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 PRACTICAL TREATISE 
 
 / 
 
 DISEASES OF THE UTERUS, 
 
 OVARIES AND FALLOPIAN TUBES^ 
 
 A. COURTY, 
 
 PROFESSOR OF CLINICAL SURGERY, MONTPELLIER, FRANCE. 
 
 TEAXSLATED FKOM THE THIKD EDITION 
 
 BY HIS PTJPIL 
 
 AGNES M'LAREN, M.D., M.K.Q.C.P.I. 
 WITH A PKEFACE 
 
 BY 
 
 J. MATTHEWS DUNCAN, M.D., LL.D., F.R.S.E. 
 
 OBSTETRIC PHYSICIAN TO ST. BARTHOLOMEW'S HOSPITAL, LONDON. 
 
 PHILADELPHIA: 
 
 P. BLAKISTON, SON & CO., 
 
 No. 1012 Walnut Street. 
 
 1883. 
 

 30/ 
 
 c^^ 
 
 . LA PRECISION DU DIAGNOSTIC ET L OPPORTUNITE DU 
 TRAITEMENT SONT LES SEULS GARANTS DE SUCCES DANS LA 
 PRATIQUE." 
 
PREFACE. 
 
 In recent times gynaecology lias been developed in a very 
 remarkable manner ; and while there can be no doubt that, on 
 the whole, the luxuriant growth is healthy and beneficent, it 
 is also certain that much of it, both in theory and in practice, 
 is rank and doomed to destruction, or at least oblivion. Too 
 little of the spirit and method of science has as yet permeated 
 gynascology, and in this respect its state may be contrasted with 
 that of the nearly allied department of obstetrics. 
 
 This modern development of gynaecology began in France 
 in the earlier years of this century, and a kind of medical en- 
 thusiasm soon appeared, which graduall}^ grew and overspread 
 G-reat Britain, G-ermany and America. It would be hard now 
 to say where the still-growing enthusiasm is most prevalent. 
 It has extended over the whole world, and several unassailable 
 statistical statements have been made (Dr. James E. Chadwick), 
 which render it probable that nowhere does gj^n^ecology thrive 
 so vigorously as in the United States of America. 'New hos- 
 pitals, books, journals, societies, practitioners, specially devoted 
 to it, are now to be found in all parts of the globe in greater 
 or less number, and can be counted and valued; and those of 
 the great French nation hold a distinguished place. 
 
 Among books devoted to diseases of women none has been, 
 or is, more important than that of Professor Courty, of Mont- 
 pellier. It is the carefully elaborated and repeatedly revised 
 work of a man at once imbued with the science and immersed 
 in the practice of gynaecology, of one who has long lived in a 
 centre of general science and learning, amidst an abounding 
 population, and who enjoys the great advantage of couibining 
 in his sphere of practical activity Ijoth hospital and private 
 patients — two classes which differ in their circumstances and in 
 their aspects for observation, favorable and unfavorable to the 
 student. 
 
VI P E E F A C E. 
 
 It is certainly a boon to the English-speaking peoples to have 
 Courty's work translated ; for the great mass of medical men 
 are, unfortunately, ignorant of French, or not familiar enough 
 with that lano;uao;e to enable them to use the book in its 
 original form. 
 
 This translation of a work on women has been, with striking 
 appropriateness, executed by a woman doctor. I have had the 
 privilege of her friendship since her childhood, and know her 
 excellent qualities. She has already, by original work, shown 
 her competence in an important respect for this now completed 
 task of translation. But she is, in addition, specially qualified, 
 having studied in the University of Montpellier, under Dr. 
 Courty among others, and having, subsequently to her gradua- 
 tion, been for a considerable time his assistant in practice. 
 Moreover, since she settled in Edinburgh, Dr. M'Laren has, in 
 her own practice, maintained her familiarity with the diseases 
 treated of in this book. 
 
 Courty's work has, since its first publication, been recognized 
 everywhere as an exponent of French doctrine. In France its 
 position is attested by the sale of two editions, numbering, I 
 am told, 10,000 copies; and by the appearance of another, the 
 third edition. It is from this third edition that this translation 
 has been made. The translation is not a simple reproduction 
 in English of the chapters of the third French edition, for it 
 has been abridged by omissions planned by the author himself. 
 As it now appears, it is a treatise on the diseases of the uterus. 
 Fallopian tubes and ovaries, with an introductory chapter on 
 the anatomy, physiology and teratology of the organs of 
 generation. I recommend to the carefal study of my profes- 
 sional brethren a book which has already been crowned by the 
 Institute of France. 
 
 J. MATTHEWS DUNCAN. 
 
CONTENTS 
 
 INTEODUCTION 
 
 ON THE ANATOMY, PHYSIOLOGY, AND TERATOLOGY OF THE 
 ORGANS OF GENERATION 
 
 PAGE 
 
 The Ovaries and Fallopian Tubes — the Uterus — Ligaments and Append- 
 ages of the Uterus — Changes in the Uterus at Different Stages — 
 Structure of the Uterus — the Vagina and Yulva — Development : 
 Comparison of the Genital Economy in the Two Sexes — Anomalies . 3 
 
 PART I 
 
 GENERAL SURVEY OF UTERINE DISEASES 
 
 CHAPTER I 
 
 Diagnosis of Uterine Diseases in General — -Presumptive Signs furnished 
 by the Symptomatology of Uterine Diseases — Certain Signs furnished 
 by Direct Exploration . . . . . .95 
 
 CHAPTER n 
 
 Treatment of Uterine Diseases in General — Indications to be Fulfilled in 
 the Treatment of Uterine Diseases — Methods of Treatment and 
 Various Medications — Means of Fulfilling Indications in the Treat- 
 ment of Uterine Diseases . . . • . .151 
 
 CHAPTER III 
 
 General Characteristics of Uterine Diseases — Their Frequency — Predis- 
 posing Causes — General and Local Symptoms — Complications — 
 Prognosis — Classification ...... 233 
 
Vlll CONTENTS 
 
 PAET II 
 
 UTERINE DISEASES Df DETAIL 
 
 CHAPTER I PAGE 
 
 Functional Disorders. — Menstruation — AmenorrHosa — Retention o£ the 
 Menses — Deviation of the Menses and Supplementary Menstruaiion 
 — Djsmenon'hoea — Uterine Neuralgia — Uterine Hemorrhage . 257 
 
 CHAPTER n 
 
 Changes of Position — Displacements — Deviations — Flexions — Inversion . 343 
 
 CHAPTER m 
 
 Morhid States without Neoplasm — Fluxion — Congestion — Engorgement — 
 Metritis^Ovaiitis and Salpingitis — Peri-uterine Inflammation — of 
 Leucorrhcea in General and Uterine Catarrh in Particular — Hyper- 
 trophy and Atrophy — Granulations and Fungosities — Ulceration 
 and Ulcers of the Uterine Cervix ..... 460 
 
 CHAPTER IV 
 
 Organic Alterations — Fihrous Tumours — Polypi and Moles — Tubercle — 
 
 Cancer .......•• 648 
 
 CHAPTER V 
 
 Diseases of the Uterine Appendages — Pelvic Haemorrhages and Peri- 
 uterine Hematocele — Cyst of the Ovary and Genito-pelvic Tumour — 
 Sterility ........ 714 
 
 Index . ... . . • • • • • 803 
 
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 2 
 
ON THE DISEASES OF THE UTERUS, OVARIES 
 AND FALLOPIAN TUBES 
 
 INTEODUOTION 
 
 ON THE ANATOMY, PHYSIOLOGY, AND TERATOLOGY OF THE 
 OEGANS OF GENERATION 
 
 THE OVAEIES AND FALLOPIAN TUBES — THE TJTEEUS — LIGAMENTS AND AP- 
 PENDAGES OF THE UTERUS — CHANGES IN THE UTEEUS AT DIFFERENT 
 STAGES — STEUCTUEE OF THE UTEEUS — THE VAGINA AND VULVA — DE- 
 VELOPMENT : COMPARISON OF THE GENITAL ECONOMY IN THE TWO SEXES 
 — ANOMALIES. 
 
 Before entering on the pathology of the uterus and ovaries, it is 
 indispensable to know their anatomy and physiology thoroughly. This 
 preliminary study is more necessary with regard to these organs than 
 any others, because till within the last few years it has been very 
 superficial. I do not refer merely to the organic structure of the uterus 
 and its mucous membrane, to the histology of the ovaries, their func- 
 tions, and all the points of anatomy and physiology relative to irritation, 
 menstruation, conception, pregnancy, &c., on which light has only 
 been thrown by modern investigations ; but even the position, direction, 
 volume, and mutual relationship of these organs, with the modifications 
 which they undergo according to age and various circumstances, have 
 been described in a most imperfect manner till quite recently. This is 
 due to the fact that there are no other organs whose position, form, 
 size and structure are so variable. Age, exercise or rest, menstrua- 
 tion or pregnancy, not to speak of various morbid conditions, modify 
 the anatomical characters so much, that differences between writers are 
 easily accounted for. 
 
INTRODUCTION 
 
 The Ovaries and Pallopian Tubes 
 
 The ovaries and Fallopian tubes constitute the internal genital 
 economy. 
 
 Ovaries} — The ovaries (pvaria) are the organs in which the 
 ova, i.e. the female germs, are formed. The ovum is not complete 
 till fecundation has taken place, i.e. the union of the female with the 
 male germs produced by the testicles. Hence the name testes muliehres 
 given to the ovaries, to recal the analogy existing between organs whose 
 products have an analogous destination. The ovaries lie in the cavity 
 of the pelvis, on each side of the uterus, in the posterior fold [meso- 
 varium) of the broad ligament (Fig. 1) ; but this position is variable : 
 at birth they are on a level with the iliac fossa, and only descend into 
 the pelvis at the tenth year. These organs are very mobile, their 
 position not being, so to speak, fixed. Certainly they are enclosed in 
 the posterior fold of the broad ligament^ behind the Fallopian tubes 
 and in front of the rectum, from which they are usually separated by 
 the inferior circumvolutions of the ileum ; their superior surface corre- 
 sponds with the central fold and with the intestinal circumvolutions ; 
 their inferior surface with the posterior surface of the broad ligaments 
 and with the utero-sacral ligaments ; their superior and posterior 
 border is convex and free, and is in relationship with the small intestines. 
 They are, however, at the same time so mobile that they may undergo 
 all the displacements to which they are liable from the neighbouring 
 organs, and which may be divided into four classes — 1. Displacements 
 owing to the laxity of the posterior fold, very limited, generally 
 momentary; transverse and vertical. 2. Displacements due to the 
 laxity of the broad ligaments, usually momentary, produced by 
 fulness of the bladder, on which the ovaries rest, and which pushes 
 them back above the utero-sacral ligaments. 3. Displacements caused 
 by enlargement of the uterus, which drags the ovary successively from 
 the pelvis into the hypogastric, the umbilical, the lumbar and, after 
 delivery, into the iliac regions. 4. Lastly, accidental or morbid 
 displacements, such as hernise, which take place through the natural 
 orifices or through lacerations. 
 
 The form of the ovary is that of an ovoid slightly flattened, pre- 
 senting two surfaces (an antero-superior and a postero-inferior), two 
 borders (the superior free, the inferior adherent), two extremities (one 
 
 ^ See Klebs, Die Eierstoclcseier der Wirhelthiere, in Vircliow's Arcliiv, 1861, 
 Bd. xxi, p. 362, and Bd. xxviii, p. 301. Schron, Beitriige zur Kenntniss zur 
 Anatoin. u. Physiol, der Eierstoches der Saiigethiere (Zeitschr. von Slebold u. 
 Kolliher, Bd. xii, 1863, pp. 409 and 426). Grohe, TJeber den Bern u. das 
 Wachsthum des menschlichen Eierstoches u. ueher einige hranhliafte Storungen 
 derselben, in Virclww''s Arcliiv, 1863, Bd. xxvi, p. 271, and Bd. xxviii, p. 
 670. Pfliiger, Ueher die Eierstoche der Saiigethiere ii. des Menschen. 
 Leipsic, 1863. His, Beobachtungen ilber den Bau des Sailgethier-Eierstoches, 
 in Schidtze's Archiv fur inihroscojpische Anat., Bd. i, p. 151, 1865, Perier, 
 Anatomic et physiologic de Vovaire, these de conconrs pour I'agregation. Paris, 
 1866. Puech, Des ovaires, de leurs anomalies. Pai-is, 1873. 
 
ANATOMYj PHYSIOLOGY AND TERATOLOGY 5 
 
 internal, to which the utero-ovarian ligament is attached ; the other 
 external, to which the tubo-ovarian ligament is attached). The size 
 varies, depending on age, menstruation, pregnancy and the menopause.^ 
 The weight during the intercalary period is on an average about a 
 quarter of an ounce. The surface, at first smooth and polished, then 
 vesicular and irregular, becomes after a time covered with cicatrices 
 and finally shrivelled. The colour, rose pink in the child and red in 
 the adult owing to vascular injection and sanguineous congestion at 
 the monthly periods, becomes greyish or brown after the menopause. 
 
 According to numerous researches, the results of which are still in- 
 complete, the ovary seems to be composed of two parts : one adherent, 
 central, the hilum of the gland (hilus ovarii), which is spongy, erectile, 
 and forms, so to speak, the bulb of the ovary (ovarian bulb, Rouget) ; 
 the other cortical, superficial, free, peripheric, white in colour, the exclu- 
 sive seat of the formation of the Graafian vesicles and of the ovules 
 (see Figs. 3, 6, and 7). The central part, called medullary, of a dark red, 
 is highly vascular, and furnished with muscular fibres. The ovarian 
 or utero-ovarian artery, analogous to the spermatic, coming from the 
 aorta, supplies the uterus as it passes along its border till it reaches 
 the cervix, where it anastomoses with the uterine artery, a branch of 
 the internal iliac. It gives off ten or twenty branches to the ovary on 
 a level with the hilum, helicine arterioles like those of the cavernous 
 bodies of the penis, a disposition which seems common to the erectile 
 organs. The veins, much more numerous, constitute at first a wonder- 
 ful venous network with muscular trabeculse (Rouget), which rests 
 on the subovarian plexus, a spongy body somewhat less than the bulb 
 of the vestibule, which plexus communicates below with the vaginal 
 plexus, above with the pampiniform plexus (more developed than in 
 the male), to empty itself into the renal vein on the left and into the 
 vena cava on the right ; these veins are without valves, or at least have 
 very insufficient ones. This association of vessels with fasciculi of 
 smooth muscular fibres in which they are enfolded, and the trabeculse 
 of which in contracting prevent the return of the blood in the capil- 
 laries and little veins into the venous trunks, gives to the spongy por- 
 tion of the ovary all the characters of an erectile organism. The same 
 changes probably take place in the ovary during coitus as in the 
 testicle ; that is to say, it increases to double its size, becomes hard and 
 extremely sensitive, and produces a considerable hyper-secretion. The 
 lymphatics, described and drawn by His, are united into six or eight 
 trunks, accompany the utero-ovarian artery, and empty themselves into 
 the middle and superior lumbar lymphatic ganglia. The nerves issuing 
 from the solar, renal and lumbo-aortic plexuses, form the ovarian 
 plexus, and accompany the ovarian vessels. 
 
