- tramural tumors the fibres surrounding the growth attain much greater dimensions, and acquire great power. Seldom, if ever, how- ever, do they assume all the qualities of the fibres in the gravid uterus at term. In these cases the fibres in the opposite wall do not keep pace with those surrounding the tumor. In the submucous variety the fibres external to the tumor in the same side in which they origi- nate are largely developed, while those between the tumor and mu- cous membrane attain considerable length, but are attenuated, and lack strength. This is one reason why they are pushed into the cavity of the uterus. When the tumor is polypoid, and occupies the cavity of the uterus, especially if it comes from the body near the fundus, filling up and distending the cavity of the body in every direction, it causes great uniformity of development of the fibres. The fibres all around grow more as they do in the pregnant uterus, attain great power, and usually expel the growth into the vagina. Very nearly the same statements may be made in reference to the growth of the vascular system in the different varieties of tumors. The vessels are more enlarged on the side occupied by the tumor in the intramural and subserous than on the unoccupied side. They are more generally enlarged in the intrauterine polypus. It may be further stated that a single tumor grows more rapidly, causes greater vascularity in the uterus, and brings about greater 486 TUMORS OF THE UTERUS. hypertrophy of the fibres of the uterus than the multinuclear fornn. Indeed, were numerous points of growth to commence at the same time, although great bulk may be attained, the bulk consists in the morbid deposits more than in the growth of the physiological struc- ture of the uterus. This is so markedly the case that after a certain time this kind of tumor stops growing for the w^ant of vascular sup- ply, and becomes transformed into a dense tissue of a vitalit}^ far be- low that in the single tumor. It sometimes becomes a true fibroid deo^eneration of the whole uterus, in which it would be hard to trace any of the anatomical elements peculiar to that organ. Symptoms. From this exposition of the growth and effects of tumors upon the surrounding structures, it will be readily inferred that the symptoms observed in connection Avith fibrous tumors of the uterus are not the same, and must vary greatly in the different varieties. The most frequent symptom is haemorrhage, either at the time of menstruation or during the intervals. In the early periods of the growth the pa- tient will observe profuseness in the menstrual flow, and some cases occur in which this is the only time when there is loss of blood, but in very many instances the losses take place at irregular intervals, and sometimes the discharge is so irregular that the patient will lose her knowledge of the time when she ought to be unwell. In quite a large proportion of cases there is no deviation from the ordinary habit of menstruation. The patient is regular. The variations of this hsemorrhagic symptom conform, in general, to well-known conditions, and we may expect to find the haemorrhage more profuse th^ nearer the tumor is situated to the mucous mem- brane. In hsemorrhagic cases we shall also find that the size of the tumor has much to do wdth the flow. The larger the tumor, other things being equal, the greater the haemorrhage. Large submucous tumors will, therefore, cause more profuse haemorrhage than any other sort. In estimating the value of the rule in the correspondence of these conditions, we must remember the frequent coexistence of small submucous with large subserous tumors, and that, as there are excep- tions to all rules, we may sometimes have profuse haemorrhage in subserous, and small losses in submucous tumors. The latter excep- tion, however, is very rare. Leucorrhoea, consisting of thick, tenacious mucus, from the cer- vical cavity, is perhaps the next most frequent symptom, and it is generally governed by the same rules with respect to frequency and SYMPTOMS. 487 profuseness as metrorrhagia, being greater in quantity in submucous than subserous tumors. Watery discharges from the uterus are also a common and signifi- cant symptom. They occur more frequently just after, and appear to be supplemental to, the hemorrhages; and I must observe with reference to them, also, that they are usually more profuse in sub- mucous tumors. It will be observed that all the discharges — hsem- orrhagic, leucorrhoeal, and watery — show themselves under the same circumstances, and there is a very good reason for this, which I men- tion in passing. The cases in which the tumors are so situated as to greatly increase the vascularity of the uterus, are also the cases in which these discharges are more profuse. Dysmenorrhoea is not so commonly met with as the three symp- toms already mentioned. When it does occur it is of the obstructive variety. It is manifested by cramping pain recurring at intervals. We may account for its assuming this phase by the fact that the tumor encroaches upon the cavity of the uterus and renders it tortuous, and in some cases occludes it by forcibly pressing the sides together. The blood is accumulated above these obstructed places, and the pains are caused by the efforts of the uterus to expel the blood thus imprisoned. The subserous tumor is the only kind that may not occasionally cause dysmenorrhoea. It is probably more frequently present where there is a number of nuclei of development, some of them being sub- mucous. Among other symptoms, I wMsh particularly to call attention to that of presmre. It begins very early in the progress of these growths, and is quite often noticed. The first evidence of pressure is suffering in the pelvis. When the tumor first becomes enlarged, the uterus presses upon the perinseum, and this pressure causes a feeling of un- usual weight in that region. This ^'bearing-down sensation'^ may increase until, finally, the uterus and vagina may protrude through the vulva; the womb may also fall backwards upon the rectum and produce tenesmus or other uneasiness in that organ; and not unusu- ally haemorrhoids are thus developed with their attendant symptoms. Should anteversion occur, the bladder will suffer from the pressure in the various forms of clysuria, and even inflammation in that viscus. When the tumor is located in the posterior wall, the uterus is retro- verted; when in the anterior, it is anteverted. When the organ is enlarged equally in all directions, it will be prolapsed. As it enlarges so as to fill up the pelvis, the pelvic veins are sometimes so pressed upon as to retard their circulation, and there may arise varicosity in 488 TUMORS OF TOE UTERUS. the legs, anus, vulva, and surrounding parts. The nerves suffer from the pressure in such a way as often to manifest sciatica, and crural and vulvar neuralgia. When the tumor is large enough to rise out of the pelvis, it may cause pressure upon the abdominal viscera, and by its bulk, hardness, and irregular shape give rise to great inconvenience from distension of the abdominal cavity, producing more suffering than the same dis- tension from most other causes. Several important complications are likely to result from pressure, such as inflammation of the pelvic viscera, cystitis, rectitis, cellulitis, and local peritonitis. I need not stop to give the symptoms of these complications, as they are the same as when arising from other causes. The pelvic inflammation sometimes extends to the veins passing through the cavity, and gives rise to phlegmasia alba dolens. Abdominal inflammations also complicate these cases, some forms of peritonitis especially. A moderate peritoneal inflammation may result in serous effusion, and the ascites sometimes gives rise to more trouble than the tumor, being in some cases the immediate cause of the fatal result. The consideration of the effects caused by pressure exerted by these tumors leads me to the subject of their progress and development. It may be said of them, in a general way, that their growth is slow. This is especially so as compared with most other growths. In very many cases it requires years for them to attain a magnitude suflicient to endanger the patient's life. Indeed, some patients carry them through a long life without experiencing more than a slight incon- venience. Occasionally exceptional instances occur, however, in which the growth is rapid and very destructive. The conditions which promote their growth are now pretty well understood, especially the general proposition : that the more vascu- lar the uterus becomes from any cause the more rapid their growth. The converse of this statement becomes a necessary corollary. They grow rapidly during pregnancy. During the period of life in which the menstrual discharges occur in a normal way, the tumor grows more rapidly than after the menopause. The submucous in- crease in size with more rapidity than the subserous, and the tumor centrally located in the uterine wall generally requires for its devel- opment a period of time which may be regarded as a mean between the other two. The multiple ones advance more slowly than the single tumors. There is one circumstance which may add greatly to the vitality of any of these growths, and consequently cause them to DIAGNOSIS. 489 grow with great energy. I allude to adhesions to the visceral or parietal peritoneum. When extensive adhesions occur, the vessel of the adherent surface penetrates the uterine tissue and greatly increases its vascularity. This is so remarkably the case in rare instances, that the peritoneal surface of the tumor becomes reticulated with large vessels. The growths thus usually become very formidable. Occa- sionally, tumors that have grown so slowly as to seem stationary in this respect, suddenly start up, and their behavior is entirely changed. We see this in subserous tumors in a remarkable manner. It is hardly necessary for me to remind the reader that this change is generally preceded by inflammation, and that this is the cause of adhesions. When the tumors, as sometimes happens, undergo interstitial de- generation in such a manner as to cause cavities in their substance, they grow rapidly by an accumulation of fluid in these hollow spaces. This change constitutes a new variety, which is called fibro-cystic. They often become very large, grow very rapidly, and are mistaken for ovarian tumors. Some of our most expert specialists have been betrayed into their removal under this misapprehension, and have been made aware of their mistake only after a careful examination subsequent to their extirpation. Diagnosis. We learn, after much observation, that the history and symptoms, although very important items in the diagnosis, are not sufficient to establish it, hence we are obliged to resort to physical examination. Another observation may be made in this connection; the greatest difficulties in forming a correct diagnosis will be experienced in tumors of each extreme in size. The medium-sized tumors may be diagnosed without much trouble. In cases of small-sized tumors we cannot always determine without much care whether the enlargement of the uterus is due to a tumor or some other cause. In such cases the depth of the uterus should be measured by the sound. While the sound is in the uterus, and that organ held in its normal posi- tion, the finger is to be passed as high as possible into the rectum, and the posterior wall thoroughly explored. If there is a tumor in that part it will be found thickened and nodulated. Should this not be the case a male catheter should be introduced into the bladder, and the anterior wall of the uterus carefully surveyed. If the symptoms are sufficiently grave to excite apprehensions, and yet leave an un- 490 TUMORS OE THE UTERUS. certainty, the finger may be passed into the bladder instead of the catheter ; otherwise it should not be used. To ascertain the existence of a small intrauterine or submucous growth the cervix should be dilated with sea-tangle, or compressed sponge- tent, until the finger can be passed into the cavity of the body, when there will be no difficulty in finding the tumor. iSTone of these proceedings are justifiable, if there is tenderness or other signs of general inflammation of the uterus. It is more frequently the case that the tumor is evident, and then the object is to ascertain if it is uterine. To determine this question it is necessary to discover its attachments. This may be done by placing one finger on the mouth of the uterus, and another in the rectum to move the tumor. If it is attached to the uterus they will move together. We should be careful, in making this kind of an examination, to make the movements vary in direction ; if possible, the tumor should be moved from the uterus, or upward, or down- ward. The tumor ought to carry the uterus with it when moved in any direction. If the sound is passed into the uterus, and the tumor moved afterwards, the instrument, as may be seen, will very plainly indicate the movement of the organ. The cavity will also be in- creased in length. When a tumor is large enough to be felt above the pubis the attachment will be more easily made out by moving it with the hands pressed upon it from above, while the sound is in the cavity, or the finger on the cervix. The second most important diagnostic indication is the firmness of the tumor. The fibrous tumor is usually hard and not elastic. Another almost essential circumstance has just been alluded to, viz., . the increased depth of the uterine cavity. The history of the case will generally enable us to decide, whether the tumor under exami- nation is one caused by inflammation or not; the inflammatory tumor moreover is seldom movable. A haematocele is behind the uterus, is elastic, and has the shape of the cul-de-sac, instead of being globular. When the tumor is large enough to fill up the abdominal cavity, and become immovable in consequence of its bulk, it is not always but usually elastic. If so, it has become fibro-cystic. We cannot always determine the relation of these tumors to the uterus by the methods I have described. Often we are unable to introduce a sound into the uterine cavity, in consequence of its tortuous direction, and the diagnosis becomes extremely difficult. These are the tumors, as I have before said, that have been mistaken for and removed as PROGNOSIS. 491 ovarian tumors. Probably the only positive way of clearing up the diagnosis, is to draw off some of the fluid with a trocar, or aspirator, and make its character the test. Dr. Washington L. Atlee, of Phil- adelphia, in his admirable work on the diagnosis of ovarian tumors, has furnished us with a description of the fluid derived from this kind of fibrous tumor, that is every way correct. The fluid does not run out of the canula of the trocar with the facility with which the ovarian fluid is evacuated, and often when it is received in a vessel, and becomes somewhat cool, it coagulates, and like blood separates into clot and serum. When examined by the microscope, debris of blood-corpuscles and fibrillse of fibrin are the characteristic substances found. One other circumstance I have failed to call attention to is, that fluctuation observed upon percussion is less decided than in ovarian tumors. If the tumor is larw enouo;h to distend the abdo- men, it may be complicated with peritoneal dropsy. This condition also renders the diagnosis obscure. Tapping will generally enable us to arrive at correct conclusions. After the ascitic fluid has been re- moved, an examination of the tumor will enable us to establish its relations to the uterus, as well as determine its density and shape. The fluid in these cases should be submitted to microscopic exami- nation with a view to ascertain whether it came from an ovarian cyst or the peritoneal cavity. Prognosis. There are several considerations which render the general prog- nosis favorable as compared with other tumors for which they may be mistaken. They occur generally in persons who have made a near approach to the menopause, and generally they cease growing after this con- dition is passed. They grow slowly, and may not be expected to arrive at dimensions sufficiently great to cause fatal consequences for many years, if ever. They often stop growing without any discover- able reason ; they sometimes undergo degeneration into inert masses, which remain as mere inconvenient bodies. jS^ature sometimes gets rid of them by expulsion, or they may be protruded from the uterus into the vagina, within reach of surgical measures. Lastly, many of them disappear under judicious medical treatment, or all the threatening symptoms attendant upon them may be removed by such means. Almost none of these conditions obtain in ovarian tumors and very few in any others found in the same locality. These considera- 492 TUMORS OF THE UTERUS. tions ^'ill establish the conclusion that the general prognosis is favor- able. The circumstances which in individual cases form an unfavorable prognosis are : the youth of the patient, as they usually grow more rapidly in young persons; the rapid growth of the tumor; hsemor- rhagic symptoms; unfavorable complications, as peritoneal dropvsy, inflammation in the pelvis or abdomen, pressure upon the pelvic or- gans, nerves, or vessels; inflammation of the tumor, impaction in the pelvis, uraemia, anaemia, pregnancy, ovarian tumor, etc. The fibro- cystic variety possesses several elements of danger ; its rapidity of growth being the cause of several others, as pressure, impaction, dropsy, etc. The complications of pregnancy and labor with fibrous tumors of the uterus is one of sufficient importance to demand special consideration, especially as we may be obliged to determine a course of action when the emergency leaves no time for research. The simple coexistence of a fibrous tumor with pregnancy is not suf- ficient reason for interference, and I am persuaded from personal observation that there are but few cases which call for any interfer- ence whatever. I do not wish to be dogmatic, but I desire to make a few definite statements of what I regard as facts. Pregnancy takes place more frequently when the tumor is situated in the central zone of the uterus and remote from the mucous membrane ; but it will not occur if the tumor belongs to the submucous variety, although it is in the middle, or even in any part of the uterus except the cervical portion of the inferior zone. I have already intimated that there are very few large tumors developed in the inferior or cervical zone compared with those that arise from the central corporeal and superior or fun- dal zone, and that such as these are usually developed in the submu- cous tissue and are generally pendulous — these do not appear to in- terfere very much with pregnancy. From what I can learn and have observed pregnancy seldom, if ever, takes place when the tumor, being of more than moderate size or situated near the mucous mem- brane, is located in the fundus or upper portion of the superior zone. In general the larger the tumor the less likelihood of pregnancy, and if it does occur the impossibility of normal uterine development leads to abortion. The dangers to be apprehended arise usually at the time of labor and consists: 1, In the obstruction to delivery caused by the tumor blocking up the pelvis; 2, in the incomplete contraction after deliv- PROGNOSIS. 493 erv failing to close up the placental vessels, and thus causing grave, if not fatal, haemorrhage. Tumors situated in the superior zone, the middle zone, or the upper portion of the inferior zone will offer little obstruction, because the head will have passed them above the pelvic brim. This leaves but a limited number and those small in size that are crowded down into the pelvis by the side of or before the fetal head ; they are the submucous or polypoid variety situated in the cervical portion of the inferior zone. Such tumors are generally pressed entirely out of the vulva and permit the head to pass out after them. I may mention, in passing, that they may sometimes be de- tached from their base by the pressure of the head ; or, remaining intact, may be retracted within the pelvis after the labor is over. The second danger is, I think, very much overrated. The fact of the fibrous tissue of the uterus having been developed sufficiently to permit of the completion of gestation is an evidence that it is sufficiently pow- erful to contract fully, and one single case recently published by Dr. Chadwick, of Boston, in which the placenta was implanted on the uterus over the seat of the tumor, and in which haemorrhage did not prove serious after delivery, goes far to prove that great danger from this cause is not likely to occur. In no case of labor associated with a tumor Avhich has come under my own observation has hsen^orrhage been a grave symptom. It is fair, I think, in the light of our present knowledge, to infer that it is seldom necessary to interrupt pregnancy when complicated with fibrous tumors of the uterus, as, in the nature of things, gesta- tion will not continue unless there is sufficient integrity of uterine tissue to permit ample development. At the time of labor the indi- cation for operative procedure will appear in the want of progress, and then the obstacles may be surmounted by turning, or forceps, if the propulsive powers of the uterus are not sufficient. Common pru- dence will incite to vigilance in preventing haemorrhage in these as in other complicated cases of labor. It will be observed that while I cannot ignore the importance of watching these cases attentively, I am far from considering them as necessarily very dangerous. Another question of great importance is, what effect does preg- nancy and labor have upon the tumor ? In a minority of cases none whatever. The tumor remains the same after the pregnancy has terminated as before. But in the ma- jority of cases it is far otherwise. In three instances of this nature, which have come under my own observation, the tumors have disap- peared ; and the manner of their disappearance is worthy of remark. /194 TUxMORS OF THE UTERUS. In one instance, occurring two years since, the tumor was located in the posterior wall of the uterus, apparently in the central portion of it, and occupied the middle zone. The pregnancy proceeded without accident, and the patient was delivered at term of a dead foetus, w^hich, judging from appearance, must have been dead three days before labor came on. Moreover, according to the calculation of the mother, the first pains did not appear until two weeks after the expiration of two hundred and eighty days. The head was arrested at the superior strait and impinged upon the symphysis pubis, but was easily moved fcom this position. I did not see the patient until four hours after the membranes had been ruptured. At this time the presenting part did not advance; and, after consultation with the attending physician. Dr. John F. Williams, of this city, it was considered best to interfere. I introduced my hand, seized one of the feet and brought it down. There was no great difficulty in the turning or delivery. The placenta came away in a few minutes with a very slight loss of blood. I had first seen this patient when gestation had advanced to the end of the third month. At this time I believed the tumor to be about the size of a fetal head at terra. It was extremely hard, and presented two distinct nodules. At this consultation I advised non-interference. I saw her again several times during her preg- nancy. She was a primipara. After the delivery of the placenta I felt curious to know what effect the pregnancy had upon the size and consistency of the tumor. In order to determine these points I in- troduced one hand into the uterus, and with the other manipulated above the symphysis. In this way I could fix and handle the tumor with facility. It then seemed to be about the size of the fetal head and very hard. The division between the firmly contracted uterus and the tumor was marked by a well-defined sulcus, traceable by the hand, above the pelvic brim. The tumor seemed harder than the contracted uterus. I had the opportunity of seeing and examining this patient frequently during the year succeeding her accouchement. The tumor was decidedly less in three months, and continued to dis- appear. At the expiration of twelve months it was no longer per- ceptible, and the cavity of the uterus measured but two inches and a quarter. The patient now menstruates normally in every respect. The careful observation of this case convinced me that the tumor had not grown materially larger nor become softened during gesta- tion, and led me to believe that the process of absorption began and proceeded with the subsequent involution of the uterus. What effects may have been wrought upon its tissues by the contractions during PROGNOSIS. 495 labor I cannot of course determine ; but the gradual disappearance of the tumor and the non-appearance of inflammatory or other urgent symptoms plainly indicate that the contractions of the uterus during labor could not have produced any very violent effects upon it. It was also evident that the tumor was absorbed and slowly removed without disturbing the good health of the patient. In the other two cases I verified the existence of fibrous tumors before pregnancy took place, and one of them I saw again after a lapse of five months, but was not present at the time of parturition of either of them, nor have I seen them subsequently. I have been assured, however, by letters from their attending physicians, that they recognized the tumor after labor, and that they both disappeared within a year. CHAPTER XXXiy. FIBEOUS TUMOES OF THE UTEEUS, CONTINUED. Treatment. The treatment of fibrous tuDiors of the uterus consists largely of the means calculated to relieve such symptoms as endanger the life of the patient or materially aifect her general health. TMien these are unayailing, resort is had to measures calculated to get rid of the tumor. Some remedies necessary to the relief of symptoms act as very powerful curative agents ; hence, while it is convenient to speak of the treatment of symptoms under one division of the subject, and the methods employed for radical cure under another, we cannot, in fact, completely separate these two branches. The reader will not be surprised, therefore, if I feel myself obliged to depart from this arbi- trary method of presenting my subject. Haemorrhage is by far the most important of the symptoms con- nected with these growths, because it is at the same time the most frequent and hazardous. It is also the symptom that leads to most suffering in consequence of depriving important organs of the blood necessary to support them in their functions. Every means, there- fore, should be made use of not only to prevent fatal losses but also to prevent even slight haemorrhage. In the outset, therefore, I would insist upon watching with great vigilance to prevent any unusual loss of blood. It wnll be understood by this that I advise not to tem- porize by adopting the milder and less efficient measures as being sufficient for cases not likely to prove fatal, but to treat all hemor- rhage arising from this cause with promptitude and energy. Fortu- nately in many cases we can anticipate the attacks of haemorrhage because we know when they will recur, and we are generally able to judge of their probable severity. To discharge our doty in this respect effectually, our patient should be properly provided with remedies and fully instructed how to use them. She should be made to understand that unusual haemorrhage at the meubtrual period may be checked without endangering her general health. Among the remedies are, dorsal recumbency with the hips elevated, cold to the hypogastric region, and cold to the dorsal spine and sacrum, which can be effected by means of a rubber pillow filled with ice water, TREATMENT, 497 ergot and some form of tampon. The best fluid extract of ergot in drachm doses, if the stomach will bear it, is probably the most effica- cious medicine, but the fresh drug in the form of infusion is also very efficient. Full doses should be given every half hour when there is much loss, until some effect is produced upon tlie haemor- rhage, and then continued every four hours as long as necessary. Compressed sponges saturated with the solution of alum make the best tampon for the patient to make use of. These may be made and kept in readiness, so that they can be introduced as soon as they are found necessary. The patient or nurse can make them by taking a fine sponge, large enough to fill the vagina, passing a ])iece of strong string through the centre to aid in its removal, and then, after dipping it in the solution, well winding it with twine from one end to the other, compressing it into as small a space as possible. The twine should so compress the sponge as to make it assume an elongated form. It should then be laid aside and permitted to dry. Several sponges should be thus prepared and dried. When necessary the twine may be unwound and the sponge introduced. Its size when in the dry condition will allow of an easy passage into the vagina, wdiere the moisture will cause it to expand, thus filling up and seal- ing the vagina so as to absolutely check the discharges. If the at- tending physician is present he may tampon the vagina with pellets of cotton secured by thread and moistened with the solution of iron, as recommended by Dr. Sims and others. The inconvenience ex- perienced from this ironized plug will be more than counterbalanced by the saving of blood. This form of tampon has the additional advantage of being antiseptic. I have allowed it to remain for three days, and upon removing it satisfied myself that there was no decom- position of the blood or the vaginal secretions. When the tampon is removed it will not be found difficult to wash out all the granular clots caused by its presence. It may be repeated as often as neces- sary, but usually if allowed to remain forty-eight hours the haemor- rhage will not return. It may be said that for small losses this is unnecessary, but I think this is a more convenient form of tampon than any other that will answer the purpose. In dangerous cases no one will question the propriety of its employment. Another very important means of arresting haemorrhage, which can be used by the physician when necessary, is the introduction of a compressed sponge into the cervix uteri for the purpose of dilating it. This will temporarily act as a tampon and stimulate the uterine fibres to contraction. A point of much importance in the use of the 32 498 FIBROUS TUMORS OF THE UTERUS. tampon or sponge, is the avoidance of septicsemic poison, and I know no medicine so efficacious and handy as th^ preparation of iron I have mentioned. The pressure of the tumor upon the pelvic viscera is another in- convenience which calls for attention. This takes place usually at a time when the tumor has acquired a size sufficient to fill that cavity. Consequently the elevation of the tumor above the pelvis is the remedy. This may be done sometimes by placing the patient in the knee-elbow position and opening the vagina by two fingers, and then pressing the growth upwards. The powerful influence of atmos- pheric pressure called to our aid, by the position and opening of the vagina, is a very material auxiliary in the process of elevation. If this is not sufficient, we may pass tlie fingers into the rectum and elevate the tumor. I once succeeded in this operation by using an ivory-headed cane in the rectum when the fingers failed to reach high enough. Dysmenorrhoea is another symptom of fibrous tumors, and some- times a very distressing one, which we are often called upon to re- lieve. It depends, no doubt, as I have before said, on the imprison- ment of blood in the uterine cavity, in consequence of the tortuosity of the canal causing the closure of some part of it. The remedy con- sists in dilating these narrow places. I know of nothing so well cal- culated to effect this object as the slippery elm tent. A tent of this material, long enough to reach the fundus uteri, and of sufficient size, moistened so as to render it very flexible, may be passed up through these tortuous places with great facility. If introduced as soon as the symptom begins to manifest itself, and allowed to remain an hour or two, the relief will be pretty certain. If used once a day, for four or five days before the attack, and three or four hours at a time, dysmenorrhoea may be generally avoided. When we broach the question of the permanent cure of these afl'ec- tions, we find that great difference of opinion exists among the mem- bers of the profession as to the value of medicines. One part, per- haps a majority, believe that no medicine has any direct effect upon them, and they ignore any means of permanent relief but surgical. There is, however, a respectable number of medical men who place great reliance upon the administration of certain medicines, and, if I am not mistaken, recent observation has added greatly to their num- ber. They do not, however, wholly agree as to the therapeutic pro- cesses that should be instituted, and consequently do not employ the same kind of medicines. Some gentlemen have more confidence in TREATMENT. 499 what I will term the sorbefacient process of treatment. They endeavor to institute measures that will cause the absorbents to attack and remove the neoplasm in the same way that tumefactions caused by effusions are removed. This they do by friction, pressure, and the administration of the old-fashioned sorbefacient medicines. The most popular among these are the iodides, chlorides, and bromides of mer- cury, potassium, sodium, calcium, and ammonium. Reports may be found in books and our periodical medical literature of cures by several, if not all, of these articles and their combinations. The late Dr. W. L. Atlee, whose experience has been very extensive, had great confidence in the action of hydrochlorate of ammonia. He caused it to be ad- ministered internally, applied externally, and used as vaginal injec- tions. The iodide of potassium has long enjoyed a great reputation in causing the absorption of these and other forms of tumors. There is no professional fairness in assuming that the faith in these reme- dies, derived from the observation of their effects, or the promulga- tion of cures from the use of sorbefacient measures, are fallacious. Some of the men arrayed in favor of the opinion that cures may be effected by a patient, and long-continued administration of some one of the articles I have mentioned, stand high as men of honesty, accu- racy of observation, and faithfulness in their records ; and for one I give full credence to their statements. Yet I must also say that I have not witnessed the good results which I unhesitatingly believe others have seen from the sorbefacient treatment alone. Others who expect much from medicinal treatment look to that class of medicines which causes contraction of the unstriped muscular fibres as the most promising. With these medicines they expect to diminish the supply of blood to the tumor, by causing con- traction of the arterioles traversing their substance, and thus disturb- ing their nutrition to such a degree as to stop their growth, lessen or destroy their vitality, and so render them subject to the influence of the absorbents, whereby they may be removed. Some of the more energetic of these medicines, as ergot, for instance^ often affect these growths very promptly. I shall limit my remarks upon this class of medicines to what is known of the effects of ergot. As an introduction to what I have to say of ergot I submit the fol- lowing propositions : 1. When properly administered, ergot fre- quently very greatly ameliorates some of the troublesome and even dangerous symptoms of fibrous tumors of the uterus, e. ^., haemor- rhage and copious leucorrhoea. 2. It often arrests their growth and 500 FIBROUS TUMORS OF THE UTERUS. checks hseraorrhage. 3. In many instances it causes the absorption of the tumor, occasionally without giving the patient any inconve- nience ; at other times the removal of the tumor by absorption is attended by painful contractions and tenderness of the uterus. 4. By inducing uterine contraction it causes the expulsion of the polypoid variety. 5. In the same way it causes the disruption and discharge of the submucous tumor. There are many cases on record to substantiate every one of these propositions. From what I consider well-authenticated sources, including the cases under my ow^n observation and in the practice of my friends and neighbors, I have collected one hundred and thirty-six cases of fibroid tumors treated by ergot. Of these, twenty-five cases were cured without giving the patient any inconvenience from painful con- tractions. In forty-six cases the tumors were diminished in size and the haemorrhage was cured. In twenty-seven others the haemorrhagic symptoms were relieved, while the size of the tumor was not affected. In eight other instances the tumors were broken to pieces and ex- pelled piecemeal. At the risk of being tedious I will copy the summary of cases and opinions reported to me and given in my address on obstetrics made before the American Medical Association in 1875 ; Cases. It is well known that Professor Hildebrandt, in a communication ,to the twenty-fifth number of the Berliner Wdchenschrift, as early as 1871 called the attention of the profession to the utility of ergotin in the treatment of fibrous tumors of the uterus. While administer- ing it by hypodermic injections to moderate the haemorrhages, so often a troublesome symptom in connection with these growths, he was struck with the decided diminution in the size of the tumor. A con- tinuation of the remedy thus administered resulted in the entire dis- appearance of one of them in fifteen weeks. In eight cases, all but two underwent great improvement. The great pain caused by injection rendered the treatment intolerable to one of these two patients. In the other the treatment was discontinued on account of ergotic in- toxication. In four others, the tumors were greatly diminished, and promised speedy cures, but for various reasons the treatment was not continued. One tumor of huge size, reaching above the umbilicus? totally disappeared; while another, extending to the ribs, and largely CASES. 5U1 distending the abdomen, was greatly reduced. The debilitating haemorrhages and leucorrhoeal discharges were promptly relieved in six of them. In the American Journal of Obstetrics for January, 1875, Dr. Hildebrandt gives a synopsis of nineteen more cases treated by him. Two of these were cured; and in six others the tumors were greatly diminished in size, and the haemorrhages relieved. In eleven of these cases all the disagreeable symptoms were relieved, but the size of the tumor was not perceptibly affected. The last two cases reported in this series of nineteen were not benefited. Soon after Professor Hildebrandt made his first report of cases. Dr. Bengelsdorf read a paper upon the subject at a meeting of the Griefs- wald Medical Society. He alluded to four cases in which he had used the hypodermic injections of ergot. Two of these w^ere in pa- tients after the menopause ; neither of them seemed to be influenced by the treatment. In the other two the patients were menstruating and the subjects of severe metrorrhagia. This symptom in both cases was very much mitigated, but the tumors were not materially, if at all diminished in size. Treatment was interrupted in one of them after the administration of sixteen injections. Dr. Bengelsdorf was favorably impressed by the treatment. Dr. Chrobak, of Vienna, reports, in the seventh volume, second number, of the Archives fitr GyncECologie, nine cases. In the first, the tumor the sizef of a small apple was partially expelled from the cavity of the body into the cervical canal ; the mouth of the uterus was dilated by sponge, and the protruding segment removed with the scissors. In case second, after forty-three injections, the tumor, which was situated in the posterior wall of the uterus, was not re- duced in size, but the haemorrhage was cured. The tumor in case third consisted of several nodules in the anterior wall of the uterus ; after twenty-four injections, there was no diminution in size, but the haemorrhage was cured. In case fourth the tumor was situated in the posterior wall and reached up to the umbilicus ; after three in- jections the treatment was discontinued on account of the pain and inflammation caused by them. In the fifth case the amount of haem- orrhage was reduced, but the treatment was discontinued for the same reason as in case fourth. The tumor in case sixth was large, the uterus rising above the umbilicus; after twelve injections with- out results, the patient could not be induced to receive further treat- ment. The seventh patient was fifty-seven years old, and the tumor showed a multitudinous development; the second injection, which 502 FIBROUS TUMORS OF THE UTERUS. was administered eight days after the first, caused severe symptoms of collapse, and the treatment was discontinued. The tumor in the eighth case was in the anterior wall of the uterus and reached above the umbilicus, and the monthly flow continued from eight to ten days ; seven injections were used, with diminution of the tumor and improvement in the hsemorrhages ; the treatment in this case he ex- pected to continue at some future time. In the ninth case the uterus was anteverted, and the cavity measured four and three-fourths inches in length ; after twelve injections the haemorrhages ceased and the tumor diminished in size ; the uterine cavity measuring only three and one-third inches in length. Dr. Lombe Atthill records three cases in the Irish Hospital Ga- zette for September 1st, 1874. The first case was benefited in the diminution of the flow and the improvement of health. The second case was under treatment but a very short time ; only five injections were administered, when the patient refused to permit another be- cause of the severe inflammation following them. The third case was benefited, but abandoned from the same cause. Dr. J. P. White, of Buffalo, IS". Y., writes me that he believes it is in this direction — the use of ergot — we must look for relief in the intramural and non-pediculated varieties of uterine fibroids. He says that in the last year and a half he has resorted to ergot in these vari- eties with marked benefit. In a few instances they have been com- pletely absorbed, and in a larger number the growth of them was arrested, the tumors were diminished in size, and the haemorrhages were suspended. He says that the number of his cases is fourteen, and that not more than one-third can be called cured, while in almost the same proportion, the growth has been stayed or diminished, and the bleeding arrested. Dr. E. W. Jenks, of Detroit, Michigan, now of Chicago, in a re- cent letter, says he has used ergot during the past two years in the treatment of fibroid tumors of the uterus with the most gratifying results. Seventy-five per cent, of all cases thus treated were bene- fited, as manifested by arrest of growth and control of haemorrhage. About ten per cent, of the patients he considered cured. Dr. H. C. Howard, of Champaign, 111., sends me an account of two cases treated by him. The first case was in an unmarried woman. The tumor was one originating from a single nucleus, intramural, and as large as a pint measure. He administered hypodermic injec- tions of ergotin for some weeks, and afterward continued treatment for eight months by administering internally the fluid extract of ergot CASES. 