 The cortical glandular portion alone includes those numerous cells 
 which do not, strictly speaking, constitute ova from the first, though 
 they may become such by development. 
 
 ' Size of the ovary in the adult during C^/-a"^^^^'^?,f^^^«^e^' ^'^^l "^• 
 inter-menstmation \ . . . ^ Vertical ditto _ . O" 18 „ 
 
 (^ Antero-postenor . O'Olo „ 
 
INTEODUOTION 
 
 The ovarian vesicles, Graafian vesicles, ovisacs of Barry, which con- 
 tain the ovum and expel it with their liquid contents at the moment of 
 
 Fig. 2. — General view of the vascular supply of the internal genital organs, 
 pv, semi-circular enlargement of the vaginal plexus ; PC, cervico-uterine 
 plexus ; pu, uterine plexus ; sp, helicine arteries of the body of the 
 uterus ; h, helicine arteries of the hilus of the ovary. 
 
 dehiscence, are developed on the cortical portion so early that they are 
 seen in the foetus in such abundance that they may be said to be innu- 
 merable.^ Erom this we may judge of the facility with which multi- 
 locular cysts are developed and of the early age at which they may be 
 observed. It is only in proportion as they are developed that the 
 ovarian vesicles project beyond the cortical substance of the ovary, 
 forming on one side a projection on its free surface, and on the other 
 penetrating more and more deeply into the bulbous portion, where they 
 were erroneously supposed to take their origin. The ovisac is spherical, 
 attaining a size of 15 milHmetres or more in diameter; it hollows out 
 for itself a cavity in the ovary, the wall of which has been mistaken 
 for its supposed external membrane. Its proper envelope, semi-trans- 
 parent, grey or reddish, resistant and capable of being enucleated 
 from the ovary to which it is only attached by fibrous tissue and small 
 vessels, is composed of laminar fibres or fibrous tissue, of fusiform bodies, 
 of embryo-plastic nuclei, of amorphous granular matter, of cells peculiar 
 
 * Sappey, Anat. Descriptive, p. 631. Paris, 1864. Kolliker has counted 
 more than 6000 on each ovary {Mih-oscop. Anat. Leipzig, 1852). 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 7 
 
 to the ovisac, and of abundant capillaries.^ The ovisac is supplied 
 with blood by two or four arterioles, which spread over its surface in a 
 delicate network. The memhrana granulosa or epithelium of the ovi- 
 sac, formed of one or more layers of hemispherical cells, has a thickness 
 of from 1 to 2 hundredths of a millimetre, except at one point where 
 there is a thickness of GO hundredths of a millimetre and which has 
 received the name of cumulus or discus proligerus^ because it bears the 
 germ. 
 
 The ovum^ lies in the centre of the cumulus and according to the 
 
 Fig. 3. — Vertical section of the ovary of the cat during gestation. Injected. 
 Magnified 60 diameters. 1, cells of the non-vascular cortical layer ; 
 2, cortical cells presenting the first rudiment of the meinbrana germina- 
 tiva, and the first trace of a vascular circle ; 3, commencing enlargement 
 of follicle, separation of the memhrana germinativa of the ovum, and 
 continuation of this membrane into the adjoining portion of the follicle ; 
 4, formation of proligerons disc. Vascular network of follicle ; 5 to 8, 
 follicles at various periods of development ; 9, small follicle from which 
 the section has only removed a disc from the zona pellucida of the ovum ; 
 
 10, half-opened follicle, the ovum of which has escaped by the section ; 
 
 11, intact portion of the follicular wall, through which the zona pellucida 
 is seen ; 12, central vein of corpus luteum ; 13, peripheric artery of corpus 
 luteum : the branches of this artery surround the polygonal cells of the 
 corpus luteum ; 14, large vessels of ovarian stroma (after Schroen). 
 
 ' Courty, De I'oeuf et de son developpement, p. 55. Montpellier, 1845. 
 Robin, Mchnoire sur les modifications de la muqueuse uterine, p. 160. 
 
 ^ I prefer this name to that of ovule for designating the female germ ; the 
 latter gives a false idea, since Baer, who invented it, meant it to convey a 
 distinction as incorrect as subtle between the ovum of birds and that of the 
 mammalia : the latter having, according to him, an ovum in an ovum, or an ovum 
 raised to the second power. In both cases there is an ovum in question, which 
 
8 
 
 INTEODUOTION 
 
 observations of Schroen, Eobin, &c., at the nearest point to the arterioles 
 which ramify in the Graafian vesicle.^ 
 
 The ovum is a spherical vesicle of from one to two tenths of a milli- 
 metre, with a very fragile envelope (zona pellucida of Baer or vitelline 
 membrane of Coste) and granular contents {germ or cicatricula in 
 birds), alone or surrounded by a more or less considerable quantity of 
 vitellus, presenting in its centre the nucleus of the cell (germinal vesicle 
 of Purkinje) and its nucleolus (germinal spot of Wagner), discovered 
 by Coste in the germinal vesicle of the human ovum. Two ova may 
 be found exceptionally in one ovisac (Baer, Bischoff, Bidder), and 
 certain anomalies have been observed by Davaine ^ in birds. Under 
 the influence of the ovarian congestion produced by the natural matu- 
 
 FiG. 4 
 
 Fig. 5. 
 
 Fig 4. — Formation of coi'pus luteum of the ovary (natural size). A, section 
 of tlie ovary : a, recently emptied follicle filled with blood (thrombus of 
 extravasation), surrounded by a thin yellow layer ; h, empty follicle, 
 puckered in front, with a smaller thrombus and a thicker wall ; c, retro- 
 gressive metamorphosis in more advanced stage. B, exterior surface of 
 the ovary and point where the recent rupture of the follicle has taken 
 place ; the thrombus projects outside. 
 
 Fig. 5. — Section of two corpora lutea of natural size. 1, in fresh condition, 
 eight days after conception ; 2, in the fifth month of pregnancy, a, tunica 
 albuginea ; b, stroma of ovary ; c, fibrous membrane of follicle, thickened 
 and puckered (internal layer) ; d, sanguineous clot within this membrane ; 
 e, discoloured clot ; /, fibrous membrane, forming the boundary of the 
 corpus luteum. 
 
 does not differ from the other as to the germ, and which is only distinguished 
 by the quantity of nutritive matter added and by the shell which protects it. 
 
 ' The ovum has often seemed to me to be placed in the superficial and 
 prominent point of the vesicle, opposite the little vascular trunks which spread 
 by iiTadiation over the ovisac. This is shown very clearly in the beautiful 
 woodcuts which Gerbe has drawn so conscientiously for Coste's groat work ; I 
 have not, however, prosecuted my researches on this point so far as to be able 
 to affirm that it is always so. 
 
 ^ Comptes rendus de la Socicte de biologie. Paris, 1860. 
 
x^NATOMY, PHYSIOLOGY AND TEEATOLOGY 9 
 
 ration of the vesicle and by the accompanying erectile phenomena 
 manifested externally by menstruation, or under the influence of the 
 congestion produced by sexual excitement, the quantity of fluid in the 
 ovisac increases rapidly, stretches the walls, renders them thin, and 
 gradually suspends the circulation in the part which is most superficial 
 and least resistant. A kind of linear ulceration with rupture of the 
 ovisac follows at this point : the ovum is expelled in the middle of the 
 cumulus proligerus, and received by the fimbriated extremity of the 
 Tallopian tube. 
 
 A work of reparation then commences in the tissue of the ovisac, 
 passing through remarkable phases, and characterised by the persistence, 
 during a longer or shorter period, of an organic production which 
 gradually diminishes in volume, and which, on account of its colour, 
 has received the name of yellow body, corpus luteum (Malpighi ^), or, 
 as signifying more exactly the cicatricial act of which it is the indica- 
 tion, the more correct name of ovariule (Robin) . This organic product 
 is a hypertrophic thickening of the membrane of the ovisac, the cells 
 of which multiply and increase in such enormous proportions as to 
 cause a puckering of the membrane, and a considerable projection 
 towards the surface of the ovary. These cells are simultaneously 
 invaded by a granular product, of fatty nature and yellow colour, 
 at least in woman, which is the real cause of the colour of the ovariule 
 in the human species. In cystosarcomata of the ovary I have seen 
 this product invade the membrane of several vesicular cysts, and 
 give rise to considerable masses of yellow matter. Then comes the 
 period of reabsorption ; the yellow body atrophies and shrivels up so 
 much that in its place there remains only a depressed cicatrix with 
 the trace of the rupture of the ovisac and a grey or slaty coloration. 
 
 The development of the Graafian follicles and of the ova takes place 
 in the ovary not only after puberty and during sexual activity but 
 even before this period and during foetal life. In 1836 Cams an- 
 nounced that ova were to be found in the ovaries of the foetus. But 
 the Graafian vesicles were considered to be independent of each other, 
 and the ovary in consequence diff'erent from other glands. The recent 
 researches of His and Pfliiger prove that probably it is not so, and 
 that the ovary resembles the testicle and other secreting organs. 
 
 In 1838 Valentin" announced that the ovary in embryos is cana- 
 liculated. In 1863 Pfliiger demonstrated this tubular structure. 
 Kolliker^ confirmed the fact by his researches on the embryos of cats, 
 cows and women. In the ovaries of young embryos cordlike glandular 
 filaments are certainly seen, sometimes in the form of a club with a 
 blind end. They are composed of a superficial layer of little cells 
 analogous to epithelium cells, precursors of the granular membrane of 
 the Graafian follicle, and of a thick mass of larger cells which will 
 become ova. 
 
 The development also takes place from the superficial part of this 
 
 ' Metovarium, after the ovriin (Raciborski). 
 
 2 Mailers Archiv, 1838, p. 531. 
 
 ^ Handbuch Gewebelchre, 5te Aufl, 1867. Leipzig. 
 
10 
 
 INTEODUCTION 
 
 gland, where it is least considerable, to the deep part,, where it is most 
 so. The transition of the glandular filaments containing ova into 
 Graafian follicles or sacs takes place even in the embryo; it com- 
 mences in the interior^ and advances slowly to the surface, so that 
 
 /v 
 
 Fig. 6. — Transverse section of the ovaiy of a lauman embryo at six montts, 
 magnified six diameters, a, external layer of glandular substance, with 
 glandular filaments cleaned by means of a brush ; h, internal layer of the 
 same substance, with ovisacs separated or in course of isolation ; c, stroma 
 of the hilus (medullary substance) ; d, mesovarium, divided near the 
 broad ligament (after His). 
 
 whilst the medullary portion increases, the tolerably thick glandular or 
 cortical portion presents an inferior zone of follicles, separated or in 
 process of separation. The separation of follicles is effected by the 
 production of fibrous tissue forming partitions, and by that of new 
 cells of epithelium lining them. The multiplication of these partitions 
 divides the entire tube into isolated sections, each smaller than the 
 preceding, and each containing only one ovum enveloped in a layer of 
 epithelium. In proportion as the follicle increases in size it becomes 
 filled with fluid, and the granular membrane, with its proligerous disc 
 containing the ovum, remains against the wall. The vascular wealth 
 of the ovary in the foetus is remarkable, and is proportioned to the 
 importance of the formation of this multitude of ovigenic or proli- 
 gerous cells. In after life there are probably periods when physiolo- 
 gical impulses of normal fluxionary movements singularly accelerate 
 the evolution of ova. Thus at birth it is probable, as Eouget has 
 affirmed and as the secretion of milk which occurs so frequently at 
 that time would seem to indicate, that a hypertrophic ovarian con- 
 gestion takes place, as if there were a general impulse towards the 
 development of the whole being. A similar impulse, the most remark- 
 able of all, occurs at puberty. Movements of less importance take 
 place at each monthly period. They cease entirely after the meno- 
 pause when the organ atrophies. This retrogressive atrophy makes 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 
 
 11 
 
 great progress in old age. Measurements of the ovary, taken by Puech 
 at different ages, confirm the variations in the size of this organ in 
 these various circumstances. 
 
 /'*»V-A , 
 
 Fig. 7. — Elementaiy stnicture of the ovaiy in the human embiyo. — A, in the 
 embryo of six months, magnified 400 diameters. 1, two ova suiTOunded 
 by an epithelial layer, one of them presents a prolongation by which it 
 was probably united to another ovum as in Fig. 2, which represents two 
 ova united by a cord of protoplasm (primitive ova) with their epithelium ; 
 3, primitive ovum with two nuclei (germinal vesicles). B, in an embryo 
 of seven months, magnified 400 diameters. 1, superficial layers of the 
 ovaiy with voluminous glandular tubes, composed each of an epithelial 
 layer and of a mass of ova, those nearest the surface being smaller than 
 those deeply situated in the glandular substance of the organ ; 2, ovigenic 
 sacs of the deep layer of the glandular substance at the time of separation, 
 two little sacs are represented completely isolated, and two others (glandular 
 tubes) each containing two ova (after KoUiker). 
 
 The differences in the aspect of the ovary at various epochs of life 
 are due to the different phenomena which characterise the normal evo- 
 lution of the Graafian vesicles. The imperfection of this evolution 
 before puberty, the frequency of this development and the almost 
 periodical ruptures during the age of sexual activity, the atrophy and 
 disappearance after the menopause, give to the surface of the ovary, 
 during the successive ages of embryo life, childhood, youth, maturity, 
 and old age, various aspects ; at first it is elongated, then ovoid, 
 smooth, or indented, with mingled projections and cicatrices, dotted 
 with circumscribed spots of various colours — white, blue, or yellow — 
 till finally it has the appearance of a wrinkled, shrunken, shrivelled 
 membrane. 
 
12 
 
 INTEODUOTION 
 
 It will readily be perceived, by the size, lengtb^ and tongue-like 
 shape of the ovaries in the embryo (Pig. 8)^ by their dimiuu- 
 
 FiG. 8, — The uterus and its appendages, and their relations with the neigh- 
 houring organs, at the end of the fifth month or beginning of the sixth, 
 natural size. External view : 1, bladder, urachus, and umbilical arteries ; 
 2, utems ; 3, rectum ; 4, ovaiy, relatively very large, almost as long as 
 the Fallopian tube ; 5, Fallopian tube, the broad portion of which is 
 prominent from early life ; 6, round ligament. Owing to the defective 
 development of the pelvis at this age these organs are situated above the 
 brim in place of being contained in the pelvic cavity. Cavities : 1, bladder ; 
 2, uterus, on the anterior surface of which the trunk of the arbor vitce is 
 seen extending to the fundus ; the isthmus, which ought to separate the 
 cavity of the body from that of the cervix, cannot be distinguished ; 3, 
 vaginal orifice of the uteras ; 4, vagina, the folds of which are well marked ; 
 5, posterior surface of the uteras ; 6, rectum ; 7, ovaiy ; 8, Fallopian 
 tube ; 9, pubic symphysis ; 10, labia minora and majora ; 11, vaginal 
 orifice ; 12, anus. 
 
 Fig. 9. — Ovary and fimbriated extremity of Fallopian tube in a woman who 
 died during menstruation (after Farre ad nat.) I, broad ligament ; o, 
 ovary ; r, r, old yellow bodies, remains of Graafian follicles ruptured 
 and cicatrised ; /, broad portion of the Fallopian tube ; i, fimbriated ex- 
 tremity applied to the ovary. 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 
 
 13 
 
 tive size and their slightly llattened form in the child, by their in- 
 creased size, ovoid appearance, and the formation of globular projec- 
 tions on their surface at puberty (l^'igs. 1, 13, 14), in the adult during 
 menstruation (Fig. 9) and in the pregnant woman (Fig. 10), by 
 the return to smaller dimensions at the period of the menopause 
 (Fig. 11), and, lastly, by their complete atrophy in old age (Fig. 13), 
 that these organs, originatiug in little bands along the inner borders of 
 
 Fig. 10. — Ovary during pregnancy, and external view of yellow body (corpns5 
 luteum) (after Coste), 
 
 the Wolffian bodies, hollowed out after the manner of blind tubes like 
 the testicles, becoming later on vesicular by the occlusion and the 
 
 Fig. 11. — Ovary at the menopause. 
 
 Fig. 12. — Ovary in old age. 
 
 partitioning of these tubes, are congested and hypertrophied during 
 the whole period of maturation of the ova and of sexual activity, to 
 be reduced to a kind of shell or shrivelled, shrunken web after the 
 extinction of the reproductive faculty. 
 
 Fallopian tubes. — Contained in the central fold, the tubes may 
 undergo displacements analogous to those of the ovaries. Passing off 
 from the uterus in a transverse direction, each tube describes in its 
 external half a curve, the concavity of which looks backwards, inwards, 
 and downwards, and by its terminal swelling it turns towards the 
 ovary. Its axis, though straight near the uterus, before long presents 
 flexuosities recalling those of the vas deferens at its origin. Its 
 medium length is 12 centimetres. Its diameter increases with its 
 distance from the uterus : it is hardly more than 15 -tenths of a milli- 
 metre at the opening and in the thickness of the uterine walls, whilst it 
 is 4 millimetres near the uterus, from 5 to (5 at the central part, from 
 
14 
 
 INTRODUCTION 
 
 7 to 8 at its external extremity, and from 18 to 20 at the circumference 
 of the terminal infundibulum. Therefore, even supposing the diameter 
 of the uterine orifice to be enlarged, it is not the less impossible to 
 catheterise the Fallopian tube. There is not, however, the same diffi- 
 culty about the penetration of liquids that there is about solids, there- 
 fore an injection may penetrate from the uterine cavity into the 
 IVllopian tube. The external orifice, ostium abdominale, opens in the 
 
 Fig. 13. — Fallopian tube and ovary. 0, ovary turned downwards and back- 
 wards ; Od, isthmus of the tube ; Od', broadest part of this canal ; J, 
 fimbriated extremity ; Oa, abdominal orifice of the tube, Fo, ovarian fringe ; 
 io, infundibulo-ovarian ligament ; Ro, organ of Eosenmiiller. 
 
 centre of a kind of fringed funnel, called the fimhriated extremity. It 
 is not uncommon to observe accessory fimbriated extremities on the 
 external third of the Pallopian tube, i. e. other orifices besides the 
 normal one, communicating, like it, with the canal of the oviduct, and 
 forming consequently a condition unfavorable to the preservation and 
 transport of the fecundated ovum, and therefore a cause of sterility.^ 
 
 The Fallopian tube is composed of a double muscular tunic, the 
 internal of circular, the external of longitudinal fibres, following all its 
 flexuosities, and apparently formed by a prolongation of the uterine 
 fibres. These are the cause of the vermicular, peristaltic movements, 
 analogous in every way to those of the intestine, which it is easy to see 
 in the females of the mammalia at the time of ovulation. Besides 
 these intrinsic muscles, the Fallopian tube is surrounded by an ex- 
 trinsic superficial layer of muscular bundles, which do not follow the 
 flexuosities of this canal, but run in a perfectly straight direction, 
 are continuous with those of the utero-ovarian and tubo -ovarian liga- 
 
 * Richard, Anatomie cles trompes cle Vuterus, Theses de Paris, 1851. 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 
 
 15 
 
 ments, as well as with those of the hilus of the ovary, determine the 
 adaptation of the fimbriated extremity to this latter organ, and form 
 part of the general system of the extrinsic muscular envelope common 
 to the uterus and its appendages which will be described hereafter. 
 
 Fig. 14. — Section of right Fallopian tube in an adult nullipara (after Richard). 
 a, uterine orifice of the tube ; h, narrowest part of the canal, corresponding 
 to the uterine end of the tube ; c, canal in the body of the tube, origin of 
 the large folds continuing into the fimbriated extremity ; d, opened fim- 
 briated extremity filled with folds, which are continuous with those of the 
 canal of the tube ; e, tubo-ovarian fringe and furrow of the same name ; 
 f, ovary ; g, round ligament. 
 
 The internal membrane of the Eallopian tube is a mucous membrane 
 furnished with very remarkable longitudinal folds, most marked in the 
 centre, but equally distinct at the two ends, on the one side on the 
 internal surface of the fimbriated extremity, on the other in the uterus 
 at each of the superior angles. Henning has found in the tubal 
 mucous membrane glands which are short, bursiform, simple, or 
 dichotomous ; some present a swelling in the form of a cluster, others 
 show circumvolutions analogous to those of the intestine and sudori- 
 parous glands, and are arranged parallel to the mucous membrane. 
 They are especially numerous on a level with the abdominal extremity. 
 The epithelium of this mucous membrane is vibratile, the cilia moving 
 from the ovary towards the uterus. 
 
 The Fallopian tubes have a double action to fulfil : on the one hand 
 they convey the spermatozoa to the ovule to be fecundated, and on the 
 other hand they transmit this ovule to the uterus, where it ought normally 
 to be developed. We may presume that the transport of the ovule is 
 effected in part by the vibratile cilia of the tubal mucous membrane. 
 
16 
 
 INTRODUCTION 
 
 The Uterus 
 
 The uterus is a hollow organ designed for gestation. In shape it 
 is like a cone flattened from before backwards, having, consequently, 
 two surfaces (one anterior and one posterior) and lateral borders. 
 The base or fundus is above, the apex below. The flattening is not 
 equal on the two surfaces ; the anterior alone is almost flat, the poste- 
 
 FiG. 15. — Uterus of an adult nullipara (posterior surface), a, body of the 
 uterus ; c, cervix ; r, isthmus or contraction indicating the junction of the 
 body with the cervix ; s, fundus ; 1 1, lateral borders ; //, Fallopian tubes ; 
 V, insertion of vagina ; i, vaginal portion of cervix ; o, external orifice. 
 
 rior is convex, and, as it were, divided into two parts by a projection 
 running the whole length of the median line. The isihmtis, a slight 
 annular depression situated on the surface of the organ immediately 
 below the middle, more marked before and on the sides than behind, 
 is the external vestige of its division into two unequal parts, an 
 upper one, the 6od?/, larger and cone shaped, a lower one, the nec&, 
 cylindrical and slightly swollen in the middle. 
 
 Volume. — If we take into account neither individual varieties nor 
 functional variations the following are the dimensions in round 
 numbers : 
 
 Length . 
 Breadth . 
 Thickness 
 
 0-060 m. to 0-070 m. 
 0-035 „ to 0.045 „ 
 0-020 „ to 0-025 „ 
 
 I may mention that the length may reach 80 millimetres without 
 the existence of any morbid condition; that the breadth from 
 one Pallopian tube to the other is the most difficult to determine 
 either in the patient or on the cadaver, whilst the thickness, or the 
 antero-posterior diameter, measured at its culminating point, is nor- 
 mally the least variable and the one in which it is easiest to discover 
 pathological changes. 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 
 
 17" 
 
 Weight. — The weight of the uterus is on an average an ounce and 
 a halfj but it varies, as do also the form and the size in different 
 physiological conditions of the organ. 
 
 Direction. — The vulva is almost in the plane of the inferior strait, 
 projecting a little beyond it below. The vagina commences by being 
 in the same axis, but as it rises it has a tendency to follow the curve 
 of the sacrum ; as for the uterus, it is in the axis of the superior strait, 
 by which it is evident that it forms a continuation of the vagina by 
 making an angle at the point of union of the two organs. The axes, 
 even of the body and neck of the uterus, are not absolutely the same, 
 the neck following slightly the curve of the sacrum, or the axis of the 
 
 Fig. 16. — Central vertical section showing the direction of the uterus and 
 chief relations of this organ, u, uterus ; w, vagina opened ; v, the bladder 
 opened ; i, urethra opened ; r, rectum opened ; o, anterior peritoneal or utero- 
 vesical cul-de-sac ; t, posterior peritoneal or utero-vagino-rectal cul-de-sac. 
 It is easily seen that these culs-de-sacs are situated on very different levels. 
 n, connection of the vagina with the uterus and utero-vaginal circular 
 cul-de-sac ; a, connection of the bladder with the uterus ; c, recto- vaginal 
 septum, thin above, m, where the walls of the vagina and rectum are 
 almost contiguous, thick below at p, where it forms the perineum ; s, left 
 half of the symphysis pubis. 
 
 pelvis proper passing in front of the vagina, the body inclining a 
 little forwards, so that its fundus looks towards the anterior abdo- 
 minal wall and its axis is perpendicular to the level of the brim. 
 There is in fact normally, as a rule, a slight anteversion, and even 
 anteflexion, the uterus having a tendency to fall forwards rather than 
 backwards. The fundus of the uterus generally inclines to the right, 
 especially during pregnancy. Is this owing to the sigmoid flexure 
 being to the left ? Mauriceau and Ereund think that the relative 
 shortness of the right appendages is the effect and not the cause of 
 this inclination, which is congenital. 
 
 Relations. — The uterus is situated in the pelvis behind the bladder. 
 The body is free and smooth, and covered in front by the peritoneum, 
 
 2 
 
18 
 
 INTEODUOTION 
 
 which adheres closely to it in the upper part, less so below, and on a 
 level with the isthmus is reflected on the posterior surface of the 
 bladder. This vesico-uterine cul-de-sac is situated high up in the 
 child, lower in the adult, and low down in the multipara and in the 
 old woman, owing to the differences which age and parturition cause 
 in the relative proportions of the body and neck. It may vary to a 
 certain extent independently of these conditions ; as a rule, however, 
 it corresponds with the isthmus. Below this point the anterior surface 
 of the cervix is in immediate contact with the lower and posterior part 
 of the bladder, to which it is attached by cellular tissue. The bladder 
 adheres to the cervix for a length of 14 millimetres. It is adherent 
 to the vagina by all the surface corresponding to the vesical trigone, 
 and by a portion of the vesical walls beyond the trigone, i. e. by almost 
 the whole of its fundus, and by all the breadth of the anterior vaginal 
 wall, a space almost quadrilateral in form and extending from 27 to 
 30 millimetres in every direction (Fig. 18 b, b). 
 
 Fig. 17. 
 
 Fig. 18. 
 
 Fig. 17. — Exact relations of the bladder with the uterus and vagina (after 
 Dubois), m, uterus ; c, cervix ; u, u, ureters ; t, trigone of bladder ; 
 
 a, a, line of connection between the bladder and cervix ; the quadilateral 
 space enclosed in the dotted lines, r, u, u, r, including the trigone, repre- 
 sents the surface of attachment of the bladder to the vagina. 
 
 Fig. 18. — Vertical antero-posterior section of the uterus, i, isthmus separating 
 the cavity of the body from that of the cervix ; a, anterior lip of the cervix ; 
 p, posterior lip ; /, posterior vagino-uterine cul-de-sac ; va, va, vagina ; 
 
 b, b, connections of the urinary bladder with the anterior surface of the 
 cervix ; r, reflexion of the peritoneum from the posterior surface of the 
 uterus and vagina to the rectum ; c, commencement of the utero-lumbar 
 suspensory ligaments. 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 19 
 
 The result of a great number of measurements taken at all ages, 
 both in the state of vacuity and of gestation^ is that the distance 
 between the opening of the ureter at the jDOsterior angle of the trigone 
 and the insertion of the vagina at the cervix, while very variable, is 
 on an average from 1 to 2 centimetres. The distance between this 
 opening and the free portion of the cervix is still more variable as it 
 depends on the size and length of the cervix. The distance between 
 the ureter and the margin of the uterus is equally variable, since the 
 ureter is sometimes at some distance from it, whilst in other circum- 
 stances, as at the end of gestation, it is in immediate contact with the 
 uterine border, as shown by the fact that the ureter and uterus may 
 be torn or ulcerated at the same point, as occurred in a case of fistula 
 after delivery which came under my own observation. When the 
 bladder is empty the anterior surface of the uterus is bent over it, 
 forming a slight curve with the concavity looking forwards and down- 
 wards. When it fills, this surface rises and is directed in turn 
 forwards and upwards. When it is distended the uterus may be com- 
 pressed by it against the sacro- vertebral angle, or if the ligaments are 
 relaxed may even be turned backwards, its base looking towards the 
 concavity of the sacrum, and may become fixed in this position when 
 such a displacement occurs at the commencement of pregnancy or after 
 delivery.^ The posterior surface of the uterus is covered in all its 
 extent by the peritoneum, which, as it passes over the utero-sacral 
 hgaments, forms at the sides Douglas's folds, whilst in the middle line 
 it extends to the upper part of the posterior vaginal wall to form, by its 
 reflection on to the rectum, the recto-vaginal culde sac (Fig. 18 r). 
 The posterior surface assumes alternate positions exactly the reverse of 
 the anterior surface, according as the bladder is full or empty. It looks 
 towards the rectum, being generally separated from it by circumvolu- 
 tions of the small intestine, though exceptionally it may rest upon it 
 when raised and pushed towards it by the distension of the bladder 
 or by one of the pathological conditions which will occupy our atten- 
 tion when studying displacements of the womb. 
 