503 and belladonna. This case, he says, was entirely cured by his treat ment. His second case was in the person of a married woman, forty years of age, and the mother of two children. When first seen by him she had been the subject of severe floodings for three years. He found, upon examination, a submucous fibroid as large as a quart cup. He used large quantities of ergot by vaginal injections and by the mouth for four months, at which time the tumor had entirely disappeared. Dr. A. Reeves Jackson reported to the Chicago Society of Physi- cians and Surgeons, April 13th, 1874, five cases of fibrous tumors of the uterus treated by hypodermic injections of the solution of the solid extract of ergot. The tumors in four of these cases were intra- mural ; in the fifth the tumor was subperitoneal. The tumor in one was entirely cured ; in two others the tumors were greatly diminished in size. In another the tumor seemed unaffected, but the profuse haemorrhages from which the patient suffered were diminished in frequency and profuseness. The fifth, a subperitoneal tumor, was not benefited. Dr. Jackson reports to me three other cases. One was in a colored woman ; the uterus reached to the umbilicus ; it was entirely cured in three months. In the second the tumor reached above the um- bilicus ; this was temporarily reduced in size by the ergot, but, after treatment was abandoned, it regained its former dimensions. The treatment was discontinued by the patient because of the distressing pain and contractions which occurred after eight weeks' use. The profuse uterine haemorrhage was checked, and health improved. At the same meeting of the Society of Physicians and Surgeons at which Dr. Jackson's first five cases were reported. Dr. Etheridge reported one case entirely cured. His diagnosis was confirmed by Drs. Gunn and Miller, Dr. Etheridge's associate professors in Rush Medical College. Dr. Fisher also reported an intramural fibrous tumor cured in six weeks. I saw this case, and have no doubt of the correctness of Dr. Fisher's diagnosis. On the same occasion Dr. Merriman, one of my colleagues, re- ported three cases ; one, intramural, in the anterior wall, cured ; one, subperitoneal, pediculated ; the health of this patient Was much im- proved, and the growth of the tumor checked ; the patient was still under treatment. The tumor in the third was intramural. At the time of reporting, the size was gradually diminishing. Dr. John Morris, of Baltimore, Md., communicates to me a case that seemed to be decidedly benefited by the ergot treatment; but. 504 FIBROUS TUMORS OF THE UTERUS. on account of the violent uterine contractions produced by the remedy, the patient would not consent to continue the treatment. Dr. Charles E. Buckingham, of Boston, Mass., has tried hypo- dermic injections of ergot in the treatment of fibrous tumors of the uterus in but one case. The result was entirely negative. Dr. George Cowan, of Danville, Ky., reports a case in the person of a colored woman, unmarried, and about forty years of age. The hypodermic injections of ergotin were used for two weeks. At the end of this time the greatest circumference of the abdomen was re- duced from thirty-six inches, which it measured before the treatment was instituted, to twenty-eight and one-half inches. The patient, returning home, used the injections herself. Such frequent and pain- ful abscesses ensued, however, that she discontinued them. During the use of the injections an obstinate constipation was removed, and her general health much improved. The abandonment of the treat- ment was followed by a return of the constipation, loss of flesh, great debility, and the abdomen increased in size until it measured thirty- two inches. A return to the treatment was followed by the same marked improvement in the general health, and a reduction of the size of the abdomen to twenty-seven and one-fourth inches. Dr. H. W. Dean, of Rochester, X. Y., sends me an account of two cases treated by him. The first case was that of a patient, forty- seven years of age, the mother of three children, the age of the youngest nineteen. She suffered from pressure upon the bladder and rectum, and Avas the subject of severe menorrhagia. The tumor extended two inches above the umbilicus, and occupied the lower half of the right lumbar, the whole of the right inguinal, and fully half of the corresponding left abdominal regions. The os uteri was a little to the left of its natural position, and sufficiently open to admit the finger half an inch. An elastic catheter was introduced into the uterine cavity between seven and a half and seven and three- fourth inches. The diagnosis was interstitial fibrous tumor of the uterus. Intrauterine injections, through the elastic catheter, of half a drachm of Squibb's fluid extract of ergot, were made four times during each menstrual interval, from April until October, 1874. Injections into the substance of the cervix were made with the same frequency from October to the middle of December. The results were, reduction in the size of the tumor until the upper margin sank two inches below the umbilicus, and the uterine cavity measured only four and a half inches. The second case was that of a woman, forty-eight years of age, the CASES. 505 mother of three children, the voung^est of whom was sixteen. She flowed irregularly, the intervals varying from one to three weeks. The flow was profuse and attended with great pain. In the inter- vals there was a copious flow of serous leucorrhoea. She also suffered from pressure upon the bladder and frequent micturition. The tumor occupied the right side of the abdomen, extending nearly to the um- bilicus, and to midway between the linea alba and the left ilium. The vagina could not be satisfactorily explored until the hand was introduced. When this was effected the finger could be easily passed into the uterus. Between the finger thus introduced and the hand on the hypogastric region, the presence of an interstitial fibrous tumor was diagnosticated. A flexible catheter was passed into the uterine cavity to the extent of eight inches. Injection into the sub- stance of the cervix was followed in fifteen minutes by continuous uterine contractions, which lasted twenty-four hours. This injection was repeated four times a month. When the amount was increased from fifteen to twenty minims, great gastric and cerebral disturbance, together with intense cutaneous engorgement and uterine pain, en- sued. The injections were continued from Xovember, 1873, to the middle of the year 1874. At this time the upper margin of the tumor was but one inch above the symphysis pubis, and the cavity of the uterus measured four and a half inches. Menstruation was quite normal as to time and quantily, and attended with little pain. The pelvic organs were not subject to disagreeable pressure. Dr. W. C. Wey, of Elmira, X. Y., in a lengthy and interesting letter, gives me the results of his treatment in one case. The patient was forty-seven years old. The bulk of the tumor was equal to both closed hands. It was reduced in six weeks about one-third, and in six months to one-half of its original size. The patient, before the treatment, was very much reduced ; her extremities had become (Edematous, and exercise was almost impossible from the effects of haemorrhage, which had become almost constant. These symptoms were relieved with great promptitude and in four months the menses had become normal in every respect. His treatment was continued twenty-seven months, but most of the good results, if not all, were obtained in the first six months. Dr. Edward M. Hodder, of Toronto, writes me that the number of cases in his notebook, since May, 1873, is twenty-five; but all of these reside at a distance, and therefore he saw or heard of them only occasionally. Xearly the whole of them were treated witli ergot, but not exclusively, as he combined with it the bromide and iodide of 606 FIBROUS TUMORS OF THE UTERUS. potassium. In the majority of the cases, treatment appeared to arrest further growth, and after a time caused the tumors to diminish in size. In a few cases the tumors disappeared entirely. He gives four cases in minutiae : in one case the treatment was commenced May, 1873; the tumor nearly disappeared, and the patient is now six or seven months advanced in pregnancy. In the second case, the treat- ment was begun in June, 1873; the tumor was greatly diminished in size, the patient became pregnant, and was delivered late last autumn. In the third case the treatment was commenced in Sep- tember, 1873; the tumor disappeared, and the patient is now preg- nant. In the fourth case treatment was commenced in September, 1873, and the tumor is now nearly gone, and the patient feels quite well. Through the kindness of Dr. Hodder I have received the report of another case by Dr. Jukes, of St. Catherines. The tumor was discovered by Dr. Jukes at the time of delivery after a normal preg- nancy. The history of the case shows that its existence had been recognized by Dr. Hodder before the patient was married. Dr. Jukes gave the fluid extract of ergot continuously to this patient for three months, first in doses of one-half drachm, and afterwards in- creased the dose to one drachm, combined with the various prepara- tions of iodine. From the beginning, the tumor slowly decreased in size, and at the end of three months had entirely disappeared. Some weeks after delivery, he passed the sound into the uterine cavity six inches, and the organ reached very nearly to the umbilicus. After the three months' treatment the measurement by the sound showed the organ to be very slightly above its normal size. Dr. Strange, of Aurora, Canada, says that he had on several occa- sions given ergot internally to arrest the haemorrhage attendant upon fibrous growths in the uterus, and had observed that it tended to re- tard their further growth. Dr. L. F. Warner, of Boston, has used ergot in two cases of fibrous tumors of the uterus, but could perceive no beneficial effects. Dr. J. H. Thompson, Surgeon in Chief of the Columbia Hospital for Women and Children, reports three cases treated by ergot, in all of which the tumors were reduced in size, the metrorrhagia cured, and the general health, which in all was much impaired, was entirely restored. In one of these cases Dr. Thompson injected the ergot into the substance of the tumor by passing this instrument through the cervical cavity, and thence penetrating the growth. No unpleasant effects followed this method of using the remedy. CASES. 507 Dr. Riissel, of Oshkosh, AYisconsin, reports one case in which the tumor of large size was very much reduced, and all the disagreeable symptoms were removed. During the year since the last meeting of the Association I have treated seven cases. One was not affected by the ergot, and the patient died six weeks after the commencement of the treatment. She was anaemic to a de- gree wdiich I have seldom before seen. The remedy was adminis- tered hypodermically every day, thirty drops of Squibb's solution of the solid extract being injected each time. The second patient "was the subject of a uninuclear tumor, situated in the anterior wall of the uterus, about the size of the fetal head. She had profuse haemorrhages at her menstrual periods, and copious leucorrhoeal discharges between them, and had become very ausemic. The discharge ceased and the tumor disappeared in five months from the time she first came under my care. The remedy was at first used hypodermically ; but, on account of the pain and inflammation at the punctures, I was obliged to cease this mode of administering it, and gave it internally. Teaspoonful doses of Squibb's fluid ex- tract were given twice a day for the last three months of the time the patient was under treatment. In three other cases, in which the medicine was given internally, the tumors were very much reduced in size, but did not disappear. The haemorrhages and leucorrhoea were cured, and the patients re- stored to health. In another, the haemorrhages and leucorrhoea were rendered much less profuse, but the tumor was not reduced in size. In a colored senile patient, over sixty years of age, with a large multiple tumor, no effect was produced by the ergot. In four of my cases I w^as obliged to suspend the treatment several times for a few days, to give the patients a respite from the almost constant pain. Five of these complained of great heat and tenderness of the uterus after they had been under treatment about four weeks. In all, the pulse was accelerated and remained small and weak. As one of my cases presented some features of more than ordinary interest, I will give it more in detail : The patient had been married twelve years, was thirty-seven years old, and sterile. She had been aware of the existence of the tumor for three years, but could not give a very clear history of its progressive enlargement. The uterus extended three inches above the pubes, and was a little to the right of 508 FIBROUS TUMORS OF THE UTERUS. the median line, very hard, and irregular in shape; but I could not discover that there were subperitoneal nodules. Per vaginam, the tumor could be felt to occupy the right side and anterior wall of the uterus, and fill up two-thirds of the pelvic cavity. The cavity of the uterus measured four and a quarter inches. A polypus, pyriform in shape, quite firm in consistence, about the size of a pigeon's egg, depended from the mouth of the uterus, and appeared to be attached to the upper part of the posterior wall of the cervix. The diagnosis was intramural fibrous tumor of the uterus, with two nuclei of de- velopment, and a fibrous polypus. The patient was somewhat anae- mic from the long continuance of profuse leucorrhoea and metror- rhagia. Without removing the polypus, I commenced treatment by giving the patient three grains of the solid extract of ergot three times a day. The next menstrual flow was not so profuse, and the leucor- rhoea diminished almost from the beginning. At the end of four months the menstruation was normal, the leucorrhoea had ceased, the tumor was reduced to half its former dimensions, and the patient's health restored. A continuation of the treatment two months longer causing no further reduction of the tumor, it was suspended. During the treatment, I w^atched with much interest the effects produced upon the polypus, examining it once in every ten or twelve days. It showed decided decrease in size at the end of the first ten days, and progressively decreased until, at the expiration of four months, it was not more than one-third the size it presented when first examined. It was twisted off at this time with great ease, and its removal was followed by almost no loss of blood. The most remarkable case of which I have any knowledge was reported to me by Dr. G. C. Goodrich, of Minneapolis, in which absorption of a large tumor took place under the administration of ergot and belladonna. I subjoin his description: "The treatment was commenced in 1870, and continued two years. The uterus filled the whole space between the ilia, and measured in the transverse diameter twelve inches, and in the vertical nineteen inches, extended up under the ensiform cartilage and close up to the margin of the cartilages of the ribs. The treatment was followed by cramps in the uterus, which produced a wild enthusiasm in the mind of the patient, and inspired her with strong hopes of recovery. Without consulting me, she doubled the dose of medicine, which was administered internally, and as a consequence she was attacked with very strong uterine contrac- tions and symptoms of metritis. This caused me to abandon treatment for about one month, and had it not been for the urgent determination CASES. 609 of the patient, I would not have resumed it. She insisted that as this was the first medicine which had ever affected the enlarged organ, she believed it would cure her, and promised to obey my directions if I •would proceed. She so promptly and rapidly improved that I doubted if it were not a coincidence with, rather than a consequence of, the treat- ment. Prompted by this doubt, I abandoned the use of the ergot and belladonna and continued alterative treatment. The patient soon as- sured me that she no longer felt the griping pains caused by the remedy, and that the tumor was softer and larger than when she took the ergot prescription. The ergot and belladonna were again resumed, and in four months she was able to make a trip to Boston alone. While absent, she continued to take the medicine. From this time she continued rapidly convalescing, and is now in the enjoyment of fine health."* I subjoin cases in which the tumors were expelled piecemeal under the administration of ergot which came under my own observation : The first case in Avhich this process was attained occurred in the practice of Dr. H. P. Merriman. So far as I am aware it is the first case on record. With several other medical gentlemen I had the opportunity of seeing the patient several times, fully verifying the diagnosis, and witnessing the results of the treatment. It was recorded in my address before the American Medical As- sociation already referred to. Dr. Merriman says : "Mrs. K., aged thirty, the mother of three children, came to me in September, 1874, in regard to a tumor in the abdomen. Examination revealed a large tumor about the size of a four and a half months' pregnancy ; it was found to be interstitial, and situated on the right side and a little anterior; the sound passed six and three-fourths inches. She was at once given twenty drops of fluid extract of ergot (Squibb's) three times a day. She came a month later saying she was much better in health, but the tnmor remained the same. I told her to continue the medicine, but to increase the dose to twenty-five drops and after a time to thirty. I have seen her three or four times during the past winter, and twice had to suspend treatment and give opium on account of severe pain and tenderness in the uterine region. Finally, March 23d, 1875, I stopped all use of ergot, as the patient was very weak, the pulse 110, the appetite poor, and a very offensive and abundant discharge was coming from the uterus. The os uteri was very patulous. On April 5th, I was summoned in great haste. Something had just come away from the pa- tient. I found it to be an offensive fleshy mass, evidently a disintegrated fibrous tumor. Examination showed no tumor in the abdomen, but * The author's address before the American Medical Association at its meeting in 1875. 510 FIBROUS TUMORS OF THE UTERUS. per vaginam the os patulous, soft, and very sensitive, and the uterus still large. A week later the uterus had regained its normal condition." As an evidence of the complete restoration of the health of the pa-^ tient, Dr. Merriman informs me that she has since had a fine healthy child. The next case, which has never been published, occurred in my own practice, and I will give a brief account of it : Mrs. W., forty years of age, had been married eighteen years, and had not borne children or been pregnant. She had enjoyed good health and noticed nothing unusual in her menses until about three years before she con- sulted me on July 17th, 1875. Three years ago she began to have an increased menstrual flow, the intervals were shorter, and she be- came the subject of an acrid leucorrhoeal discharge. For the last seven or eight months the flow has been almost constant, but moder- ate. The catamenial periods had been during the time well marked by a profuse discharge every four weeks. She was quite feeble from the great loss of blood she had sustained, very nervous and dispirited. For more than a year she had been conscious of the presence of a tumor in the hypogastric region. She had at no time observed that the discharge was fetid, or indeed had any smell. By palpation, a tumor could be found extending to within about two inches of the umbilicus, and filling up the same space in the lower part of the ab- domen which the uterus occupies at five months' pregnancy. It was globular, very hard, somewhat nodulated in shape, and movable. The cervix, when examined per vaginam, was ascertained to be long and pointed, and the rnouth small, and not at all patulous. The probe entered the uterine cavity, passing upward and backward fully four inches, and moved with the impressions made upon the tumor above the symphysis. From the history and examination it was not difficult to diagnose a fibrous tumor in the anterior wall of the uterus. I prescribed thirty drops of the fluid extract of ergot three times a day, to be taken in a wineglassful of water, and large injections of cold water twice a day. On July 19th the patient called to see me again. She informed me that the medicine had caused great pain in the tumor, resembling cram23S, with a strong desire to bear down, as though something was coming out of her. An examination revealed no change in the size of the tumor, but increased hardness and irresrularitv of its surface. She was directed to continue the medicine. On the 25th the patient complained that the pains were almost unendurable on account of CASES. 511 their sev^erity and continiiousness. She said they prevented her from sleeping, or resting in any position. For the two days previons to her call on the 25th she had noticed in the discharges — which were less bloody — stringy and lumpy substances. This was different from anything she had seen before. Still there was no fetor. The tumor seemed to be somewdiat less in size than upon the first examination. There were some changes in the cervix ; it was soft, and the mouth was patulous ; the finger entered it a short distance, but would not pass the inner os uteri. The cervix was still as long as before the commencement of the pains, and I thought the lower portion of the tumor seemed more elastic than at first. On the 27th the pain was so severe and persistent that I thought it advisable to diminish the doses of ergot, and directed her to take only fifteen drops three times a day. The discharge ^vas increasing in quantity, and she gave me several pieces, one of which was as large as a cherry. It w^as so firm that it was difficult to break it up with the fingers, and of grayish color. There was no odor that I could discover in the piece examined. Dr. AV. H. Warn was kind enough to examine this specimen with the microscope. He found it composed mostly of hypertrophied con- nective tissue fibres, with bloodvessels running parallel to them. The tumor had decidedly decreased in size. On July 31st the pains, with less severity, were still continuous for the greater part of the day and night. There was a constant dis- charge of these small fibrous lumps. Judging from a close exami- nation, the tumor was not half so large as when first seen. The discharge continued without diminution until the 15th of August, when it became less, and the pain also decreased. At this time the upper part of the tumor could barely be felt above the sym- physis. The cervix was still long, but the mouth was less patulous, and the probe would not pass more than two and a half inches. Since the commencement of treatment the bloody discharge has not indicated a menstrual flow. In fact, the bloody discharge be- came progressively less, until it had entirely ceased about the middle of August. The patient^s health greatly improved, and she was permitted to return to her home in the country. She wrote me on the 1st of September that she still sufi^ered pain, and the discharge still con- tinued, but that it now had the appearance of pus, and was somewhat fetid for the first time. In October she wrote me again to say that there was no sign of the tumor; she had no pain, and never enjoyed 512 FIBROUS TUMORS OF THE UTERUS. better health. She had menstruated twice since she had returned home, but the discharge at both periods was moderate, and she had no pain. She continued the ergot up to the middle of September. Mrs. Arthur King, of Sterling, Illinois, called on me December 13th, 1875. She was thirty-five years old, married, and had never been pregnant. On the 1st of the preceding June she noticed a circumscribed hard lump two inches below and to the left of the umbilicus. She was the subject of serious uterine and sympathetic symptoms, for which she had at different times had treatment. She had profuse menor- rhagia, leucorrhoea, and great sense of weight in the pelvis. Upon examination I found a hard, round, movable tumor, extend- ing up to within two inches of the umbilicus, filling up the whole of the right iliac, the hypogastric, lower half of the umbilical, and more than half of the left iliac regions. The contour of the tumor was somewhat uneven, though not dis- tinctly nodular. The cervix was long, pointed, and thrown backward and to the left. The sound entered the small uterine mouth and passed upward, backward, and to the left five and a half inches. The diagnosis was a fibrous tumor of the right anterior wall of the uterus. I prescribed thirty drops of Squibb's fluid extract of ergot to be taken three times a day. She went home, but did not com- mence taking the medicine until the 20th of December. On the 26th of December Dr. J. B. Crandall was called to see her, and describes her condition as follows: "The patient was in a state of great nervous prostration, and worn out by severe pain and loss of sleep. The pains commenced soon after taking the second dose of ergot, and were excruciatingly severe for about three hours, after which they continued less severely for two days and nights. She had more or less haemorrhage from the uterus after taking the ergot. Her pulse was feeble, 110 to 120 to the minute. The skin was hot and dry, and she complained of great pain and tenderness over the uterus and lower bowels. The feet were drawn up, and the face wore a pinched and peculiar expression." Under these circumstances the doctor administered anodynes, tonics, and nourishment, to the great relief of the patient. On January 11th, 1876, the patient began to pass from the vagina small masses of fibrous substance, from the size of a chestnut to that of an English walnut. The substances thus discharged* were firm and gray in color, and were exceedingly fetid. This discharge con- CASES. 513 tinned up to the 21st of January, when the uterus was very much diminished in size, the tenderness had subsided, and the patient ap- peared comparatively comfortable. Up to that time she had taken but three doses of ergot, on the 20th of the preceding month, and the doctor ordered it to be resumed again. This time the ergot produced no pain, and after three or four days was discontinued. From the 21st of January there ^vere no more pieces discharged, but up to February 1st a yellowish, thin, offensive fluid passed from the vagina in considerable quantities. On the first day of February the ergot was again ordered and continued two weeks, when, as no results ensued, it was finally dropped. Dr. Crandall states that on the 14th of February the uterus was reduced to its normal size, and on the 26tli the patient was up and about her work, completely cured. He remarked, in this connection, that the first three doses of ergot taken by the patient was the cause of her recovery. This case is published in the August (1875) number of the Chicago Medical Journal and Examiner, as reported by Dr. Crandall. Mrs. L. D. M., aged forty -seven years, had a fibroid tumor in the anterior w^all of the uterus, which, with the enlarged uterus, arose to within two inches of the umbilicus. She commenced taking thirty drops of the fluid extract of ergot on the 22d of September, 1876, and was to increase gradually the dose with the object in view of causing the disruption and expulsion of the tumor. The ergot at first produced no perceptible effect until she had taken it ten days, when she began to experience the pain of contraction. The pain became so severe and continuous that it w^as necessary to omit it for two or three days at a time. The patient was intelligent and understood the object and mode of action of the ergot, and when the pain entirely subsided, she courageously resumed it in the smaller doses, and increased again until the pains became intolerable. On the 13th of January, 1877, small pieces of the tumor showed themselves in the vaginal discharges, and by the 26th of the same month the whole of it had been discharged piecemeal. She wrote me on the 30th of January, saying : "I think I wrote one week ago to-day. At that time the tumor was passing. It continued to pass until the 26th, when, I think, the last was expelled. To-day I send you by express a portion of the last that came. I think the whole of it, including the portion I sent you, would have weighed one and a half pounds. I do not believe a quart can would hold it if the whole had been preserved. It commenced to come 33 514 FIBROUS TUMORS OF THE UTERUS. on Saturday, and from Saturday evening to Sunday morning there was a pint or more. After that, the stench was so disagreeable that we could not cleanse it, consequently we threw it away. Wednesday and Thurs- day it seemed to be in one continuous mass. I cannot better describe it than to say that it came like sausage-meat from a stuffer. I would cut off about four inches a day, that is on Wednesday and Thursday. On Friday morning the last of it came away." During, and for some days after, the expulsion she suffered slight symptoms of septicaemia, but recovered from them, and in the course of a month afterward she visited me, when I found the uterus meas- ured two inches and a half in depth. She then had some leucorrhoea, but was fast regaining her health. She is now perfectly well, and has passed in safety the menopause.* The following case is reported to me by letter by William Fox, M.D., of Milwaukee, January 19th, 1880: " Mrs. B., aged forty-three ; last child four years old ; did not get up well. Menstruation returned earlier than usual, and gradually became more frequent and profuse, and of longer duration. Finally the abdo- men began to enlarge so much that her friends believed her pregnant. But her health began to fail ; her losses became greater, and almost con- tinuous. She w^as without treatment, as she believed her condition due to her time of life. An examination revealed a uterus as large as at the sixth month of gestation, and could be easily felt and moved through the abdominak walls. A sound entered five and a half inches, and with it in the uterus and the hand outside, a tumor could be felt in the anterior wall. The patient was put upon 30-drop doses of Squibb's extract of ergot, four times daily, and sent to consult Dr. Byford February 3d, who confirmed the diagnosis and approved the treatment, and made a prognosis more favorable than I believed. He said, with the above treat- ment we would starve the growth, and possibly expel it. The period was detained a week, when it came on, February 21st, five weeks from the commencement of treatment, with a great deal of pain. The ergot was continued, the pain increasing, until, on the third day, I found the patient with a temperature of 105° ; pulse, 140, an offensive discharge, and complaining of a feeling as of some foreign body in the vagina. The vagina was full of a stinking mass, not unlike a placenta in feel, but harder. The os was quite open, and the fingers could readily pass into the uterus and describe the growth. All the gangrenous mass was taken away as fast as possible with the fingers and forceps, and the uterus care- fully washed out with carbolized hot water every four hours. The ergot ■^ This case, the abstract of which I have here given, was in the May 15th, 1877, number of the Archives of Clinical Surgery, N. Y. SUMMARY OP CASES CURED BY ABSORPTION. 515 was discontinued because of the pain. Whiskey, quinine, and milk con- stituted the treatment. She rapidly improved, and in less than a month was out driving, walking, and feeling well. In six weeks, menstruation returned ; came on without warning ; lasted less than three days ; the first natural period she remembers having had in four years. She has had three since, perfectly natural in every way. She is perfectly well." I have known ten cases in which the tumors were expelled piece- meal by ergot, with but one death. The death occurred in a patient who rode one hundred and fifty miles on a railroad train to see me, with pieces of the tumor hanging from the vagina, which she would not allow her physician to remove. When she arrived, I passed my fingers up into the contracted capsule and scooped out the remaining portion of the tumor. She was so exhausted, however, by the journey and the sepsis, that she died three days afterwards. I cannot help believing that if she had remained at home and submitted to the treatment of her physician, her life need not have been sacrificed. Summary of Cases cured by Absorption. The total number of cases here cited is one hundred and one. Twenty-two of them are reported cured. In thirty-nine more the tumors were diminished in size, and the haemorrhage and other dis- agreeable symptoms removed. Nineteen of the remainder were benefited by the relief of the haemorrhages and leucorrhoeal discharges, while the size and other conditions of the tumors were unchanged. Out of the whole number only twenty-one cases entirely resisted the treatment. This shows results decidedly favorable in eighty of the one hundred and one cases. We may still further appreciate the favorable effects of the treat- ment by the consideration that in twenty-one cases it was suspended, which is as great a number as resisted treatment. It is also a noticeable fact that some of the cases in which the treatment was suspended were very much benefited by it. I have no doubt that many more cases of fibrous tumors of the uterus treated by ergot might have been collected, had time per- mitted, as I have heard of cases the history of which I could not obtain. In collating my cases, I have in no way selected or arranged them to influence inferences as to results, but I have faithfully recorded all I have received from correspondents, or found in journals, which 516 FIBROUS TUMORS OF THE UTERUS. were given sufficiently in detail to enable me to arrive at a correct idea of the treatment and its effect. S N G rf pii Hildebrandt, Beno^elsdorf, . Chrobak, . . Atthill, . . White, . . . Goodrich, Howard, . . Jackson, . . Etheridge, Merriman, . Fisher, . . Morris, . . Buckingham, Cowan, . . Dean, . . . Wey, . . . Hodder, . . Jukes, . . . Warner, . . Bvford, . . Allen, . . . Thomson, . . Kussell, . . 3 14 1 2 8 1 4 1 1 1 1 2 1 4 1 2 9 1 3 1 Total, 101 11 2 5 3 2 1 'i' 2 1 3 39 19 21 i Modes of using Ergot. Not much uniformity has been observ^ed by the writers above quoted in the manner of using ergot. Drs. Hildebrandt, Bengelsdorf, Chrobak, Atthill, and Jackson recommend, and use it hypodermically. Drs. White, Jenks, and Howard administer it hypodermically, internally by the stomach, and in the form of suppositories in the vagina and rectum. Some of the arguments in favor of the hypodermic injections are : 1st. It acts more rapidly and with more certainty. 2d. It does not produce the gastric disturbances sometimes caused by ergot when taken internally. 3d. It can be administered in this way when it is entirely impracticable to give it internally on account of the great exhaustion or gastric irritability of a patient. The main objections to the hypodermic method seem to be : 1st, MODES OF USING ERGOT. 517 the pain inflicted by the needle; and, 2d, the inflammation and sup- puration which ensue. Dr. Hildebrandt has met with but one case where the pain of the puncture was an objection to its hypodermic use. With regard to abscesses he says : ^' I am sure I do not exaggerate when I say that up to the present time I have myself made one thousand hypodermic injections of ergotine for various purposes, or have seen them made and observed their results in the clinical wards in charge of my assistants." And he then adds: ^^I have never seen an abscess follow the injections made by me personally, and only in three clinical cases did this occur. The chief reason why no abscesses formed among the large number of other injections is that I always injected the fluid very deep into the subcutaneous cellular tissue — perhaps even into the abdominal muscles." Dr. Atthill met with this difficulty in all three of his cases, although he also injects the fluid deep into the tissues. Dr. Chrobak was obliged to desist from treatment on this account, in four out of his nine cases. Dr. Cowan was interrupted in his case by the formation of abscesses. Thus it will be seen that much difficulty is experienced by many in carrying out the treatment. Dr. Hildebrandt's reason does not seem to be the only one why practitioners are so troubled with this objection, since Dr. Atthill and others have also injected deeply. As far as I can judge, very few have been able, even by the most careful efforts, to achieve the same happy results in this respect as Dr. Hildebrandt. Dr. Hildebrandt, and also Dr. Atthill, select the lower part of the abdomen as the part in which to make the injections. Dr. Keating, of Philadelphia, injects just posterior to the great trochanter. Dr. Jackson selects the deltoid region, and thinks it makes but little difference where the insertion is made. Dr. White, of Buffalo, injects over the abdomen, into the cervix uteri, and into the substance of the tumor if it is accessible, and has met with no bad results. Dr. Wey used over two hundred injections in the abdominal region above the pubes in one case, and abscesses occurred in the seat of the puncture as often as once in eight operations. Dr. Dean commenced using ergot in the form of Squibb's fluid extract by injecting it into the cavity of the uterus through a flexible 518 FIBROUS TUMORS OF THE UTERUS. catheter, but now he employs the sohition of Squibb's solid extract dissolved in water — one grain to five minims. Of this he injects from ten to fifteen drops into the substance of the cervix about four times a month or once a week. He thinks the effects are more prompt and energetic than when administered hypodermically. His instrument consists of a barrel the same size as the common hypoder- mic syringe and a tube six inches long. He has known inflamma- tion and suppuration to follow but once in his whole experience. Different Preparations. Believing the preparation of the medicine employed had much to do in causing the irritation thus observed, efforts have been made to find some form that would not produce the painful results thus de- scribed. Hildebrandt is now in the habit of using Dr. Wernich's formula for the w^atery extract of ergot, and Dr. Mund^ thinks it is very similar to the preparation made by Dr. Squibb. Dr. Hildebrandt added pure glycerin in the proportion of about one part to four of the solution, and the amount of the injection was forty minims. This contained a little over two grains of the extract, probably represent- ing ten to twelve grains of the crude ergot. Most American practitioners now use Dr. Squibb's preparation above referred to, some of them by dissolving it in pure water, while others add to the water a small amount of pure glycerin. Dr. Squibb recommends a solution of this extract as follows: Dissolve two hun- dred grains of the extract in tw^o hundred and fifty minims of water by stirring ; filter the solution through paper, and make up to three hundred minims by washing the residue on the filter with a little water. Each minim of this solution represents six grains of ergot in powder. Of this solution from ten to twenty minims are injected once daily, or once in two days. This is the only preparation I have used in hypodermic injections, and I believe it the best we can at present procure. Dr. Wey properly lays great stress on the necessity of having the solution fresh, believing that in a very short time it deteriorates, and becomes more irritating to the tissues. He says: "Ergot thus ad- ministered generally produces prompt effects.'' In most instances, in half an hour the patient experiences painful contractions of the uterus. The hand applied over the organ at once recognizes the in- creased hardness in the mass. These contractions increase in severity for the first two hours, and then continue with vigor for from six to ten hours, gradually becoming less until they cease entirely. Some DIFFERENT PREPARATIONS. 