 The upper margin is in relation with the circumvolutions of the 
 small intestine, of which it somewhat retains the impression. In 
 the majority of women it does not reach the level of the brim 
 (Sappey). However it extends beyond the horizontal plane, passing 
 immediately above the symphysis of the pubis, which allows of its 
 being examined by palpation in the greater number of patients. 
 
 The lateral borders correspond with the interstices of the two 
 peritoneal folds, anterior and posterior, which, as they leave the 
 uterus, form the broad hgaments. They are continuous with those 
 of the vagina. Both are in immediate relation with the numerous 
 vessels which enter these two organs. The lower extremity projects 
 into the cavity of the vagina, which encircles it. It is a little lower 
 before than behind, and the posterior utero-vaginal cul-de-sac has 
 in consequence a greater depth than the anterior one (Fig. 18). 
 
 * Sappey, Anat. descript, t. iii, p. 661. Paris, 1864 ; Comte, Bulletin de la 
 Societe anatomique, 1826, t. i, p. 49. 
 
20 INTRODUCTION 
 
 This extremity^ often incorrectly designated as the neck, is the vaginal 
 portion of the neck (Fig. 15). Normally it looks downwards and 
 backwards, and this direction may be exaggerated to such an extent 
 that the axis of the neck may form a right angle with the vagina, its 
 vaginal portion resting on the posterior wall of this membranous canal. 
 Sometimes it hardly projects ; at other times it does so considerably ; 
 on an average it is from 10 to 12 millimetres long. Its slightly 
 rounded form may be flattened, or, on the contrary, be elongated till 
 it becomes conical. 
 
 A transverse orifice divides it into two lips, united right and left 
 by thick commissures. The projection and size of these lips are un- 
 equal. The anterior is the more prominent, the lower and the easier 
 to find, owing to the cervix being directed backwards ; the posterior, 
 however, has a larger surface on account of the vaginal insertion being 
 higher behind than before. This circumstance, added to the difPerence 
 in length of the two walls of the vagina (the posterior being the 
 longer), should remind us to pass the finger or sound along the pos- 
 terior wall in order to make sure of reaching the cervix (Mg. 18). 
 
 Ligaments and Appendages of the Uterus 
 
 The study of these ligaments is very important from a double 
 point of view, whether we consider them as a means of suspension 
 of the uterus, or whether we study the consequences resulting 
 from the partitioning produced by their presence in the pelvic 
 excavation. 
 
 I. Means of suspension. — They are of two kinds : some suspend 
 the uterus by its fundus and by its sides, others by its neck.^ 
 
 The former are the broad ligaments and the round ligaments ; the 
 latter are the utero-sacral ligaments and the suspensory ring. 
 
 A. 1. The broad ligaments are the two lateral parts of the double 
 peritoneal fold which, continued from the bladder to the uterus to be 
 reflected afterwards from the uterus to the rectum, contains within 
 its folds the uterus in the centre with its appendages on either side 
 and divides the pelvis into two unequal parts, the one anterior, vesical, 
 the other posterior, recto-intestinal. Commencing from the lateral 
 margins of the uterus, they become continuous with the peritoneum 
 which covers the brim and pelvic cavity, and are reflected below before 
 touching the floor of the pelvis, the anterior fold towards the bladder, 
 the posterior lower down on to the utero-sacral ligaments, whilst above 
 they are subdivided into three secondary folds, the anterior containing 
 the round ligament, the middle the Pallopian tube, and the posterior 
 the ovary and its ligament (Figs. 1, 20). They are not formed merely 
 by a fold of peritoneum, for this serous membrane is lined throughout 
 their whole extent with a muscular layer, to which I shall call atten- 
 
 ' See Fig. 20, p. 22, where tbese ligaments are represented in a newly born 
 child, seen from before ; and Fig. 1, front, where they are seen from behind in 
 an adult. 
 
ANATOMY, PHYSIOLOGY AND TEEATOLOGY 
 
 21 
 
 tion in describing the contractile organs of the uterus. Apart^ how- 
 ever, from their contractility they may be said to contribute in main- 
 
 PiG. 19. — Horizontal section of the pelvis of a woman, aged twenty (after 
 Le Gendre). The section, which is made at 1 cm. above the pubis, passes 
 through the ilium about the middle of the coxo-femoral articulation, on a 
 level with the upper borders of the bladder and uterus, the fundus of the 
 latter being divided. The bladder is but slightly distended, the rectum 
 is pushed a little to the right of the sacrum and enveloped by the peri- 
 toneum, except the portion which is adherent to this bone. The uterus on 
 its posterior surface is in contact with the bladder. It presents a deviation 
 from its normal position, as is often observed on the cadaver. The 
 fundus, which is strongly inclined to the left instead of to the right as is 
 usual, fits into the cotyloid cavity of the same side ; the deviation is such 
 that the body of the utenis occupies all the left side of the true pelvis. 
 Besides this lateral deviation there is a considerable anteflexion of the 
 body. The distance which separates the anterior surface of the uterus 
 from the abdominal wall is about 7 cm. In the right side of the pelvic 
 cavity are seen the uterine appendages in their normal order of super- 
 position ; the round ligament with the Fallopian tube below, and quite 
 behind and to the outer side the ovary. N, peritoneum ; A, upper border 
 of the bladder ; B, angle of union of the fundus with the neck of the 
 uterus ; M, fundus of the uterus, divided ; H, right ovary ; i, round 
 ligament ; J, Fallopian tube ; L, broad ligament of the right side ; K, 
 fibrous tissue between the rectum and fundus uteri ; c, rectum ; n, meso- 
 rectum ; T>, sacrum ; E, head of the femur ; g, cotyloid cavity ; E, fibrous 
 capsule of the coxo-femoral articulation ; o, femoral vein ; p, femoral 
 artery ; a, crural nerve ; b, epigastric artery and vein ; c, c, lymphatic 
 ganglia ; i, inguinal canal ; Q, sciatic nerve ; I, gluteal vessels ; F, gluteus 
 maximus ; s, 8, gluteus medius ; T, gluteus minimus ; it, v, s, t, z, fascia 
 lata, sartorius, right rectus, iliacus and psoas muscles ; d, pyramidalis 
 muscle ; e, rectus abdominis muscle ; /, internal oblique muscle ; g, ob- 
 turator internus muscle ; h, levator ani muscle ; j, sacro-sciatic ligament ; 
 K, superior gemellus muscle ; m, aponeurosis of the external oblique 
 muscle. 
 
 taining the uterus in position ; when they are cut in the dead body 
 the uterus is seen to obey the laws of gravity, and to incline to the 
 side towards which the pelvis inclines, whilst it reassumes its proper 
 
22 INTEODUCTION 
 
 place as soon as their continuity is once more effected by means of a 
 
 Fig. 20. — General view of the internal genital organs of a child at birth. 
 
 1, bladder with the urachus above and on each side the umbilical arteiies ; 
 
 2, 2, round ligaments ; 3, body of the uterus bent forwards ; 4, 4, Fallopian 
 tubes ; 5, 5, ovaries, above which is seen on each side an ascending longi- 
 tudinal projection of peritoneum, near Douglas's fold, formed by the 
 ovarian vessels and the superior round ligament, which raises the serous 
 membrane ; 6, 6, Douglas's peritoneal folds covering the utero-lumbar 
 ligaments ; 7, rectum. This woodcut is intended to show all the means of 
 suspension of the uterus, including the broad ligaments and the superficial 
 muscular layer lining them, a common envelope embracing the womb and 
 its appendages, and connecting them simultaneously with the anterior, 
 posterior, and lateral portions of the pelvis. It shows at the same time 
 the position and form of these organs peculiar to the foetus and infant. 
 
 suture.^ Repeated pregnancies, together with other causes, produce 
 considerable relaxation in these organs. 
 
 2. The round ligaments, originating in smooth muscular fibres from 
 the whole extent of the sides of the womb, and especially from its 
 ' Sappey, Traite d'anaiomie, t. iii, p. 651. Paris, 1864. 
 
ANAT0M7, PHYSIOLOGY AND TERATOLOGY 23 
 
 upper half, pass off from its lateral angles or from the extremities of 
 the fundus in front of and a little below the Fallopian tubes, are en- 
 veloped on each side by the anterior fold of the broad ligament, reach, 
 at their outer extremity, the brim of the pelvis, and from there, being 
 deflected inwards, the abdominal orifice of the inguinal canal, having 
 traversed which, they are inserted by some of their fibres into its inferior 
 wall, by others into the spine of the pubis, and by others, again, into the 
 upper part of the labia majora. They evidently contribute to maintain 
 the fundus of the uterus in a forward position ; if too short, they may 
 determine anteversion or anteflexion ; if too long, they let the uterus 
 fall or become retroflexed ; if unequal, they may favour lateral flexion 
 (Fig. 20). 
 
 B. The means of suspension of the cervix are more certain and more 
 resistant than those of the body. They consist of the posterior liga- 
 ments and the anterior adhesions of the uterus to the bladder. 
 
 1. The posterior ligaments arise from the sides of the posterior 
 surface of the uterus at the union of the body and neck, or rather at 
 the point where the vagina is inserted, and are formed of muscular 
 fibres which are continuous with those of the organ itself and pass 
 under the posterior layer of the broad ligament. Covered by the peri- 
 toneum, which being reflected from the broad ligament above them to 
 descend from there into the utero-rectal cul-de-sac forms in this manner 
 the fold of Douglas, they pass outwards to be inserted immediately to 
 the inside of the sacro-iliac symphysis at the third sacral vertebra, and 
 often above as far as the promontory or the anterior and lateral part of 
 the last lumbar vertebra, which has led Huguier' to designate them as 
 utero-lmnhar in place of utero-sacral ligaments. It is these ligaments 
 which prevent the cervix from descending, even in the majority of 
 raultiparse, unless gentle but sustained traction is made on the two 
 lips. 
 
 2. The anterior adhesions of the uterus to the bladder (Fig. 18) 
 are not less important as means of suspension. These adhesions 
 evidently prevent the cervix, if not from falling or from being dragged 
 forwards towards the pubis in cases where the utero-sacral liga- 
 ments are relaxed or torn, at least from inclining backwards towards 
 the sacrum ; for even when the bladder is distended by urine, as its 
 base is only moderately developed, the uterus, in place of being pushed 
 back as a whole towards the sacrum, is raised, and its fundus which 
 looked forwards is directed upwards and then backwards and some- 
 times even it may be completely retroverted towards the sacrum. 
 
 As the result of these two means of suspension (Douglases ligaments 
 embracing the posterior and upper part of the cervix, and the adhesions 
 with the bladder the anterior and upper partj the cervix may be 
 said to be suspended by two half rings ; the one posterior, preventing 
 it from inclining forwards and downwards ; the other anterior, pre- 
 venting it from inclining backwards, which complement each other 
 and form a real suspensory ring which maintains the upper third of 
 the cervix in a sufficiently fixed position in the pelvic cavity (Figs. 1, 
 ' Allongements hypertrophiques du col, p. 80. Pnris, 1859. 
 
24 IKTEODUGTION 
 
 18) . At the same time it results from the point of attachment of this 
 double half ring that the free portion of the cervix, below and the 
 whole body above may oscillate and, under the influence of various 
 kinds of pressure, incUne in different directions without the portion of 
 the cervix embraced by this ring leaving the centre of the pelvis. The 
 uterus cannot descend unless the posterior half ring is relaxed ; it cannot 
 rise unless the anterior half ring is stretched; but it may oscillate in 
 all directions round this double half ring as round a suspensory ring. 
 We cannot judge better of the nature, direction and extent of these 
 movements than by provoking them by means of the finger introduced 
 into the vagina : in pushing the cervix backwards we perceive that the 
 body is directed forwards; in pushing it to the right the fundus is 
 directed to the leftj and vice versa ; in other words, the fundus by a 
 swinging motion is always directed in the opposite direction from the 
 cervix. 
 
 II. Division of the pelvic cavity. — The ligaments are not less im- 
 portant as regards the divisions which they establish in the pelvic 
 cavity than as means of suspension. The vast folds which have just 
 been described under the name of broad ligaments divide the pelvis 
 proper into two unequal compartments : the one anterior, occupied in 
 great part by the bladder ; the other posterior, containing the rectum 
 and the utero-vagino- rectal cavity. So that whilst the uterus at the 
 brim is connected with the bladder in front, behind it is separated 
 from the rectum by a large cavity. This, which may be called the 
 utero vaginu-reclal cavity, is very deep, especially in multiparse. When 
 no adhesion limits its extent, either from before backwards from the 
 vagina to the rectum, or from one side to another between and below 
 the folds of Douglas, this cavity may attain great dimensions ; for the 
 dimensions are those of the pelvic cavity itself, exclusive of the thick- 
 ness of the rectum, vagina and bladder, which occupy very little 
 space in a state of vacuity. I have often measured this cavity in 
 various directions, the antero-posterior, and even the transverse 
 diameter, may exceed eight centimetres if the folds of Douglas are 
 stretched ; if they are left in their natural position there may be a 
 space of five or six centimetres between them ; as to the depth of the 
 cavity, from the upper border of the uterus to the bottom of the vagino- 
 rectal cul-de-sac there is from fifteen to eighteen centimetres j taken 
 below the utero-sacral ligaments it measures from five to nine centi- 
 metres. Into this cavity the small intestine may descend in a state of 
 health, in various diseases the ovary may be dragged there by its own 
 weight, and in extreme retroflexions the fundus of the uterus may fall 
 even below the ligaments of Douglas ; and lastly, it is there that 
 sanguineous, serous and purulent effusions are formed, and that fibri- 
 nous adhesions take place in hematoceles and retro-uterine peritonitis. 
 
 To the right and left of the bladder are superficial fossae ; to the right 
 and left of the retro-uterine cavity, behind the ligaments of the ovary 
 and above the folds of Douglas, are two deeper and more extensive 
 fospse, where tubo-ovarian and uterine adliesions are often formed after 
 inflammations of the ovary and Fallopian tubes. Secondary longi- 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 
 
 25\ 
 
 tudinal fossse, or rather grooves, separate the upper margins of the 
 small folds and are also frequently the seat of inflammatory sero- 
 purulent adhesions and efl^usions. It is useless to describe the relations 
 of these peritoneal surfaces with the abdomino-pelvic viscera, or the 
 
 \ 
 
 Fig. 21. — -Relations of the viscera contained in the female pelvic cavity (after 
 Tillaux). L F, ligament of the Fallopian tube ; L o, ligament of the 
 ovary ; L E, round ligament ; E, rectum ; s, sacrum ; s p, symphysis pubis ; 
 u, uterus ; v s, utero-sacral ligament ; v, bladder. 
 
 continuity of this peritoneal covering with that of the ihac fossa, Fal- 
 lopian ligament, &c. It is important, however, to remember them in 
 order to account for the extension of inflammation to various points 
 not only of the retro-uterine peritoneal cavity but also of the iliac 
 and hypogastric portions of the peritoneum, which may be affected by- 
 suppuration, or may give rise to a purulent collection contained within 
 septa of new formation. It is also important to remember that these 
 broad ligaments contain a more or less abundant and dense cellular 
 tissue within their folds in addition to the muscular tissue lining 
 them. 
 
 Their two smooth surfaces are in relation, the anterior with the 
 
26 
 
 INTRODUCTION 
 
 bladder, the posterior with the rectum ; it is at right angles from the 
 latter that the two folds of Douglas arise, which cover the utero-sacral 
 ligaments. There are four borders — superior, inferior, internal, and ex- 
 ternal. The superior is subdivided into three small folds. Tine inferior 
 is in relation with the subperitoneal cellular tissue of the pelvis and 
 
 M.U 
 
 Fig. 22. — Section of the uterus aud broad ligaments perpendicular to the 
 large axis of the womb at 2 centimetres from its base (after Tillaux). 
 B, pelvic wall ; cu, uterine cavity ; ll, broad ligament ; MU, uterine 
 mucous membrane ; P, P, peritoneum ; TU, uterine tissue ; vu, utero- 
 ovarian veins. 
 
 with the superior perineal aponeurosis. The internal is very wide 
 (Fig. 22), the two folds being separated from each other by the thicic- 
 ness of the uterus ; it is in relation with the uterine artery and the 
 utero-ovarian plexuses, venous and lymphatic ; it is continuous with the 
 inferior border on the lateral portions of the vagina (Fig. 28, l s p), 
 having the same relations with the veins and lymphatics, and allowing 
 of the recognition by vaginal touch of phlebitis, lymphangitis, tumours 
 and purulent collections formed in this ligament. The external is in 
 relation with the walls of the cavity ; it is very thin, the two folds of 
 peritoneum being in close proximity ; a horizontal section of the broad 
 ligaments and of the uterus at about an inch from its base shows very 
 clearly the difference in thickness of the two borders (Fig. 22). 
 
 The cellular tissue with which this vast peritoneal fold is lined is 
 loose and abundant, especially below where it is continuous with the 
 cellular tissue covering the upper perineal aponeuroses and levator ani 
 (Fig. 23) and with that which covers the lateral surfaces of the 
 bladder, the peritoneal lining of the abdominal wall at the hypogas- 
 trium and of the internal iliac fossa. Consequently an inflammation 
 of the broad ligament may be propagated in any of these various 
 regions, or an abscess of this ligament may open into the vagina, 
 bladder, rectum, into the ischio-rectal fossa, at the top of the sacro- 
 sciatic groove, or may appear at the hip with the sacral plexus and the 
 sciatic nerve or may reach the abdominal wall on a level with the Fallo- 
 pian ligament, above or below the crural arch or even at the obturator 
 foramen. Pelvi-peritonitis is most frequently posterior (retro-uterine 
 cavity) ; it may be anterior or it may surround the uterus on all sides 
 
ANATOMY, PHYSIOLOGY AND TEEATOLOGY 
 
 27 
 
 rising to a greater or less height^ to the brim or even above the cavity, 
 according to the height of the adhesions or new membranes which 
 limit it, and may open into the rectum, into a part of the intestine, 
 the sigmoid flexure or even the csecum, or at the abdominal wall above 
 the crural arch, on a level with the hernial fossse. Abscess of the 
 broad ligament is lateral, on one or other side of the uterus and 
 vagina, pushing back these organs towards the opposite side without 
 
 Fig. 23. — Transverse section of the pelvis, showing the three cavities (after 
 Beigel). 1. cp, peritoneal cavity ; 2. lsp, sub-peritoneal space ; 3. esc, sub- 
 cutaneous space ; v, vagina ; na, levator ani ; p, peritoneum ; u, uterus. 
 
 extending all round, and making an exit for itself by all the communi- 
 cations which may be established from the pelvic cellular tissue through 
 the natural orifices to outside the pelvis, at the iliac fossa, hip, 
 thigh, &c. 
 
 Thus the broad ligaments, besides being a means of suspension for 
 the uterus, are of capital importance in the physiological and patho- 
 logical history of this organ, of its appendages, and of the peri- uterine 
 regions ; they give the key to the difl'erential diagnosis of hematoceles, 
 pelvi-peritonitis, peri-uterine phlegmons, abscesses of the broad liga- 
 ments, phlebitis, peri-uterine angioleucitis and adenites of the same 
 region, both in a puerperal and non-puerperal condition. They cannot 
 be too much studied or too well known. 
 
28 
 
 INTRODUCTION 
 
 Changes in the Uterus at Different Ages ' 
 
 In the genital organs of women^ and especially in the uterus, the 
 volume, form, external aspect, cavities, structure, all the anatomical 
 conditions in fact, vary from age to age. 
 
 External aspect. — The size of the organ, which is small in the foetus 
 and chUd, increases considerably at puberty, as do all other parts of 
 the generative system : but it is very inferior in the nullipara to what 
 it is in the multipara, and it diminishes in old age under the influence 
 of the retrogression and atrophy which follow the menopause. 
 
 The form, which is almost cylindrical in the fcetus, gradually 
 assumes the aspect peculiar to it, in proportion as the body undergoes 
 its normal development : so that at puberty in the nullipara, but espe- 
 cially in the multipara, the resemblance of the uterus to a small 
 inverted gourd becomes very striking. Its position, direction, and 
 relations change also with age on account of the difference of develop- 
 ment which exists from one period of life to the other, not only between 
 the various parts of the genital organs, but also between those of the 
 pelvis. The pelvic cavity being but slightly developed in childhood, 
 the uterus, like the bladder, is higher above the brim at this age than 
 in the adult, and is generally inclined, and even curved, forwards 
 (Figs. I, 28). 
 
 Fig. 24. — The uterus and its appendages in the fcetus at the end of the fourth 
 month, natural size. A, external view : a, a, ovai'ies relatively voluminous, 
 almost as long as the Fallopian tubes ; b, h, oviducts ; c, c, round ligaments ; 
 d, uterus ; e, vagina ; /, vaginal orifice. B, cavities : a, branches of the 
 arbm- vita extending to the fundus ; b, vaginal portion of the uterus ; 
 c, vagina. 
 
 It is, however, especially in the antagonism of the hody and neck that 
 the most remarkable differences are to be seen from one age to 
 another. 
 
 In the child the neck is very large, the body very small. The neck 
 is almost cylindrical. The body is triangular, more flattened than in 
 the adult; its superior border is straight or slightly concave, a vestige 
 of the coalescence of the uterine cornua; its lower extremity is con- 
 tinuous with the neck without any hne of demarcation. The isthmus 
 is indicated at this age less by a contraction than by a change of direc- 
 
ANATOMY, PHYSIOLOGY, AND TERATOLOGY 
 
 29 
 
 tion between the neck and the body ; for the result of Boullard's i 
 researches, confirmed by my own observations, is that there is very 
 
 -=-^-^=^A 
 
 Fig 95 — Uterus at the commencement of the seventh month, opened, of 
 'natural size, a, fundus with thin walls; fc &, orifices of the Fallopian 
 tubes ; c, arbor vitse ; d, neck, remarkable for the relative thickness of its 
 walls. 
 
 frequently, if not always, anteflexion of the body on the cervix. (Fig. 
 28.) In the girl at puberty, and still more in the adult, the body is 
 
 
 Fig. 26. 
 
 Fig. 26. — Utems at birth, natural size ; external view, a, body ; h, neck, very 
 large, rendered clearly distinct from the body by the formation of the 
 isthmus ; c, vaginal portion of the neck ; d, d, Fallopian tubes ; e, e, round 
 ligaments. Cavities : h, cavity of the body showing the arbor vitee. The 
 fundus a and the walls are relatively thin ; c, neck, the walls of which 
 are very thick ; d, vaginal portion of the cervix ; e, vagina. 
 
 Fig. 27. — Section of uterus at seventh year, open, of natural size, a, fundus ; 
 6, body, the cavity of which still shows a trace of the internal longitudinal 
 fold resulting from the union of the two primitive uteri, and forming a 
 continuation of the arbor vitse of the neck ; c, neck still longer than the 
 body and with thicker walls ; d, vaginal portion of the neck ; e, vagina. 
 
 developed more than the neck, and becomes slightly curved, especially 
 behind. The upper border is often straight, sometimes even it is 
 almost convex ; its union with the neck is well marked by an isthmus. 
 The neck, in place of remaining cylindrical, has assumed the form of a 
 
 ' Quelques mots sur I'uterus. Theses de Paris, 1853, No. 87. 
 
30 
 
 INTRODUCTION 
 
 small barrel, contracted above, tapering below, and is shorter. The 
 anterior flexion of the body on the neck diminishes, according to 
 Cusco,^ in consequence of the unequal development, which being 
 greater on the anterior than on the posterior surface, helps to straighten 
 the organ. Still, a slight degree of anteflexion or rather inclination 
 forwards often continues, not only in the girl after puberty, but in the 
 married woman, provided she has never been pregnant. 
 
 In the nullipara the characteristics of virginity remain, with the 
 exception of a slight increase in the size of the whole of the organ, 
 caused doubtless by the exercise of a new function. We may also 
 admit some difference in the vaginal portion of the neck : it often loses 
 its slightly conical shape, and becomes rather flattened. The cases in 
 which the neck is normal must be distinguished from those in which it 
 is quite conical. In the latter cases coitus does not modify the conicity 
 
 Fig. 28. — Uterus of a foetus at birth, side view seen in its relations, showing 
 the normal anteflexion natural during foetal and infantile life (after 
 Boullard and Bourgery). a, body of the uterus flexed forwards ; &, fundus 
 of body looking forwards ; c, neck, relatively very large ; d, section of the 
 peritoneum ; e, cervix ; /, vagina ; g, hymen ; I, Fallopian tube, behind 
 which the ovary is seen ; j, bladder ; h, rectum ; n, symphysis pubis. 
 
 in the least ; on the contrary, it persists and is even increased to a 
 certain extent, owing to the penis being apt to pass below the neck 
 and so increase the depth of the posterior utero- vaginal cul de-sac, and 
 is one of the most unmistakable causes of sterility. 
 
 In cases where the cervix is of normal shape, the pressure deter- 
 mined by the penis during coitus is made on this organ, and gradually 
 diminishes the convexity so as shghtly to flatten it and render the two 
 
 1 De V anteflexion et de la retroflexion de Vuterus. These de concours, pp. 18, 
 21. Paris, 1853. 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 
 
 31 
 
 lips more distinct. These characters are very nearly those of Roe- 
 derer's -^ ulerus virgineus. 
 
 In the primipara, and still more in the multipara, the body is much 
 larger than the neck ; besides increasing in size it changes in form 
 and becomes convex in every direction, especially at its superior border. 
 Generally it becomes quite straight, sometimes, on the contrary, the 
 flexion increases. In this case, however, the flexion is not exclusively 
 forwards ; it may be backwards or to one side, according to the direc- 
 tion in which the determining cause has acted on a uterus in which the 
 consistency may have been diminished, whilst the size has been in- 
 creased by pregnancy and parturition. 
 
 In old women atrophy of the organ takes place. This is more 
 active in the body than in the neck, restoring in some degree the rela- 
 tive proportion of these two parts to what it was in the child, or at 
 least before the period of sexual activity. Like Cruveilhier,^ I have 
 
 Fig. 29. 
 
 Fig. 30. 
 
 Fig. 29. — Mould of the uterine cavities in a virgin of seventeen years, 
 c, cornua of the uterus, ceratine portion of the body ; cb, inferior segment 
 of the body ; ha, isthmus ; ad, neck, with impression of the folds of the 
 arhor vitce and the lateral depression of the column, t, Fallopian tubes, 
 slight contraction at the point of union of their cavity with that of the 
 body (after Guyon). 
 
 Fig. 30. — Mould of the uterine cavities in a multipara, triangular form of the 
 cavity of the body, enlargement and deformity of the uterine cornua, 
 enlargement of the inferior segment of the body which blends with them. 
 ab, isthmus ; ad, neck, with double depression (after Guyon). 
 
 remarked that the obhteration of the vaginal portion of the neck is 
 very common. 
 
 Internal conformation. — The cavities of the uterus are very small, 
 but they still differ considerably in their size and form in the child, the 
 
 1 Icones uteri humani. 
 
 - Anat. descript., t. ii, p. 474. 
 
 Paris, 1866. 
 
32 INTRODUCTION 
 
 nullipara and multipara. They form together a sort of canal flattened 
 from before backwards, constricted at the isthmus and widening out in 
 the body as it approaches the fundus. According to Sappej,i their 
 length is : 
 
 In the nullipara about 52 millimetres, the body measuring 22, the 
 neck 25, the isthmus 5. 
 
 In the multipara about 57 millimetres, the body measuring 28, the 
 neck 24, the isthmus 5. 
 