519 patients suffer so much from these pains as to refuse to proceed in the treatment, while others bear them without much inconvenience. We do not always observe these painful effects even when the drug operates very beneficially. Sometimes the haemorrhages are controlled, as it were, insensibly, and the tumor slowly dscreases in size without the patient experiencing any considerable discomfort. It seems highly probable, from the statements made by my correspondents, and espe- cially Dr. Wey, as well as my own observations, that the benefits of the remedy are produced with more rapidity in the early part of the treatment. The preparation used internally more frequently than any other is the fluid extract, either alone or in combination with belladonna. Each minim of Squibb's fluid extract is equal to one grain of ergot. Some recommend that it be given in doses of thirty drops three or four times a day. Others believe that it should be given in larger doses less frequently repeated, as, for example, one drachm once or twice in twenty-four hours. It is efficacious given in either way, but probably more so in the larger and less frequent doses. This preparation is so offensive, and causes so much nausea in exceptional instances, that it cannot be borne. Dr. Squibb claims that his solid extract does not offend the stomach so frequently as the fluid extract. This extract may be used in pills coated with gelatin. A pill of five grains is equal to twenty grains of the crude ergot, and may be administered twice or three times daily. From observation of the effects of the different prepara- tions, I am satisfied that this is altogether the most efficient and agree- able for internal administration. A suppository for the rectum, which, in Dr. White's practice, acted satisfactorily, may be composed of fifteen grains of the solid extract, and enough gelatin to give it size and form. I have no doubt of the great usefulness of this method of administering ergot. I think it is also quite certain that the addition of belladonna in some cases increases the curative effects of ergot ; how much, I am not quite sure. Dr. Goodrich, who reached such splendid results, gave the fluid extract of ergot and belladonna together throughout the entire treatment of his case. From what has been said it may be inferred that hypodermic in- jection, if the most efficacious, is also the most objectionable method of using the ergot, and that in many cases the exhibition of it in this way is rendered entirely impracticable, because intolerable, to the patients. 520 FIBROUS TUMORS OF THE UTERUS. May we not hope for great improvement still in the pharmacy of ergot? Ergot produces many good effects besides reducing the size of the tumors and relief of haemorrhage. I have seen, and some of my correspondents mention, great functional improvement in the more important organs. Some patients are relieved by it of obsti- nate constipation ; the appetite is improved, and the general health restored. This remarkable salutary effect is obviously due to its action on the ganglionic nervous system. In exceptional instances ergot has very disagreeable effects. Dr. Goodrich mentions inflam- mation of the uterus as one, and my patients often complain of great heat and tenderness in the uterine region. Hildebrandt speaks of one case in which, after the sixth injection, the patient complained of vertigo, imperfect control of her lower extremities, and slight spasms of the flexor muscles of the forearm. Dr. "Wey observed severe gen- eral nervous perturbation to follow its use in one instance. And Dr. Morris's patient discontinued treatment because of the terrible and tumultuous effects upon the uterus. Dr. E. P. Allen, of Athens, Pennsylvania, sends me the report of a very interesting case of fibrous tumor treated by hypodermic injec- tions of ergot, in which phlebitis supervened. A condition of one limb was produced precisely similar to phlegmasia alba dolens, and ran its protracted course to a favorable termination. Prior to the accident the tumor had very much decreased in size ; but, after the treatment was suspended, and during the course of the phlegmasia, it rapidly increased again, and the haemorrhages which had been con- trolled returned. After trying other methods of treatment without any good results, he and his patient in despair were driven to the use of ergot again. It was tried internally with some good effects, but as the remedy thus administered disagreed with the stomach, it was again injected hypodermically with rapid improvenient. The injections were used on the side. of the abdomen, opposite to that formerly affected with phlebitis. After a number of injections, signs of in- flammation of the veins were again observed, and the sound leg passed through all the stages of phlegmasia that had been observed in the first. From the intelligent observation of Dr. Wey and others, we may fairly conclude that it is not improper to continue the use of ergot during the menstrual flow. I can also add my testimony as to the entire harmlessness when given during that periodical flow. Auxiliary Treatment. With the exception of Drs. Goodrich and Howard, all the writers and correspondents quoted have depended exclusively on ergot for CORRECTIVE TREATMENT. 521 the removal of fibrous tumors of the uterus ; in fact, the treatment has been experimental, and had for its object the solution of the ques- tion suggested by the publication of Hildebrandt's articles on the use of ergot, viz., will ergot cure fibrous tumors of the uterus? The course pursued was well calculated to, and I think did, test Hilde- brandt's treatment pretty thoroughly, but it is doubtful whether this exclusiveness is the best practice. The well-known alterative and sorbefacient medicines have, in rare instances, been credited with the cure of these tumors without the aid of ergot, and it is not difficult to understand that absorption may be promoted with more certainty by the alkaline bromides and iodides, where the vitality of the tumor is first impaired by the action of ergot on its vessels and the muscular fibres surrounding it. Dr. Goodrich seems to have held this view of the alterative treatment, as he prescribed iodide of potassium and bichloride of mercury with ergot. Dr. Howard also employed alter- atives in the same way. Both of these gentlemen combined bella- donna with ergot. The efficiency of this combination, as represented by their reports, justifies us in believing that the alteratives employed by them were auxiliary in a high degree. How much may be effected by judicious alterative and other auxiliary treatment will, doubtless, be determined by future observation. Corrective Treatment By this I mean treatment that will prevent or ameliorate the dis- agreeable effects of ergot in certain exceptional instances. The dis- tressing pain caused by it may sometimes be made more tolerable by the administration of hydrate of chloral, without very materially in- fluencing its other effects. Indigestion, constipation, hydrsemia, and nervous debility may be corrected by tonics, alteratives, laxatives, and stimulants given simultaneously with ergot. In short, the general condition of the patient should be cared for in the same rational manner as if ergot was not being administered. Modus Operandi. The influence of ergot over the uterus has been a familiar fact to the profession for a long time. It is not long, however, since we were aware of its effects upon the muscular fibres entering into the formation of other oro^ans. We now know that this medicine acts upon the unstriped muscular fibre wherever found, whether in the viscera or in the vessels of the body. The fibres of the uterine walls, and the arteries supplying them 522 FIBROUS TUMORS OF THE UTERUS. with blood, both belong to this class ; this fact in the formation of the uterus renders it particularly susceptible to the action of ergot. The drug acts upon the uterus in a threefold manner, and causes a diminished flow of blood to the morbid as well as healthy tissues in the uterine structure. 1st. The calibre of the arterial tubes is diminished by the contrac- tion of the muscular fibres which enter into their composition. 2d. The arterioles are diminished in size by compression from the contrac- tion of the uterine muscular fibres which surround them. 3d. These vessels are distorted and drawn in diverse directions by both the con- traction and compression, and hence are rendered less fit for san- guineous conduits. , Another consideration of prime importance is that, under the in- fluence of these medicines, the nutrition of fibrous tumors is inter- fered with, not only from diminution of blood in their tissues, but also from compression of their substance by the proper fibres of the uterus, their trophic energies are arrested, and are therefore made more susceptible to the process of disintegration and absorption. The great influence exerted by ergot over the circulation of the uterus is rendered more efficacious in the removal of fibroid tumors of that organ, because of the peculiar organization of the growths. It is now pretty well understood that this neoplasm is not very gen- erously supplied with arterial blood, and that its supply is derived from numerous minute vessels instead of one or two of larger calibre. From these circumstances it results that its vitality is very low, its circulation easily disturbed, and consequently its nutrition impaired. I think we are justified from observation in assuming that the action of ergot may be graded from an almost imperceptible to a very intense degree. Probably the first degree aff'ects the vascular supply ; the second, in addition to this, causes so much contraction as to merely render the fibres tense without causing pain ; and the third prompts the uterine fibres to vigorous and painful contraction. This inference is plainly deducible, I think, from the several modes by which tumors are made to disappear under its action, as well as from direct observation of the uterine fibres. I will now venture to call attention especially to the manner of expulsion of the polypoid and submucous intramural varieties. It will be seen from Fig. 147 that when the uterus contracts, all the fibres unite in pressing the polypus through the cervical canal, which is usually already shortened, and rendered dilatable in consequence of its increased vascularity. MODUS OPERANDI. 523 The cervical canal dilates, and after more or less painful efforts the polypus is expelled entire, covered by the mucous membrane. This membrane is often in a state of gangrene, but so far as I have observed these cases, the tumor is not broken to pieces. Fig. 148 represents an intramural fibroid between the central line of the uterine wall and the mucous membrane. It is intended to show a tumor where a thin layer of fibres separate it from the mucous membrane, and how a thick and heavy layer is spread over its external hemisphere. Three-quarters of the thickness of the muscular wall are applied to that side of the tumor. If in this position all the fibres of the uterus vigorously contract, the fibres near the mucous mem- brane must be overcome by the heavy layer outside (at c). But the Fig. 147. Fig. 148. opposite wall of the uterus plays an important part by supporting the weaker layer at the fundus of the tumor, and adding its own force in overcoming the capsule (at e), where it usually gives way. The posi- tion of the tumor makes its escape from the concentric action of all the fibres of the uterus impossible, and every one knows that when the resistance is partially overcome, the uterus is stimulated to more vigorous action, and the pains will not abate until the mass is ex- pelled. If not too large, it is driven out without undergoing great laceration, but if its size and attachments are such as to make this im- practicable, it will be broken into fragments and expelled piecemeal. Allow me to supplement the above description by explaining the effect of ergot on the sub-peritoneal and central intramural tumor. 524 FIBROUS TUMORS OF THE UTERUS. In Fig. 149, we see the disposition of the fibres on the sub-peritoneal variety ; next the uterine cavity there is a thick and strong stratum of fibres, while immediately under the peritoneum the layer is very thin and comparatively weak. When the uterus is acting with vigor, the fibres between A and B will cause those two points to approxi- mate each other, and the tumor will become pediculated; but that is all, for the tumor lays outside the field of concentric action and escapes the crushing influence to which the submucous variety is subjected. Fig. 149. The amount of force exerted upon it is that exercised by the weaker layer of fibres in a state of conquered antagonism, and the rupture of the capsule is impossible. If we take Fig. 150 as a correct representation of the fibrous tumor when situated in the central stratum of fibres, in which the antago- nism is equal at all points, it will be evident that there is no ten- dency to rapture of the capsule, and much less crushing influence exerted upon it than if it were situated slightly nearer the mucous membrane. This variety of the tumor, therefore, yields to the influence of ergot, only as it may be ^^ starved out " by diminution of its blood supply, and as the efi^ect of pressure, which we all know are the two conditions most favorable to absorption. MODUS OPERANDI. 625 Now I think we have arrived at a point in this investigation where we can draw inferences as to the forms of tumors likely to be effected by ergot in different ways, as w^ell as those that will not be eflPected by it. AVe do not expect ergot to cause painful and efficient contractions in the healthy unimpregnated uterus; its fibres are not capable of such contraction, and it is not until the fibres have become greatly Fig. 150. developed that they are susceptible to the impressions of ergot. In cases of early abortion, its action is very unreliable, but after the fourth month of pregnancy it acts quite efficiently. In tumors of the uterus, the development of the fibrous structure is sometimes so slight that it is incapable of contraction ; there may be so many nuclei of degeneration that there are not enough sound fibres left for efficient contraction. Then, where there are many small tumors developed in the uterine walls, the circulation is cut ofi* to such a degree that they degenerate into a cartilaginoid substance, and sometimes they are infiltrated with calcareous material. In none of these cases will ergot cause any appreciable results. When, how- ever, there are but one, two, or three nuclei of morbid growths, as they increase in size the fibres undergo the development necessary to enable them to contract with great efficiency, and render them sus- ceptible to the influence of ergot. Another condition w^hich influences the hypertrophic growth of the fibres is the situation of the tumor. Subperitoneal tumors do not cause as great growth in the fibres of their neighborhood as the intramural or submucous varieties. A 526 FIBROUS TUMORS OF THE UTERUS. single intramural tumor causes great development of the whole uterine tissues, but the development of the wall in which it is situated de- cidedly predominates. The submucous neoplasm so soon gains the uterine cavity that the development is nearly the same in the whole organ. When, therefore, we administer ergot for the cure of fibrous tumors of the uterus, the beneficial action of the drug will depend upon the degree of development of the fibres of the uterus, and the position of the tumor with reference to the serous or mucous surface. The nearer the mucous surface, the better the effects. If the tumor is very near the lining membrane, we may hope for its expulsion en masse, or by disintegration. We can often select the cases in which good results may be expected. There are four conditions which are usually reliable for this purpose. They are: smoothness of contour, haemorrhage, lengthened uterine cavity, and elasticity. A smooth, round tumor denotes, for the most part, uniform textural development, hsemorrhage, a certain proximity to the mucous membrane, a lengthened cavity, great increase in the length and strength of the fibres; and elasticity" assures us of the fact that cartilaginoid or calcareous degeneration has not begun in the tumor. An uneven, nodulated tumor may be composed of many separate solid masses. These displace and prevent the growth of the fibre? to such an extent as to render contractions inefficient. When hsemor- rhage is not present, the tumor is probably near the serous surface, and consequently not surrounded by fibres. A short ca\^ty denotes short, undeveloped fibres, while hardness is indicative of unimpress- ible induration. Although I have no experience in the use of ergot in such cases, I should expect large fibro-cystic tumors to resist its action. From this view of the subject, it will be seen that I freely admit that there is a large number of cases in which ergot cannot produce any good results in consequence of their nature; but there is another reason of equal moment why ergot may fail to act upon such cases as would seem to be favorable, bv the worthlessness of the dru^ and its preparations. Dr. Squibb, of New York, a high authority, says in reference to this subject : "The molecular constitution of the active portion of the drug seems, however, in its natural condition to be loose, aud, like a slow fermenta- MODUS OPERANDI. 527 tion, to be undergoing slow molecular changes, so that by age its pecu- liar activity is slowly diminished uutil finally lost." And again : "The ergot in the grain, however well kept, is known to become in- active without any known change in appearance, though the sensible properties, such as odor and taste, may and probably do not change. Ergot, in powder, is known to diminish in activity much more rapidly than when in grain, and probably soon becomes inert. The tincture and wine of ergot are believed to change, though more slowly than the ergot in substance; while the extracts, and so-called ergotins, are all supposed to change more rapidly." These facts, so explicitly stated by Dr. Squibb, are very sugges- tive as to the causes of the frequent failures of ergot, and need no comment. When all these causes of failure are considered, the variety of ex- perience met with in the reports upon its trial in the treatment of these tumors is not surprising. It should not, however, be discour- aging, but should prompt us to more care in selecting the cases and securing reliable preparations of ergot. I have implicit faith in the action of ergot when all the conditions I have pointed out are present. I do not believe it to be uncertain in its action. In addition to the above conditions, I believe perseverance an in- dispensable condition to success, as it often requires several months to get the best results. In concluding, I desire to disclaim any expectation that ergot will supplant other modes of treatment. The expert surgeon will, as he alw'ays has, use his instruments to the neglect of remedies less sum- mary in their effects, and in his hands the maximum of safety will obtain ; but there are very few general practitioners w^ho ought, or would be willing, to undertake enucleation of fibroid tumors of the uterus. I do claim, however, that the judicious gynaecologist will lose fewer patients, and make more cures, by the consistent adminis- tration of this medicine than can be looked for from surgery. I am surprised that others who have written upon the subject should be so incredulous as to the effect of ergot, and the only way I can account for it is what, I think, I can see in their practice as related by themselves, viz., that they do not give it a fair trial. They fail to give it in large enough doses and persevere long enough in its use. The treatment of some of my successful cases extended over many months. When the pains that indicate efficient action, and 528 FIBROUS TUMORS OF THE UTERUS. always precede disruption and expulsion occur, the practitioner gen- erally becomes alarmed, gives anodynes, and withdraws the medicine, thus abandoning the case, and declaring that ergot is a dangerous remedy. If he had witnessed the same, or even severer, pains in labor, he would have encouraged them, and so he should do in ex- pelling the tumor, and the result would be a safe delivery. The tumor would be expelled and the patient relieved. Before drawing my remarks on the use of ergot to a close allow me to mention some of the queries that have arisen in my own mind, or have been propounded to me by medical men. If the ergot acts so powerfully in expelling submucous tumors, is there not danger that it may rupture the capsule of the subserous variety, thus expelling them from the uterine substance into the peritoneal cavity, and en- danger the life of the patient by causing peritonitis? A proper con- sideration of the conditions existing in such cases will justify my answering this query in the negative. There is a great difference in the influence exerted by the uterine fibres on the two varieties of tumors. In the submucous variety the whole power of the uterine contractions is exerted toward the tumor, driving it in the direction of the OS uteri. When the tumor is subserous the contractions are from the axis of the tumor, and their effect is merely to render it pedunculated, and lessen the vascular supply going to it. The main effect, therefore, will be to check the rapidity of its growth, or to prevent its further enlargement altogether. This statement will suffi- ciently explain the effects of the medicine upon this variety of these morbid growths. Another question is, does the long-continued ad- ministration of ergot induce the gangrene of the extremities, that has been attributed to it? And still another, does it cause inconvenience or danger by affecting seriously the nervous centres? After having given this remedy in frequently repeated and large doses, and ob- served its effects with great care for a nnmber of months consecu- tively, I can say that I have not noticed any such consequences. I am not prepared to assert that there is, and always will be, immunity from such effects.^ The worst symptoms I have witnessed are the severe and persistent pains, and the apparent inflammation of the uterus and peritoneum, where its action has been excessive. These symptoms, however, have been invariably controlled by proper treat- ment, and have in no instance proved disastrous. In other cases, when the tumor was slowly disintegrated and expelled, a moderate form of septicaemia has invariably occurred ; but this condition has not been sufficiently grave to excite alarm in my mind. ELECTROLYSIS. 529 A simultaneous employment of sorbefacients and the administra- tion of ergot would, doubtless, in some cases prove more efficacious than either alone. But I am free to confess that this conclusion, so far as I am concerned, is arrived at more from therapeutic inference than observation. As I am giving the results of my own observa- tion, more than those derived from the research of others, I deem it but fair to state that I have not given this combined method of treatment an extensive trial. We should remember, in the employment of any course of treat- ment for the cure of these fibrous tumors, that reliable results are not to be obtained without the long-continued use of the remedies, and a thoucrhtful manao;ement of them in individual cases. And I must say, in this connection, that I believe a want of these considerations has led to much false experience. The treatment of fibrous tumors, located in other organs than the uterus, will not serve as a useful guide in the management of the uterine neoplasm. The same con- ditions do not exist elsewhere. The tumors are nowhere else sur- rounded with muscular fibres whose action can be commanded by any remedy within our knowledge. Whether the observation of the pro- fession at large will or will not at present bear me out in my earnest belief in the curability of some of these tumors by the means I am now teaching," I do not know ; but I am sure that there is so much logic in the method that it deserves a much more extensive trial than has hitherto been made of it. Eledrolysis. Recently the treatment of fibrous tumors of the uterus by electro- lysis has received considerable attention. Foremost among those who are pursuing investigations in this direction stand Drs. Kimball and Cutter, of Massachusetts. In a report to the New York Obstet- rical Society Dr. Thomas gives a summary of the results of their treatment in thirty-six cases. The account given was very favorable, showing that a small number were entirely cured ; that the growth of the majority was arrested, while less than one-third were not affected by the treatment. There were but two deaths in the thirty- six cases, and from the report I should judge this termination was not the result of the operation, the conditions of both cases being hope- less, in consequence of the grave conditions existing in connection with the tumor. At a meeting of the American Medical Association in this city, Dr. Cutter was kind enough to illustrate his method of operating. 34 530 FIBROUS TUMORS OF THE UTERUS. He uses electrodes invented especially for this purpose. They are spear-shaped and mounted upon handles, in order that they may be directed with the more certainty, and made to penetrate hard, fibrous growths without deviating from their intended course. The blades are five and one-half inches long, and are insulated to within nearly one inch of the point. Two of these electrodes are inserted through the abdominal wall into the substance of the tumor, the points being separated by a space of several inches. Through these electrodes a galvanic current is passed, the electricity being generated by eight pairs of carbon and zinc plates, excited by saturated solu- tion of potassic bichromate and sulphuric acid, one part of the former to two of the latter. The time allowed at each sitting varies from three to fifteen minutes. It was said that this operation did not pro- duce much pain, and was usually followed by a copious flow of urine. The number of operations for the individual cases varied from one to nineteen, and the intervals between them from a day to two months. In certain desperate cases this seems to me to be a valuable resource. Although, however, in the hands of these brilliant surgeons this mode of performing electrolysis seems not to be attended with the dangers one would expect to follow such free penetration of the ab- dominal cavity and galvanic excitement of these growths, most of us would hesitate to follow their example. They will, doubtless, pursue this mode of treatment sufficiently to test its efficacy and danger, and thus enable the profession to properly estimate its value. Possibly it will be found, by further experiment with electricity, that very much smaller electrodes and a less powerful battery may produce altogether effects sufficient to dissipate these tumors, and at the same time greatly reduce the hazard of the operation. CHAPTER XXXV. SUEGICAL TBEATMENT. Removal of Polypoid Tumors, The first thing I have to say about the operations intended for this purpose is that they should be as simple as possible, compatible with thoroughness. It is not necessary to exemplify this idea. It is self-evident, and yet often ignored. The most effectual plan of avoiding danger is to have a distinct idea of the sources whence the danger may arise, and in connection with these tumors dangers may arise, (1) from laceration, contusion, or other damage to the uterus, resulting in hsemorrhage or inflammation ; (2) incomplete ablation, — the remaining portion producing septicsemia; (3) shock sometimes following protracted efforts at removal. This last is a very important source of peril. These dangers will, therefore, for the most part be proportionate to the extent of manipulation and instrumental procedure and the incompleteness of the operation. The old operation of tying the neck of the tumor, and allowing it to slough away, especially when it was situated in the uterine cavity, combined all the causes of danger above enumerated except that arising from hsemorrhage ; and it is a curious fact that this operation was invented for the sole purpose of avoiding hsemorrhage, Avhich is really the least dangerous of all, according to my observation. Indeed I have never seen serious haemorrhage caused by the removal of a polypus, however effected. The practice of ligating the tumor and then amputating it is to a less degree open to the same criticism. Torsion or amputation are the methods now usually employed by the best gynaecological surgeons of the present day, and the first is the one I have for several years resorted to in almost every instance. Amputation may be performed by the scissors, knife, by the ecraseur or galvano-cautery wire. All possible danger from haemorrhage will be avoided by the last means indicated ; but I may state that there is scarcely any danger of haemorrhage from the use of either of the other instruments. Torsion is performed by seizing the tumor 532 SURGICAL TREATMENT. with strong vulsellum or fenestrated forceps and twisting the tumor several times around and making moderate traction until the detach- ment and removal are completed. In order to amputate a polypus when the tumor is partially or wholly expelled from the uterus the tumor should be drawn down with one of the forceps mentioned until its attachment is brought into view, when with the scissors or the knife the neck may be divided as close to the uterine attachment as possible without cutting the substance of the uterus ; or the neck of the tumor mav be surrounded by the ecraseur or galvano-cautery wire and separated by it. A tumor attached to the fundus, or high up in the body of the uterus, cannot always be drawn down and amputated in this wav without causing inversion of the organ, and consequently a knife in the shape of the blunt hook in our obstetric case, with an edge upon the concavity of the curve, will be necessary. This may be introduced and guided as nearly as possible to the point of attach- ment by the finger or hand. This process is very much facilitated by a piece of twine passed through a small hole in the extremity of the hook ; the twine should be long enough to hang out of the vagina and give a firm hold. When placed, the convexity of this knife should be turned towards the neck of the tumor and a sawing motion executed by the handle and twine until the tumor is cut through. The chain of an ecraseur may be carried to or near the point of attachment by means of two flexible rods with small holes in the ex- tremities. The wire is passed through the opening at the ends of the rods, and being held closely together they are introduced, carried be- hind the polypus, as high up as possible. One of the rods is then held in position while the other is carried around the tumor, thus en- circling it by the wire. Sometimes it will be easy to pass the wire by drawing a loop of it through the perforated ends of the rods, large enough to pass entirely around the lower end of the tumor, and as the rod ascends, the wire surrounding the polypus is carried up to the point of attachment. When well placed, the ends of the wire may be fitted to the ecraseur, and that instrument carried up to the ends of the rods. The ecraseur can then be manipulated until the tumor is separated. There is no need of removing the rods from the wire before the ecraseur is fixed, as their presence does not complicate the operation. All this explanation presupposes an open or dilatable condition of the OS uteri which does not always exist. If the mouth of the uterus is not already thus patent, it should be dilated by compressed sponges until it will admit of free access. REMOVAL OF POLYPOID TUMORS. 533 It requires much experience and tact to perform this operation with the ecraseur, and we will find in the books and periodicals a number of instruments intended to facilitate the application of the wire to the neck of the tumor. The dangers connected with this operation are those caused by the protracted ef- forts to replace the chain or wire of the ecraseur, and an inability always to remove the whole tumor. The operation of torsion can be . performed when the tumor wholly or partly occupies the vagina without any preparation, and is preferable, because the tumor is removed at the point of at- tachment. The reason of this is, the point of attachment is always the weakest, and yields to the force applied before any violence occurs to the other parts of the tumor or the uterine tissue. The tumor is thus completely removed, and with- out protracted manipulation. !N'o haemorrhage results, for two reasons: 1, there are no large vessels entering the tumor, and the small ones are torn instead of being cut as in amputation ; 3, septicaemia does not occur, for no portion of the tumor is left to slough. When the tumor is higher up, or within the cavity of the uterus, torsion is equally appropriate, and more easily executed than amputation with or without ligation. Of course if the mouth of the uterus is not open enough to permit the seizure of the polypus at a point high enough to secure a sufficiently firm hold upon it, dilation is just as necessary as in the other operations. The amount of dilation, however, will not need to be so great. In performing this operation, the operator must guide the forceps with his fingers to the part of the tumor necessary to enable him to fasten the instrument upon or near the central part of the polypus. In two instances when the tumor was too large to be firmly held by any forceps at my command, I introduced the hand inside the uterus and detached the tumors by rotating them Fig, 151. Chasignac's Ecraseur. 534 SURGICAL TREATMENT, with the hand until they were detached, and afterwards making trac- tion with the forceps. I brought them into the vagina and delivered them with the obstetrical forceps. One of these weighed forty-six ounces. To perform torsion for the removal of a polypus, the surgeon, after fixing the instrument firmly in the desired position should be careful to twist it enough to be sure of its detachment before com- FiG. 152. EMSARGEfiJT Chicago. Small Vulsellum. mencing traction. Not less than from four to six complete revolu- tions should be effected. This procedure will prevent the danger of lacerating the tissues of the uterus. The greatest objection urged against the operation of torsion is the likelihood of lacerating the wall of the uterus at the point of attach- FlG. 153. £-.//. SA/?GE/^r Chicago. Medium-sized Vulsellum. Forceps. ment. If we will call to mind what was said about the relative thickness of the muscular strata upon each side of the different kinds of fibrous tumors, we will at once perceive the groundlessness of this objection. In the pendulous variety, the whole wall of the uterus is Fig. 151. Large Vtilsellum Forceps. outside the point of attachment and is strong enough to resist the very few fibres that are carried down with it. Indeed in the polypus there is almost no substantial attachment except that formed by the REMOVAL OF POLYPOID TUMORS. 535 investing mucous membrane. If, therefore, the torsion is performed with sufficient tliorous^hness before traction is begun, laceration of more than the superficial tissues surrounding the neck of the tumor is next to impossible, and consequently the operation is perfectly safe. Haemorrhage is not so likely to occur after torsion as when the tumor is amputated by the knife, or scissors, or even by the ecraseur. The danger of haemorrhage, then, is an objection that cannot with any show of reason be urged against torsion. I have never seen haemorrhage succeed torsion. The contractions of the uterus which take place after removing the polypous growth from the cavity of the uterus in the great majority of cases is as effective in the prevention of haemorrhage as it is when its contents are expelled at the time of labor. I trust that it is not necessary to dilate further upon this part of the subject. However, let me remind the reader that as haemor- rhage, although improbable, is yet possible, we should be prepared for it. After what has been said under palliative treatment about the management of this complication, it will not be necessary to en- large upon that point. After an operation of this kind the only treatment necessary is perfect quietude for a few days, cleanliness by injections, and if need- ful the administration of anodynes to quiet pain. AYhen a tumor has been removed from high up in the uterus the patient should of course be carefully watched, and if symptoms of inflammation or septicaemia arise they should be treated by suitable measures. Surgical operations having the relief of haemorrhage for their primary object, but which sometimes eventuate in the cure of the tumor, have been recommended and successfully practiced. The first I shall mention, is that brought into general notice by the late J. Baker Brown, viz., incising the cervix. Mr. Brown first discovered that free incision of the cervix would check haemorrhage by doing it as a preliminary step to coring or goug- ing out some of the tumor. He says, in tumors of recent origin and moderate size, free incision not only checks the haemorrhage, but often arrests the growth of the tumor, and even causes its disappearance. Of fourteen cases thus treated, in two only was it necessary to incise or gouge the tumor. When the vagina is small he first dilates it with bougies (some prefer sponge surrounded by thin india-rubber tubing). After the preparation of the vagina is satisfactorily accomplished, he exposes the cervix by introducing Sims's speculum, seizes, fixes, and incises it freely, its whole length from within outward with Simpson's metro- 536 SURGICAL TREATMEN'T. tome, the incisions being made on both sides. He then plugs the cavity thus made with lint saturated with sweet-oil (if the oil was car- bolizecl it would be better . to prevent hemorrhage and to exclude air- Mr. Brown lays great stress upon a thorough plugging of the cervix after the operation, and filling the vagina w-ith cotton to sup- port the cervic-al plug. He allows this to remain for forty-eight hours. He insists upon making the incision in the cervix to extend within the internal os uteri. The cavity produceil in the cervix by the incision should be kept dilated until the surfaces cicatrize. If then the symptoms are not relieved, he proceeds to the operation of gouging out a piece of the most dependent part of the tumor. This may be done with a knife, but he prefers pointed scissors. The object of removing a part of the tumor is to inaugurate a de- structive inflammation, which will result in the disintegration and expulsion of the tumor. Sir J. Y. Simpson introduced the cauter}^ or caustics into the sub- .stance of the tumor for the same purpose. In two instances I have caused fibrous tumors to disappear bypassing cotton-wool into them. A large trochar was thrust through the cervical cavity as deep into the tumor as practicable, and after the stilet was withdrawm, several pieces of cotton secured by thread around them, were passed to the extremity of the canula into the tumor and held there by a probe. while the canula was also withdrawn. A discharge of fetid pus and serum followed moderate inflammation, and the tumor grew smaller until it d:-:yy-::;.r-d. ^\ ith Lnyprc.--nt experience. I would commend the administration of ergot, as soon as the tumor was effected by either of these opera- tions, with a view to aid in the expulsion of the growth. For the relief of excessive haemorrhage. Dr. Atlee passed a blunt- pointed bistoury into the cavity ot the uterus, and by turning the edge of the instrument upon the tumor, cut deeply into it. The dilata- tion of the cervix, so generally indispensable, can be done by com- pressed sponge or sea-tangle tents, instead of incision. iLny.c^to.tion. This term is applied to the operation of splitting the capsule and turning the tumor out of its bed. In favorable cases this operation is easily performed, but such cases are very rare ; generally it is one of the most formidable and dangerous operations that we are called upon to perform. I say this, with reference to the operation, when it is done bv the most skilful ENUCLEATION. 