 I think these measurements rather exaggerated, especially that of 
 the body in the multipara when there is no disease. Apart from this, 
 the difference in the relative length of the body and neck, the latter of 
 which is the greater in the nullipara and the former in the multipara, is 
 in harmony with the difference in size of the two parts seen externally 
 (Eigs. 29, 30, 34, 35). The other two dimensions are very small, 
 especially the distance separating the anterior from the posterior 
 surface. On this account it is very difficult to move the sound in 
 either direction. 
 
 The cavity of the body, which hardly exists in the foetus, becomes 
 triangular after puberty. The walls are flat, and applied one against 
 the other, unless a little mucus is interposed between them. The 
 borders are convex, and are directed towards each other in such a way 
 that the convergence of their convexity towards the centre diminishes 
 to an equal extent the uterine cavity. Therefore a slightly curved 
 sound when introduced into this cavity cannot easily be moved from 
 one side to the other, still less be rotated upon itself. The superior 
 angles, very acute, present the last folds of the mucous membrane of 
 the Fallopian tubes, and it is the very close proximity of these folds 
 which forms the only obstacle to the passage of a fluid from the cavity 
 of the body into that of the Fallopian tubes. The inferior angle, 
 less acute, corresponds with the os internum. In the multipara 
 the cavity of the body is distinguished by different characters — 
 greater capacity and an interval between the two surfaces, or at 
 least the possibiKty of separating them and of moving the sound 
 between them ; superior angles less acute. The form is triangular, but 
 the margins are very seldom convex, sometimes they are straight, often 
 concave, hence the marked increase of the cavity circumscribed by 
 them. This latter tendency seems to be more marked when the 
 number of pregnancies has been considerable, and when they have 
 occurred in quick succession. 
 
 The cervical cavity, large in the child, is fusiform, flattened from 
 before backwards, presenting consequently two walls, two borders and 
 two orifices. The walls are unequal, traversed from top to bottom by 
 a vertical projection, from which secondary oblique and ascending 
 projections are given off, an arrangement which has received the name 
 of arbor vita. (Figs. 29, 32, 35, 38). The posterior tree only becomes 
 visible a few millimetres above the inferior orifice ; it increases in size, 
 and deviates to the left in proportion as it approaches the superior 
 orifice. The anterior tree is, on tlie contrary, directed towards the right. 
 ' Op. cit., p. 664 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 
 
 33 
 
 Consequently the two cervical walls fit into each other in place of one 
 being applied one against the other^ as in the cavity of the body. 
 These kind of columns are analogous to the columnse carnese of the 
 
 Tig. 31. — Transvei-se sections taken from the upper half of the cervix, showing 
 the dovetailing of its walls, especially of the two longitudinal projections, 
 which may be said to be the trunks of the arhor vitce, and consequently 
 the mechanism for the occlusion of the isthmus or os internutn (after 
 Guyon) . 1, virgin uterus at sixteen years old ; 2, uterus in a nullipara ; 
 3, uterus in a multipara. Exceptionally there are two posterior projections, 
 but only one anterior and median. 
 
 heart. It is to Guyon ^ that we owe the knowledge of their fitting 
 into each other, and of several other facts relative to the study of the 
 uterine cavities. 
 
 The OS internum is a true strait of 5 millimetres in length, in which 
 the arbor vitse, stripped of their branches, dovetail into each other so 
 well that, owing to the narrowness of the orifice, they fill it entirely 
 and make it difficult for the sound to enter ; but this resistance over- 
 come, it enters easily into the cavity. The sensibility of this orifice and 
 the circular arrangement of the bundles of muscles which form a veri- 
 table sphincter at this point, in addition to the narrowness of the 
 opening and the dovetailing of the posterior and anterior columns, 
 increase the difficulties experienced, in the case of certain morbid con- 
 ditions or of virgins, in passing the sound from the cavity of the neck 
 into that of the body (Figs. 29, 35). At other times, on the contrary, 
 as the result of other morbid conditions, nothing is easier than to pass 
 through this orifice (Fig. 32). As a rule, a catheter of 2 milli- 
 metres in diameter will enter it. After the menopause the os internum 
 gradually contracts, and in some women is at last obliterated. 
 
 The OS externum is broader, though occasionally it is rounded and 
 narrow. This narrowness may be more or less marked, even reach- 
 ing the degree at which it is known as atresia, which is really im- 
 perforation or obliteration. Then the retention of mucus or of 
 menstrual blood increases the capacities of the cavities, as may be 
 seen in the accompanying figure taken from Guyon (Fig. 32 eh, 
 ad). Often, too, in such a case the projection of the uterus into 
 the vagina is conical, and the orifice may be at the summit of this 
 cone or on one of its sides a little in front or a little behind. Gene- 
 rally, however, it is in the form of a slit, on which, in the foetus and 
 infant, we can see the starting-point of the trunks of the arhor vita, 
 which gives to this opening a form somewhat similar to that of the 
 
 • Etude sur les cavites de I'uterus a I'etat de vaeuile. Theses de Paris, 1858. 
 Hagemann {ArcJiivfilr Gynecologic, Bd. v, p. 295) has arrived at the same results. 
 
 3 
 
34 
 
 INTEODUCTIOX 
 
 mouth (Guyon). These projections are effaced with age so as to 
 reduce the orifice to a straight line^ the margins of which are iu contact 
 in the child and adult nullipara. The latter differs from the former in 
 
 Fig. 32. — Mould of the uteiine cavities in a nuUipai-a foi-tj-two years of age. 
 There "n-as a Tvell-marked contraction of the os externum. Its form is the 
 same as that of the nteras in the virgin (Fig. 29), but the comua are 
 broader, the cervico-nterine isthmus is dilated, the upper segment of the 
 body and the cervical cavity are more developed (after Guyon) . 
 
 the slight flattening of the cervix, the lips of which seem to allow the 
 orifice to open more easily. In the multipara the slit is open, irregular, 
 
 1 2 
 
 Fig. 33. — Differences in the vaginal poi-tions of the cervix in the nullipara, 1 ; 
 and in the multipara, 2. 
 
 and indented by cicatrices consequent on lacerations caused at de- 
 livery. To sum up, there are differences in the uterus of a nuUipara 
 and that of a multipara which should prevent their being confounded. 
 1st. Externally, the uterus of the multipara is less fixed, it has a 
 less elevated position and a more marked variability of inclination than 
 the uterus of a nullipara. Its two surfaces and its upper border are 
 rounded. The vaginal portion of the neck is less conical and less 
 elongated. The orifice is longer, the lips irregular and indented, open- 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 
 
 35 
 
 ing easily and allowing the entrance of the point of the finger. The 
 uterus is larger ; all its diameters have increased, especially the longi- 
 
 FiG. 34. — Differences in the external conformation o£ the uterus in a nullipara, 
 1 ; and in a multipara, 2 (after Dubois). 
 
 tudinal one. The increase of size, and especially of length, is shown 
 
 J2 
 
 Fig. 35. — Differences in form and size of the uterine cavities. The nullipara 
 1 ; and the multipara, 2 (after Dubois) . 
 
 more in the body than in the neck. The walls of the organ have 
 acquired a greater thickness. 
 
 2nd. Internally y the cavity of the body is increased and has changed 
 in shape : its borders, in place of being convex, have become concave. 
 The superior angles are no longer funnel-shaped. The openings of the 
 Fallopian tubes are broader. The cavity of the neck is proportionally 
 shorter and rather broader. The os internum is more open, and allows 
 
36 INTEODUOTION 
 
 the sound to penetrate more easily. The axis of the two cavities is 
 less frequently curved forwards^ and when it is curved either forwards, 
 backwards, or to one side, it is more easily rectified by the introduc- 
 tion of an instrument, unless there are adhesions or some morbid 
 condition. 
 
 Steucture op the Uterus 
 
 The structure of the uterus is not analogous to that of any other 
 organ. The walls are thick, but not equally so throughout. Hardly 
 exceeding 8 millimetres at the opening of the Fallopian tubes, they are 
 as a rule, according to Sappey,^ 10 millimetres thick at the fundus and 
 from 12 to 15 anteriorly and posteriorly and at the lateral borders. 
 
 1. Its arteries are the ovarian from the aorta and the uterine from 
 the internal iliac, without counting those of the round ligaments arising 
 from the epigastric. They enter the uterus by its borders, not without 
 anastomosing considerably, describing numerous flexuosities and cork- 
 screw windings, which have led to their being compared to the helicine 
 arteries of the erectile tissues generally and of the cavernous bodies of 
 the penis in particular. 
 
 3. Its veins, which are voluminous and almost without valves, 
 anastomose largely and are adherent to the tissue of the organ, forming 
 during pregnancy dilatations known as sinuses. They emerge along 
 the lateral borders and form two vast plexuses contained in the folds of 
 the broad ligaments and, without joining the veins of these ligaments 
 which flow into the epigastric or external iliac, they empty themselves, 
 some into the internal iliac, others into the vena cava on the right and 
 the renal vein on the left, being marked during the whole length of 
 their course by a plexus analogous to the pampiniform plexus in man. 
 
 3. Its lymphatic vessels, studied especially during pregnancy or after 
 delivery by Mascagni, Cruveilhier and others, have lately been investi- 
 gated by Leopold^ in the unimpregnated uterus in woman, as well as in 
 the female mammalia, and by Lucas Championnierc^ in the uterus after 
 delivery. Whether they arise from the mucous membrane or from the 
 muscular wall, the hypertrophy of which they share in pregnancy, these 
 lymphatic vessels are divided, like the veins, into two principal groups 
 on each side ; the inferior, which come from the cervix, open into the 
 lateral pelvic glands; the superior into the lumbar ganglia. Cham- 
 pionniere has discovered that the lymphatics of the cervix unite in 
 vessels of various sizes at the union of the body and cervix ; generally 
 there is one much larger than the others ; they emerge at this level 
 into the lateral cellular tissue at the base of the broad ligaments fol- 
 lowing the course of the blood-vessels and at once join one or two 
 little ganglia which are not constant but which, when wanting, are 
 replaced by a lymphatic network which forms a real and important 
 
 ' Op. cit., p. 665. 
 
 2 ArcMvfur Gynecologie, Bd. vi, p. 1. Berlin, 1873. 
 
 3 Lymphatiriues uterins ei Lymphavgite uterine. Paris, 1870. 
 
ANATOMY, PHYSIOLOGY AND TEllATOLOGY 37 
 
 vascular plexus. The largest at last reach the posterior subperitoneal 
 surface of the broad ligamentj and from there pass to the deep pelvic 
 and sacral ganglia, sometimes even reaching an inguinal and obturator 
 ganglion. 
 
 The lymphatics of the body arise chiefly from the portion which 
 adjoins the placental surface ; they anastomose with those of the 
 ovaries and Fallopian tubes and, following the utero-ovarian venous 
 plexus, they accompany these vessels to the vascular plexuses and 
 lumbar ganglia where they end. It is impossible to attach too much 
 importance to the exact knowledge of the lymphatics of the uterus and 
 its appendages. In the sites indicated by anatomists I have frequently 
 observed, kernels of inflammatory induration, which could be nothing 
 else than retro-uterine adenitis, and this opinion has occasionally been 
 confirmed by autopsies. I am more and more convinced every day of 
 the important part played by angioleucitis, adenitis and even peri- 
 uterine adenomata, not only in the history of uterine and peri-uterine 
 phlegmasia in puerperal maladies, but in a number of others accom- 
 panied by deep and continuous pain, which otherwise would be 
 inexplicable. 
 
 4. The nerves of the uterus and ovaries, according to Tranken- 
 hauser, arise directly and indirectly from the coeliac plexus through 
 the intervention of the renal plexus which, through its inferior gan- 
 glion, is distributed to the ovaries and spermatic ganglia. The aortic 
 plexus by its upper part (superior mesenteric plexus) suppHes these 
 spermatic ganglia, which would be more correctly designated genital 
 ganglia. These ganglia, four in number, receive two large branches 
 from the great sympathetic and give ufi" a great number of nerves to 
 the ovaries. Below the origin of the inferior mesenteric artery is the 
 great uterine plexus (lumbo-aortic), which descends to 1 centimetre 
 from the division of the aorta and is formed of the principal branches 
 of the genital ganglia with the addition of small branches proceeding 
 from the four lumbar ganglia of the great sympathetic. On the pro- 
 montory it is divided into hypogastric plexuses, which are joined by 
 branches from the terminal ganglia of the sympathetic and are situated 
 behind the rectum, on the inner side of the pelvic vessels, and are dis- 
 tributed to the lateral borders of the cervix uteri. Each hypogastric 
 plexus measures from 7 to 10 centimetres, and in its course supplies 
 branches to the mesorectum, to the mesentery of the sigmoid flexure, 
 and to the ureter. There is a large cervical ganglion on each side of 
 the neck, easily discovered in the newly-born even without prepara- 
 tion, but covered in adults by the pelvic fascia and superimposed 
 nerves. It extends downwards as far as the folds of Douglas, and 
 measures, in the empty uterus, about 2 centimetres in length and 1 in 
 breadth, and during pregnancy 5 centimetres in length and 2 or 
 3 in breadth. The greater number of the uterine nerves arise from 
 these two ganglia, the rest coming directly from the hypogastric 
 plexus. The cervico-uterine ganglia receive their afferent branches 
 not only from the hypogastric plexuses, but also from the second, third 
 and fourth sacral pairs. They supply branches not only to the uterus 
 
38 INTEODUCTION 
 
 but also to the vagina, bladder and rectum. Besides tliese principal 
 ganglia there are on each side two small ones for the urethra and bladder, 
 the latter sending some branches to the anterior surface of the uterus. 
 The nervous branches from the cervico-uterine ganglia enter the cervix 
 horizontally ; passing upwards they pierce the inferior portion of the 
 body obliquely, whilst above, along the borders of the uterus, they run 
 almost vertically, uniting with each other in the thickness of the ante- 
 rior and posterior walls ; they also anastomose with the ovarian nerves. 
 The ramifications of the uterine nerves may be traced as far as the 
 mucous membrane in the neck, but this cannot be done in the case of 
 the body. Erankenhaiiser has found motor fibres in the uterine 
 plexus but he has not been able to discover sensory fibres. It seems 
 impossible to distinguish the filaments arising from the cerebro-spinal 
 and ganglionic systems. 
 
 5. The serous envelope of the uterus is nothing else than the peri- 
 toneum, which, being reflected from the posterior surface of the 
 bladder to the anterior surface of the body of the womb, covers all 
 tlie posterior surface of the fundus including the nech and the upper 
 part of the posterior vaginal wall and extends right and left over the 
 broad ligaments. 
 