537 and efficient gynaecologist. In the hands of the reckless, unin- structed, and inexperienced, it is still more likely to be done badly* and indeed barbarously than any other operation. The operation of enucleation should be confined to submucous tumors, or to speak more definitely, to tumors situated between the central stratum of muscular fibre and the mucous membrane. The intrusion of such tumors into the cavity of the uterus enables us to attack them from that cavity, and the thick, strong layer of muscular fibre lying outside of the tumor, makes the operation less dangerous by protecting the peritoneal cavity from the violence which might otherwise result from the most cautious use of the instruments. When are we justified in making an attempt at enucleation ? The first item in the answer to this question is, when it is evident that the patient's life will soon be sacrificed if the tumor is not in some way disposed of. The second item is, where every reasonable palliative measure has been tried without success, or where there is not time to wait for their trial, if such a condition can exist ; and I may add a third, where appropriate attempts have been made and failed to break them up and expel them with ergot. Some will object, saying that ergot will not do this w^ith any uniformity ; to which I would answer, that I do not believe the objectors have given it a thorough and intelligent trial. Some will further object, by saying, that the septic fever attendant upon such expulsion is more dangerous than the operation of enucleation ; to w^hich I would answer, that my cases will not bear out the objection. I will also add, that the general practitioner will conduct a case of ex- pulsion more successfully than he can the operation of enuclea- tion. The first step in enucleation is thorough dilatation of the cervix, if it is not already sufficiently open. The dilatation should be suffi- cient to permit the fingers to pass as far up into the cavity of the uterus by the side of the tumor as they can be made to reach. If the vagina is small, it should also be prepared by stretching or dilat- ing it. When these conditions have been obtained, the patient should be placed upon her left side with her left hand behind her, and by Sims's speculum, the cervix and tumor exposed to view. The cervix should then be seized with vulsellum forceps, drawn down as much as possible, and held firmly by an assistant until the operation is completed, varying the direction of the traction as the operator may require. The capsule may then be opened by making an incision 538 SURGICAL TREATMENT. with loDg curved scissors, at the junction of the tumor with the wall of the uterus the whole width of the tumor ; at the middle of the in- cision another should be commenced, and carried as high up over the longitudinal centre of the tumor as possible. These incisions should not penetrate the tumor to any great depth. They should simply divide the capsule, and when the capsule is not adherent, the space between it and the tumor will be easily recog- nized. The fingers can then be inserted between the capsule and the tumor, thus separating them as high as the operator can reach. This separation should extend around the whole circumference of the growth. The fingers will not be long enough, usually, to reach over the upper end of the tumor ; the separation may be completed by Sims's enucleator as seen in Fig. loo. It may be passed with the concave Fig. 155. Siins"s Enucleator. side next to the tumor, gently to the top, and then passed around in any direction until the separation is complete. While this last part of the operation is being accomplished, another vulsellum should be fastened upon the tumor as high up as possible, and by traction made to depress and steady it. When the tumor is thus separated from its capsule, we should make an effort to turn it upon its longitudinal axis. Fig. 156. Sims"s Guarded Hooks to aid in drawing the Tumor. ■ This will enable us to determine whether it is entirely detached or not, as well as to dislodge it from the muscular bed into which it has been moulded. If the detachment is not complete, the point of resistance Avill generally be discoverable by swaying it from one side to the other, or backward and forward, thus enabling us to apply the enucleator to the right place, and complete the separation. At this stage of the operation we may make more traction, the dislodgement ENUCLEATION. 539 will be facilitated by pressure upon the fundus of the uterus by the hand of an assistant. When the tumor is not too large, it will de- scend as we pull upon it, and pass out through the vagina. If, how- ever, it is so large that it cannot be made to pass through the vagina in this way, then the tumor should be split by the scissors from the bottom upward, as near the top as possible, without danger of wounding the fundus of the uterus, and then (as Dr. Sims instructs us) one-half should be seized by the vulsellum and drawn down, so as to cause the tumor to undergo evolution ; the portion grasped coming down first, and by virtue of its attachment at the top, brings the other after it ; but if this cannot be done, we must cut off the part in the grasp of the vulsellum, seize another portion and treat it in the same man- ner, until the whole is removed by pieces. Under favorable circumstances this operation may be performed as above described ; but obstacles will sometimes be met with that will give the best operators much trouble, and render the results very unsatisfactory. The first I will mention is that presented by imperfect capsulation, or adhesion of the tumor to the walls of the uterus. Some cases occur where the tumor is not isolated by a capsule from the uterine struc- tures, but the substance seems to be continuous with them. Whether this condition depends upon original formation, or is the result of disease, which causes adhesion between the surfaces of the tumor and the capsule, I am not able to say; but in either case it presents an insurmountable obstacle to the perfect removal of the tumor ; and, if this condition could be diagnosed beforehand, it would contraindicate the operation for enucleation. When in the performance of the operation we meet with this ob- stacle, and can clearly ascertain its existence, I think it would be best to gouge out as much of the tumor as we could safely remove, and then commence the administration of ergot, to remove the remainder. I would do this, because cutting through the superficial layer of the tumor would be sure to disturb its vitality. The next obstacle to the removal of the tumor by enucleation is the great size to which it may attain. I have already spoken of the necessity of sometimes cutting the tumor in pieces with scissors to facilitate its removal. The wire ecraseur will often be very useful in lessening the size of the tumor. We slip the wire over a portion of the tumor and cut it off, then pull down more wdth the vulsellum, when that is possible, and pass 540 SURGICAL TREATMENT. the wire over another piece, and so on until it is small enough to remove. This plan, where practicable, and especially in the hands of the experienced operator, is the safest way. Dr. Thomas's serrated spoon, or a very small, crescent-shaped knife, such as is used by Dr. E. Warren Sawver, of this city, for cutting into and removing mass, may, by careful use, aid us in this respect. Haemorrhage constitutes a very formidable complication, in rare instances, in the operation of enucleation. I have never met with Fig. 157. Thomas's Serrated Spoon. this difficulty in the removal of these tumors by any method ; but there are too many cases on record to leave any doubt that we should be provided with the means of meeting haemorrhage of the most formidable degree. In considering this matter in relation to the cases reported, I believe it to be the result of inertia, or want of firm contraction in the muscular fibre, or on account of the separation of a vessel in the uterine walls. In. either case, if we continue the operation, we should follow the example of Dr. Emmet in throwing ice- water freely into the cavity of the uterus. I would also resort to obstetric doses of ergot ; both of them would serve to contract the vessels of the uterus, and overcome the inertia by prompting the uterine fibres to act. If, in spite of these remedies, the haemorrhage is so copious as to make delay veiy dangerous, we may inject the uterus with tinc- ture of iodine ; but I should greatly prefer immediate and complete plugging to anything else. If the haemorrhage has been sudden, shall we proceed with the operation? I think not, but would assign this to the category of cases which should be treatsd by ergot. What has been said of enucleation has reference more particularly to deeply-seated submucous tumors which project into the cavity, but are imbedded their whole length in the wall of the uterus. The more superficial or sessile variety of submucous tumors project so far into the cavity as to appear to be implanted upon the wall beneath the mucous membrane of the uterus. The attachment, or base, upon which it sits, is nearly or quite the size of the tumor. This variety can be removed with much more facilitv. LAPAROTOMY. 541 After exposing the tumor, and steadying it by traction with the vulsellum, it may be separated from the wall, and that very neatly by the serrated spoon. This instrument should be inserted through the capsule, at the juncture between the tumor and the uterus, by a rotary sawing motion ; the growth severed by passing it through the capsule in any direction where the attachment exists. This is Dr. Thomas's method of removing this variety of tumors. Dr. Emmet pulls them steadily and persistently down into or toward the vagina ; this allows the upper portion of the uterus, from which the tumor is withdrawn, to contract. Further traction upon the tumor gives room for the fibres beneath the point of implication also to contract, until the circumference of the attachment, becoming smaller, assumes a pedunculated form, and may be severed by the ecraseur, scissors, or knife. This form of tumor may also be removed by passing an Ecraseur over and amputating a part of it, and then, by means of the finger or enucleator, remove the remainder. Patients who have undergone any of these operations for removal of fibrous tumors may die from shock, haemorrhage, inflammation, or septicaemia. For the treatment of shock, I will refer the reader to the subject as taught in the after-treatment of ovariotomy. I have already said sufficient upon the subject of treatment of haemorrhage as a complication in such cases. Inflammation, when it occurs, should be treated as in the after- treatment of ovariotomy. Septicaemia may be more effectually treated in connection with this than almost any other of the great operations, as we can keep the cavity clean by hot- water injections, and disinfected by carbolic acid. For the general treatment, I will refer the reader to the after-treat- ment of ovariotomy. Laparotomy, For the extirpation of the tumor, is another surgical resource, of which we may avail ourselves under circumstances where the em- ployment of less hazardous measures are either impracticable or un- availing. The extirpation of the tumor, where it is subserous and pedicu- lated, has been performed a number of times successfully; and where the tumor is not adherent, there is no great difficulty in removing it in this way. The incision through the abdominal wall may be made in the same 5J2 SURGICAL TREATMENT. place and in the same way as for ovariotomy, although it will be uecessar}^ evidently to make it larger. The pedicle being exposed and ligated by a double silk ligature, it will be found that the substance through and around which the ligature is passed, is not so firm as the pedicle of an ovarian tumor; hence it will be necessary to be more careful, lest it give way and cause secondary hsemorrbage. The ligature should not be passed through any part of the tumor, but between it and the uterine substance; then, to get sufficient sub- stance beyond the ligature, the capsule may be divided an inch from the ligature and the tumor enucleated. When the tumor is sessile, instead of being pediculated, and the base too broad to be included in a ligature or clamp after the abdo- men has been opened, it may be enucleated by splitting the capsule and peeling it out with the fingers. I would suggest that when enucleation has been thus performed, that an opening be made from the bed of the tumor into the uterus, so that the discharge from the empty capsule may find its way out through the uterus and vagina. To secure this evacuation, we might pass a drainage-tube through the opening into the vagina. Where this, or some other effective arrangement for drainage is made, the capsule may be closed by silver sutures, and the abdominal wound treated as for ovariotomy. If the capsule should not be large, and the operation has been per- formed, as it always should be performed, under the antiseptic con- ditions, it may not be necessary to make any provisions for drainage. When a subserous tumor is situated on the posterior wall, occupy- ing the cul-de-sac behind the uterus, it may be removed by making an incision along the median line of the posterior vaginal wall and removing the tumor through the vagina. Dr. R. S. Sutton, of Pittsburg, has successfully removed one in this way, as also has Dr. Clifton Wing, of Boston. Of course none but the small-sized tumors can be removed in this way. The thermo-cautery, or the actual cautery, should always be in readiness to stop haemorrhage in either of these operations. Laparo-hyderotomy. The last measure I will mention, as one resorted to for the relief of patients afflicted with these tumors, is laparo-hysterotomy, or the removal partially, or wholly, of the uterus with the tumor. This operation resembles in many respects that of ovariotomy. LAPARO-HYSTEROTOMY. 543 Our preparation of the patient should be the same. The anaesthetic and the carbolic spray are used in the same way, as also is the anti- septic dressing. When we undertake the operation, we should be especially well prepared with means of arresting haemorrhage. To this end we should have in readiness the thermo-cautery, a number of haemostatic forceps, persulphate of iron, etc., and every other arrangement should be complete, so that there might be no delay from this cause, as the operation is almost of necessity one of long duration under the most favorable circumstances ; and it should be remembered that every- thing, except haste, which may shorten the duration of the operation is of great importance, as the longer the operation lasts, the more depressing its effects. For fear that what I may say should encourage precipitation, I would protest against hurry, and advise deliberation in all the steps of the operation. The incision is made in the same place and manner as in ovari- otomy ; first a small incision, say four inches long, for exploration, to ascertain the character of the tumor, its probable adhesions, and its relation to the viscera. As some viscera, especially the intestine, is more frequently found to lie across the front part of the tumor, the necessity of ascertaining any such condition is much greater than in ovariotomy. When it comes to the separation of the adhesions and the removal of the tumor, the size of the incision must be increased sufficiently to permit the extraction of the whole mass, instead of an effort being made to lessen the size of the tumor, as in ovariotomy. An exception may be made to this teaching, if the tumor is not entirely solid, but of the fibro-cystic variety. In this case, if a large cyst presents itself, we may hold the tumor close to the incision with vulsellum forceps and evacuate the fluid through a large trochar, or an incision into the wall of the cyst. If in doing this we find there are a number of cysts, we may introduce a finger, or even the whole hand, as I once did, into the centre of the tumor, and break it up as far as possible. In this way we may sometimes very greatly lessen the size of the tumor. In this operation, as in ovariotomy, the size of the incision is of great importance ; in no case should we risk bruising or tearing the abdominal walls. In operating for fibrous tumors, we should not trust to the sound in searching for adhesions ; the hand alone should be used, and the 544 SURGICAL TREATMENT. whole surface examined before any attempt is made to dislodge the tumor. We should also remember that the adhesions, as a rule, are more vascular than in ovarian tumor, and hence, when necessary, they should be ligated twice and cut between the ligatures. When solid, the tumor may be lifted from its bed more easily by means of the vulsellum forceps than by the hands. After it is lifted out, the uterus will generally be found to be removed from the pelvis with the tumor constituting a part of the mass. If there are no more adhesions, the junction between the body and the cervix uteri should be sought for and ligated at this point with a strong double ligature. Before applying the ligature to the pedicle, remember that the bladder is in danger in consecjuence of its proximity. We should remember also, that the tissues in the pedicle are less yielding than the pedicle of the ovarian tumor. " Dr. Leon Labbe communicated, at a late meeting of the Academic de Medicine, a note relative to a modification of the operation of hys- terectomy as applied to fibrous tumors (exsauguinification of the tumor). " Gastrotomy applied to the treatment of fibrous tumors of the uterus is an operation about which there is no longer any dispute. The note which M. Labbe communicated to the Academy is not for the purpose of describing this operation, but simply to make known an important modification that he has introduced in the operative process. "The quantity of blood contained in these enormous uterine tumors is always considerable ; it is certain that the loss of this blood by the ablation of the tumor is a factor, the importance of which cannot be passed over, especially if we consider that the extirpation of these tumors almost always takes place in the cases of women who are in an advanced state of cachexia. Based upon the principle which had led Esmarch to apply a compress bandage on limbs which were to be amputated, M. Labbe thought the same bandage could be utilized to press back into the general circulation the blood contained in large uterine tumors, and thus practise a kind of transfusion. '"The patient for whom he had occasion to apply this principle for the first time, was in a deplorable condition before the operation, and she succumbed six days later to septicemic symptoms; but M. Labbe has been able to prove that the enormous fibroma upon which compression was first practiced was entirely exsanguined, and that about a litre of blood was by this means restored to his patient. " The theory which led M. Labbe to apply Esmarch's compress to re- store to the general circulation, at the time of their extirpation, the LAPARO-HYSTEROTOMY. 545 blood contained in such great abundance in the fibro-myomas of the uterus, is very clearly justified by the case which has been reported to the academy. " The peculiar conformation of the tumor was such that no very par- ticular method was employed in this case ; but if the tumor to be operated on is more regular in form we would have just reason to fear that the application of the elastic band might present some difficulties. In this case, to fasten the band and give it a support we should transfix the tumor near its summit by one or more metallic needles. Several of these needles may even be placed at diflferent heights so as to give sup- port to the compress, and to prevent its slipping. "M. Labbe concludes : "1st. That there must be a positive advantage in operations on large uterine fibro-myomas removed by gastrotomy, in restoring to the patient the blood which these tumors always contain in large quantity. " 2d. That this result may be employed in a complete manner by applying to the tumor Esmarch's compress, or any other compress en- dowed with the same elastic properties." — Gazette Hehdomadaire, 6 Aouty 1880; American Journal Medical Sciences, October, 1880. When the ligature is satisfactorily applied we must remember also that in cutting away the tumor there is great danger of retraction of the parts included in it. The abdomen must be carefully cleansed and haemorrhage entirely checked before closing the wound. The after-treatment of these cases is more difficult than in ovari- otomy, as the shock is ordinarily much greater, and inflammation and septicaemia more likely to follow the operation. I have performed the operation three times, and in all instances lost my patients from the severity of the shock. My cases were of the fibro-cystic variety. I do not believe the complete extirpation of the uterus and ova- ries will bear any reasonable comparison with ovariotomy, even double ovariotomy. In comparing these operations we must remember that when the uterus and both ovaries are removed, the whole genital system, with all its reflex capacities and sympathetic relations, is suddenly torn from its connections. The complex system of nerves supplying these organs with centric connections, the moral, emotional, and physical energies they are continually exerting over the whole of the rest of the organism are destroyed. The importance of the relations between the genital system of woman and the rest of her body and brain is so 35 646 SURGICAL TREATMENT. great that it can scarcely be appreciated. These relations constitute the major part of her life. From such considerations, I can but believe that the shock of this operation is incomparably greater than in ovariotomy or double oophorectomy. When one ovary is removed, the other maintains the ovarian in- fluence over the uterus and the system at large. When both are removed, there is still left the larger part of the genital nervous system, with its relations, although impaired, not entirely severed; and we know, from observation, that in such cases womanhood is well preserved. In operations of this kind, conservative surgery is of the greatest importance, and we ought never to remove the ovaries when we can preserve them. While there will continually occur cases for which this operation is the only remedy, experience will prove it to be an operation of much more gravity than ovariotomy in any of its forms. Kimball, Burnham, H. R. Storer, Thomas, and other Americans have performed this operation successfully. In Europe, Pean, Koeberle, Wells, Clay, and others have con- tributed toward perfecting hysterectomy for fibrous tumors. Oophorectomy — Battey^s Operation — Spaying. These are terms intended to designate an operation for the removal of the ovaries. To Dr. Robert Battey, of Rome, Georgia, is due the credit of first removing the ovaries for the purpose of artificially inducing the menopause. The knowledge that the change of life generally brings relief from the intolerable and irremediable forms of obphoro-neuroses that so often perplex the practitioner, would lead to the hope that the re- moval of these bodies would produce similar cures. This operation has been before the professional public for about seven years, and there are reported, according to Dr. Paul F. Munde [American Journal of Obstetrics), up to this time 120 cases, with an average mortality of 22.6 per cent. Dr. Mund6 very correctly observes that if the posi- tive benefits of the operation were as assured as the favorable rate of mortality, the opposition to it would soon cease. The operation has also been repeatedly performed for the purpose of arresting the growth of fibrous tumors of the uterus, on account of the favorable effect the LAPARO-HYSTEROTOMY. 647 natural menopause so generally produces upon them, and in some instances with very favorable results. We should not forget, however, that menopause is not the change of life. This condition — menopause — is sometimes brought about by some of the very conditions for w^iich Battey's operation is performed without producing change of life. It is true that the ovary, if not the essential agent, is certainly necessary to the proper development of the female genital organs. After the genital apparatus is mature, it is probably the fountain of the excito-motor influence upon which depends the functions of the uterus and its appendages in all their relations to the generative acts. The ovaries ought not, therefore, to be classed as appendages to the uterus ; rather the latter is, in the proper sense, an appendage to the former. As an accompaniment of ovulation, which is the development and disengagement of the ovule, the trophic energies of the uterus are excited in corresponding degree. The repletion and activity of its circulatory system corresponds to like changes transpiring in the ovaries, and the nervous system of the uterus is acted upon by that of the ovaries, prompting glandular changes in the mucous membrane. Even the intramenstrual growth and hypertrophy of fibrous and other tissues of the uterus are but the reflex complement of the stromal hypertrophy of the ovaries. As the ovarian excito-motor stimulation is withdrawn from the uterus, involution simultaneously occurs in the two. It is true that the removal of the ovaries with- draws the source of the excito-motor influence from the uterus, and this generally brings about the menopause in the sense of the cessa- tion of periodical haemorrhages; but the same operation, after the uterus has obtained maturity of organization, and especially when its tissues have become hypertrophied (vascular, nervous, and muscular), leaves a large, highly organized organ without its regulating appa- ratus, the subject of any morbific cause which in its nature has any aptitude for the production of uterine derangement. We see this illustrated in the case given by Dr. Trenholme, the after-history of which, subsequent to the operation, I give below. This, I think, is the effect produced by suddenly removing the ovaries in large fibrous tumors of the uterus. In smaller growths, and a less vascular state of the uterus, the same conditions exist, and the same consequences will follow, only in a less noticeable degree. 548 SURGICAL TREATMENT. The senile menopause, one of the symptoms of the change of life, is the consequence of gradual changes in all of the organs concerned. This change is a degeneration of the genital organs. The tissues are not merely diminished in size^ but they degenerate into those of a lower order of organization, and this same degenera- tion extends itself to the morbid growths of the organs. Tumors lose their vascularity, their fibres disappear, and the whole becomes a degenerate mass. It is not certain how much of this general and regular degenera- tion is due to the presence of the ovaries and their exci to-motor ener- gies in prompting it and in governing its nature. It is a plausible supposition, however, that as the ovarian changes and influences are so great in building up the uterus and sustaining its functions, that it might be as efficient in its retrograde transfor- mation, thus making it more complete. The removal of the ovaries in the presence of a large fibroid and hypertrophied uterus, simply takes away their governing agency before the process of degeneration has begun. We have then a highly organized uterus and tumor, and if degeneration takes place at all, — which I very much doubt, — it is not normal in any respect, and may be the cause of morbid instead of salutary conditions. "We then exchange one evil for another ; a greater for a lesser it may be ; to the advantage of the patient somewhat, but yet not so as to make a perfect cure. Dr. E. H. Tenholme, of Montreal, reports a case'^ of abdominal oophorectomy for a large fibrous growth of the uterus in January, 1876. Severe uterine pains and haemorrhage were the actuating reasons for the operation. The patient according to her own account was very much improved for four months succeeding the operation, the uterus then (in May, 1876) suddenly commenced enlarging and gave her very great pain. The enlargement and pain were accom- panied by copious hsemorrhage. As the result of this attack, she was confined to her bed more or less constantly for three months. Recovering from this attack she Avas able to support herself a part of the time as a saleswoman, and a part of the time as a nurse, for several months. In December, 1877, she had a similar attack and of like duration. The patient has now been in this city about two years, and I have had the opportunity of seeing her in two or three of these attacks. * Obstetric Journal of Great Britain, October, 1876, p. 430. 1 LAPARO-HYSTEROTOMY. 549 The pain is exceedingly severe and requires the use of anodynes in considerable doses to relieve it. In April, 1878, one of these attacks commenced and kept her in bed for several weeks. And in Decem- ber, 1879, another similar attack prostrated her, with pain and haemor- rhage, lasting until the middle of March, 1880. During the whole continuance of this attack she was in the Woman's Hospital, of the State of Illinois, under my immediate supervision. During the early part of this last paroxysm, the uterus was enlarged until it extended two inches or more above the umbilicus, and occupied all of the central and lower portion of the abdomen to within two inches of the crest of the iliac bones on either side. Since the subsidence of the symptoms, the size of the uterus and tumor have decreased about twenty-five per cent. It is now somewhat elastic, whereas, during the early part of the paroxysm it was very firm. The health of the patient is so very poor and uncertain, and she so dreads the suffering she experiences during the attack, that she now begs the removal of the entire mass. She is an intelligent woman and has made herself quite conversant with her condition, and the extreme measures sometimes resorted to for relief, and is entirely willing to abide the consequences of the operation. I am deterred from indulging her wish for removal of the tumor by hysterectomy, from the apparent general and very firm adhesions of the front surface of the tumor to the anterior walls of the abdomen. Whether this patient's life has been prolonged by the operation or not, of course no one can know. That her condition, so far as suf- fering is concerned, has been greatly improved, I think no one wit- nessing her agony and prostration during a paroxysm would hardly believe. And while I have no doubt of the thoroughness and skill of the operation, I must say I believe it to be a partial failure. In presenting these reflections on the difference between the effect of a natural change of life and oophorectomy upon fibrous tumors of the uterus, I do not wish to be understood as opposing oophorectomy altogether. They, however, make me hesitate to give an uncon- ditional adhesion to the practice, even where in our present knowl- edge it would seem indicated. 550 SURGICAL TREATMENT. The following table, showing the result of all the reported cases within his reach, was published by Dr. Mann, October, 1880:* Primary Result. Secondary- Result. Reference. ' Operator. S 1 ft t o '6 1 Trenholme, Hegar, . . . Goodell,. . Martin, . . Kaltenbach, Freund, . . Shroder, . . Tait, . . . Pernice, . . Von Nussbaum Tr«' ■ • Mann, . . ^> • 1 13 2 2 1 3 1 11 1 1 1 1 1 10 1 2 1 9 I 1 *3 1 1 1 2 *1 1 7 1 2 2 9 1 1 1 1 1 Obst. Journ., G. B. & S., 76. Centralbl. f. Gynaecology, No. 21-79. Goodell, Lessons in Gynaecology, 2d ed. Centralbl. f. Gynaecology, No. 21-79. Hegar, Journ. Klin. Vortrage. Centralbl. f. Gynaecology, No. 21-79. Centralbl. f. Gynaecology, No. 21-79. British Med. Journ., July 10, 1880. Arch. f. Gyn., Bd. xiv, H. 3. Goodell, loc. cit. Personal Communication. 38 29 9 25 2 Dr. Mann thinks that the operation when performed for fibroids, should be through the abdominal wall ; as they are generally re- moved from their normal position, by being lifted up as the uterus becomes larger. The effect of removing the ovaries for intolerable and incurable cases of oophoro-neuroses, is quite another thing ; for then we re- move the cause of the disease, or rather the symptoms ; because, as they are the organic origin of the neuroses, their condition is the disease, and like amputating a limb, that is incurably diseased, to get rid of the symptoms, we cut off the ovaries for the same purpose. There is another side to this subject, however, and that is the general condition of the patients, who are the subjects of these nervous symptoms, is such, as, in part, to account for their suffering. And we sometimes find that a radical change in the circumstances under which they live, will dispel their trouble. Instances of this kind must * Oophorectomy for Uterine Fibroids, by Matthew Mann, A.M., M.D. Clinical Lecturer in the Medical Department of Yale College. American Journal Obstetrics, October, 1880. LAPARO-HYSTEROTOMY. 651 have fallen under the observation of most practitioners of long ex- perience. Muscular labor, outdoor exercise, and the loss of luxuries, when brought by inexorable bad fortune, have done wonders in the way of removing oophoro-neuroses. Then the question comes up, whether we ought to spay our patient or prescribe and enforce the proper amount and kind of primitive living necessary to revolutionize her nervous functions. The former course is the easiest, and, I am sorry to say, most acceptable to some patients. The following are Dr. Battey's* conclusions as to the proper cases for o5phorectomy : " It is not a question as to whether extirpation of the ovaries shall be resorted to, or whether valerian or asafoetida be given, or resort be had to any other known resource of gynaecology, but the case must be nar- rowed down to this, as the only expedient available." The following are the classes in which he regarded the operation as justifiable: " 1. Congenital absence of the uterus, coupled with ovulation, in which, at the menstrual epochs, there are violent vascular and nervous per- turbations, that are either dangerous to life or destructive to the health and happiness of the patient. 2d. Complete occlusion of the utero- vaginal canal. 3d. Certaincasesofmenstruo-mania, absolutely incurable by any of the known resources of medical science or art. 4th. Ovarian epilepsy. 5th. Certain cases of chronic ovaritis. 6th. Certain cases of amenorrhoea. 7th. Ovarian hernia. 8th. Submucous or interstitial fibroids. 9th. Incurable flexion of the uterus. 10th. Csesarean sec- tion." This last, of course, means cases in which patients cannot be de- livered per vias naturalis. In deciding whether or not he should advise the operation, he asks himself three questions : " 1st. Is this a grave case ? 2d. Is it a case incurable by any other known resource of medical and surgical art? 3d. Is it curable by the menopause ?" If all are satisfactorily answered in the affirmative, he regarded the case as a proper one by the operation known as Battey's. If either * "What is the Field for Battey's Operation?" A paper read before the Amer- ican Gynaecological Society in Cincinnati, September 1st, 1880, by Dr. Kobert Bat- tey, of Eome, Georgia. 552 SURGICAL TREATMENT. question cannot be answered satisfactorily, he regarded the case as one in which the operation is not justifiable.* While these positions are not all as definitely put as they ought to be in a matter of so great importance, one thing is made plain by them, and that is, Dr. Battey regards the operation as a last resort. We are not yet able to do more than practice Battey 's operation according to the imperfect light we have upon the subject, because it is the only available means of relief we can command. By intel- ligently watching effects we will be able after awhile to arrive at definiteness of indications for its employment. Physical and Psychical Results. I have four patients from whom I have removed both ovaries, whom I occasionally meet, and, so far as I can see of them, and from explicit assurances given by them, I believe they are not unsexed in any other sense than that they are sterile, and do not menstruate. In morals, manners, appearances, affections, propensities, and voice, they remain the same. The operation of removing the ovaries per vaginam was first per- formed by Dr. Battey. After exploring the posterior and vaginal walls Dr. Battey made an incision in the central line, about one inch and a half long, and with his finger drew the ovaries through the opening, ligated them and cut them off. Since then the operation has been repeated in the same way by others. The ovaries have also been removed a number of times through the abdominal walls. The main obstacle to be met in the performance of the operation is the adhesions arising from previous or existing inflammation. Sometimes this obstacle is so great that the operation through the vaginal wall is extremely difficult, and occasionally quite impossible. In such cases laparo-oophorectomy would be the easiest operation. The incision in this operation should be made in the same place as for ovariotomy, and no larger than is necessary. Hegar sometimes removes the ovaries through an opening an inch long, but probably two inches will be a more frequent incision. * October No., 1880, American Journal of Obstetrics. CHAPTER XXXVI. THE OYAEIES. The ovaries are situated upon each side of the uterus, to which they are attached by a strong fibrous ligament about one and a half inches in length, and they occupy the posterior part of the broad ligament just behind and a little below the Fallopian tubes. AVhen in their normal position they are slightly below the linea ilio-pectinea, and somewhat anterior to the sacro-iliac synchondrosis. When their size and weight are somewhat increased by congestion they may vary from their normal locality by sinking lower down in the pelvis. The peritoneal membrane is reflected around them, and embraces the lower two-thirds of their substance, while the upper border stands out free in the peritoneal cavity and in contact with some of the fimbria of the Fallopian tube. The entire organ is inclosed in its proper fibrous covering, the tunica albuginia, which is extremely dense and firm in structure and incloses a peculiar firm, spongy substance, or stroma, held together by delicate connective tissue, and abundantly supplied with bloodvessels. In the meshes of this spongy stroma are numerous dark micro- scopic points, which by some are supposed to be the points around which the ovisacs are formed. In each ovary of the adult woman may be seen several ovisacs of diflPerent dimensions, from the size of a pin's head to that of a pea. The main body of the stroma presents a delicate buff color when in- cised. Method of Examining the Ovaries. The ovaries are situated so deep in the pelvis as to make them seem to be inaccessible to every means of investigation. In very fleshy persons it is indeed difficult to reach them, but even in most of such patients we can gain valuable information by thorough and perse- vering effort, and in women of thin habit we can generally reach them with the finger. When it is remembered that there are very few of the diseases to which these organs are subject that do not in- crease their volume and weight, and that in displacements of the uterus they are frequently drawn down below their natural place, 554 THE OVARIES. we shall not be at a loss to understand the possibility of generally procuring information by the right kind of an examination. The most simple plan of examining them is to introduce the index and middle fingers as deeply into the vagina as possible, and direct them high up in the pelvis to the side and behind the uterus, while with the other hand above the pubis we press the pelvic contents down as low as we can. To do this in the most effective manner the patient should lie on her back across the bed, or on the operating-table, so that we may have the free use of both hands. If we do not reach the ovary in this way it is very proper in some cases to etherize the patient, and introduce the hand all but the thumb. We may thus ex- plore the sides of the pelvis quite thoroughly, and, in favorable sub- jects, will seldom fail to find and get a pretty good idea of the state of the organ. The ovary is rather nearer to the anus than to the vaginal orifice, hence an exploration, with one, two, or more fingers in the rectum, may lead to definite results, with less inconvenience to the operator. It should be said, however, with reference to examinations per rectum, that they are both more painful and disgusting than those through the vagina, and should be resorted to only when we cannot succeed in getting the proper information by examination through the latter canal. In rectal explorations we may avail our- selves of the bimanual method, and the pressure above will be of more service than when examining per vaginam. CHAPTER XXXVII. AFFECTIONS OF THE OVARIES. Congenital Atrophy. The ovaries, like the rest of the genital organs of woman, may be imperfectly developed. It is not unusual to meet with women whose whole sexual system is developed to a degree usually found to indi- cate the completion of childhood. The breasts are about the size and shape of the girl twelve years of age. She does not menstruate, and perhaps is not endowed with the sexual desires common to the sex; and if married, fails to bear children. The uterus, if examined, is found small, as are the clitoris labia and nympha. In all the instances of this kind that have come under my observation, the individuals were otherwise well developed. Not unfrequently, however, as shown by other observers, the whole person is deficient, never attaining to more than the stature of a child. Cases of the congenital atropliy of the ovaries are given in this work under the head of amenorrhoea, with the method of treating the condition. Senile atrophy of the ovaries needs no description in this place. Hypertrophy. Enlargement of the ovaries is probably occasionally due to an in- crease in size without other alteration of their tissues. This is hyper- trophy. It is supposed to result from prolonged congestion, causing hypernutrition of the organ. The disease is hypothetical, as it has not been demonstrated. More frequently the enlargement is caused by an increase of some of the natural tissues and by inflammatory effusions. This last en- largement is, of course, due to chronic inflammations. It is not easy, if at all practicable, to diagnosticate hypertrophy of the ovaries. We can generally detect enlargement of these bodies by physical exami- nation, but cannot in all cases determine with certainty the nature of the enlargement. Displacement. Their intimate and firm ligamentous connection with the fundus of the uterus causes them to partake of the changes in the position of 556 AFFECTIONS OF THE OVARIES. that part of the organ. Thus, when the fundus rises into the ab- dominal cavity during pregnancy, the ovaries are carried up with it, and in very thin persons they may sometimes be felt as small, mov- able, sensitive tumors upon the side of the uterus. The same thing occurs in some cases when the uterus is much enlarged by a fibroid tumor. In the former condition the displace- ment is physiological, and does not ordinarily give rise to serious inconvenience, unless the organ is rendered unusually sensitive by disease. When the uterus is retroverted or retroflected, the ovaries are displaced to a greater or less extent downward and backward, and sometimes this displacement is so great that they may be felt in the posterior cul-de-sac and constitute a very annoying complication. In fact, this condition is of more consequence than the uterine displace- ment, and is a serious barrier to the correction of the malposition of the uterus, on account of their, liability to be compressed by the in- strument used to hold the uterus in place. But sometimes the ova- ries fall into this position without the uterine deviation. When this is the case there are likely to be many grave symptoms, which are included in the vague and imperfectly understood term "ovarian irritation.^' In most cases of this nature the ovaries are the sub- ject of some form of organic disease, and we may reasonably doubt whether the symptoms arise from the pre-existing disease any more than from the deviation from their normal position. There can be no doubt, however, that the displacement may greatly embarrass the circulation in them, and thus contribute still farther to their mor- bid condition. In such cases, the extensive reflex nervous influence exerted through the genito-spinal centres awakens a long chain of mor- bid phenomena destructive of the comfort of the patient, and some- times establishes a series of oophoro-neuroses that wrecks the patient mentally and physically. Finally, I may say that rarely these organs may make their way out through the inguinal canal, in something of the same way that the testes do in the male. As there is no scrotum, however, in which they can find lodgment, they are arrested at the upper border of the pubis, and there constitute a harassing and painful hernia. This ovarian hernia may generally be diagnosed from the omental or in- testinal hernia, from the facts, first, that these two latter seldom pass out through the inguinal ring in the female, though frequently through the femoral ring ; second, that they are not particularly sensitive to the touch unless in a state of inflammation from strangulation, while the ovary is quite sensitive; and, third, that the sensitiveness of the DISPLACEMENT. 557 ovary is said to be peculiar, resembling nothing so much as the sick- ening sensation experienced upon pressing the testicle, while the sensation of omental or intestinal hernia is rather the tenderness of inflammation. Having referred to the different varieties of ovarian displacements, I desire now to confine myself to the pelvic deviations of position. Symptoms, What are the symptoms of pelvic displacements of the ovaries ? Having already referred to them, I shall be brief in their further consideration. They may be included under two heads, local and general. The local symptoms are not distinctive. They are pain, weight, or bear- ing-down sensation, sometimes heat in the pelvis, backache, sacral and coccygeal tenderness, and occasionally radiating neuralgia ; there are also very frequently though not always, menstrual derange- ments, but these local symptoms may be produced by many of the disorders incident to most of the pelvic organs. As to the general symptoms. They are quite numerous and varied. It is indeed questionable whether all of the hystero-neuroses should not be regarded as oophoro-neuroses ; that is, direct or indirect morbid emanations from the ovaries themselves. It is probably impossible for us to separate the general symptoms arising from disease of the pelvic viscera into uterine, ovarian, vaginal, and vulval, as the nerve- supply to these organs are essentially a unit, and for their nervous manifestations are subject to the same presiding centre. In them is comprised a circle of functions to the perfection of which, soundness in all of the organs is essential. Whether the ter- rible nervous symptoms arising from certain diseases of the vulva, the vagina, or the uterus can be reflected upon the organization in any otter way than through their connection with the ovaries is a ques- tion not yet solved. I think we cannot doubt, however, that to " ovarian irritation^' may be attributed the whole array of reflex phenomena so frequently noticed in the wrecked condition of broken-down women. In the retrouterine displacements of the ovaries, these conditions are prominent features, the numerous symptoms often assuming a very aggravated form, and the suffering of the patient becoming un- endurable. The general symptoms are those of ovarian irritation, and this is to be expected, because the circulation and the innervation of these organs must necessarily be very much interfered with by their malposition. 558 AFIECTIOyS OF THE OVARIES. Th.e Din gnosis Of these displacements is not generally very difficult. AVheu in the inguinal canal, an examination of the tumor, its shape and peculiar sensitiveness are both characteristic, the only thing for which it may be mistaken is hernia of the omentum or intestine, and a tumor formed by the protrusion of either of these is more globular, less firm, and unless in a state of inflammation is not very sensitive. When in the cvl-de-sa.c behind the uterus if not changed in shape by disease the ovary has the same outline as when naturally situated and is movable. TTe may reach it by passing one or two fingers deep into the vagina or rectum. In many instances this displacement is associated with retrover- sion or retroflexion of the uterus, and is apparently the result of the malposition of that organ. In others, however, the ovaries fall behind the uterus, because of their enlargement and increased weight from structural disease. Possibly a relaxed condition of the fold in the broad ligament in which it is contained, may peruiit the ovary to settle down out of its natural position. Are displacements of the ovaries always and necessarily accom- panied by serious local symptoms or destructive general disturbances ? I think not. Probably every gynaecologist of extensive observa- tion has noticed instances, in which the ovaries could be felt in the cul-de-sac, and the patient experience little if any inconvenience, from such malposition. These, judging from my own observation, are not very uncommon cases. Why should some patients suffer so much from these displace- ments while others experience so little inconvenience from them ? In answering this, I must employ a term that is not very definite, and perhaps not always intelligible, " nervous susceptibility." This nervous susceptibility with some patients, appeai-s to be a part of their original construction or " make up '' if you please, while with others it is an acquired condition. Xervous susceptibility and neurasthenia, if not connected as cause and effect are at least very intimately associated, and to treat these cases successfully therefore, we must have in mind tliis item of nervous susceptibility or neurastlieuia connection. Prognosis. When displacements give rise to symptoms of ovarian irritation, what is the prospect of relief? TREATMENT. 559 Such cases are justly regarded as very unpromising, but not neces- sarily incurable. Treatment. The treatment of the symptoms attendant, and to some extent de- pendent upon displacements of the ovaries, is sometimes followed by most satisfactory results. By treating the symptoms, I do not mean the administration of medicines for the relief of nervous headache, hysterical convulsions, sleeplessness, etc., but the removal of those conditions from the system which encourage their manifestation. Whatever may have been the diathesis of our immediate ancestors, whether they were effected by diseases resulting from hypersemia or plethora or not, it is evident that we have fallen upon times when ansemia or hydrsemia among women, is, to say the least, a very com- mon state of the general system. This is especially the case with a large proportion of patients suffering from ovarian irritation, either with or without displacements of the ovaries, and the nerve centres in such people are habitually ansemic. Nervous exhaustion means imperfect nutrition or lack of trophic energy in the nerve centres. This, I have no doubt, is mainly be- cause there is not a sufficient amount of good, rich blood circulating through them. I cannot understand how nervous exhaustion can take place when there is an unfailing supply of nutrition in these centres, but it is plain that an exhaustion of supply will render the regular working of the brain and spinal cord impossible. It is blood exhaustion then in- stead of nerve exhaustion. What we want to do with these patients is to turn them entirely around in their habits, and lead them to the adoption of measures that will make them plenty of blood and fat. Dr. Weir Mitchell has taught us how to do this, and his system of managing patients of this character is admirable. It is not always practical nor in- deed necessary to adopt his method as a whole. This, however, does not detract from its merits. Absolute rest is necessary only in cases of extreme prostration. In most cases active exercise will be better than passive, and should always be enjoined upon the patient and attendants. The exercise in kind and quantity should be prescribed and enforced with exacting regularity, and urged by decision that will not fail. The most important part of the treatment, however, is the regula- tion of food, by which I mean the prescription of it in items and quantity from day to day. 560 AFFECTIONS OF THE OVARIES. My routine prescription is three ounces of beefsteak for break- fast, with bread and butter, or toast, potatoes, and other vegetables, as the capacity for digestion will allow ; six ounces of roast beef or mutton, bread and butter, potatoes, vegetables, etc., for dinner ; for supper the same as for breakfast, and after each meal, and at bedtime, one pint of good fresh milk. The only limit I would place upon the amount of food of the kind I have indicated is the capacity of the stomach to retain it. If the food is not rejected by vomiting, or it does not irritate the bowels enough to cause diarrhoea, I would not allow the want of appetite nor the inconvenience that may arise du- ring digestion to be considered as a reason for not taking it. Usually the stomach will soon become tolerant and, after a time, the enriched blood, circulating through its glandular apparatus, will en- gender a relish for food, and the patient will eat with pleasure. This intimation, that an ansemic stomach necessarily digests with difficulty, is intentional, for I do not believe that energetic innervation is possible without the supply of blood is sufficient to secure good digestion. With this, or some other equivalent method of feeding the patient, there should be associated some plan by which she can get plenty of fresh air, and have as much exercise as she is able to take. The ex- ercise may be passive at first, but as soon as it is possible it ought to be active. Active exercise may be begun by having the patient walk, sup- ported as much as necessary by a strong nurse, but as soon as she can walk alone the support should be withheld. Then it is not rest, but exercise, that should be advised in these cases. Of this I am fully convinced by experiments and unmistakable proofs in my own practice. As long as nutrition can be supplied the patient will profit by ex- ercise, but if nutrition is impossible then of course exercise is impos- sible also. Thus far I have said nothing about medicines to aid digestion or to increase nerve force, not because I have no faith in them, but because I believe them of secondary importance, mere ad- juvants instead of principals in the treatment of this condition of the system. I could cite a number of instances in which this course of manage- ment resulted in averting the dangers and mutilation of the more heroic treatment of castration by establishing a vigorous and tolerant con- dition of the nerve system, and thus curing ovarian irritation. These suggestions are applicable in other cases than displacements of the ovaries in which there is ovarian irritation. OVARITIS. 561 As to the management of the displacement. In some few cases, when the ovaries are borne down by a displaced uterus, we may occasionally correct the displacement so far as to greatly improve the circulation of these organs, and thus remove a great element in ova- rian distress. This, of course, is done by correcting the displacement of the uterus, by proper means of support, as a well-adjusted pes- sary. In the cases, however, in which the symptoms are the most grave, — retroversion and retroflexion of the uterus, — the location of the ovaries in the cul-de-sac by the side of the fundus renders the satis- factory adjustment of the pessary almost impossible, as the instru- ment is pretty certain to cause pressure upon these sensitive organs, and thus become intolerant. We ought not to despair of accom- plishing the object, however, until we have exhausted our ingenuity in mechanical appliances for this purpose. When every other measure fails either to render the condition of the patient bearable, or save her from becoming a mental and physi- cal wTeck, we still have the resource furnished us by Dr. Battey, of Rome, Georgia, namely, the removal of these organs. In taking the consequences of this operation, however, we should remember that it is very dangerous, and that, if successful, it unsexes our patient in the sense that she is at least barren for all future time. AVhen the ovaries are displaced so as to occupy the inguinal canal the operation for removing them is less hazardous than when in the pelvic cavity, and for that reason may be resorted to with less hesitation. Ovaritis. Acute inflammation of the ovaries, in connection with local peri- tonitis, or inflammation of the cellular tissue in the pelvis, is not an uncommon affection. As a simple, uncomplicated disease, it is con- ceded to be of infrequent occurrence. Post-mortem examinations reveal the existence of inflammation of the ovaries, as a com])lication of inflammation of the surrounding tissue, in all stages, from mere phlogistic hypersemia to destructive suppuration. In such instances it is involved in the general mass of disease. This occurs after abor- tion, labor at full term, and even in the more puerperal condition, as the result of cold. As ovaritis in this connection is the disease causing no separate symptoms, and requiring no other treatment than is necessary for the cure of the inflammation accompanying it, all that is requisite to say upon the subject will be found under the head of perimetritis. 36 . 562 AFFECTIONS OF THE OVARIES. As the result of the infrequent occurrence of ovaritis in an un- complicated state, our knowledge of it is very meagre, many experi- enced practitioners never having recognized it. The intense interest the profession now feel and manifest in diseases of women will soon lead to a clearer understanding of this subject. The following case is the nearest approximation to simple acute inflammation of the ovaries ever observed by the author: "January 5th, 1872, I was called to see Mrs. S., widow, aged thirty- five years. She is the mother of three children, the youngest of whom is eight years old. She had been attacked fourteen days before with pain in the hypogastric and iliac regions; chill, nausea, headache, and great nervous excitement. Fever succeeded the chill, and the nausea was sometimes accompanied by vomiting. The pain continued, and was aggravated by the erect or sitting posture. She was attended by a homoeopathic practitioner, and after a few days improved until she was able to sit up a part of the time ; but the pain, accompanied with ten- derness upon pressure in the iliac region, continued in a subdued degree. Upon the 13th, about 10 p.m., after having exerted herself too much, she had another chill, with an aggravation of the symptoms. In the morning, when I was called, I found her vomiting, and unable to retain anything but cold water. She had headache, with pain and tenderness in both iliac regions. There was no tumefaction. The pulse was 110 to the minute ; the tongue was coated white ; the mouth dry, and other febrile symptoms usual in moderate attacks of acute inflammation were present. The attack had occurred at the time the menstrual flow was subsiding, and was attributed to exposure after being overheated and fatigued. At the time I saw her there was no discharge from the vagina ; the passage of the urine gave her pain of a burning character, and she suffered pain also in passing the faeces. Upon examining per vaginam with the finger I could feel both ovaries prolapsed and tender. The uterus was prolapsed somewhat; also swollen and tender to the touch. Upon making pressure in the hypogastric region the patient complained of but little tenderness. Downward pressure in the iliac region caused more pain, and increased the sensations of tenderness in the pelvis. The ovaries, as felt through the vagina, were tender, mov- able, and appeared to be three times their natural volume. The pa- tient complained of increased nausea when they were touched in the examination. I found no difficulty, by using the fore and middle fingers, in examining them thoroughly and recognizing their shape and size. The diagnosis was moderate inflammation of the uterus, with more acute inflammation of the ovaries. The patient informed me that she was not aware of being the subject of chronic inflammation of the TREATMENT. 663 uterus, as she had not previously suffered from pelvic pain or incon- venience, indicating chronic disease of any kind about the uterus or ovaries. There did not seem to be local peritonitis nor cellulitis, and but slight metritis. The bladder was irritable, and the vagina slightly tender. " Treatment. "Four grains of calomel were given, and succeeded in eight hours by a saline cathartic. Poultices were applied to the hypogastric region, and the patient ordered to keep quiet in the recumbent posture. The cath- artics operated well, and relieved much of the pain and suffering. One- fourth of a grain of morphia enabled her to rest with some degree of comfort. When the pain returned the morphia was repeated, and thus continued when necessary for the pain. The bowels were kept soluble by the administration of a fluidounce of the saturated solution of citrate of magnesia. By continuing this course of treatment for six or seven days the inflammation was subdued, and convalescence was fairly estab- lished, In three or four weeks she was entirely well, and still remains so." CHAPTER XXXVIII. AFFECTIONS OF THE OVAKIES CONTINUED— OVAEIAN TUMORS. Anatomy. In the proper ovarian tumors, we may trace three coats or layers of tissue forming their walls. The external is the serous or perito- neal. It is shining and smooth as this membrane is elsewhere, and seldom changed in any way, except it may be thickened and hyper- trophied. It can be traced into the peritoneal covering of the viscera and abdominal parietes, and consequently needs no elaborate descrip- tion. The internal coat or lining membrane is doubtless the mem- brana granulosa of the ovisac, very much hypertrophied. When small, something like epithelium seems to be its entire composition. As it grows and develops, the epithelial arrangement is less perfect, until, when very large, we can observe it only in patches. In many cases when thus large, this membrane has a smooth, lustrous appear- ance, but in others it is more or less thickly studded with granular projections, varying from almost imperceptible minuteness to the size of peas, or even larger. Regarding the main sac as an hypertrophied ovisac, I think these little granular sacs (for they prove to be sacs upon examination) are also of the same nature and are the origin of the numerous endogenous or supplementary growths which constitute one of the polycystic varieties. The middle coat is made up from the stroma of the ovary. Its strength depends upon quite a considerable amount of fibres, which enter into its composition. As the tumor develops, these fibres are enlarged, and apparently, if not really, increased in numbers, until they constitute the most of the thickness of the walls, and in some parts make quite a thickness, density, and toughness of tissue. These qualities are greater in old large sacs than in the smaller and younger ones. At the pedicle, and for some distance up the sides, they are greater than in other portions, being in these parts sometimes a quar- ter of an inch thick, while at the fundus or distal portion they may be thin and fragile. The whole of this coat may be very tough and thick, so as to resist great force, or it may be thin throughout, so as to be easily ruptured at almost any point. Entangled in the meshes of these fibres may be discovered, in many cases, the minute micro- NATURE AND ANATOMY. 565 scopic points so numerously scattered through the substance of the ovaria. These points are believed to be the origin of the germinal spot in the ovum by some physiologists, and around which are de- veloped the ovum, and progressively the whole ovisacs and their contents; and I believe that their presence in the walls of the tumors, over much, if not the whole, of their extent, accounts for the devel- opment of the minute granular internal projections above described. In a tumor recently removed from the body, by holding it up to the light, we may not unfrequently discover the peculiar buffy tinge seen in the stroma. The vessels are situated in this coat. They are nu- merous and some of them large, so large that great care is necessary to prevent them from bleeding when the peduncle is divided. They are developed, it is hardly necessary to say, to this great size from the minute twigs w^hich penetrate the substance of the ovary. The shape of ovarian tumors may vary much. They may be regu- larly globular, polyglobular, angular, or irregular in almost every way. AYhen small, the ovary may be seen as constituting a consider- able portion of the tumor. When large, the ovary may be almost lost in the walls, or observed as a mere tubercle sticking to or im- bedded in its side. Generally but one ovary is the seat of disease, but in rare instances both are aifected. Ovarian tumors divide them- selves anatomically into monocystic and polycystic, — the one having a single cystic cavity, the other several. The polycystic variety is formed by the development of several cysts adjoining or by the side of each other, and independently attached to or springing from each other on the external surface, or within the cavity of one large one. The instances of polycysts growing by the side of each other, and being independently attached, resembles at first the single. At an early stage of development they may stand free of contact one with the other, but as they grow in size, in consequence of the small surface of the ovary to which they are attached, they crowd together, so that it is not always easy to say whether they were not developed from each other. The cysts from which smaller ones grow are called pro- liferous. They are doubtless single for some time in their early de- velopment, but carrying up, as they increase in size, the proper sub- stance of the ovary, with its rudimentary ovisacs, after awhile the inner or outer surface is bulged by the maturity of these last, which, if they do not dehisce and allow the escape of the ovum, grow into a subordinate tumor. This process is separate until there is a glomera- tiou of cysts to quite a number, from four to fifty, of various sizes, from the size of a man's head down to that of a pin's head. Small 666 OVARIAN TUMORS. ones may be so numerous as to stud a large part of the inner surface with granulated elevations. This is the most frequent variety met with in practice. When the minor sacs grow from the inner surface of a large cyst, the tumor is denominated olygocystic. There is a great difference in the sensible qualities of the contents of the cysts in different cases, and of the different cysts in the same case. In some it is very thin, in others very thick and tenacious, while the color shades from black, inky, to limpid clearness. Not unfrequently large fibroid growths are observed in the ovary at the base of a single or multiple cystic tumor. These solid fibroid or fibrous growths may be simple or benign in their nature, or malig- nant. This complication of ovarian dropsy I think more frequent in persons advanced in years — over forty — than younger ones. The contained fluid of the polycystic tumor is ordinarily highly albumi- nous, of high specific gravity, tenacious, and more or less colored. The fluid is so thick sometimes as not to flow through a canula. Occasionally we meet with sacs which contain blood; more frequently serum colored with blood; in others pus, or serum and pus. From one tumor of several cysts, I drew pus from one cyst; dark coffee- grounds sanguineo-serous fluid from another; a beautiful straw color from another; and lastly, from another, fluid of a delicate azure tint. After tapping, more or less alteration is observed in the fluid, each operation withdrawing fluid affected by chemical or pathological cir- cumstances. In the former, putridity or acridity; in the latter, the purulent productions of inflammation. There are some chemical and microscopic resemblances in the fluid from almost all varieties of ovarian tumor. Albumen in some of its forms is always present. In some specimens of fluid, strong acids, or heat, causes it to assume a solid form, coagulating and adhering like the white of an egg when cooked in boiling water ; in others a small precipitate is all that is observed. Between these extremes all shades of difference exist. The reaction is alkaline. Mr. Nunn says that, '' As the results of many examinations (microscopic) of different specimens of ovarian fluid, the most constant characteristic of such fluid is its containing, in greater or less abundance, cells gorged with granules; and, in addition, circumambient granules, having the same measurement, encompassed by the cell. The size of the gorged cells and included granules varies greatly, even in fluid from different cysts in the same ovary.'^ This description of fluid could, with certainty, remain good of the first evacuation only, as pus and blood-globules are not unfrequently found in subsequent evacuations. NATURE AND ANATOMY. 567 The fibrous or solid variety of ovarian tumors is occasionally met with. Dr. Bogue, about ten years since, removed a solid tumor of the ovary at the Cook County Hospital, which weighed forty ounces. It was very dense and fibrous in structure. The very remarkable tumor called dermoid is so seldom met with and so little is said of them in the textbooks that I feel justified in copying somewhat at length from my article on dermoid ovarian tumors, in the third volume of the Transactions of the American Gynaecological Society : Case I. — In the spring of 1874, the patient, a girl, eighteen years of age, noticed an enlargement in the left iliac region, which finally became so great that in October, 1875, she was distressed from the distension. At this time she was tapped and about ten quarts of fluid evacuated. The physical nature of the fluid was somewhat tenacious, of a clear, slightly bluish tinge, and contained the ovarian cell. The outline of the tumor could be traced quite easily after the tapping. It occupied the whole width of the abdomen between the two iliac fossse and extended upwards to within two inches of the umbilicus. It was globular and of soft consistence. After this operation the tumor filled quite rapidly, and on Jan- uary 1st, 1876, the patient was as large as before the fluid was evacuated. On January 4th, ovariotomy was performed. There were no ad- hesions or other source of embarrassment to the removal of the tumor, and the patient made a good recovery. The sac was thin but firm, and presented the peculiarly pearly aspect of the ordinary ovarian tumor. When the large Wells's trocar was introduced nothing but serum flowed through the tube. Upon being opened the tumor was found to contain about half a pound of sebaceous fat. The inner surface was smooth, except a small part about the size of the palm of the hand situated at the bottom near the pedicle. Here the surface was depressed at least an inch below the level of the inner surface, and, although not sacculated, had a well-defined and pursy margin. The bottom of this depression was covered with dermic tissue, and upon it grew an abundant crop of dark -brown hair about an inch long. It was very fine, and firmly attached. Doubtless the dermic patch was the source of the fatty material found floating in the cyst which on cooling assumed the consistence and appearance of yellow butter. Upon closer inspection of the smooth lining of the larger part of the tumor it was found to 568 OVARIAN TUMORS. be studded with very miaiite papillae, such as we sometimes see in oligocystic ovarian tumors. This specimen I regard as not a true dermoid cyst, but as a com- plex dermo-ovariau tumor, a tumor originating in a Graafian follicle in which a tegumentary element had been inclosed. It contained no bone or teeth such as are often found in the true dermoid tumor, but did contain undoubted colloid fluid, diluted with the watery pro- duct from the sweat glands of the dermic membrane upon which the hair was implanted. Case II. — Mrs. P., aged forty-three years, the mother of one child eighteen years old, became aware of an enlargement of the abdomen about ten months before the operation, which was performed June 28th, 1876. During that time she grew to the size of preg- nancy at full term. The tumor filled the abdominal cavity and ex- tended to the eiisiform cartilage. There was no difficulty in deciding that it was monocystic and contained a thin fluid. The operation was not attended with difficulty in any respect. There were no ad- hesions, and after evacuation the sac passed through an incision only three inches long. The patient experienced considerable depression from the shock of the operation. This, however, lasted but a few hours, no other disagreeable symptoms supervening. The recovery was rapid. The care of the case after the operation was undertaken by Dr. S. W. Green, of Marengo, Illinois. The cyst was single, thin, and uniform, except at the part opposite the pedicle, where its wall was about half an inch thick and contained a thick layer of adipose tissue. Upon the inner surface of this part was a thick tegumentary covering, upon which was implanted a dense mass of blonde hair, matted together, and nearly the size of an orange. The whole of the inner surface of the sac elsewhere was smooth and of a bufF color. The external surface was of a pearly hue and smooth. There was no evidence of bony or dental tissue. The fluid was quite thin, of a slightly blue tinge, and floating in it in considerable masses were ten to twelve ounces of yellow sebaceous fat. The hairs when straightened out measured from six to fifteen inches in length. This example I regard as a simple dermoid cyst of the ovary, there being no sign of follicular papillfe upon the inner surface, and the fluid not being in the least tenacious or colloid in appearance ; more- over I was unable to find in it the ovarian cell. I think the fluid was the product of the sweat glands in the dermic structure at the bottom of the cvst. NATURE AND ANATOMY. 569 Case III. — Mrs. P., a small Jewess, thirty-one years of age, the mother of four children, the youngest being three years old, noticed about nine months before the operation — which was performed April 7th, 1875 — that the abdomen had commenced enlarging. The tumor was foimd to be raonocystic and so completely filling the abdomen that the patient had great inconvenience from distension. The removal of this tumor, which originated in the left ovary, was easy, as no adhesion or other obstacles were encountered. The patient recovered without experiencing any untoward symptoms. The tumor was composed of a single cyst, of which the wall was thin over about three-fourths of its circumference and easily ruptured. At the bottom or pedicular portion, involving about one-fourth of the inner surface, was a dense mass of areolar tissue literally filled with pieces of bone. The greater number of these i)ieces were cyl- indrical, from half an inch to two inches in length, and varying from an eighth to a quarter of an inch in thickness. They seemed to be imbedded in loose cellular tissue, were not attached to each other, and were easily removed by the finger. Other masses of bone, made up of alveolae, were not unlike the maxillary processes, and varied in length.from one to two inches, and in width from one- third to one-half inch. They resembled honeycomb, and were quite firmly attached to the cyst wall. The microscope showed their structure to be that of true bony tissue. This mass was covered by a tegumentary membrane to which was attached more than a hundred imperfect in- cisor teeth, distributed over the whole surface, their adhesions being so slight that they could easily be scraped from the surface with the finger. These dental bodies were all about the same size and con- sisted merely of the crown ; but the enamel and dentine seemed per- fect. They had no connection whatever with the bony tissue. In- terspersed among these teeth was a dense crop of blonde hair, aver- aging an inch in length. The fluid, of which there was about ten quarts, sp. gr. 1008, was clear, with a slight bluish tinge, and entirely devoid of tenacity or other colloid properties. I believed it to be perspiratory serum. There were also several ounces of yellow sebaceous fatty matter within the cyst. I should class this tumor among the true dermoid cysts of the ovary, and believe that it possessed none of the properties of the ordi- nary ovarian tumor. Its structure was much more complex than that of the two preceding tumors, but much less so than that to which I shall now call attention. 570 OVARIAN TUMORS. Case IV. — Mrs. B., thirty-five years of age, the mother of four children, the last twenty months old, first noticed a tumor in the rio"ht iliac region nine years before the operation. It was then about the size of her fist. It had grown steadily but slowly until June 19th, 1878, when it was extirpated. The growth did not seem to be influenced by pregnancy. She had borne three children from the time when the tumor was discovered to the time of its removal. Her health had been feeble for several years, but from the birth of her last child she had been confined to bed half of each day, and, for several weeks, all the time. The main inconvenience was from tlie w^eight and mobility of the tumor. When she was in the erect pos- ture it caused dysuria and rectal tenesmus ; when lying on either side it pressed upon the subjacent viscera and also dragged upon the upper side ; the only comfortable position was the dorsal. The pulse and temperature were decidedly and continuously above the normal standard. She was sleepless, had a very poor appetite, and was rapidly becoming emaciated. The above very brief history was given me by the attending physician, Dr. J. H. Low, of Brimfield, Illi- nois. The appearance of the abdomen was very singular. It was con- siderably distended; from its centre, including in fact the whole umbilical region, arose a round projection exactly resembling a ven- tral hernia, the umbilicus occupying its apex. It measured five inches in diameter, and protruded three and a half inches above the common level. It was fluctuating and dull upon percussion. On each side I could easily distinguish two other, apparently larger, cysts not projecting above the surface. Percussion over these elicited no resonance, but it was easy to detect fluctuation. The tumor could be moved pretty freely in all directions without traction upon any part of the abdominal walls. By external and internal manipulation I could trace the attachment of the mass to the right side of the pelvis and assure myself that it was not of uterine origin. It was clear that I had to deal w^ith a tumor made up, principally at least, of three cysts, and quite certainly originating in the right ovary, but it pre- sented so many unusual symptoms and appearances, that further diagnostic measures were necessary before I w^ould venture to remove it. After making preparations for its extirpation, the patient being fully etherized, I introduced a small trochar into the prominent cyst. A little sebaceous fat flowed through the canula, and at once made the diagnosis complete. The usual small incision exposed the pearly cyst and allowed me to evacuate the prominent sac of one quart of NATURE AND ANATOMY. 571 thin, yellow fat. The other two cysts were drawn to the opening, and their contents, of a similar character, evacuated. By this time the rubber blanket was smeared with a sticky grease, the instruments had become slippery, and my fingers were encumbered with a mass of fat which had to be removed before I could proceed with the operation. The cysts were drawn through an incision about three inches long, and a short, slender pedicle, consisting of the right ovarian ligament, part of the broad ligament, and Fallopian tube, was brought up into the wounds, ligated, cut, and dropped into the pelvic cavity. The left ovary was healthy. As nothing had been allowed to pass into the peritoneal cavity the incision was then closed. It will have been seen by this description that no adhesions or other impediment hindered or complicated the operation. It was remark- able how extremely greasy everything employed in the operation became, and I had more trouble in cleansing the instruments from the grease than is usually experienced in getting rid of the blood and mucoid fluid of the common ovarian tumor. The patient had no untoward symptoms, seeming to me more like one recovering from the exhaustion and irritation in which I had found her than from the hazardous operation for the removal of an ovarian tumor. Before describing the tumor I wish to call attention to the fact that there was no serum evacuated during the operation ; no fluid but the soft fat was observed. The tumor proved to be a remarkable specimen of the true dermoid variety, nothing in its contents seem- ing to be of ovarian origin. The cyst wall was thin, but of firm structure, and divided into three compartments of about equal di- mensions. The septa were complete, and of the same consistence and density as the external walL At the base of the tumor the sac was more dense and firm than elsewhere. The peculiar formations con- tained in each cyst were so nearly alike that a description of the con- tents of one will suffice for each of the other two. On opening the cysts each was found to contain a mass of matted hair, the size of a lemon, thoroughly supplied with the same fatty substance that had been evacuated from the tumor. One of these rolls of hair was red, another blonde, and the other gray. The patient's hair was dark brown. Some of this hair was twenty inches long, and it was all attached to tegumentary substance closely re- sembling the scalp. The dermic structure, which was about four inches across, rested upon a very uneven layer of adipose tissue an inch thick. By the side of the dermic patch, and not covered by it, was a loose layer of areolar tissue, an inch and a half thick, contain- 572 OVARIAN TUMORS. ing bones in a great variety of shapes, — scales, round bones an incli or more in length, alveolar nodules, etc. Upon- the surface of this part of the tumor in each cyst was a half-arch of teeth the shape of one-half the superior maxilla. In one cyst the crowns of the teeth projected above the surface, while in the other two they were thinly covered by tissue so soft that it could be pinched off by the thumb and finger. The teeth were not attached to the subjacent bones, but were simply imbedded in the loose mass. The teeth in each segment verv perfectly represented, respectively, an incisor and three molars, each having three well-marked fangs. One of the molars in each row stronglv resembled the wisdom tooth. The perfection of their forma- tion will be recognized in the specimens which I submit for your examination. The crown with the enamel and eminences, the main body, and roots are as distinctly marked as if they had been removed from alveolar cavities. Before leaving the description of the tumors and their removal, I would call your attention to the great simplicity of the operation and the fortunate recovery of all the patients, no adhesions or other com- plications having existed. Now what is a dermoid tumor? This name is given to a cyst formed anywhere in the body, the internal or lining membrane of which is in part or wholly tegumentary in structure. As now un- derstood, the presence of this condition alone would justify this nomenclature. The formation seems to be no less an error of struc- ture than location. Lebert, Paget, Virchow, and most other modern pathologists agree that the dermic tissue thus located is essentially the same in structure as true skin. The products are all the same, hair, sebaceous fat, and perspiratory fluid. In many of these tumors we find subcutaneous adipose tissue very perfectly formed. Less con- stantly, teeth, bone, muscular, nervous, and even brain tissues. These latter, except the teeth, in some instances, are found either beneath the dermic membrane or beneath the portion of the internal surface not lined by this cutaneous substance. My experience shows that the dermic tissue and its products char- acterize one variety of these formations, as in Cases II and III. These constituents are sometimes found alone, and may tlien be re- garded as indicative of a more simple formation, while the addition of bone, muscle, etc., constitute a more complex order of tumor rep- resented by Case IV. The bone and muscle, however, are never found in a tumor of this kind without the dermic membrane, its essential glands, and their products. Another thing quite apparent NATURE AND ANATOMY. 