 6. The uterine mucous memhrane was for a long time unknown. It 
 was Coste^ who demonstrated at the same time its existence, its struc- 
 ture and its hypertrophy into the decidua during pregnancy. I 
 helped to make this discovery known and to develop it twenty years 
 ago.^ Since then Robin has described the histology of this membrane,^ 
 and other writers have studied the formation of the decidua and the 
 regeneration of the uterine mucous membrane.^ 
 
 The mucous membrane of the uterus is different in the body and in 
 the neck. 
 
 In the body it is attenuated toward the angles, where it is con- 
 tinuous with that of the neck and of the Pallopian tubes. It is 
 thickest towards the centre, varying from 3 to 6 millimetres, 
 according to Coste. The free surface is smooth, without wrinkles, 
 
 1 Memoire sur la formation de la caduque dans I'ceuf humain. Comptes 
 rendus des seances de I'Academie des Sciences de Paris, t. xv, 1842, and t. xxiv, 
 1847. Traite general du develojopement. Paris, 1848. 
 
 2 De I'ceuf et de son develojppement dans I'espece humaine, p. 127. Montpellier, 
 1845. 
 
 3 Cli. Robin, Memoire poiir servir a I'histoire anatomique et patliologique de 
 la memhrane imiqueuse uterine, de son mucus et des oeufs, ou inieux glandes de 
 Naboth, see Archives generales de medecine, t. xvii and xviii. Paris, 1848. 
 
 ^ Colin, Mtude a I'ceil nu sur la surface interne de I'uterus apres V accoiiche- 
 ment dans I'etat physiologique, dans V etat patliologique, et en particulier dans 
 la fievre puerperale. Theses de Paris, 1847, No. 229 ; see also A. Richard, De 
 la muqueuse uterine. Paris, 1848 ; Ch. Robin, Memoire sur les modifications 
 de la Tnuqueuse uterine pendant et apres la grossesse ; see Memoires de I'Aca- 
 demie de medecine, t. xxv, p. 81, Paris, 1861 ; Ercolani, Delia struttura della 
 caduca uterina, Bologna, 1874 ; Leopold, Studien iiber die Uterusschleimhant 
 ivahrend Menstruation, Schwangerschaft u. Wochenbett ; the paper is accom- 
 panied by a larj^e number of figures representing sections of the miicous 
 membrane magnified in these various states. Archiv filr Gyncecologie, Bd. xi, 
 pp. 110, 443, &c. Berlin, 1877. 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 
 
 39 
 
 papillse or villosities, but perforated with a multitude of orifices which 
 are the mouths of as many follicles or tubular glands, and covered 
 
 Fig. 37. 
 
 Fig. 36. — Internal mucous membrane of a uterus, the anterior wall of which 
 has been partially removed (after Coste). p p, tissue proper, in which 
 numerous vascular orifices are seen, resulting from section of the vessels ; 
 vi m, mucous membrane, the regularly striated appearance of which is 
 remarkable, as well as its rose colour. The little vermicular body placed 
 below the uterus is a small gland ; t, initial extremity, ending in cul-de- 
 sac ; 0, terminal extremity, presenting a narrow orifice opening upon the 
 internal surface of the uterine cavity. 
 
 Fig. 37. — General view of the glands or flexuous follicles of the uterine mucous 
 membrane, ddd, simple or double cul-de-sac of these follicles ; a aa, thin 
 cup-shaped orifice opening on to the surface of the mucous membrane. 
 
 with conical cells of from 3 to 4 hundredths of a millimetre, with 
 pyramidal base furnished with vibratile cilia smaller than the vibratile 
 epithelium cells of the Fallopian tubes which are not less than 7 
 hundredths of a millimetre. This epithelium, vibratile in the empty 
 uterus, becomes tesselated during gestation, when the mucous mem- 
 brane becomes the decidua. The tubular glands, shghtly flexuous 
 and cylindrical, adhere by their blind end which is sometimes bifid to 
 the subjacent tissue ; they open on the surface of the mucous mem- 
 brane into a little cup surrounded by a kind of vascular polygon, and 
 are lined with nucleated epithelium. Their diameter is about equal to i 
 the twelfth part of their length, and the space separating them is i 
 about equal to their diameter. They participate in the general hyper- 
 trophy of the organ during pregnancy. The tissue between the 
 follicles is formed of occasional fibrous bundles (cellular, laminar or 
 connective tissue), of fibro-plastic elements, esneciallv of nuclei, cells. 
 
40 INTEODUCTION 
 
 fusiform bodies aud of a great deal of granular amorphous matter. 
 ( Thus the framework of the membrane is in the embryonic state and 
 ! in every stage of development. The uterus is the only organ in which 
 i we constantly find a tissue in process of organisation. This pecu- 
 liarity is in direct relation with the modifications in size and structure 
 which are necessitated by the fulfilment of its functions ; it determines 
 at the same time a special direction for its morbid processes ; it 
 explains several obscure points in its pathology ; it helps also in the 
 search after therapeutical remedies and may explain the occasional 
 unexpected effects produced by them. At the menstrual period the 
 mucous membrane greatly increases in thickness, it becomes congested 
 and remains gorged with blood till the hsemorrhage is established, or 
 rather till it has ceased. Its surface is pufi'ed out and furrowed with 
 wrinkles which resemble the cerebral circumvolutions. The glands 
 participate in this congestion which is almost a temporary hyper- 
 trophy. Their secretion, generally insignificant, becomes consider- 
 able, especially before and after the hsemorrhage. 
 
 In the tieck the mucous membrane is very adherent as in the body, 
 but it is thinner, having a thickness of only 1 or 2 millimetres ; it 
 is wrinkled, lined with ciliated epithelium formed of a subsirakim 
 analogous to that of the mucous membrane of the body, and in which 
 embryonic elements, such as the fibro-plastic fusiform bodies, pre- 
 dominate : lastly, it is furnished abundantly with secreting organs, 
 regarded formerly as simple follicles with ampullary blind ends and 
 constricted neck, but lately described by Sappey as racemose glands 
 with two or three branches and subdividing to terminate in a 
 cul-de-sac. These glands are found in the uterine and vaginal orifices 
 as well as in the cavity of the neck. They are remarkable for their 
 size in their whole course. Their orifices are seen at the bottom of 
 the grooves which separate the branches of the arbor vitce. They 
 secrete a thick and very viscous mucus, alkaline like that of the body, 
 the reverse of the vaginal fluid which is acid. This mucus in accu- 
 mulating forms in the foetus, and often in the adult, especially during 
 pregnancy, a very adherent gelatinous cylinder which fills up the 
 cavity of the neck. These glands frequently become the seat of a 
 partial or total dilatation, which transforms them into a kind of cyst 
 known as Naboth's eggs. These cysts, as they grow, become em- 
 bedded in the muscular coat. The glands of the neck are the organs 
 which specially produce uterine leucorrhoea. Although more acces- 
 sible than the follicles of the body to our means of treatment because 
 nearer to us, they are not any more amenable to the action of the means 
 employed, owing to their position at the bottom of the rugged grooves 
 into which they open between the ramifications of the arbor vita. 
 Fig. 38, taken from Tyler Smith,^ gives an idea of the difficulty there 
 is in reaching them. __ 
 
 The muscular envelope, or what has been called the tissue proper 
 of the uterus is very complicated. Super-position of deep layers, 
 intersection of superficial bundles, a vascular development peculiar to 
 ' On Pathology and Treatment of Leucorrhcea, p. 25. Londou, 1855. 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 
 
 erectile organs, all contribute in giving this organ a texture rendered 
 more difficult of description by the fact that till now anatomists 
 
 Fig. 38. — General view of the transverse or oblique ramifications of one of tte 
 two median columns of the mucous membrane which constitute the anterior 
 and posterior arhores vita in the cervical canal of a virgin, magnified 
 nine diameters. 
 
 have hardly taken into account the facts gathered from development, 
 from comparative anatomy and from the musculo-vascular conditions 
 of erectility which alone could throw any light on this study. At 
 present we know the structure of the uterine tissue, the elements 
 which enter into its composition, the wealth and special arrangement 
 of its blood-vessels, and the super-position and the mutual relations 
 of the majority of the muscular bundles which characterise the texture 
 of the womb. 
 
 The essential elements of the tissue of the uterus are smooth mus- 
 
J. INTEODUOTION 
 
 cular fibres, incorrectly called fibre-cells, muscular fibres of organic 
 life characterised by the presence of a nucleus not exceeding 7 hun- 
 dredths of a millimetre in length and 5 thousandths of a millimetre in 
 width in the unimpregnated uterus, but attaining, during gestation, 
 ten times the length and five times the width and allowing of the pene- 
 tration of a few fatty granulations. The hypertrophy of the organ 
 during pregnancy does not consist merely in the increased size of the 
 elements already existing ; there is also a formation of new muscular 
 elements and, in addition to the growth of contractile fibres, is added 
 that of the fibrous or connective tissue which joins them together. 
 
 Fig. 39. — Smooth muscular fibres of tlie 
 Tinimpregnated uterus (after Farre). 
 
 Fig. 40. — Fibre-cells of the utenis 
 in state of gestation (after 
 "Wagner). 
 
 After delivery atrophy brings these elements back to their normal 
 condition. This peculiarity characterises the muscular membrane of 
 the uterus as well as its mucous membrane. If the muscular tissue 
 
 Fig. 41. — Progress of involution or disintegration and rene-R-al of uterine fibres 
 after delivery. Process of fatty degeneration (after Hescbl). 
 
 has not, like the mucous membrane, the faculty of development carried 
 to the point of renewal, it is always, like the latter, to a certain extent 
 in process of development, and consequently has the characteristic of 
 anatomical instability, this forming a striking contrast to the stability 
 of all other organs. This special property of the uterine tissue plays 
 an important part in the development of its diseases, imprints a special 
 
ANAT03JT, PHTSIOLOGT AND TERATOLOGY 43 
 
 character on its pathology and exercises a marked influence on its 
 therapeutics. 
 
 It IS now agreed that the contractile bundles are composed of three 
 layers of elementary fibres. The deep layer is formed of two orbicular 
 muscles arranged in concentric curves, which converge right and left 
 around the orifice of the Fallopian tubes as a central point, and to which 
 Ruysch gave the name of detrusor placenta, attributing to them the 
 function of loosening the placenta. At the isthmus which unites the 
 cavity of the body with that of the neck this layer is formed of simple 
 circular bundles, intersecting at acute angles and constituting a con- 
 strictor, the presence of which accounts for the occlusion of the 
 uterus during gestation and explains its tendency to contract at this 
 point like a sphincter, the difficulty often experienced in passing the 
 sound, and the difference between the resistance presented by this 
 orifice and the dilatability of the os externum and cervical cavity 
 either during pregnancy or in certain morbid conditions, and lastly, the 
 frequent obliteration of the os internum after the menopause. 
 
 Hehe's^ recent researches have confirmed the truth of this descrip- 
 tion. The central layer seems to be the thickest and most inextricable. 
 According to Pajot- it is composed principally (in the upper regions of 
 the anterior and posterior surfaces where it can be studied) of muscular 
 bands in loops which cover one another. The superficial layer, on the 
 contrary, is most easily studied in the unimpregnated uterus, especially 
 in children. As Puouget has observed, these organs preserve the traces 
 of the primitive forms till puberty, the -uterine cornua are still distin- 
 guishable under the thin muscular layer which covers them, the tissue 
 proper of the uterus is only slightly developed, the connections of 
 the superficial layers with neighbouring membranes are more marked, 
 and these membranes themselves are thin, transparent and free from 
 the adipose tissue which afterwards invades them, and thus present them- 
 selves to the observer under the most favorable conditions for study. 
 
 The right and left segments of the uterus have doubtless, like the 
 Fallopian tubes, longitudinal fibres and layers of circular fibres which 
 are a continuation of those of the oviducts. In addition, however, to 
 these special fibres, which are found in much greater number on the 
 two lateral halves of this organ than on the Fallopian tubes, there are 
 doubtless common fibres which complete the fusion of these two halves 
 in order to make one central organ having one cavity. Above these 
 muscular layers there is a common envelope, also muscular, forming a 
 broad contractile apparatus, uniting the movements of the womb with 
 those of the Fallopian tubes, ovaries, broad ligaments, round ligaments 
 and ligament of the ovarian vessels, i.e. with the so-called uterine 
 appendages. 
 
 If we spread the genital organs of a child on a piece of glass, it is 
 
 1 Journal de la section de medecine de la Societe academique du departement 
 de la Loire-Inferieiire, t. Ix, p. 125. Nantes, 1864. Becherches surla disposi- 
 tion des fibres musculaires de I'uterus developpe par la grossesse, avec un atlas 
 de dix planches. Paris, 1865. 
 
 2 Dubois et Pajot, Traite complet de I'art des accouche^nents, p. 437. Paris, 
 1860. 
 
44 
 
 INTRODUCTION 
 
 easy to observe that in the human species, as in the mammalia, the 
 uterus and its appendages are contained in the thickness of a broad 
 muscular membrane; to which the peritoneal hgaments are only sub- 
 sidiary. It is easy to follow the continuity of the muscular bundles 
 of this membrane with the upper layer of the uterine tissue so well 
 described by Deville.^ 
 
 Fig. 42. — G-eneral view of the vascular structures of the internal genital organs 
 in woman, in their relations with the superficial muscular system (after 
 Eouget). The vagina, uteras and appendages are seen from behind. 
 Vascular system, — b, bulb communicating on the one side with the spongy 
 tissue of the clitoris, and on the other with the venous plexus of tlie 
 vagina ; PV, semi-circular enlargement of the vaginal venous plexus ; PC, 
 cervico-uterine plexus ; pit, uterine plexus ; SP, helicine arteries of the 
 body of the uterus ; h, heliciae arteiies of the hilum of the ovary. Mus- 
 cular stractures : vp, insertion of the muscular bundles of the vagina into 
 the pubis ; vs, bundles of fibres of the same muscular layer from the 
 region of the sacro-iliac symphysis ; rs, bundles of iiterine muscular fibres 
 accompanying the preceding, and constituting in great part the posterior 
 fold of the broad ligaments ; rn, retro-uterine ligaments ; Li, inguinal 
 or pubic round ligaments spreading over the whole anterior surface of the 
 uterus ; LO, ligament of the ovary ; LS, superior or lumbar round liga- 
 ment which accompanies and envelopes the ovarian vessels ; a, bundles of 
 muscular fibres from the ligament of the ovary LO, spreading over and 
 interlacing with bundles of fibres b, from the lumbar ligament LS, 
 within the thickness of the ovary and beyond in the fold of the Fallopian 
 tube before their attachment to this tube and to the fimbriated extremity ; a', 
 bundles of fibres from the ovary, forming, with those coming directly from 
 the superior ligament, the tubo-ovarian fringe. 
 