673 is that the skin and its appendages are not only constantly present, but comparatively perfect in their organization. The teeth, which are very closely associated in embryonic metamorphosis with the formation of the skin, stand next; many being quite perfect in their structure. The bony, muscular, and nervous structures, although complete in their texture and formation, are never developed into complete organs. I am aware that cases have been recorded, — as for instance by Blumbach and Rokitansky, — that would seem to be at variance with this assertion ; but the bones in these cases lacked the completeness in structure necessary to entitle them to be classified with any of the bones in the human skeleton. When some or all of these structures, together with the products of the dermic tissue, con- stitute all the contents of the cyst, the specimen should be regarded as a simple dermic tumor, even when formed in the ovary, the fact of its having found a lodgment in that organ being an accidental rather than a necessary condition. When, however, it exists in the ovary, and with these substances there is found the colloid or mucoid fluid characteristic of the ordinary ovarian tumor, it is not merely a dermoid, but an ovarian dermoid tumor. It is a mixed neoplasm, a morbid development of the ovarian follicles in connection with the congenital dermoid. In my first case this was the character of the tumor ; and instances of this kind are recorded in the well-known books of Drs. Atlee, Peaslee, and Mr. Wells. The first variety, then, although often found in the ovary, differs in no essential particular from those found elsewhere, except in magnitude, and perhaps greater perfection of organized development. Possibly this last difference does not exist. When found in the ovary, either in the single or mixed form, the investing membrane seems to be the same in appearance and structure as in ordinary ovarian tumors ; and, when first exposed, it is often not easy, if at all possible, to distinguish between them until some of their contents are evacuated. To the more fluid products of the first variety of simple dermoid cysts, especially the secretion from the dermic tissue, such as the serous or perspiratory fluid, we must attribute the difference in the size of this form of tumor. The sebaceous product is also sometimes quite bulky, as seen in Case IV; but when the sudoriparous glands are numerous and active, the amount of watery fluid is sometimes enor- mous, and consequently the tumor grows to be very large, as may be specially noted in the second case. In such instances, from causes which are not appreciated, the sudoriparous glands seem suddenly to 574 OVARIAN TUMORS. acquire great functional activity, and bv pouring into the tumor a large supply of fluid make it grow with great rapidity. As there was no appreciable amount of serum in Case IT. the sac beino; filled with the sebaceous matter, it is easily understood why the tumor was a lono- time in attaining the dimensions it finally acquired. The solid contents of these tumors, as far as I can learn, do not grow to a sufficient extent to give them any great bulk, and consequently, when situated in the ovary, such a tumor, apart from its fluid con- tents, would hardly require extirpation. The compound variety, or ovarian dermoid, would be likely to grow to a great size in consequence of the accumulation of the colloid secretion, just as they would if the dermoid element did not exist. By consulting the literature of the subject, I am led to the conclusion that the dermoid and colloid contents of these compound cysts are usually contained in different compartments of the tumor. This was notablv the case in some of Mr. Wells's specimens. There are one or two facts which may have some bearing upon the production and development of these tumors: The dermic membrane is always superficial with reference to the inner surface of the tumor; the hair always, and the teeth often, grow from its surface; while the bone and other tissues are situated below it, but not always im- mediately under it. In my fourth specimen the bone was imbedded in a mass of cellular substance by the side of the cutaneous layer, giving me the idea that it belonged to a blastodermic formation deeper than the tegumentary portion of the surface. The question here naturally presents itself: Whether the simpler forms of these dermoid cysts, in which the dermoid structure, with hair, fat, and serum are found without any of the deeper tissues, are tumors in the process of development into the more complicated va- riet^'? I think not, and belie re that each tumor receives during its embryonic state all the elements of formation it is capable of produc- ing; that the trophic qualities imparted to it then definitely limit its possibilities. If so, it necessarily follows that the tumor, containing all the variety of structure ever found in them, should manifest these qualities and structures without gradation of growth, and possess from the beginning the complex qualities found in advanced periods of life. Theories of their Origin. The theories devised to explain the origin and development of ovarian dermoid tumors represent, with some degree of exactness, the physiology of the times in which they originated. In the earlier ages NATURE AND ANATOMY. 575 of medicine, physiology was the creature of imagination. Definite knowledge of the internal organs was wholly wanting; if possible, even less was known of their functions. Pathology also rested upon the same unsubstantial basis. As a consequence, the theories of the origin and development of these curious growths were all vague and imaginary. In the latest and most plausible explanation yet offered, we have the results of the present highly cultivated science of physi- ology; and if not absolutely true, there can be fewer rational and scientific objections opposed to it than to any of its predecessors. It is not my present purpose to do more than give a very cursory view of some of the most prominent theories which have at different ages been presented to, and accepted by, a large portion of the pro- fession at the time they were promulgated. I will classify the theo- ries under three divisions : I. Those originating in the imagination alone without any scientific foundation. II. Those w^hich have for their basis the superstitions of the times in which they originated, and of the people by whom they were entertained. III. The scien- tific theories. I. The most ancient of the imaginative theories is, I believe, at- tributed to Aristotle. It taught that the dermoid products of these tumors — as the hair, teeth, etc. — had been swallowed and transmitted in some unknown manner to the localities occupied by them. This idea is a good match for many of the ingenious vagaries of that wise man. Belief in virginal pregnancy supplied the basis of another and ex- tensively prevalent theory. It assumed several forms. One was the abstract possibility of a virgin becoming impregnated without sexual intercourse, or true parthogenesis. Another was that the ovaries pos- sessed properties that enabled them to produce, to a limited extent, the organized bodies resembling the parts of a foetus; or, again, that certain unsatisfied sexual longings of an isolated woman might stimu- late the ovaries to imperfect generative processes. Still another was that certain individuals possessed a sort of ovario- cystic diathesis which took this direction. It is easy to see that these vagaries — for they ought not to be dig- nified by the term theories — had no physiological basis and could be the products of imagination alone. II. The superstition of mediaeval times gave rise to the theory that these tumors were visitations of Providence upon the subjects of them on account of particular sins. The infliction of this punishment upon males as well as females showed Providence to be no respecter 576 OVARIAN TUMORS. of persons. One man had a pregnancy in the thigh because he laughed at his wife in her suffering during labor. It is said that the products of these tumors were sometimes baptized in the hope of avoiding the perdition in which they would be involved without such a ceremony. Hence, it seemed that the priests believed in their own invention, and that the theory was not a mere trick with which they tried to practice upon the credulity and ignorance of the people. III. As the knowledge of physiology advanced somewhat among the profession, the theories became more rational, and the possibility of natural causes was employed to explain the occurrence of these singular tumors. They were regarded by many as ovarian pregnancy, in w^hich the formation of the foetus was imperfect, or, after having undergone development, the foetus had become disintegrated, and the skin, bones, and teeth being more difficult of destruction, had withstood decom- position and remained in the sac. Another theory accounted for their peculiarities by supposing that the ovum had become blighted after having been developed to a certain extent. Some one else has propagated the doctrine of inclusion, or of a foetus in foetu, believing that somehow one ovum had become en- gulphed in the organization of the other, and on account of the na- ture of its nidus could not attain to complete organization or devel- opment. Still later, plastic heterology and heterotopy were supposed to afford a more rational explanation of their production. According to this theory, the origin of these tumors in any part of the body is no more wonderful than the growth of other forms of heterologous tumors in the same localities. In the light of the patient physiological research of our own day, and especially from the revelations of the microscope, a theory of these curious tumors has been developed, which I regard by far the most satisfactory and scientific. This theory is based upon a supposition which is at least physio- logically plausible. It may be stated thus : In the early period of ovulation or embryonic development, by some accident or imperfection of formation, an indentation of the blastoderm is produced. In the wonderful trophic energy of that period the minute depression is inclosed by the approximation of its blastodermic margin and becomes an isolated cavity, and the growth and perfection of the embryo are accomplished notwithstanding this early accident to the integrity of its envelope. The depression thus NATURE AND ANATOMY. 577 formed involves, perhaps, all the layers of the blastodermic mem- brane, but the external layer becomes the lining membrane of the cavity, and is completely cut off from the rest of the blastodermic surface and invaginated with all its essential structures and processes of organization ; all its products, therefore, must be retained in the cavity. The contents of this cavity correspond in miniature with what the formation might have been if the displacement had not occurred. In the further development of the embryo the portion of the blastoderm covering this adventitious cavity develops its tissues and organs in the ordinary way, and thus incloses it in the body by the structures usually found to cover it. The internal layer of the blastoderm is doubtless also displaced, but it is not isolated, and con- sequently its products are never found inside the tumor. Therefore, in instances where the dermoid patch occupies any of the mucous cavities, the neoplasm will always be found external to the mucous membrane. This theory serves to explain why these hairy tumors are found in the foetus, child, virgin, matron, or male, and with equal plausibility why they may exist in any part of the body. Dr. Pauly, in an excellent paper in the American Journal of Obstetrics, expresses a doubt whether they exist more frequently in the ovary than elsewhere, notwithstanding the generally received opinion that this is the case, and at present it cannot be asserted that they are not as common in the male as in the female. This theory would certainly not furnish us with reasons for their occurrence more frequently in woman than in man. If nothing unusual happens the adventitious sac grows with the individual in whom it is situated, and perhaps attains maturity as the same character of organs mature elsewhere. The sac itself continues to increase in size, because of the constant secretion of the glands of the dermic structure. Growth from this cause would probably be slow if the activity of the tegumentary glands were not preternatu- rally quickened by morbific causes. When situated in the ovary, however, the conditions naturally calculated to impart an impetus, exclusive of what is termed pathological states, exist. Hence in them they grow more rapidly and larger than in other places or organs. The fluctuation of nerve force, circulatory supply, and nutritional conditions which take place in the ovaries in consequence of the processes of menstruation, sexual excitement, and the varied states of generation, disturb the states of these otherwise nearly sta- tionary neoplasms. 37 578 OVARIAN TUMORS. These reasons would lead us to expect the dermoids situated in the ovaries to become large and to grow more rapidly than in any other organ or locality. When situated in these bodies their progress is usually tardy until the age of puberty is reached. At this time the tumor is likely to be influenced by the increased nervous and vascular activity assumed by the ovary, and thenceforward they manifestly possess all the conditions necessary to cause copious dermic secretions. In the ovaries, also, their growth is more likely to be influenced by the morbid impressions to which these organs are more frequently subjected than almost any other part or organ of the body. They are also doubtless especially stimulated by the occurrence of the con- ditions which give rise to the colloid tumors. For in connection with this form of tumor they are generally found to have assumed great proportions. The condition imparted to dermoid tumors by the ovaries would almost necessarily lead to their discovery during the lifetime of the patient, and thus favor the idea that they are more frequently located in these organs. Situated in organs of more unvarying functions they would be likely to remain dormant, and never attain dimensions that would cause them to be discovered ; consequently they are over- looked in the general statistics on the subject. Aftep ovarian tumors have been developed to a certain extent they become subject to diseases and accidents, and thus play an im- portant part in the sanitary conditions of patients in whom they exist. Inflammation attacks them, and causes ulceration in their walls so as even to perforate them, making a communication between the cavities of contiguous cysts, or with the peritoneal cavity. With- out perforating the walls of the tumor, the ulceration may produce a good deal of pus, which is mingled with the other contents of the cyst in which it occurs. General inflammation of its walls may pro- ceed to a fatally exhaustive extent, or spread to the peritoneum, and thus indirectly cause death. Gangrene may also result, which may be confined to the cavity of some of the cysts, and induce a putrid, ofiensive state of the contents, or perforate the dividing partitions, and thus make a communication between cysts, or open them into the peritoneal cavity. The walls may also rupture from distension in consequence of their becoming attenuated, or as the efi^ect of a violent stroke or fall, or other shock, and the contents escape into the perito- neal cavity. By means of ulcerative communication with the Fallo- pian tubes the fluid sometimes escapes. Adhesion to the walls of the abdomen from inflammation and ulceration through the parts thus NATURE AND ANATOMY. 579 agglomerated sometimes results, and the fluid so discharged. Inflam- mation also causes adhesion at various parts. The fibrin eff'used glues it to the surrounding parts, — the abdominal walls, the intes- tinal canal, bladder, and other viscera. Slight inflammation is sup- posed to increase the effusion in their cavities, and cause them to grow very rapidly. Inflammation, also, sometimes, no doubt, causes oblit- eration of the cavity from adhesion of the walls. This is more fre- quently the case when it results from external causes, as blows, tap- ping, pressure, injection, etc. Now, it hardly ever happens that these diseased conditions and accidents of the tumors fail to produce their effects upon the health of the patient. No doubt but that death occurs from extensive disease in the sac, without any organ being directly involved. A large production of pus would exhaust the patient ; gangrene, to a large extent, would cause death, as extensive gangrene of unimportant organs generally does. But an extension of disease to the peritoneum and surrounding viscera, or by the effu- sion of the acrid contents of a diseased cyst, is more likely to be the mode of progress to constitutional disturbances inaugurated by in- flammation in the tumors. When the tumor bursts, and its contents are effused into the peri- toneal cavity, the peritoneum seldom escapes without inflammation; but the degree will depend upon the nature of its contents. If they are not vitiated, but consist of the bland albuminous fluid found there ordinarily, it is very slight indeed, and lasts for a very short time only. But should pus, or the ichor of decomposition, be mingled with it, we should be prepared to expect serious if not fatal results. I once had an opportunity of observing the progress of a case for several months, where this rupture and eftusion were frequently re- peated. About every three weeks the woman would attain to a large size, and a well-defined large cyst could be felt filling up the whole abdomen and distending it greatly, when suddenly, without premoni- tion or apparent cause, the cyst would give way, the swelling would become more diffuse, fluctuation more obvious, and the cyst could be no longer defined by the touch ; slight fever and some tenderness of the abdomen would last for two or three days, when copious per- spiration and diuresis would evacuate the fluid in a few days more. After this process was completed, the abdomen would be lank, and a small cyst could be felt rising up from the left ilium ; it would in- crease and burst at the end of three weeks, as the other had done be- fore. I saw the patient frequently while this process was repeated six or seven times, when, as she would not submit to the operative 580 OVARIAN TUMORS. procedure which I insisted upon, I was dismissed, and an irregular practitioner, who was sure he could cure her, installed in my place. Not long (perhaps three months) after I was discharged she died from the inflammation resulting from one of these. effusions, probably be- cause the contents of the cyst had become vitiated by inflammation. But these growths may produce a pathological condition of the system without becoming themselves the seat of disease, by the great size they may attain mechanically interfering with the functions of the pelvic and abdominal viscera. Before rising out of the pelvis it may displace the uterus, and cause inconvenience from this effect; it may press upon and obstruct the rectum, bladder, and urethra, or upon the iliac veins, causing obstruction to the flow of blood, and varicose veins in the legs, phlebitis or phlegmasia dolens ; or, pressing upon the nerves, cause neuralgic pains in the limbs, hips, etc. It is plain that such pathological effects, when induced, would be serious, in proportion with the greater or less impaction in the pelvis by its continued growth. Ordinarily, these inconveniences do not prove very embarrassing to the functions of the important vital organs, but sometimes the case is far otherwise, and life is very much shortened and health rendered miserable. As it rises into the abdomen, these mechanical troubles are apt to be lessened ; and as the room is com- paratively so great in that cavity, quite a while elapses before any great disturbance results from mechanical pressure. After awhile, however, the abdominal muscles are distended beyond convenient size, and the tumor is strongly pressed among the viscera. The kid- neys, liver, stomach, intestinal tube, in fact, all the abdominal organs, may become the subject of great and even fatal pressure. In many instances, however, enormous size is attained before fatal damage re- sults. One hundred and fifty pints of fluid have been taken at a single tapping. A much less amount, in most cases, w^ould produce very grave results by pressure. When the growth is rapid, its mechanical effects will be more distressing; and, on the contrary, the organs accommodate themselves to a great deal more pressure if gradually brought about. Besides the inflammatory changes that take place in the tumor, chronic degeneration is occasionally observed. Deposits of earthy substances in the walls, bony spiculse, etc., are the most frequent. Small tumors, containing solid material, are more commonly thus affected. The modes of termination are worthy of some consideration. Many cases, in consequence of a low grade of vitality, last through a great TERMINATION. 581 many years without materially influencing the general health, and up to the death of the patient, at an advanced age, when large, prove to be nothing more than an inconvenient burden, and when small not the cause of even this kind of trouble. Others, in consequence of their bounteous vascular supply and energetic vitality, bring about fatal conditions of the abdominal organs in a few months. Sponta- neously favorable terminations are so rare that we can base no calcu- lation upon them. Perhaps rupture of the sac into the peritoneal cavity, collapse, and adhesion of its walls, is the most common anscurity is so great that we will be at a loss by this management to decide whether the contents are solid or fluid. A slight variation of this combination of tact and percussion will often clear it up, however. When we wish to ascertain whether the fluid is contained in several cysts, we should place the pulp of the fingers of the left hand in the centre of the tumor, and then percuss w^ith those of the right, first very near, then gradually increase the distance between them, until we find a point at which the fluctuation becomes less distinct ; this is the margin of the cyst over which our left fingers are placed. Still keeping them in position, we percuss around in every direction, until we have made out the boundary and size of the cyst under examination, when we may move the fixed fingers to its margin, and commence the same process around this point. Proceeding in this way from one point in the abdomen to another, in most instances we maj' trace the outline of all the cysts superficially situated, and thus enumerate them, and learn their rela- tion and absolute size. If solid bodies, of whatever structure, are incorporated in the mass and superficially situated, they may be de- tected with their relative position, size, etc. After tapping, when the abdomen is lessened, its walls lax and soft, palpation, and percussion, singly or combined, become more demonstrative than before this operation. It not unfrequently is necessary, on account of the sensitiveness of the patient, when the DIAGNOSIS. 589 tumor is small, and the abdominal muscles not much under con- trol of the will, to administer chloroform until unconsciousness is induced, and the influence should often be so profound as to abolish reflex sensibility. Palpation and percussion should both be prac- ticed ordinarily with the patient in the recumbent position on the back, with knees drawn up, shoulders elevated, and the abdomen stripped quite bare of covering ; in many instances, however, varia- tion of posture is indispensable to definite results, — the standing, prone, etc. Very little need be said in this place about auscultation, as it is only applicable to the diagnosis between it and pregnancy, and will be dwelt upon when I come to speak of that more particu- larly. Vaginal and rectal digital examinations in ovarian disease are proper, and should not be dispensed with. The pelvis should be carefully surveyed by this method. The attachments, consistence, and relations of the diseased mass to the various organs in this cavity should be carefully noted. The uterus, rectum, and bladder, so far as* practicable, ought to be examined with reference to their healthy condition, position, and involvement. Combined with external pal- pation, we may examine the tumor more thoroughly than with either one alone. Two fingers introduced into the vagina, and pressed firmly upward against it, will perceive any impulse imparted to the tumor above. With the left hand, if we press downward toward the pelvis, we may feel the motion of the diseased accumulation down- ward, and, if the sudden impulse of percussion is applied above, we may feel an impression from its contents ; if fluid, a wave or sense of fluctuation ; if solid, the deadened impulse always given in such cases. When the tumor is small, and occupies the posterior peri- toneal cul-de-sac, by introducing one finger in the rectum, and the other into the vagina, the tumor may be included between them, and thus examined with more accuracy than with either alone. Dr. Simpson has taught us how to extend our examinations into the uterus, so that our information in this direction is very materially increased by the use of the probe mounted upon a handle. Members of the profession who appreciate the labors of Dr. Simpson have, by consent, named the instrument, the improvements and uses of which he has so ably promulgated, ^'Simpson's sound." The sound may be introduced into the uterus, and varied in its direction, while we gently urge it forward to the extremity of the uterine cavity. The only obstacle a sound of the proper size will meet with in a uterus of ordinary size arises from want of correspond- ence with the direction of the cavity. The most simple and ready 590 OVARIAN TUMORS. revelation of the sound or probe is the direction and length of the uterine cavity. From this knowledge much valuable deduction may be drawn. But it is employed for determining the relation of the uterus to pelvic tumors, according to the ingenious directions of Dr. Simpson, very handily and to excellent purpose. While the sound is in the cavity of the uterus, this organ may be fixed by holding the instrument firmly in one position, or be moved in any direction, if not restrained by adhesion or accretional attachment to the diseased mass, or to some other organ. If the uterus be fixed, and the tumor moved by its side or from it, with the fingers introduced for the pur- pose, the motion w^ill be felt affecting the uterus through the attach- BOSTON. Aspirator. ments. On the other hand, if we watch the motion of the tumor with the fingers while the uterus is moved, the attachment or not will be determined, or the uterus may be moved in one direction and the tumor in another. In this way their attachments may be pretty cer- tainly diagnosticated. The sound may be employed in the uterus with one hand, while palpation on the abdominal surface is effected with the other ; and, if the uterus reaches above the pubis, the distance the probe is separated from the external hand, or its relation with the median line of the abdomen, or the main bulk of the growth, w411 enable us to determine some interesting problems. The motion re- ceived by the sound from the pressure of the hand without, or vice versd, is of important significance, as will be more apparent as we advance. When, from all these sources of inquiry, we fail to get a suffi- ciently definite answer, there is still another physical means of diag- DIAGNOSIS. 591 Dosis which we are justified in employing, viz., exploration. By means of an exploring needle, or aspirator, we can draw oif a small quantity of fluid ; it may be subjected to microscopic and chemical tests that will often enable us to determine the nature of the disease. Dr. J. Hughes Bennett, in a paper on " Ovarian Disease,'' in the Edinburgh 3Iedical and Surgical Journal, quoted by Mr. Brown, says, as the result of his microscopic '' examinations of different speci- mens of ovarian fluid, that the most constant characteristic of such fluid is its containing, in greater or less abundance, cells gorged with granules ; and, in addition, circumambient granules, having the same measurement as those encompassed by the cell-wall. At one time I considered the size of these granules (if they can properly be so called) was constant, but subsequent observations have convinced me of the incorrectness of this conclusion ; the size of the gorged cells and granules varies greatly, even in the fluids from different cysts of the same ovary." There can be no question but that the nature of the fluid contained in these cysts is, in all its essential features, pretty constantly the same in the early stages of progress ; but it is equally true that, as they grow large enough to be influenced by pressure or other external causes, their microscopic composition must vary. Although my opportunities for microscopic examination of ovarian fluid have been quite limited as compared to others, I cannot but express a decided belief in the conclusion arrived at by Dr. J. M. Drysdale. I have never found the ovarian cell described by Drysdale in any but ovarian fluid ; nor have I failed to find it in specimens that I knew to be fluid from an ovarian tumor. It is but fair to say, how- ever, so many of the best gynaecologists doubt the accuracy of his conclusions, that the question is far from being settled. The fluid drawn from the tumor is generally turbid and discolored, often chocolate color. When felt between the thumb and finger is sticky, and sometimes very tenacious and ropy. The granular cell revealed by the microscope, according to Drys- dale, is best exhibited in contrast with other pathological products contained in the sac, as given in the plate and description on pages 458-59 of Ovarian Tumors, by Dr. W. L. Atlee. " On the Granular Cell found in Ovarian Fluid. " On placing a drop of the fluid removed from an ovarian cyst under the microscope, we usually find a number of granular cells, E, some free granular matter, c, and small oil-globules, b; and frequently, in 592 OVARIAN TUMORS. additioD to these, epithelial cells of various forms, A, and crystals of cholesterin, D. These, together with blood -corpuscles, F, the inflam- matorv globules of Gluge, i, the pus-cell, G h, and disintegrated blood and other cells, mav all be sometimes seen floating in either a clear or a turbid fluid. " To find them all present in one specimen, however, is rare; more commonlv we can discover but three or four of them in the fluid. But no matterr what other cells may he present or absent ^ the cell ichich is almost invariably found in these fluids is the granular cell. "This granular cell, E, in ovarian fluid is generally round, but sometimes a little oval in form, is very delicate, transparent, and contains a number of fine granules, but no nucleus. The granules have a clear, well-defined outline. These cells differ greatly in size, but the structure is always the same. They may be seen as small as the one five-thousandth of an inch in diameter, and from this to the one two-thousandth of an inch. In some instances I have found them much larger, but the size most commonly met with is about that of a pus-cell.* " The addition of acetic acid causes the granules to become more distinct, while the. cell becomes more transparent. When ether is added, the granules become nearly transparent, but the appearance of the cell is not changed. " This granular cell may be distinguished from the pus-cell, lymph- corpuscle, white blood-cell, and other cells which resemble them, both by the appearance of the cell and by its behavior with acetic acid, '• The pus and other cells, G, which have just been named, have often a distinctly granular appearance; but the granules are not so clearly definee imperfection of its execution, and greater lack of skill in the after-treatment, we are warranted in indulging the hope that electrolysis may some day emerge from its present uncertainty and claim success to sufficient degree to be ap- plicable to certain conditions of ovarian cases. There are two methods of applying electrolysis to ovarian tumors, one is the external or precutaneous, in which the electrodes are ap- plied over the skin in such a manner as to allow the current to pass through the tumor. This method is less prompt and also less dan- gerous in its effects. Dr. Frencisco Dichiara, Professor of Surgery, Palermo, Italy, re- ports a case in which there was great constitutional debility caused by some three hundred sittings. (Dr. Munde's paper.) The other plan of electrolyzing the tumor consists in inserting one or more needles into the tumor and connecting it or them with one electrode, while the other electrode is applied over the surface of the tumor or in the vagina, or by applying both electrodes to needles in- troduced into different parts of the tumor. Experimenters in this practice are not sufficiently definite as to the kind of battery, the strength of current, the frequency or length of time of each sitting. These conditions, as well as the character of tumors likely to yield to the treatment, are points to be ascertained by further experiment. Neither is it yet determined whether the constant current or the induced is the better to use. Dr. Trommhold, of Buda Pesth, is reported by Semeleder to have cured an ovarian cyst by the external application of the Faradian current. For further information on this interesting subject, I would refer the reader to Dr. Munde's paper, and to one in the New York Medi- cal Journal, of June, 1876, by Dr. Frederic Semeleder. The third object in the treatment, partial or complete removal of the growth, remains to be considered. Vaginal Ovariotomy. Six cases of vaginal ovariotomy are now on record, by Drs. Thomas, J. F. Gilmore, of Mobile, C. E. Wing, of Boston, W. Goodell, of \ SURGICAL TREATMENT. 623 Philadelphia, R. Davis, of Wilkesbarre, Pa., and Robert Battey, of Georgia, all of which were successful.''' The practice originated with Dr. Thomas. The operation consists in raaking an incision through the posterior wall of the vagina, punc- turing the cyst, withdrawing it, and tying the pedicle. Dr. Thomas ligated and returned the pedicle, and closed up the wound. The most disagreeable circumstance following his operation was a smart attack of pelvic cellulitis. In Dr. Goodell's case the cyst was in a state of suppurative inflammation, and had contracted many adhesions, which he overcame by introducing the fingers through the incision and traction with the volsellum forceps. The expediency of this operation is unquestionable where the diag- nosis is complete, because the favorable termination of the cases indi- cate a greater degree of safety than abdominal ovariotomy, and the patient escapes the annoyance and dangers which attend the great development that necessarily follows, especially when the operator is an experienced gynaecological surgeon. I should decidedly favor the idea of leaving the vaginal incision open for drainage, and through which the cavity might be washed out, to prevent septic poison from entering the system. * Eiumett's Principles and Practice of Gjneecology. CHAPTER XL. OVAEIAN TUMOES, CONTINUED. GENEEAL OBSERVATIONS. Abdominal Ovariotomy. During the time that surgeons were experimenting with different methods of performing ovariotomy, the incision was made in different localities, but now all operators make it in the linea alba, and between the umbilicus and the pubis. As to the length of the incision, the exigencies of the case must govern us. Three inches will often be sufficiently long to permit the removal of an oligocystic tumor with slight or no adhesions; much more frequently, however, it will be necessary to make the in- cision five inches long; very seldom will it be necessary to make it longer than this. Mr. Wells thinks that incisions which do not extend above the umbilicus are safer than those which do. Dr. Peaslee believes that the incision may be too short; less than three inches he thinks more dangerous than a greater length. The practical rule, according to Peaslee* (and I fully concur with it), is to make the opening into the peritoneal cavity for the removal of the tumor at least three inches long at first, then to prolong it if necessary, and only so far as is actually required. If the incision is to be carried above the umbilicus, it should be carried around to the left and then back to the linea alba. Treatment of the Pedicle. Operators have not arrived at the same unanimity in reference to the management of the pedicle that obtain as to the size and location of the incision. The application of the clamp is a very simple way of securing the vessels in the pedicle. After the tumor has been withdrawn from the abdominal cavity, the pedicle should be embraced by the clamp within half an inch of it. * Ovarian Tumors, p. 417. TREATMENT OF THE PEDICLE. 625 The instrument should be tightened with sufficient force to per- fectly secure the vessels against bleeding. The pressure should be as great as possible to not cut through the intervening tissues. After preparing the peritoneal cavity, the wound may be closed by silk sutures from above downward, the clamp placed crosswise on the skin at the lower extremity of the incision. Mr. Wells directs us to tan the extremity of the pedicle extending beyond the clamp with persulphate of iron. In from four to ten days, sometimes longer, the instrument will become detached and may be removed. Mr. I. Baker Brown, according t<) Peaslee, first nsed the actual cautery to divide the pedicle. A clamp is first applied so as to secure and fix the pedicle, and then the cautery at a red heat is applied in such a manner as to cook the parts between the tumor and the clamp, and afterward to burn through the pedicle and thus sepa- rate it. If we have the iron at so low a temperature that we can make a prolonged contact and pass it over a larger space, the coagulation of the albumen in the tissue is so complete that there is no danger of haemorrhage. If, however, the cautery is very hot, it will sever the arteries with- out consolidating the parts, and thus permit as free bleeding as if the division was made by the knife or scissors. The thermo-cautery of Paquelin, or the galvano-cautery, are the handiest instruments with which to cauterize the pedicle, but iron cauteries heated by properly constructed blowpipes, or a small porta- ble furnace, such as is used by tinners for soldering purposes, will answer very well. Dr. G. H. B. McLeod, of Glasgow, first conceived and executed the idea of securing the vessels by torsion of the whole pedicle. He twisted it with two stout forceps. Torsion of the vessels separately has also been practiced successfully. The ecraseur has been used for dividing the pedicle. In my first case of ovariotomy I divided the pedicle with that instrument, and secured it in the wound with its edge upon a level with the skin by passing the pins through it with which I closed the wounds. Many other methods of securing the vessels in the pedicle have been devised, a thorough summary of which may be found in the admirable work of Dr. Peaslee, above mentioned, to which I would refer all who wish to study the subject in an extensive manner. 40 626 OVARIAN TUMORS. The Ligature. It remains for me In this connection to say something in reference to the ligature which I generally use as a means of securing the ves- sels of the pedicle. The kind of material used for ligating the pedicle has engaged the attention of the profession for a long time. Silk, hemp, catgut, horsehair, fibres from tendons of animals, — notably the deer, — metallic wire, etc., have all been used successfully, and most of them earnestly recommended by those who have tried them. Four qualities seem to be of material importance, if not essential to uniform success, viz. : 1st. SuflScient pliability to secure perfect adaptation to the inequalities of the structure and density of the pedicle. 2d. Strength to bear the force necessary to complete the constriction of the vessels. 3d. Solidity enough to resist the effects of moisture for a sufficient time. 4th. Absorbability. Of all the articles mentioned in the list I think silk is the only one that pre- sents all these qualities to any desirable extent, and I think it is now generally regarded as the best material for ligation of the pedicle. The ligature should be long enough to enable the surgeon to manipulate it easily and handle it securely. If the pedicle is of suf- ficient length to permit of it, we should not apply it nearer than an inch to the tumor, and then separation should be made close to the tumor, thus giving almost an inch of tissue beyond the ligature. If the pedicle is too short for this we ought to cut into the tumor to lengthen out the substance beyond the ligature. This will do away with the danger of retraction and consequent loosening of the liga- ture. I have known of one fatal case of haemorrhage resulting from retraction of the tissue of the pedicle through the ligature that I have no doubt might have terminated otherwise if this precaution had been observed. Should the ligature be cut short, or left out of the lower angle of the wound ? Dr. McDowell, in his first operation, tied the pedicle with a strong ligature, and left the end hanging out of the wound, and, before we learned how to use antiseptics, I have no doubt that was the best way to use the ligature, as it kept the wound open and acted as a means of drainage. But such use of the ligature is incom- patible with antiseptic treatment, for the reason that it permits the ingress of septic particles. There can be no question that, as the operation is now done under the carbolic spray, we ought always to cut the ligature short, return the pedicle carefully to its proper place, and close the wound as completely as possible. DRAINAGE. 627 Drainage. It will be noticed that, in the description of the operation, I have not alluded to the subject of drainage. I believe, nevertheless, that there are some cases in which, some time during the after-treatment, drainage will become necessary. If the difficulties of the operation render it impossible to secure the patient against hsemorrhagic transudation, — a thing scarcely pos- sible with our improved methods, — a drainage-tube might be inserted at the close of the operation. Drainage will become necessary more frequently after septic symp- toms have developed. After operating with all the antiseptic precautions now so easily at our command, we should be careful not to be too ready to decide that drainage is advisable, for it is not certain that even if some blood and serum should escape into the abdomen after the operation, it is not rendered innoxious by antiseptic precautions. The case of Dr. Goodell would seem to indicate that decomposition does not always occur in accidental effusion. Should Ave conclude to employ drainage from the beginning, I would generally prefer to use the glass tube employed by Dr. Thomas and others, by introducing it through the lower angle of the wound to the bottom of the cul-de-sac, behind the uterus. Or, as Dr. Atlee told me, in conversation upon the subject, he sometimes made a siphon of thread or linen, by placing it in the lower angle of the wound, and leaving the outer end much longer than that within leading from the bottom of the pelvis. It should be remembered that the drainage-tube does not evacuate clots of blood ; and that, as blood coagulates almost immediately after extravasation, it is con- sequently not removed by this kind of drainage. In all cases where septic fever is developed some days after an operation we should examine the pelvis through the vagina, and, if fluid or clots are found behind the uterus, we should make a free opening and evacuate it. After thus removing the decomposing fluid we should introduce a somewhat large tube, and throw hot water, slightly impregnated with carbolic acid, through it, and wash out the cavity from which the offending material has been evacuated, and leave the tube in place until the symptoms have subsided. The value of the antiseptic method employed during the opera- tion and after-treatment is so well established that I do not consider it necessary to do more than to express my concurrence in its use, and nsist that no ovariotomy should be performed without it. CHAPTEE XLL ABDOMIXAL OVAEIOTOMY, CONTINUED. Befoee describing ovariotomy, I propose considering some of the more important questions presenting themselves to us, and which often embarrass the experienced operator. First. Shall we operate on a small tumor? This question may be answered, with some qualifications, in the negative. As our object is to save the life of the patient rather than to remove the tumor, we should wait until some condition connected with the growth of the tumor begins to affect the health and thereby threaten the life of the patient. Until the life of the patient is jeopardized by the effects of the tumor upon the general health, in some way, we have no moral nor professional right to subject her to so great a risk as is incurred in ovariotomy. Inflammation in the Tumor. We should regard inflammation in the tumor, whether the tumor be large or small, with or without suppuration, as an indication for immediate operation, as the risks of the inflammation are very great, and are probably lessened by the removal of the tumor. This is especially the case if the inflammation is attended with hectic symp- toms. Although rupture of the cyst and effusion into the peritoneal cavity is not always attended with grave symptoms, yet the supervention of peritonitis to a serious degree, or a toxsemic state of the system which threatens life or the general welfare of the patient, demands the opera- tion for the removal of the tumor, large or small, and drainage of the peritoneal cavity. Pregnancy neither absolutely contraindicates nor demands ovariot- omy. Unless there is very injurious pressure from distension, the operation is not demanded, and we should wait for that condition before we determine to interfere in any way. When dangerous pres- sure does occur, if the tumor is multilocular to such a degree as to make it impossible to remove any considerable quantity of the fluid by tapping, the choice lies between evacuating the uterus and remov- ing the tumor. Dr. Barnes is in favor of inducing abortion first, PREGNANCY WITH THE TUMOR. 629 and removing the tumor after the patient recovers from this opera- tion, and the symptoms require it; while Mr. Wells advocates and practices the removal of the tumor, and a number of successful cases attest the soundness of his judgment. If, however, the tumor is oli- gocystic, or presents a large sac from which a great quantity of fluid may be removed, and much room thus gained, the tumor may be tapped once or several times until gestation is completed. I have in this way treated two cases, in which gestation went on to term, and the patients gave birth to living, healthy children. From one of these I removed the tumor six months after the child was born; the other, although the child is nearly a year old, is still carrying her tumor with comparative comfort. Sometimes errors or carelessness in diagnosis lead us into mistakes of so grave a character as to call for unexpected resources. One of them is the unsuspected coexistence of pregnancy and ovarian tumor, and the wounding of the gravid uterus during the operation. I have collected the following cases as illustrative of the proper method of managing them. The rarity of this class of cases, and the interest attached to them in a diagnostic and therapeutic sense, leads me to report the following case of my own, and to collect all I can find of a similar character:* A physician from a neighboring city visited Chicago, accompanied by a patient, to consult me about an ovarian tumor. The physician is a man of the highest standing in the profession, and of unquestion- able integrity and honor. The tumor had been first noticed about one year previous to my. seeing the patient, and had grown more rapidly in the last six months. The diagnosis given by the doctor was easily verified, viz., an ovarian tumor, most likely originating in the left ovary, and probably mono- cystic in character. The patient was an unmarried lady, twenty-three years of age, very modest in her demeanor, and, as I was assured by friends, of unblemished reputation. The cessation of the menses had occurred at an uncertain period, expressed by the term ^'several months since." Before visiting the city, her physician had proposed a vaginal examination, as one of the means of adding certainty to the diagnosis; but the patient begged so hard to be spared from what she regarded as a huuiiliation, that he was induced to yield to her wish. When I investigated the case, she shrank from it with much ear- nestness, and very plausibly contended that it could not be necessary,* * From American Obstetrical Journal. 630 ABDOMINAL OVARIOTOMY. as neither of us seemed to have any doubt as to the presence and na- ture of the tumor; consequently I, too, omitted this important means of diagnosis. At this interview it was determined that an operation could not be long postponed, and that, as soon as arrangements could be made, I should remove it at her own home. Accordingly, in about two weeks, I was informed that everything was in readiness, and the patient desired to be relieved at once. Upon my arrival, I met four physicians besides the attendant, and in their presence another careful examination was made, and as before, and for the same reasons, vaginal exploration was dispensed with. All, however, seemed perfectly satisfied with the correctness of the diag- nosis, and the necessity of an operation for the removal of the tumor. Preparations were at once perfected, the patient etherized, placed upon the table, and an incision about three inches long in the linea alba exposed the sac. After assuring myself that there were no ad- hesions on the anterior surface, I introduced Spencer Wells's trocar, and drew off about twelve quarts of an amber-colored fluid. The fluid was thin, but somewhat viscid, presenting the appearance I had often witnessed in ovarian tumors. When the sac was nearly emptied, I noticed a tumor behind it, adhering to the sac and preventing it from passing out through the incision. The second tumor was elastic, and so perfectly resembled a secondary cyst that I had no hesitation in plunging the trocar through its walls, with a view still further to lessen the bulk of the entire mass by evacuating its contents. As the trocar met with unusual resistance, and nothing but blood passed through it, I became convinced that there was something unusual about it. The incision was somewhat enlarged, and as much of the emptied sac drawn out as would pass, when it was discovered that slight adhesions, and not continuity of tissue, connected the two. After the cyst was entirely withdrawn, I was astonished to find that the second tumor was the impregnated uterus, and, still worse, that it was wounded and bleeding. This revelation was accepted with many doubts by the physicians present, who were the friends and neighbors of the patient, and believed it impossible that she should be pregnant. The facts were so patent, however, as soon to overcome their incredulity. At that moment I did not call to mind an almost precisely similar instance that had occurred to Mr. Wells, and could not recall a prece- 'dent for my guidance. The wound in the uterus had been very much enlarged by the contraction of the transverse, oblique, and longitudi- nal fibres of that organ, until, in the few moments that had elapsed PREGNANCY WITH THE TUMOR. 631 since the puncture, it had become as large as a silver dollar. It seemed to me, in the short time I had for reflection, that the only- way out of the difficulty was to evacuate the uterus. This was done by making an incision about four inches long from near the fundus downwards, so as to include the accidental aperture. The incision exposed the placenta at about the middle of its attachment. This organ was easily and rapidly separated by passing the index finger between it and the uterine walls, and completely removed. After this was done, the right side of the foetus, the arm, hip, and feet were perfectly exposed. The breech was seized and drawn towards th.^ opening, when the foetus Avas expelled by uterine contraction. The membranes and liquor amnii were next removed, when the uterus was perfectly devoid of all its former contents. Gestation had advanced to about the middle of the seventh month. The foetus evinced no signs of life after its removal, and had doubt- less died from the effect of haemorrhage from the wounded placenta. The incision in the uterus was closed by interrupted sutures of fine silk, including the visceral peritoneum, the whole of the muscular wall, and the mucous membrane. The sutures were cut short, and no provision made for their removal. By the time the sutures were all inserted and tied, the uterus had contracted very firmly. Thanks to the valuable aid afforded me by the gentlemen present (whose names for obvious reasons I dare not mention) neither blood, nor amniotic, nor ovarian fluids had found their way into the peri- toneal cavity. In order to secure a free exit of the lochia from the cavity of the uterus, and thus prevent the danger of its passing through the wound, the OS uteri was freely dilated with the finger, and a long flexible catheter left in it some hours. The pedicle of the ovarian cyst was tied with a double ligature of plaited silk, and returned into the ab- dominal cavity. The ligatures were brought out at the lower angle of the wound, and left long enough to hang down between the thighs. The wound in the abdomen was closed by interrupted sutures, and dressed with a thick layer of carbolized cotton batting. The only interest connected with the future progress of the case is, that there was not a disagreeable symptom, except a few trivial after- pains. After the operation was concluded, I was consoled for my error in not making a vaginal examination, and consequent ignorance of the complicating pregnancy, by the assurance of all the gentlemen who assisted me, that their confidence in the chastity of the patient was 632 ABDOMINAL OVARIOTOMY. equal to their reliance upon the faithfulness of their own wives, and that a suspicion of her purity would not be entertained by any one who was acquainted with her. Her complete recovery, however, and up to the present time her own entire ignorance that a foetus had been removed with the tumor, together with the preservation of her reputation, which could not have been done by any other course, fully compensates me for the chagrin I felt for all my shortcomings in the case. I have purposely omitted names, dates, and places, to avoid the possibility of identification of the patient ; I am persuaded, however, that this will not detract from the interest of the case. As the subject and manner of closing the w^ound in the operations for gastro-hysterotomy is now under discussion, I would call atten- tion to this part of the procedure. The entire absence of septic or inflammatory symptoms, I think, gives evidence that there was no escape of blood from the edges of the wound, or from the uterine cavity into the peritoneal sac, and warrants us in assuming that the closure by sutures was judicious, if not the all-important condition of success. After the operation, it was quite apparent that a great change must take place in the relation of the edges of the incision in the uterus, to allow the least drainage into the peritoneal cavity. The frequent occurrence of pregnancy during the growth of ovarian tumors is recognized by all experienced ovariotomists, and is a subject for consideration in all instances where a diagnosis is to be made preparatory to the removal of the tumor. Under ordinary circum- stances, the diagnosis of this complication is not very difficult, as the uterus lies anterior to or on one side of the tumor, so that its presence and contents are easily ascertained, but exceptional cases are some- times found when the difficulties are sufficient to mislead an ex- perienced and accomplished observer. Mr. Wells acknowledges mis- takes in his own practice, and mentions the fact that Dr. J. Marion Sims fell into an error of diagnosis and did not discover the compli- cation until the gravid uterus was exposed during the operation for the extirpation of the ovarian tumor. A considerable number of other cases might be cited in which mistakes of this kind have oc- curred. The probabilities are that more of these errors arise from insufficient scrutiny in cases where the diagnosis might be made, than from an entire iui possibility to ascertain the true state of things. Our improved methods of examination, and more perfect knowledge in interpreting the phenomena of pregnancy, ought to secure us PREGNANCY WITH THE TUMOR. 633 against errors of this kind in all but the very rarest combination of circumstances. As the known cases in which the double operation of ovariotomy and hysterotomy has been performed are very few, I have collected all I could find with my limited means of research, and will not apologize for reproducing them in a condensed form in this con- nection. Mr. Wells publishes a case, alluded to above, in his well-known work on Diseases of the Ovaries^ almost exactly like the one I have recorded. It was first reported in the Medical Times and Gazette of September 30th, 1865. He had entirely overlooked the existence of pregnancy with ova- rian disease, and after removing an adherent multilocular cyst of the left ovary, he felt what he thought was a cyst of the right ovary, — tapped it, and then found it was the gravid uterus. From this puncture two or three pints of bloody fluid escaped through the canula, when the tumor became much less tense; and he says on raising the tumor up, he saw the Fallopian tube passing from its upper part, and thus he knew at once he had punctured the uterus. He says : " On withdrawing the canula, a soft, spongy, bleeding mass protruded, and on putting in my finger to push this back and examine the uterine cavity, the anterior wall of the uterus, which was very soft and friable, as it had undergone fatty degeneration, gave way along the middle line from the puncture (which was near the fundus) for an extent of from three to four inches down the body toward the neck. With very slight pressure a quantity of liquor aranii and a foetus of about five months escaped. I then easily peeled off the placenta from the inner surface of the uterus ; the organ did not contract, and there was free bleeding from three vessels close beneath the peritoneum at the lower angle of the rupture in the uterus. These vessels were secured by three silk liga- tures. Oozing still going on from the surface where the placenta was attached, I made a free opening into the vagiua by passing my finger from above through the cervix and os, and then put a piece of ice into the uterus and held it within by firmly grasping the organ, which then contracted. I then brought the peritoneal edges of the tear in the uterus together by an uninterrupted suture of fine silk, one long end of which I had previously passed into the uterine cavity and out through the OS into the vagina. By seven or eight points the edges were brought accurately together, and the other end of the silk was brought through the opening in the abdominal wall, with the ends of the three ligatures on the vessels in the uterine wall close to the pedicle, and were tied to the clamp." 634 ABDOMI>-AL OVARIOTOMY. The patient completely recovered. I am indebted to Dr. INIunde for the following very interestino- case, published in the Aae applied the whole length of the patient, to the feet, legs, trunk, arms, shoulders, and head, and at the same time the tem- perature of the room should be raised. Applications of heat to the head is of more importance probably than anywhere else, for stimu- lating the brain will often arouse the whole nervous system and dispel the symptoms. The most effective way to do this is by using Thornton's (or its [ HEMORRHAGE. G59 modification) cap, and passing hot water through it instead of cold. Plenty of warm covering will be necessary, of course, and if the stomach is not irritable the patient should drink as much hot water as she can. I am quite sure that the vigorous application of heat in this way is much more effective than alcoholic or other medical stimulants. These, however, may be added and administered by the stomach, rectum, or hypodermically. If the depression succeeding Fig. 164. Modified Thornton Cap. the shock should last and be threatening in degree the heat should be continued; nourishment and internal stimulants administered per- severingly until reaction is established. Haemorrhage Is said to proceed from the following different sources : 1st. From the pedicle in consequence of the imperfect application of the ligature, or the retraction of the tissues included in its grasp, so that it becomes loosened. 2d. From wounded surfaces left by the separation of ad- hesions. This last is not often fatal as a haemorrhage, but it may become so in rare instances. The blood derived from this source is however apt to decompose and cause septicaemia. 3d. From rupture of a plexus of veins near the ligature or elsewhere in the pelvis. Dr. Peaslee lost a patient from hsemorrhage, and on a post-mortem exam- ination found that it proceeded from this source. He also speaks of others. 4th. In certain conditions of the blood predisposing to haemorrhage, the blood from the inner portion of the incision finds its way into the abdominal cavity in considerable quantities. I met with an instance where haemorrhage from the wound im- mediately under the skin, the blood escaping outside, gave me a great deal of trouble. In this case the blood was so changed that coagu- lation did not occur after standing ten hours, and astringents locally 660 OVARIOTOMY. applied failed to stop the haemorrhage, and the only way it was ar- rested was by putting pins through the lips of the wound half an inch apart, and plugging the wound tightly in the interspaces. 5th. From an artery perforated by a needle used in closing the wound (Wells). 6th. From the patulous extremity of the Fallopian tube. In all of these conditions haemorrhage may follow the operation immediately or occur any time during the convalescence. Succus- siou from coughing, straining to vomit, moving about too much, mental excitement, may all contribute to start up haemorrhage when the predisposing conditions exist. When the haemorrhage takes place from the pedicle or ruptured veins, the symptoms generally appear suddenly and are marked in character. They need not be enumerated here, because they are so familiar ; but where the haem- orrhage goes on slowly from abraded surfaces the symptoms are sometimes very obscure. Increasing rapidity and weakness of the pulse, paleness of the face, coldness of the extremities, profuse perspi- ration, nausea, and vomiting coming on any time after the first twelve hours when not preceded by evidence of shock, are symp- toms which point strongly to this accident. When the symptoms of haemorrhage become marked, there is but one sure way of giving the patient a chance for her life, and that is, to open the wound, explore for the course of the haemorrhage, and ligate the vessels or bleeding points when found. The abdomen should be very carefully cleansed of the blood. Judging from the experience of Clay, Wells, Koeberle, and Atlee, this second opening of the abdomen is reasonably safe. Traumatic Peritonitis. Peritonitis, caused by opening the abdomen, judging from my own observations, as well as the reports of others, is not very common, and has become less so since the antiseptic vapor and dressing have come into so general use. At a time when our experience was small, compared with what it now is, this was the most feared of all the consequences of the operation. This fear was founded upon the well-known fact of the fatality resulting from accidental peritoneal wounds. Fortunately, however, the peritoneum, in cases requiring ovariot- omy, has lost much of the susceptibility to inflammation which it possesses in a healthy condition. The long-continued distension, friction, and frequent inflammations, to which it has been subjected, TRAUMATIC PERITONITIS. 661 SO modify its structure as to greatly alter its appearances, and in al- most all instances to reduce its tendency to inflammatory processes very much. Hence we expect oftentimes to escape this very danger- ous affection. When it does come, it makes its appearance within the forty-eight hours immediately succeeding the operation. Its symptoms are pain, tenderness, and tumefaction of the lower part of the abdomen, frequent pulse, and elevation of the temperature. In unfavorable cases these symptoms rapidly increase until the abdo- men is largely distended and very tender; the pulse rises to 130 to 150, or even 160; the heat increases as high as 106 degrees. Mental disturbances become a prominent feature toward the close. These cases often run their course to a fatal termination in two or three days from the beginning. The temperature and the pulse are the best guides to the intensity of the inflammation. When the former does not rise above 103 degrees, and the latter above 120 per minute, we may have a reasonable hope of recovery. The objects in the treatment of this form of peritonitis are to curb the rapidity of the pulse, reduce the temperature, and control pain. Opium in large doses, commenced at once and continued to deep nar- cotism, will go a great way toward accomplishing all of these objects. I believe that this treatment, at the very inception, will sometimes at once break the force of the attack. After the first forty-eight hours, or even sooner, large doses of quinine may be added to the opiate treatment, when the opium should be slowly withdrawn and brandy substituted for it. The quinine, however, should be continued. These remedies, quinine and brandy, arrest the waste which follows the first stage. With these, nourishment should be pushed to the capacity of the stomach and rectum. When there is vomiting, these remedies may be given hypodermically and per rectum. Ice and ice-cold water may be allowed as desired, according to the craving of the patient. Thornton's cap will be of great service in these cases also, as the cold water circulating through it will greatly reduce the general temperature. A question of great importance is. What ap- plications shall be made to the abdomen? In the first two days, if the temperature is high, I should have no hesitancy in applying cold by means of the water-bag ; but I should promptly change from this to warm applications after the stage of effusion had passed, about the third day of the disease. 662 OVARIOTOMY. Septicoeniia. This is another of the formidable and fatal sequences of ovariot- omy. As the operation is now performed, — that is, with antiseptic precautions, — it may generally be avoided. The cause of septicaemia is the retention, decomposition, and absorp- tion of fluids from the sac or sacs of the tumor, or from extravasated blood. The observations of numerous operators have established the fact that the retention of these fluids does not always result in septic fever, because they do not always undergo decomposition; especially is this the case, as before intimated, if the antiseptic precautions have been faithfully and sufficiently carried out. When it does occur, it may follow the reaction which succeeds the protracted depression of shock ; but when not occurring in this way, it comes on in from four to seven, and even ten, days after the operation. Its course is vari- able, terminating sometimes in five or six days, especially when com- plicated, and this, I think, rather a frequent thing with peritonitis; while in the simple form it may last for ten or twenty days, or even longer, before wearing the patient out or merging into convalescence. The prognosis, although bad, is not absolutely desperate. Some- times the attack is sudden, inaugurated by a chill, and succeeded by a rise of temperature and accelerated pulse; or it may be established in a very gradual manner, the pulse and temperature rising slowly. They are generally both much higher in the after-part of the day. Derangement of particular organs is not uniform. The skin, some- times dry and hot, is often bathed in a copious perspiration, the per- spired fluid being sometimes very thin and watery, and again quite viscid and sticky. The stomach may or may not be disturbed, but generally the rest of the alimentary canal is more or less irritated, and diarrhoea, with profuse, thin, stinking stools, is often a marked feature of septicaemia. Nervous excitement and delirium, or somnolence and apathy, form parts of the symptoms in different cases. In many instances great tympanites, with or without peritonitis, add to this mischief. In the course of the disease, the circulating fluid some- times becomes decomposed to such an extent as to pass easily out of the capillaries, giving rise to maculae, blebs, and bullae, or appearing in the urine or dejecta from the bowels, or exuding from the exposed mucous membrane in the mouth or nostrils. More frequently, how- ever, the disease runs its course rapidly when a very quick pulse, from 120 upward, high temperature, from 104 degrees upward, de- lirium, excitement, or somnolence, and apathy constitute the import- TREATMENT. 663 ant and noticeable symptoms. In either the slow or rapid case the stomach will not digest the food taken, and the lacteals will not absorb the material exposed to their action. Sanguification is ar- rested, and the scorching temperature is maintained by combustion of the material in the blood, which ought to sustain the vital func- tions. The patient is soon exhausted under this rapid waste, being incapable of appropriating anything with which to supply the de- ficiency. Treatment. The most important item in the treatment of septicaemia arising after ovariotomy is to remove the cause. This, as has already been said, is decomposing substances in the peritoneal cavity. In almost all cases the decomposing substances, serum, blood, etc., gravitate to the bottom of the cul-de-sac of Douglas, where we can reach it. The fluid can usually be detected per vaginam, but sometimes the quantity is so small as not to be appreciable by such an examination. In either case we should open the peritoneal cavity through the vagina, introduce a drainage-tube, and wash out the pelvic cavity with warm carbolized water. We may open the peritoneal cavity by means of scissors. The patient may be turned upon her side, Sims's speculum introduced, and the posterior wall of the vagina lifted up by a hook and perforated. The opening in the vagina should be in the median line as nearly as possible. The incision should be large enough to admit a good-sized tube. Through this the fluid will escape, and we may throw carbolized water into the pelvis. We may also perforate the posterior vaginal wall with a trocar. This may be done very easily when the quantity of fluid is considerable and the retrouterine pouch well distended. If opened in this way the first washing may be done through the canula before it is withdrawn, after which a tube should be passed through the canula, and as the latter is withdrawn the former is retained, or we may remove the two lower stitches and introduce the drainage-tube through the lower end of the wound. The cleansing of the abdominal cavity will require repetition in proportion to the amount of decomposing materials. Of course no one would think of performing this operation until septic fever is evident. When this is the case the risk of evacuating the fluid and cleansing the pelvic cavity ought certainly to be considered a neces- sity, and when indicated it is worth more than all the remedies we can bring to bear in the treatment. The rest of the treatment has for its object the relief of symptoms, preventing waste, and introducing Q6i OVARIOTOMY. as much nourishment as can be borne by the stomach, rectum, or both, and hypodermically. Probably the most important symptom to be attended to is the high temperature. This may be combated by cold externally ap- plied or administered internally. Cold can be very effectually applied to the head by means of the ice-cap invented by Mr. Thorn- ton, of the Samaritan Hospital. It is very highly recommended by Mr. Wells. It is a coil of rubber tubing so arranged as to fit the head like a cap, and when applied to the head the tube is filled with ice-water, and one end is placed in a bucket of ice-water very slightly elevated above the head of the patient, while the other end is passed into a tub under the bed or elsewhere."^ By elevating and depressing the two ends of the tube the water may be made to run more or less swiftly through the portion forming the cap as we may desire. If this cap cannot be commanded, india- rubber bags filled with ice-water, or a large beefs bladder, or ice in- closed in rubber cloth or oiled silk may be substituted. Cold may thus be applied with sufficient intensity to lessen the heat of the entire body in a very short time, and I think is very much to be preferred to any general application of cold however made. Quinine administered in large quantities is very efficient in re- ducing temperature and preventing waste ; so also is alcohol. Five grains of quinine every four hours, or ten grains every eight hours, is the proper dose. Brandy in ounce doses every two hours may be given for a like purpose. If tympanites or peritonitis, or both, com- plicate the fever, there are local means for their treatment, as else- where detailed. Remarks and Personal Statistics. I am among those who believe in antiseptic surgery. My opera- tions date back to 1861, when everything in connection with ovari- otomy was in an unsettled state. It is true that there is not perfect accord among ovariotomists at the present time, but we have had a great deal of experience in different methods of procedure, in the several steps of the operation and after-treatment, and can conse- quently more intelligently estimate them ; and I think it safe to say that the antiseptic process has about done away with the clamp and primary drainage; in fact, both of them are incompatible with a complete antiseptic dressing. ^ See modification of it on page 659. I REMARKS AND PERSONAL STATISTICS. 665 My convictions as to the benefit of the antiseptic processes in ovariotomy are grounded upon ray own experience more than gen- eral statistics, although I think the latter are sufficiently convincing. I have only operated eighty-two times, and in accordance with the experience of other ov^ariotomists my success grows with the number of my operations. Before I commenced the use of the antiseptic spray and dressing my successes, taking the whole together, did not exceed sixty-six per cent. Since I have been operating as I now do I have had about eighty-six per cent, of recoveries. The general conditions are, it is true, somewhat more favorable now than before, and may have had something to do with the favorable termination of my cases. Of the twenty-two cases operated upon antiseptically, eighteen operations were performed in a small hos^^ital (Woman's Hospital of the State of Illinois), surrounded by every favorable circumstance at our command. The three deaths all occurred in the hospital. The other four cases were in small cities in this State. Whether the improved circumstances would have been sufficient to give the more favorable results than formerly without the antiseptic measures, I am of course unable positively to assert. Neither can I say how much may be due to increased skill acquired from expe- rience in operating. The number of cases I know are also too small to base conclusions upon. AVhile there has been a very marked change for the better since adopting the antiseptic method, I think my mind has been influenced in coming to a conclusion favoring antiseptic practice by the appearance of the wound. So far as the wound is concerned there is no question about the effects of the dressing. When properly managed there is no smell, no pus, and no ulceration. It heals without any evidence of decreased vitality in the part. In expressing my belief in the efficacy of antiseptic processes in surgery I do not announce any opinion of the modus operandi. 1 am not sure that there are septic particles that fall upon and induce ferment in the wounded parts, or living germs or ova that infest, breed, and diffuse themselves in such numbers as to destroy the vitality of the points of attack, and gaining access to the vessels disintegrate the circulating fluid so that it is not fit to support the vital forces, and that the carbolic acid operates by consuming these deleterious particles. But I do believe that the vapor and fluid con- taining this substance when used so as to shut out the atmospheric air from the abdominal wound adds greatly to our means of avoiding one if not more of the untoward conditions sometimes experienced after ovariotomy. CHAPTER XLIV. FALLOPIAN TUBES. The Fallopian tubes are sometimes absent ; this is the case gen- erally when the uterus is absent. But, according to Rokitansky, they are not always wanting when the uterus is. One, or even both of them, may be wanting when there is no other fault in the genital organs. Occasionally they are met with of diminutive or rudimen- tary size. They are also deformed, having two sets of fimbrillse, one at the end and the other nearer the uterus, with openings at both places ; or bifurcated, the branches entering the uterus at diiferent points. Or one may be longer than usual, and enter the cervical portion of the uterus as mentioned and described by Pole, and quoted by Scanzoni. They are often displaced with the uterus and with the ovaries, and, with the latter organs, are found to enter into the forma- tion of a hernia. Inflammation of the Fallopian tube is, probably, not an unfrequent affection, but almost always it is but a small part of the disease that exists in its locality ; inflammation of the uterus, peritoneum, locally or generally, and ovaritis being separately or collectively connected with it, and by their symptoms making the manifestation of disease in the tubes. In such cases it is not only impossible, but is of no importance, to diagnosticate salpingitis. If the diagnosis could be made, it would not influence the treatment. Involved, as they are, in the inflammation of surrounding organs, they are occasionally destroyed by suppuration, or constricted by bands of fibrin, and the tubal cavity is obliterated by exudations. They also' are the subjects of catarrhal inflammation, discovered after the death of the patient, associated with endometritis, seldom as an independent affection. The tubes are doubtless the channel through which inflammation of the uterus finds its way into the peritoneal cavity, and also the con- duit for fluids — pus, blood, mucus, etc. — from the uterus to the peri- toneal cavity. As they are not seldom found dilated so as to admit a uterine sound to pass them, — Hildebrant, Mathew Duncan, Thomas Budd, and others, have seen and diagnosticated dilatation of the Fallopian tube during life, — we need not be surprised at the transi- tion of fluids through them in both directions. Thus the serous con- FALLOPIAN TUBES. 667 tents of the peritoneal cavity may be passed into the uterus and vagina. The reader will not fail to see the importance of diseases of the tubes, on account of the sterility that would result from oblitera- tion or constriction of them, or the danger from a too free communi- cation between tlie peritoneal sac and the uterine cavity. Cancer of the Fallopian tubes is not often observed independent of the existence of the same disease in the surrounding tissue. They are generally though necessarily involved in cancerous degeneration of the ovary and the uterus. Hypertrophy and atrophy of them accompany the same changes in the uterus. They are enlarged when the uterus is by tumor, inflam- mation, congestion, or pregnancy, and become atrophied as the uterus diminishes in size, in old age or from any other cause. Dropsy of the tubes is occasionally observed. Obliteration of the cavity near each extremity leaves the portion of the tube between these points free to receive exudation from the lining membrane, which cannot find its way out. The fluid accumulates and fills the isolated portion of the tube, which continues to increase until it becomes a cyst from the size of the finger to that of an orange, and perhaps even larger. Dr. C. S. Ward presented a specimen to the New York Obstetric Society of double tubal dropsy, the size of a pullet's Qgg. August, 1871, Journal of Obstetrics. We also meet with small serous cysts attached to the fimbriated extremity of the Fallopian tube. They are usually small cysts, dis- tended by serum, scarcely ever exceeding the size of the finger's end. CHAPTEK XLV. COCCYGODYNIA, COCCYALGIA. Neuralgia of the Coccyx. These terms are used to denominate one of the several peculiar neuroses of the pelvic organs, especially those situated at the bottom of the excavation. It belongs, I think, clearly to the same class of cases as vaginismus, urethrismus, spasm of the bladder, rectum, etc., and is purely a nervous affection. They are all peculiar hypersesthesias, and sometimes have a demon- strable basis of excito-motor origin, as fissures, ulcers, inflammation, etc., while in other instances there seems to be no material change in any of the organs. That coccygodynia, like vaginismus, is often associated with uterine disease, disease of the rectum, bladder, urethra, etc., is certain from observation. Whether these more common affections, after continu- ing a long time, may excite the nerves into a state of instability that becomes permanent or not, is a question worth asking in this con- nection. In common with other nervous affections having a reflex origin, may not the symptoms become a disease, and remain an inde- pendent affection after the excito-reflex cause has been removed ? The irritation so protracted and unremitting I think may and often does induce organic change in the nerves or the subordinate centres with which they are connected, and thus perpetuate the symptoms. Structure Affected. There was, in all cases I have examined, room to doubt the exact tissue affected, whether in the periosteum, interosseous ligaments, muscles, or nerves. Symptoms. Pain on moving the coccygeal bone, in sitting down, rising up, passing the faeces, coughing, sneezing, walking, or standing. In bad cases the patients are not able to sit, stand, or walk without great dis- comfort, and are so pained by the sitting or erect posture that they are confined to recumbency. They thus lose their general health and become permanent invalids. DIAGNOSIS — PROGNOSIS — TREATMENT. 669 This is very rare, however, and the most of the cases we meet with are in patients who enjoy a tolerable state of general health, but are continually annoyed by everything that causes contractions of the muscles inserted to the coccyx or closely connected with them. They sit on one side of the buttocks or on cushions that remove the pres- sure from the coccyx. They rise to the standing position with great care, and must be very guarded in walking, coughing, or sneezing, etc. Diagnosis. This is made by considering the history of the case and by physical examinations. The finger passed into the vagina or rectum, and pressed backw^ard upon the coccyx, so as to move it, gives the patient great pain. Pressure exerted upon the posterior surface, with suf- ficient force to move it, causes even greater pain. When the dis- ease is severe the suffering is so great that it is with difficulty we can examine the coccyx as to its mobility. Dr. Jenks says that when a patient is examined under the influ- ence of ether the muscles connected with the coccyx are relaxed, while they are very strongly contracted w^hen the patient is not ether- ized. Prognosis. There seems to be very little tendency to spontaneous subsidence of coccygodynia. The menopause does not affect it as it does most of the pelvic dis- eases, and it is often a long time after the change of life before the patient recovers. It occurs in the young nulliparous and parous women alike, but not in the senile. It generally causes more suffer- ing in women who are bearing children. Treoiment The palliation of the symptoms in coccygodynia consists in the use of anodynes and tonics, the former to relieve the great suffering for the time. They may be used in suppositories per rectum, per vaginam, or hypodermically. We can add greatly to the comfort of the patients also by contriving cushions or easy chairs for them. A tonic or roborant course of treatment will sometimes brace up her nervous system so that the patient can bear her ills without breaking down physically. Among the means to accomplish this end, when the patient is not too bad, travel is of great service, a change of climate from hot to cold in the summer, and from cold to 670 COCCYGODYNIA — COCCYALGIA. warm in the winter. Quinine and iron administered internally, with liberal and systematic feeding, contribute to the same purpose. In the earlier periods of coccygodynia we may hope to arrive at a cure by searching for and removing all disorders in the neighbor- hood, founding our treatment upon the idea of removing the excito- reflex centre of disturbance. Dr. Robert Barnes, of London, believes that it is caused by retro- versions of the uterus. Anal fissures, haemorrhoids, ulcers in the rec- tum, should command our special attention if they exist, and every pains should be taken to restore all deviations from general health. After the disease has existed long enough to become an inde- pendent affection, probably nothing short of a surgical operation will result in a cure. To the late Dr. IlTott belongs the credit of first describing this dis- ease and devising a surgical operation for its cure. He called it neuralgia of the coccyx, and, after trying all other measures that occurred to him, extirpated the bone. His operation consisted in cutting through the attachments of the bone on each side, from the base to the apex, everting it and dislocating it from the sacrum. This may best be done by incising the integument in the central line, and raising and turning aside the flaps until both margins of the bone are exposed. The next step is to cut carefully down through attachments at the point of the coccyx and introduce a blunt-pointed bistoury, or the point of scissors, and separate the attachments upward to the base on both sides. The bone can then be lifted up and turned backward to expose the articulation, which may be divided by a bone forceps or a strong knife. The loose cel- lular tissue, on the inner surface of the bone, easily gives way as it is lifted from its bed, or may be divided by the knife. There is generally very little haemorrhage, and the bleeding will in a few minutes subside. All that remains to be done is to close the wound by replacing the flaps and joining them by four or five stitches. This is neither a dangerous nor a difficult operation, and is very efiPective in a curative point of view. In 1858 Professor James Y. Simpson, apparently with knowledge of Dr. Nott's description of the operation for this affection, published in the London Medical Gazette his lectures on the diseases of women, in which the disease is recognized and his operation described. His operation consists in the subcutaneous division of the connections of the bone without removing it. CHAPTEE XLVL ELECTRICITY. Electricity has been used in the treatment of diseases of women, and with considerable success. All forms have been used, viz., static, galvanic, and faradic. Static electricity may be conveniently obtained by Holtz's electrical machine. The prime conductor fur- nishes positive and the rubber negative fluid. The modes of appli- cation are various. Sparks may be sent directly through the tissues, or the patient may be insulated and be filled from either electrode, when sparks may be drawn through the part affected by presenting to it a metallic conductor. A surface thus acted upon will present points of irritation. In chronic ovarian difficulties such an applica- tion would be suggested. Galvanic electricity is best obtained from the galvanic machine, which may contain any number of cells, made of zinc and copper, or platinized silver or carbon, and a proper fluid to excite chemical action. Upon the latter will depend the quantity of electricity, while its intensity will depend upon the number of elements undergoing chemical action. Of galvanic batteries there are many forms. One that is constant and easily kept in order is desirable. Faradic electricity differs from both the static and galvanic in this, that the faradic current is induced, and is a to-and-fro current, going both ways. Its tension is also greater, and current is broken slowly or rapidly as one desires by the rheotome of the electro-magnetic machine, from which the current is derived. It differs from the galvanic current in this, that the latter is unbroken, that is, it is a constant current. In using electricity a few things are necessary: first, proper in- struments, and a knowledge of a few simple facts. A moist surface or tissue is always a better conductor of the fluid than dry tissue or a dry surface. The most succulent tissues present the least resistance to the cur- rent. Thus, for instance, bones and nerves are poorer conductors than the muscles, and a dry skin will resist the current still more. In view of this fact, we wet the electrodes before applying them to the skin. 672 ELECTRICITY. The galvanic current, by reason of its constancy, is the most pene- trating form of electricity. It is also the most diffusive, for its presence is often discernible at points not between the electrodes. Of late we have heard much of electrolysis. "What is it? If we place the poles of a galvanic battery near one another in a basin of water, bubbles will appear, due to the decomposition of the water by the current. This action is called electrolysis. We need only attach the wires to insulated needles and pass them into fluids within the body to decompose them also. We may thus decompose the tissues of the body, and in the process the alkalies will appear at the nega- tive and the acids at the positive pole. Electrolysis then is the decomposition by electricity of either fluids or solids. After being thus acted upon these elements are supposed to undergo absorption. Electrolysis of ovarian cysts has been suc- cessfully practiced. Dr. Frederick Semeleder, of Mexico, claims to have thus cured the disease. His enthusiasm led to the publication of the facts in 1875, and to the premature assertion of "no more ovariotomy.'' In 1874, Fieber, of Vienna, reported two successful cases by this method, which, however, seems to have been original with Dr. J. F. Biihring, who announced it in 1848. The method has been well tried in New York, and unsuccessfully {Gyncecological Transactions, vol. ii, 1877). The method necessitates the introduction, through the abdominal wall, into the cyst of one or more needles for the conveyance of the current. This simple procedure may permit of subsequent leakage, peritonitis, and death, and is especially dangerous in multilocular cysts. The method, notwithstanding it may cure unilocular cysts, is scarcely less dangerous than ovariotomy at the present day. The method is seriously objectionable in practice, inasmuch as it is not always pos- sible to say positively that a cyst is or is not multiple. For solid fibroids of the uterus these objections are not applicable, and the mere introduction of proper needles is tolerably safe. Dr. Ephriam Cutter, of Boston, has thus treated uterine fibroids suc- cessfully. If the electrical current is passed through a wire, platinum for example, which offers considerable resistance, the current will raise the temperature of the wire even to a white heat. This is a simple galvanic cautery. With it we may cut away tissues or divide them. The electro-cautery has been found very useful for the removal of the cervix when the site of malignant disease. It is an admirable method of removing uterine polypi. ELECTRICITY. 673 An exhaustive paper on this subject by Dr. John Byrne may be found in the GyiKxcoJogical Transactions, vol. ii, 1877. The same gentleman uses the electro-cautery for kolpocystotomy, burning an opening in the base of the female bladder where drainage is desirable. See a paper on the subject, Gync^cological Transactions, vol. iv, 1880. The advantages of surgery done in this way, are that there is less risk of haemorrhage, and openings are not so liable to heal up rapidly. The disadvantages are the time consumed, the uncertainty of batte- ries, and the fuss. The physiological phenomena produced by electricity vary with the kind used, also with the quantity and tension, also with the posi- tion of the poles, and also as to the tissues acted upon. Ascending currents excite as they reverse the natural nerve current. Descending currents soothe as they flow with the nerve current. The former affect the sensory nerves, while the latter affect specially the motor nerves. Upward currents increase reflex action, while downward currents diminish it. A constant current passed through a muscle produces contraction, from the positive toward the negative pole, and drives the blood in the same direction. Reverse the position of the poles, and the con- traction of tissue is in the reverse direction and circulation is re- tarded. If you occasionally break the current by any method, you shock the muscle, give it a spasm, the bloodvessels also contract and the blood is propelled forward and diminished momentarily in the muscle. But observe, the muscle has been exercised. If instead of breaking the galvanic current you apply the faradic, the result is the same. The galvanic and faradic currents are tonic. They exhila- rate, raise the temperature, increase the circulation of the blood and enliven the brain. They produce sleep, increase digestion and appe- tite. When locally applied they increase the nutrition of the part. Descending currents act on the motor nerves, contracting the mus- cles, but give pain by their action on the sensory nerves. Ascending currents excite the spinal cord and increase reflex functions. By these currents, applied by electrodes, we may increase or diminish the blood in a given part, exercise the muscles, singly or in groups, and excite the sensory nerves. By these currents constipation may be relieved. The circulation may be equalized, and hysteria, melan- cholia, dyspepsia, and other symptoms of nervous exhaustion, so common in women, may be successfully treated by general electriza- tion. As already intimated the muscles under the influence of the faradic 43 674 ELECTRICITY. or broken galvanic current may be increased in size and strength. Hence for production of passive motion we find it an excellent agent. As a direct result of the tonic influence of electricity the disposition and capacity for mental labor increases. The lack of concentrative- ness and the loss of memory in nervous exhaustion rapidly disap- pear. Such symptoms as leucorrhoea, amenorrhoea, dysmenorrhoea, and purely functional menorrhagia accompanying nervous exhaus- tion may be successfully treated by electricity. It gives tone to the walls of the bloodvessels^ improves the important functions of the body. The remedy may be used generally over the body, locally or in both ways. If given locally the external or internal application may be selected, as the character of the case requires. If given locally, one pole may be placed over the spine and the other over the hypogastric region, or one pole may be placed against the cervix or in the cervical or uterine cavity. Currents thus given are well borne and often productive of much good. Subinvolution of the uterus, especially when not the result of laceration of the cervix, may be treated by this method ; one electrode may be introduced directly into the uterus. The contraction of the uterus thus produced relieves congestion of the organ, and changes are brought about which favor the absorption of the superfluous tissue. Doubtless some such rationale led Simpson to use the galvanic stem pessary. The use of electricity for the cure of nervous exhaustion is somewhat general. But when combined with massage, rest, seclusion, and overfeeding, according to the method of Dr. S. Wier Mitchell, the results are^ often but little short of miracles. To produce uterine contraction, to arrest bleeding, to empty the uterus of a body loose within its cavity, the faradic current will be found reliable. One pole may be placed upon the spine and the other over or against or within the uterus itself. As an adjunct "in the treatment of gynaecological cases electricity is often a good remedy.* * This chapter was written at the request of the author by E. Stansbiiry Sutton, M.D., of Pittsburgh, now lecturer on Gynaecology in the Spring Course of Lectures in Kush Medical College. I INDEX. Abdominal ovariotomy, 624 supporters. 389 Abortion, an effect of uterine disease, 229 condition of the uteruo in, 230 a predisposing cause of uterine dis- ease, 242 Abscess of labia, 23 following acute perimetritis, 365 Absence, congenital, of the uterus, 121 of labia, 25 of vagina, 65 Absorption, summary of cases of fibrous tumors cured by, 515 Abstract of sympathetic influences of uterine disease and spermatorrhoea, 197 Accident in injection, 311 Accidents that may occur during ovariot- ' omy, 650 | Adhesions, complicating ovariotomy, 650 | of the labia, 17 in adults, 18 in children, 17 After-treatment of ovariotomy, 654 Alteratives, in the treatment of fibrous tumors of the uterus, 521 local, in uterine disease, 319 Amenorrhoea, 116 as an effect of uterine disease, 227 diagnosis, 120 from retention, 120 pathologv and morbid anatomv of, | 117 prognosis, 123 symptoms, 117 treatment, 124 treatment by local electrization, 129 Amputation of the cervix for chronic in- ! version, 426 Ansemia, 291 Anaesthesia, a sympathetic symptom of uterine disease, 210 Anodvnes after ovariotomy, 656 Anteversion, 382, 396 Atresia vaginse, 66 Atrophy of the Fallopian tubes, 667 of the uterus, acquired, 122 congenital, 122 as the result of inflammation, 275 Banning supporter, 390 Baths, 303 Battey's conclusions as to the proper cases for oophorectomy, 551 Battey's operation, 546 Battey's operation, physical and psychi- cal results of, 552 Bearing-down pain, or uterine tenesmus, 221 not alwavs caused bv displace- ments, >23 Becquerel's diagnostic summary between cancer and chronic inflammation of the cervix, 275 Bernutz, conclusions in study of uterine haematocele, 171 Binder, propriety of using after labor, 28 Bladder, chronic inflammation of, 55 diseases of, 51 foreign bodies in, 63 haemorrhage from, 53 hyperfesthesia of, 54 inversion of, 64 irritable, 54 paralysis of, 51 stone in, 60 Bozeman's apparatus for retaining the patient in position, 102 operation for vesico-vaginal fistula, 102 Bowels, svmpathv of, in uterine disease, 202 Butlin, histologic distinction between sarcoma and carcinoma, 479 Buttle's uterine scarificator, 317 Byrne's cautery battery, 469 cautery ecraseur, 469 cautery electrodes, 470 Calculus, vesical, 60 Cancer of labia, 24 of the uterus, 443 causes of, 447 Chian turpentine in, 451 diagnosis, 448 palliation of, 458 symptoms of, 445 treatment, 450 Cancroid of the uterus, 464 Caruncles of the urethra, 48 Catheter, Goodman's for dilating the ure- thra, 60 Skene's double perforated, 58 Cautery battery, Byrne's, 469 Ecraseur, Byrne's, 469 electrodes, JByrne's, 470 Caustic potassa in corroding ulcer of vulva, 46 Cellulitis, 346 676 INDEX. Cervix uteri, elongation of, 342 hypertrophy of, 341 lacerations of, 329 Change of life, 185 Chronic perimetritis, 365 treatment of, 369 Clitoris, hypertrophy of, and nympha, 50 treatment of, 50 Condylomata of the vulva, 40 Constipation, 292 Corroding ulcer of the vulva, 46 Cutter's method of electrolysis, 529 Cystocle, 372 treatment of, 374 Cysts, dermoid, 567 theories of origin, 574 Dangers that may occur after uterine manipulation, 340 Davidson's syringe, 307 Delayed involution of the uterus, 428 causes of, 428 symptoms, 429 treatment, 430 Dermoid tumors, 567 theories of origin, 574 Diagnosis, 245-278 of acute inflammation of unimpreg- nated uterus, 188 acute vaginitis, 73 amenorrhoea, 120 cancer of the uterus, 448 cellulitis, 352 chronic vaginitis, 76 displacements of the uterus, 384 dysmenorrhea, 147 endocervicitis, 273 hyperinvolution, 442 inversion of the uterus, 414 lacerations of the cervix, 332 menorrhagia, 133 metatithmenia, 175 ovarian tumors, 585 paralysis of the bladder, 52 perimetritis, 368 stone in the bladder, 61 submucous inflammation, 274 urinary fistula, 83 Diagnostic summary (Becquerel's) be- tween cancer and chronic inflammation of the cervix, 275 Diiferential diagnosis of ovarian tumors, 694 Difiicnlt menstruation, 146 Digital examination, 248 Dilatation, 167 of the uterus, 268 Dilator, Hunter's, 167 Molesworth's, 271 Nelson's uterine, 167 Dilators, tupelo, 270 Disease of the bladder, 51 labia and perinaeum, 17 ovaries, 555 vulva, 40 Displacement of the ovaries, 555 diagnosis, 558 symptoms, 557 treatment, 559 Displacements of the vagina, bladder, and rectum, 372 causes of, 378 treatment, 386 uterus, 376 Division of sphincter vaginae in vaginis- mus, Sims's method, 71 Drainage in ovariotomy, 627 Dressing forceps, 263 Dropsy of the Falloj^ian tubes, 667 ovarian, 596 Drvsdale's description of the ovarian cell, 591 Duverney's glands, phlegmon of, 21 Dysmenorrhoea, 146 as a symptom of fibrous tumors of the uterus, 498 inflammatory form of, 148 membranous, 150 treatment of, 152 neuralgic, 146 treatment of, 147 obstructive, 153 treatment of, 156 Ecraseur, amputation by, in hypertrophy of the cervix, 341 Chassaignac's, 533 Electricity, in diseases of women, 671 in local treatment of amenorrhoea, 129 Electrolysis, 529 Cutter's method, 529 in ovarian tumors, 621 treatment of fibrous tumors of the uterus by, 529 Elephantiasis of labia, 24 Elongation of the cervix, 342 tensile, of the cervix, 343 Emmett's knife for dividing the cervix, 158 speculum, 264 Endocervicitis, 239 diagnosis, 273 gonorrhoea a frequent cause of chronic, 243 in aged women, 240 in virgins, 240 Endometritis, 143, 192, 323 application of iodized phenol in, 321 Enucleation for removal of tumors of the uterus, 536 Enucleator, Sims's, 538 Entero- vaginal fistula, 107 vesical fistula, 107 Epithelial cancer of the uterus, 464 Epithelioma of the uterus, 464 diagnosis, 466 structure of, 467 treatment, 468 Ergot, causes of failure of, 526 INDEX. 677 Ergot, dangers from use, in fibrous tumors of the uterus, 528 different preparations, 518 hypodermic injections of, 520 in fibrous tumors of the uterus, 499 in paralysis of the bladder, 53 in uterine hemorrhage, 138, 143, 144 mode of action, 521 using, 516 Etiology of uterine disease, 241 Extirpation of the uterus, 473 Excrescences, urethral, 48 Exsecting the uterus, Lane's operation, 473 Fallopian tubes, 666 cancer of, 667 dropsy of, 667 hypertrophy and atrophy of, 667 inflammation of, 666 tumors (hydrosalpinx), 357 Fibrous tumors of the uterus, 481 diagnosis, 489 nature of, 483 prognosis, 491 symptoms, 485 treatment, 495 Fistula, urinary, 81 Bozeman's method for cure, 102 diagnosis, 83 entero- vaginal, 107 vesical, 107 recto-vaginal, 107 treatment of, 108 Simons's method for cure, 95 Sims's operation, 86 Fistulous opening as a means of treat- ment in ovarian tumors, 617 Fitch's abdominal supporter, 389 measuring sound, 255 Follicular vulvitis, 42 causes of, 43 treatment, 43 Foreign bodies in the bladder, 63 Galvano-cautery, 468 Gangrenous vulvitis, or noma, 47 Gastrotomy, modification of operation, by Dr.Leon Labbe, 544 for removal of tumors of the uterus, 544 Generation, afiected by uterine disease, 228 Genu-pectoral position in treatment of displacement of the uterus, 388 Gillette's, Dr., operation for rectocele, 375 Glycerin, depletion by means of, 318 Gonorrhoea, a cause of chronic endocer- vicitis, 243 a cause of local peritonitis, 357 and endometritis, 243 Goodell's operation for supra-vaginal elongation of cervix, 344 Goodman's catheter in chronic inflam- mation of bladder, 60 Granular cell of ovarian tumor, 591 Drysdale's description of, 591 Gum-elastic air-bag to restore the in- verted uterus, 421 Hackenberg's method of treating pro- lapse, 401 Hsematoceie, chronic retrouterine, 179 periuterine, 170 uterine, 171 Haemorrhage, as a symptom of fibrous tumors of the uterus, 496 during menstruation, 133 in nursing women, 142 following ovariotomy, 659 from the bladder, 53 Haemorrhagic diathesis, 136 Higby's speculum, 260 Huguier's gland, labial abscess from in- flammation of duct, 23 Hunter's dilator, 167 Hydrosalpinx, 357 Hymen, hyperaesthesia of, 70 treatment, 71 Hyperaemia, 234 Hyperaesthesia, 209 of the bladder and urethra, 54 of vulva and hymen, 70 Hyperinvolution, 441 Hypertrophied labia, 24 Hypertrophy of the cervix, 341 of the clitoris and nympha, 50 treatment, 50 of the Fallopian tubes, 667 of the ovaries, 555 of the uterus, 274 Hysterectomy, modification, by Dr. Leon Labbe, 544 Hystero-epilepsy, 205 Hysterometer, 258 method of applying, 259 Hysteropathy, 193, 233 Inflammation, acute, of the mucous mem- brane of the uterus, 191 of the unimpregnated uterus, 188 characteristic signs of, 272 chronic of the bladder, 55 treatment of, 57 Sims's method of treatment, 60 erythematous, papular, vesicular, and pustular, of the vulva, 41 of- the ovaries, 561 treatment of, 563 vesicular of vulva, 44 Injections, 306 accidents in, 311 manner of using, 307 medicated, 308 intrauterine, 328 of the sac in ovarian tumors, 615 Intrauterine injections, 328 pessary, Simpson's, 130, 442 Inversion of the bladder, 64 of the uterus, 412 678 INDEX. Inversion of the nterus, symptoms of, 413 prognosis, 415 treatment, 416 Involution, 428 delayed, 428 treatment of, 430 of the uterus, diseased deviations of, 428 Iodized phenol, 321 Jenks's, Professor Edward W., method of denuding in perinseorrhaphy, 35 uterine probe, 254 uterine sound, 254 Jennison's exploring and indicating sound, 255 Kolpokleisis, 302 Labb^'s, Dr. Leon, modification of the operation of hysterectomy as applied to fibrous tumors (exsanguinification of the tumor), 544 Labia, abscesses of, 23 absence of, 25 adhesions of, 17 cancer of, 24 hypertrophied, 24 oedema of, 20 phlegmon of, 21 sanguineous infiltration of, 19 tumors of, 23 varices of, and vulva, 20 wounds of, 18 Lacerations of the cervix uteri, 329 operations for, 334 Laminaria tents, 269 Lane's operation (pervaginal enucleation of the uterus), 474 Laparo-hysterotomy, 542 Laparotomy, 541 Lapse (falling of the womb), 379 Leeches, application to uterus, 316 Lever for dilating the vagina, 266 Leucorrhoea, an evidence of disease of uterus, 221 a symptom of tumors of the uterus, 486 Ligature in ovariotomy, 626 Linen test for minute urinary fistulse, 104 Lithotomy, 63 Lithotrity, 62 Liver, sympathy of, in uterine disease, 203 Local congestions in uterine disease, 291 Local peritonitis, 355 diagnosis of, 358 Local symptoms of uterine disease, 219 Mammary bodies excited by uterine dis- ease, 215 Medicated pessaries, 314 Membranous dysmenorrhoea, 150 treatment of, 152 Menopause, 185 Menorrhagia, 133, 227 Menorrhagia, frequent in endooervicitis, 227 treatment of, 137 Menstruation and its disorders, 110 effects of partial closure of the os uteri on, 225 haemorrhage during, 133 misplaced, 170 pain during, 225 Mercury, acid nitrate of, as a local altera- tive, 321 Metatithmenia, 170 treatment of, 177 Metrorrhagia, 133 treatment of, 137 Metrotome, Dr. Peaslee's, 164 Microscopic examination of ovarian fluid, 566 Mcintosh's natural uterine supporter, 395 Moles worth's dilator, 271 Mucous inflammation of uterus, 238 Mucous membrane of uterus, acute in- flammation of, 191 Nelson's speculum, 261 uterine dilator, 167 Nervous prostration in uterine disease, 286 Nervous system, sympathetic aflfections of, 203 Neuralgia of the coccyx, 668 treatment of, 669 Nitrate of silver, application in vaginis- mus, 72 as a local alterative, 322 Noeggerath, Dr. Emil, treatment of small ovarian cysts, 621 Noma, 47 Nott's operation for cure of coccygodynia, 670 Nott's speculum, 260 Nott's tenaculum forceps, 264 Nympha, hypertrophy of the clitoris and, 50 Obstructive dysmenorrhoea, 153 Peaslee's conclusions in, 159 Sims's operation for, 157 treatment of, 156 Occlusion of the vagina, 17 QEdema of the labia, 20 Oophorectomy, 546 Operating chair, 246 Operating table, 247 Organic disease complicating ovariotomy, 637 Os and cervix, appearance of in the aged, 267 in the multiparous uterus, 266 in the virgin, 266 Os, stenosis of external, 163 of internal, 162 Os uteri, in the aged, 257, 267 how to find the, 262 Ovarian cell, described by Drysdale, 591 1 INDEX, 679 Ovarian dermoid tumors, 567 theories of origin, 574 fluid, microscopical examination of, 566, 591,593 tumors, 564 anatomy of, 564 causes of, 582 differential diagnosis of, 594 exploration by means of the as- pirator, 591 granular cell of, 591 general remarks on the diag- nosis of, 585 inflammation and ulceration of, 578 injection of the sac of, 615 modes of termination of, 580 pressure in conjunction with tap- ping in treatment of, 612 prognosis of, 584 tapping as a palliative means in, 604 treatment, 602 of the pedicle, 624 Ovaries, 553 affections of, 555 congenital atrophy of, 555 displacements of, 555 hypertrophy of, 555 inflammation of, 561 the method of examining, 553 tumors of, 564 Ovaritis, 561 treatment, 563 Ovariotomy, abdominal, 624 accidents that may occur during, 650 adhesions complicating, 650 after-treatment of, 654 complicated by organic diseases, 637 by pregnancy, 628 drainage in, 627 ligature in, 626 preparatory steps, 639 remarks and personal statistics, 664 vaginal, 622 wounds of the stomach and intestines complicating, 651 wounds of the urinary organs and gall-bladder, 651 Pain, attendant upon uterine inflamma- tion, 225 Painful menstruation, 225, 145 Palpitation, a sympathetic symptom of uterine disease, 212 Papin's Dr. J. L., method of dilating the urethra, 58 Paquelin's thermo-cautery, 468 Paralysis of the bladder, 51 diagnosis, 52 prognosis, 51 symptoms, 51 treatment, 52 Partial closure of the os uteri, effects on menstruation, 225 Parturition a predisposing cause of uterine disease, 242 Pathology of hysteropathy, 233 Pea-lee's conclusions in obstructive dys- inenorrhoea, 159 IVaslee's metrotome, 164 Pedicle, treatment of in ovariotomy, 624 Pelvic peritonitis, 355 Perineorrhaphy, 35 Periufeum, 26 effects of laceration, 30 rupture of the, 29 immediate operation for, 33 prevention of, 31 treatment, 31 spontaneous cure, 32 Perimetritis, acute, 346 symptoms, 349 treatment, 360 chronic, 365 symptoms and diagnosis, 368 Peritonitis, following uterine manipula- tions, 339 local, 355 diagnosis, 358 symptoms, 357 Periuterine hsematocele, 170 Pervagiual enucleation of the uterus. Lane's operation, 474 : Pessaries, 390 medicated, 314 Pessarv : Cutler's, 394 : Gehring's, 392 ; Hewitt's, 392; Thomas's, 397; Scott's, 393 ; Smith's, 391 ; Zwank's, 392 Simpson's intrauterine, 130, 442 Phlegmon of the labia, 21 Plethora, 291 Plugging in uterine haemorrhage, 139 Sims's method, 139 Thomas's method, 141 Polypoid tumors, removal of, 531 Pregnancy, a predisposing cause of uter- ine disease, 242 ■ complicating ovariotomy, 628 complications with fibrous tumoi-s of the uterus, 492 growth of uterine tumors during, 488 injections and baths in, 313 retroversion and retroflexion during, 407 Pressure, in conjunction with tapping in treatment of ovarian tumors, 612 Probe, object in using, 253 mode of using, 257 Prolapse, 380, 400 Brown's operation, 405 Hackenberg's method of treatment, 401 Sims's operation, 403 Protrusion of the uterus, 381 Pruritus pudendi, 43 treatment, 44 Puberty, 111 680 INDEX. Purulent vulvitis, 41 treatment, 41 Quinine, 297, 664 use in dysmenorrhoea, 148 Eadical treatment of inversion of the uterus, 419 Rectal examinations, 252 Rectal injections after ovariotomy, 657 Rectocele, 372 treatment, 874 complicating laceration of the per- inseum, 38 Recto-vaginal fistula, 107 treatment, 108 Renal lesions complicating ovariotomy, 652 Repositor, White's, in inversion of the uterus, 420 Retention of urine, an effect of inflam- mation of the urethra, 52 Retroflexion during pregnancy, 407 treatment, 410 Retrouterine hsematocele, chronic, 179 treatment, 183 Retroversion, 382, 397 and retroflexion during pregnancy, 407 treatment, 410 Rupture of the perinseum, by injudicious use of ergot, 30 by unskilful use of the forceps, 29 prevention of, 31 Sanguineous infiltration of labia, 19 Sarcoma of the uterus, 443 diagnosis, 479 histological distinction between, and carcinoma, 479 treatment, 480 Savage's definition of the perinfeum, 26 Sawyer's round knife for denuding sur- face, 336 Scarification of the cervix, 316 Scarificator, uterine, 317 Sea-tangle tents, 269 Senility, 185 Septicaemia, 461 following ovariotomy, 662 treatment, 663 Serre-fine in rupture of perinseum, 34 Shield, Wilson's, 472 Shock following ovariotomy, 658 Simon's operation for urinary fistula, 95 retractors, 266 speculum, 265 Simpson's intrauterine pessarv, 130, 442 _ operation for cure of coccygodynia, 670 uterine sound, 253 Sims's depressor, 264 guarded hooks, 538 method of examination, 263 Sims's method of plugging in uterine haemorrhage, 139 in menorrhagia, 139 operation for chronic inflammation of the bladder, 60 for obstructive dysmenorrhoea, 157^ for urinary fistula, 86 Skene's double perforated catheter, 58 Slippery elm tents, 325 Smith's , Dr. Albert H., knife for perinse- orraphy. 37 pessary, 391 Thomas's modification, 391 Dr. Tyler's mode of restoring the in- verted uterus, 421 Sorbefacient treatment of fibrous tumors of the uterus, 499 Spaying, 546 Speculum, mode of using, 262 Spermatorrhoea, sympathetic influences of, 197 Spinal cord, sympathetic aflfections of, in uterine disease, 209 Spielberg, Professor O., diagnosis of can- cerous infiltration, 277 Sponge-tents, 269 Statistics, remarks and personal, upon ovariotomy, 664 Stenosis, 153 treatment, 157 complicating endometritis, 324 of the external os, 163 of the internal os, 162 Sterility, an efifect of uterine disease, 228 Stomach, sympathy in uterine disease, 200 Stone in the bladder, 60 treatment, 62 Storer, Professor D. H., comparative merits of incision and dilatati on in dysmenorrhoea, 168 Strychnia in paralysis of the bladder, 53 Subinvolution of the uterus, 433 diagnosis, 437 treatment, 438 Submucous inflammation of the uterus, diagnosis of, 274 Superficial trachelotomy, 161 Suppuration following acute perimetritis, 365 Supporters, 389 Supravaginal elongation of the cervix, 342 Goodell's treatment of, 344 Surgical operation for relief of haemor- rhage, 535 Brown's operation, 535 treatment of fibrous tumors, 531 of prolapse, 402 Suspension pessaries, 395 Sympathetic influences of uterine dis- ease, 193 and spermatorrhoea abstract of, 197 symptoms of uterine disease, 200 Syringe, Davidson's, 307 fountain, 307 I INDEX. 681 Tampon, .glycerin, 318 Tampon in uterine hiiemorrhage, 139 Thomas's method, 141 Tapping, as a palliative in ovarian tu- mors, 604 Tents, 269, 327^ Tensile elongation of the cervix, 343 Thermo-cautery, Paquelin's, 468 Thomas's anteversion pessary, 397 Tincture of the chloride of iron in pruri- tus pudendi, 45 Trachelorrhaphy, 334 Trachelotomy, superficial, 161 Traumatic peritonitis following ovariot- omy, 660 Treatment of abscess of the vagina, 67 abscess of the labia, 23 acute inflammation of the unimpreg- nated uterus, 188 acute vaginitis, 74 adhesions of the labia, 17 amenorrhoea, 124 by local electrization, 129 atresia vaginae, 67 cancer of labia, 24 of uterus, 450 chronic retrouterine hfematocele, 183 chronic perimetritis, 360 chronic vaginitis. 77 condylomata of vulva, 40 displacements of uterus, 386 endometritis, 323 epithelioma of the uterus, 468 hypersesthesia of the bladder, 54 hvpertrophv of clitoris and uvmpha, 50 * of labia, 24 inversion of the bladder, 64 of uterus, 416 chronic form of, 418 Treatment of lacerations of the cervix. 333 of perinseura, 31 menorrhagia, 137 nausea and vomiting after ovariot- omy, 656 neuralgia of the coccyx, 668 obstructive dysmenorrhoea, 156 oedema of labia, 20 ovarian tumors, 602 bv means of a fistulous opening, '617 medical, 610 ovaritis, 563 paralysis of the bladder, pedicle in ovariotomy, 624 perimetritis, 360 phlegmon of labia, 22 prolapse, 400 puerperal vaginitis, 78 purulent vulvitis, 41 ■ rectocele and cystocele, 374 retroversion and retroflexion during pregnancy, 410 sanguineous intiltration of labia, 19 Treatment of septicaemia after ovariot- omy, 663 surgical, of fibrous tumors of uterus, 531 urinary fistula, 84 uterine disease, general, 278 local, 315 special, 303 vaginismus, 71 varices of labia, 20 wounds of, IS Trocar, I'itch's, 643 Tumors, labial, 23 in the vagina, 70 of the uterus, 481 complicated with pregnane v, 492 diagnosis of, 489 growth during pregnancy, 488 prognosis, 491 treatment, 496 ovarian, 564 Tupelo dilators, 270 Tympanites alter ovariotomy, 657 Ulceration and abrasion as results of hy- pertemia, 237 I Urethra, caruncles of. 43 I excrescences of, 48 treatment, 49 foreign bodies in, 63 hyperaesthesia of, 54 irritable bladder and, 54 vascular, 49 Urinary fistula, 81 treatment, 84 Uterine dilator, Hunter's, 167 Nelson's, 167 disease, 193 a cause of abortion, 229 diagnosis of. 245 efiect upon generation, 228 upon labor, 231 upon post-partum condi- tion, 231 ' etiology of, 241 ( sympathetic influence of, 197 I sympathetic symptoms, 200 i treatment, general, 278 local, 315 special, 303 haematocele, 171 Bernutz's conclusions upon study of, 171 diagnosis of, 175 symptoms, 173 treatment, 177 haemorrhage, 133 treatment, 137 use of ergot in, 138 inertia, 428 inflammation, pain of, 225 manipulation and operation, unto- ward effects of, 339 scissoi-s, 336 682 INDEX Uterine tenesmus, 221 Uterus, absence of, 121 acute inflammation of mucous mem- brane of, 191 acute inflammation of unimpreg- nated, 190 treatment, 190 atrophy of, acquired, 122 as a result of inflammation, 275 congenital, 122 cancer of, 443 treatment, 450 dilatation of, by means of tents, 268 extirpation of, 473 Freund's operation for, 473 vaginal, 474 hyperinvolution of, 441 inversion of, 412 treatment, 416 involution of, 428 treatment, 430 mucous inflammation of, 238 subinvolution, 433 treatment, 438 tumors of, 481 Vagina, absence of, 65 fistulous opening of, for treatment of ovarian tumors, 620 tumors of, 70 Vaginae, atresia, 66 treatment, 67 Vaginal extirpation of the uterus, 474, Schroeder's operation, 476 ovariotomy, 622 Vaginismus, 70 division of sphincter, Sims's method for, 72 Vaginismus, forcible dilatation in, 72 Vaginitis, acute, 73 treatment, 74 chronic, 75 treatment, 77 puerperal, 78 treatment, 80 Varices of labia and vulva, 20 Vascular tumor of urethra, 48 urethra, 49 Vesical calculus, 60 lesions complicating ovariotomy, 652 Vesico-vaginal fistula, Simon's method, 95 Sims's, 86 Vesicular inflammation of vulva, 44 Vulva, condylomata of, 40 corroding ulcer of, 46 diseases of, 40 hypersesthesia of, 70 treatment, 71 inflammations of, 41 treatment, 41 varices of, and labia, 20 vesicular inflammation of, 44 Vulvitis, follicular, 42 treatment, 43 gangrenous, 47 purulent, 41 White's repositor, 420 Wilson's operating chair, 246 shield, addition to the thermo-cau- tery, 472 Wounds of the intestines complicating ovariotomy, 651 of labia, 18 of urinary organs complicating ovari- otomy, 651 i Sept. 1, 1881. 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The unexceptional large and raj^id sale of this book, and the universal com- mendation it has received from the profession, seems to be a sufficient guaran- tee of its merit as a Textbook. The publishers are in receipt of numerous letters from Professors in the medical schools, speaking fiavorably of it, and below the}- give extracts from the medical i)ress, American and English, attesting its superiority and va^e to both student and practitioner. The present edition has been thoroughly revised and much of it re-written. " The best Textbook for Students in the English language. We know of no work in the English language, or in any other, which competes with this one." — Edinburgh Medical Journal. " It is a remarkable evidence of industry, experience, and research."— Pmcii7ioner. "Dr. Roberts' book is admirably titted to supply the want of a good handbook, so much felt by every medical student." — Students Journal and Hospital Gazette. 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For this purpose he has properly chosen to use academic detail, not ex- haustively, but as a means to this end, and he has brilliantly succeeded." — Westminster Rci'iew. " The most interesting chapter is undoubtedly that on the gouty heart, a subject which Dr. Fothergill has specially studied, and on which he entertains views such as are likely, we think, to be generally accepted by clinical physicians, although they have not before been stated, so for as we are aware, with the same breadth of view and extended illustration." — British Med. Journal. " Dr. Fothergill's remark-; on rest, on proper blood nutrition in heart disease, on the treat- ment of the sequelae of it, and on the actions of special medicine, all indicate that, in studying the pathology of heart disease, he has earnestly kept in view the best means of mitigating suf- fering and of prolonging life." — The Lancet. LINDSAY & BLAKISTON, Publishers, AMERICAN HEALTH PRIMERS. Edited by W. W. KEEN, M. D., Fellow of the College of Physicians of Philadelphia ; Surgeon to St. Mary-s Hospital, etc. This serins of American Health Primers is prepared to diffuse as widely and cheaply as possible, among all classes, a knowledge of the elementary tacts of Preventive Medicine, and the l)earing3 and applications of the latest and best researches in every branch of Medical and Hygienic Science. Tliey are not intended (save incidentally) to assist in curing disease, but to teach people how to take care of themselves, their children, pujiils, employees, etc. They are written fiom an American standpoint, with especial reference to our Climate, Sanitary Legislation, and Modes of Life; and in those respects Me ditfer materially frum other nations. The subjects selected are of vital and practical importance in every-diiy life, and are treated in as popular a style as is consistent with their nature. Each volume, when the subject calls for it, is fully illustiated, so that the text may be clearly and readily understood by any one heretofore vntirelj Ignorant of the structure and functions of the body. The object being to furnish the ge^ieral or un- scientific reader, in a compact form and at a low price, reliable guides lor the prevention of disease and the ]ireservation of both body and mind in a healthy state. The authors have been selected with great care, and on account of special fitness, each for his subject, by reason of its previous careful study, either privately or as public teachers. Dr. Keen has supervised the Series, as Editor; but is not responsible for the statements or opinions of the individual authors. I. Hearing^ and How to Keep It, With Illustrations. By Chas. H. Burnett, M. D., of Philadelphia, Consulting Aurist to the Pennsylvania Institution for the Deaf and Dumb, Aurist to the Presby- terian Hospital, etc. II. Long Life^ and How to Meach It, By J. G. Bichardson, M. D., of Philadelphia, Professor of Hygiene in the University of Pennsylvania, etc. III, The Summer and its Diseases, By James C. Wilson, M. D., of Philadelphia, Lecturer on Physical Diagnosis in Jefferson Medical College, etc. IV, Eyesight f and How to Care for It, With Illustrations. By Geokge C. Harlan, M. D., of Philadelphia, Surgeon to the Wills (Eye) Hospital. F. The Throat and the Voice, ' With Illustrations. By J. Solis Cohen, M. D., of Philadelphia, Lecturer on Diseases of the Throat in Jefferson Medical College. VI, The Winter and its Dangers, By Hamilton Osgood, M. D., of Boston, Editorial Staff Boston Medical and Surgical Journal. VII, The Mouth and the Teeth, With Illustrations. By J. W. White, M. D., D. D. S., of Philadelphia, Editor of the Dental Cosmos. VIII, Brain Work and Overwork, By H. C.Wood, Jr., M.D., of Philadelphia, Clinical Professor of Nervous Diseases in the University of Pennsylvania, etc. IX, Our Homes, With Illustrations. By Henry Hartshorne,M.D., of Philadelphia, formerly Professor of Hygiene in the University of Pennsylvania. X, The Skin, in Health and Disease, By L. D. Bulkley, M.D., of New York, Physician to the Skin Department of the Demilt Dispensary and of the New York Hospital. XI, Sea Air and Sea Bathing, By John H. Packard, M. D., of Philadelphia, Surgeon to the Episcopal Hospital. XII, School and Industrial Hygiene, By D. F. Lincoln, M. D.. of Boston, Mass., Chairman Department of Health, American Social Science Association. The volumps are sold separately. Price 50 cents each, neatly bound in cloth, or the set complete, put up in boxes, price $6.00 ; with a specially liberal discount to the Trade when ordered by the dozen volumes assorted^ or in larger quantities. PRESLEY BLAKISTON, Publisher, jl012 IValnat Street, Pbiladelpbia. LINDSAY «c BLAKISTON'S PHYSICIANS' VISITING LIST, PUBLISHED ANNUALLY. For Thirty Years this Yisitiug List has steadily increased in popularity, and the publishers have constantly modified or re-arranged it as the wants of the profession have become known. NEW FEATUEES IN THE LIST. A New Table of Poisons and their Antidotes. The Metric or French Decimal System of Weights and Measures. Posological Tables, showing the relation of our present system of Apothecaries' Weights and Measures to that of the Metric System, giving the Doses in both. This is a most valuable addition and will materially aid the Physician. So many writers now use the metric system, especially in foreign books and journals, that one not familiar with it is constantly confused, and in many cases unable to understand the measurements or doses. SIZES AND PRICES. For 25 Patients weekly. Tucks, pockets, and pencil, . . . . $1 00 50 " " " " " .... 1 25 75 " " " " " .... 1 50 100 " " " " " .... 2 00 ( Jan. to June I July to Dec 100 " " 2.01. {^r,r/,°/C} " . . . .3 00 INTERLEAVED EDITION. 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SIXTH ST., PHILADELPHIA. 50 " " 2 vols. rT^Tl'i^.'UV""} ' .... 250 i r I /'^'/'^/^^'/J/f'.Tv; '-'> "'■ '^ ' J -J^