 ^ See Cazeaux, Traite theorique et pratique swr I'Art des Accouchenients, 
 p, 108, 3id edit. Paris, 1850. 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 45 
 
 Eouget^ set out with the double fact that the superficial muscular 
 tunic of the hollow viscera does not always by any means mould itself 
 exactly on their form and dimensions, and that the muscles of organic 
 life at their terminal extremity are constantly in connexion with some 
 portion of the locomotor economy of animal life, bones, tendons, 
 aponeurosis and even muscles. He then studied the arrange- 
 ment of the superficial contractile envelope of the genital organs in 
 the vertebrate animals as well as in woman. He succeeded in this way 
 in demonstrating that the broad ligaments are not a simple fold of 
 peritoneum, but an expansion of the lateral portions of the uterus, or 
 rather of the subjacent muscular folds, with the serous folds adhering 
 to them very closely, and made up of bundles of smooth fibres, which 
 interlace, forming a network. The central portion of the membrane 
 formed by the whole thickness of these folds at their point of inter- 
 section is nothing more than the external layer of the muscular 
 envelope of the uterus. On the median line of the womb down its 
 whole length may be seen the decussation of the muscular bundles 
 from one side to the other (vertical fibres), indicating the meeting and 
 crossing of the two lateral muscular organs (Fig. 43). In this way 
 the bundles derived from the pubic round ligament (li) spread out 
 in the form of a fan throughout the length of the uterus and interlace 
 with those of the opposite side. The insertions to the sacrum and 
 iliac region (ur, vs, us) are found in the utero-sacral ligaments 
 and the posterior fold of the broad ligament. The bundles of fibres 
 dependent on the ovarian ligament, mesovarium (lo) and central fold 
 arise chiefly from the posterior surface of the uterus ; the fibres with 
 numerous and elongated nuclei, which intermingle in the stroma of 
 the gland and enclose the Graafian vesicles in the meshes of their net- 
 work, are probably only their continuation. Another portion of the 
 fibres of the mesovarium runs along the lower border of the ovary, and, 
 having reached the external extremity, helps to form the muscular 
 cord attaching the fimbriated extremity to this gland [a'). Lastly, 
 some fibres are detached from the upper border of the utero-ovarian 
 ligament to mingle with the muscular groundwork of the fold of the 
 Pallopian tube, ending in this tube and the fimbriated extremity. 
 
 The fibres which constitute the means of insertion of the superficial 
 muscular envelope of the uterus at the lumbar region (superior round 
 ligament), in place of being narrowed into a band, are spread out like 
 a membrane, envelope the vascular cord of the ovarian vessels, traverse 
 it, rise with it to the lumbar region, and are gradually lost in the 
 fascia propria, by means of which they are fixed to the posterior wall 
 of the trunk. At their termination some of these fibres radiate into 
 the posterior fold of the broad ligament towards the uterus, others, 
 raising the peritoneum in the form of a fold, are deflected outwards on 
 a level with the ovary, and are attached to the fimbriated extremity 
 (b), whilst the greater number, accompanying the vessels to the hilum 
 
 1 Becherches sur les organes orcctiles cle lafemme, et sur I'a^jpareil musculaire 
 tuho-ovarien, see Journal de physiologie of Brown-Sequard, t. i, p. 203. Paris, 
 1859. 
 
46 I^^TEOD^CTION 
 
 of the ovarVj seem partly to penetrate into tlie parenchyma of this 
 gland, partly to cross its erectile bulb, and, continuing their course 
 into the fold of the rallopian tube_, are lost in the contractile envelope 
 of the latter, intermingling with those which arise from the ovarian 
 ligament. 
 
 The discovery of this superficial muscular layer explains the 
 mechanism of the application of the oviduct to the ovary at the moment 
 of dehiscence, an important phenomenon the cause of which was un- 
 known. The direction of the two kinds of muscular fibres which, 
 arising from the lumbar region and the uterus, embrace the whole 
 length of the TaUopian tube and fimbriated extremity (lo, ls, a h, a' b), 
 perfectly explains the movements executed by these organs when in- 
 clining backwards and inwards, the possibility of the flexion of the 
 tube on itself, and the application of the fimbriated end to the surface 
 of the ovary (Tig. 42). The mechanism, in fact, is exactly similar to 
 that by which the opening of a bag purse is closed, the edges of which 
 pucker up when drawn together by traction upon the strings which 
 pass through rings attached at intervals round the mouth of the bag 
 (fig. 43). The movements of the fimbrise, which, so to speak, sweep 
 the surface of the ovary, and the peristaltic contractions of the Tallopian 
 tube, receive the ovum and carry it to the uterus (Tig. 44). 
 
 The movements of the uterus are also due to the morbid or spas- 
 modic contractions of this superficial layer of muscular fibres. Patients 
 are aware of this by the sensations they sometimes experience. These 
 
 Fig. 43. — Muscular tubo-ovariaii arrangement in the rabbit (after Eouget). 
 The muscular membranes of the ovary L and of the Fallopian tube t 
 form a double fold, the borders of -n-hich, brought together by muscular 
 contraction, enclose the ovaiy and fimbriae which are thus brought 
 into close contact ; s, upper round ligament, the muscular fibres of which 
 descend from the lumbar region towaords the ovaiy and the fimbriated 
 extremity ; 0, ovary ; r, uterus. 
 
 sensations are not to be confounded with the spasmodic action propa- 
 gated to other organs which produces such various effects, e.g. the 
 globus hystericus. They are so marked that we must admit their 
 reality and attribute them to the partial or total contraction of the 
 superficial muscular envelope. TThen I add that this contraction is 
 itself the starting point of the erection of the ovary and uterus, that 
 these movements and this erection are probably directly connected 
 with ovulation, menstruation and venereal orgasm, it will be at once 
 
ANATOMY, PHYSIOLOGY AND TEEATOLOGY 47 
 
 understood what importance is to be attached to them in appreciating 
 the various impressions experienced by women and the subjective 
 phenomena of uterine diseases. 
 
 Fig. 44. — Ovaiy and fimbriated extremity of Fallopiaii tube in a woman who died 
 during menstruation (after Farre, ad. nat.). I, broad ligament; o, ovary ; 
 r r, old coi-pora lutea, traces of Graafian vesicles previously ruptured and 
 cicatrised ; /, broad portion of the Fallopian tube ; i, fimbriated extremity 
 applied to the ovaiy. 
 
 The tissue proper of the uterus is erectile as well as contractile. 
 It is to Eouget^ that we owe the demonstration of this fact also. 
 According to this observer, every erectile organ is nothing more than 
 a muscular organ in which the blood brought by the arteries may be 
 temporarily retained in the capillaries or in the veins transformed into 
 cavernous sinuses and retiform plexuses ; the immediate cause, there- 
 fore, of erection is to be found in the contraction of the muscular 
 fibres, the primary element of all erectile orgasm. He also observed 
 in the branches of the tubo- ovarian arteries an arrangement exactly 
 similar to that which he had remarked in the helicine arteries of the 
 corpus cavernosum. He discovered that the uterus and ovary each 
 possess a true corpus spongiosum (Fig. 42), and that they may be the 
 seat of phenomena analogous to those of erection. In fact, he de- 
 monstrated that, besides the intrinsic muscles of the uterus which 
 may participate in the production of these phenomena, the fibres of the 
 tubo-ovarian muscular membranes have such intimate relationship with 
 the corpora spongiosa of the uterus and ovary, and especially with their 
 efferent vessels, that at the moment of contraction the meshes of the 
 network through which the veins make their way being drawn tighter 
 in every direction, the latter are necessarily compressed and the 
 passage of blood more or less completely obstructed. The erectility 
 of these organs and the part that it plays in ovulation, menstruation 
 and copulation, can be proved by producing an artificial erection in these 
 organs on the dead body. Normally, the uterus and ovaries after 
 
 ^ Becker ches sur le type des organes genitaux et de leurs appareils muscu- 
 laires. Inaugural thesis. Paris, 1855. 
 
48 
 
 INTEODUCTION 
 
 death, if unimpregnated, sink into the pelvic cavity, and even when 
 freed from the mass of intestines weighing on them, the uterus, unless 
 supported by the bladder and rectum, yields to every movement com- 
 
 
 Fia. 45. — General view of the vascular formations of the internal genital 
 organs. PV, semi-circiilar enlargement of the vaginal plexus ; PC, cervico- 
 uterine plexus ; sp, helicine arteries of the body of the uteras ; h, helicine 
 arteries of the hilum of the ovary. 
 
 municated to it, bending and falling when no longer held up. In such 
 circumstances, if, after having placed the pelvis in hot water, we inject 
 the ovarian veins till the corpora spongiosa of the ovary and uterus 
 are filled, we shall see the body of the uterus (as soon as it is distended 
 by the injection) plainly straightening itself in the axis of the neck and 
 rising in the pelvic cavity, executing a movement, that is to say, quite 
 analogous to that of the pendent portion of the penis when it 
 straightens itself into the axis of the portion fixed to the pubis and 
 rises towards the abdomen. This change of position is accompanied 
 by a marked change of size and form ; the uterus becomes more convex 
 in front, but especially behind; its borders, previously attenuated 
 become round ; and the walls of the uterine cavity separate sensibly 
 at the same time, as Gunther and Kobelt have shown in the case of 
 the walls of the urethra. 
 
 Analogous, although less marked phenomena occur simultaneously 
 in the ovary, whilst the Pallopian tube undergoes no change of any 
 kind. 
 
 As for the vagina, there seems to be no portion which can properly 
 be said to be erectile, unless it be the plexus of broad veins which 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 49 
 
 runs along its lateral borders, and the sometimes circular plexus which 
 surrounds the first portion only of this canal. 
 
 Doubtless, as Eouget remarks, sexual excitement in women is fre- 
 quently limited to the erectile structures of the bulbs and clitoris ; 
 but when it is complete — when venereal erethism reaches its summum 
 of intensity — it must exceed these limits and extend to the essential 
 organs of the genital function, in which is then developed the special 
 voluptuous sensation which announces the accomplishment of the 
 sexual act which the organs of copulation have only prepared. 
 
 The Vagina and Vulva 
 
 The vagina is a membranous canal extending from the neck of the 
 uterus, which it embraces, to the vulva, from which it is separated by 
 the hymen and vulval ring. It is in great part situated in the pelvic 
 cavity, the curve of which it follows pretty closely, having an oblique 
 direction from above downwards and from behind forwards which 
 crosses the axis of the perineal strait, so that its lower extremity is in 
 a plane anterior to the axis of this strait. It forms, therefore, with 
 the uterus which is placed almost in the direction of the axis of the 
 superior strait, an angle with an anterior sinus corresponding to the 
 bladder and a posterior convexity in relation with the rectum. The aper- 
 ture of the angle varies according to the vacuity or fulness of the bladder. 
 Its length is from 10 to 12 centimetres, measuring it from the vulval 
 ring; the anterior wall, according to Sappey, is only 75 milli- 
 metres, whilst the posterior is 95 millimetres ; its width varies accord- 
 ing to the individual, the age, virginity, pregnancy, &c. It varies also 
 at different points, being narrow at the vulval orifice and increasing 
 gradually from below upwards or from before backwards as far as the 
 neck of the uterus. The dilated portion which surrounds the cervix 
 is called the cul-de-sac or sinus, and is divided into anterior, posterior 
 and lateral ; the posterior is the deepest, and often conceals morbid 
 states of the vagina or of the corresponding cervical lip which are 
 both difficult to diagnose and to cure. 
 
 When left to themselves the anterior and posterior walls are in imme- 
 diate contact, so that in place of being cylindrical the vagina, in a state 
 of repose, is really flattened. The anterior surface is in relation with 
 the urethra, and at the base of the bladder with the ureters (Figs. 16, 
 17, 18) ; its posterior surface with the perineum, rectum, and with the 
 peritoneum to an extent of from 10 to 15 millimetres (recto-vaginal 
 C7cl-de-sac) ; its borders with the levator ani muscles (which may com- 
 bine their action with that of the constrictor), with the perineal or 
 upper pelvic aponeurosis, with abundant adipose cellular tissue, and 
 with the inferior portion of the broad ligaments. Above, the vagina 
 adheres to the neck throughout the extent of the central third of the 
 latter, leaving the posterior lip more exposed than the anterior and 
 the posterior sinus broader than the anterior. Below it terminates in 
 the vulval ring, the elastic tissue of which, with the constrictor and the 
 
 4 
 
50 
 
 INTEODUCTION 
 
 bulb, together con'stitute the narrowest part of the vagina and 
 present a greater obstacle to the introduction of the penis than the 
 hymen, may offer so much resistance during delivery as to require 
 incision, and become the seat of a spasmodic contraction, with or 
 without fissure, similar to that of the anus. To this vulval ring is 
 attached the hymen, apparently formed by the apposition of the vaginal 
 
 Fig. 46. 
 
 Fig. 47. 
 
 Fig. 46. — Horizontal section of soft parts on a level with the inferior strait of 
 the vagina, showing its walls in contact. Va, vagina ; Ua, urethra ; 
 R, rectum and levator ani (after Cmveilhier). 
 
 Fig. 47. — B, anterior vaginal wall, the posterior having been removed ; Ou, 
 meatus ; above, anterior column formed by two enlargements diverging 
 towards the base ; Oue, os externum ; *, section of the utero-vaginal cul-de- 
 
 mucous membrane (intermediary formation) to the vulval mucous 
 membrane (external formation), and which, like all orifices placed on 
 the borders of two different embryogenic fields, may be imperforate. 
 As a rule, the hymen has an annular or semi-lunar form ;i it is destroyed 
 by coitus, leaving no other trace than the carunculie myrtiformes.^ 
 
 ^ Roze, De I'hymen: Inaugural thesis. Strasbourg, 1865. We shall consider 
 these various anomalies afterwards. 
 
 ^ Puech has seen the singular case of a lady who never had a hymen, and 
 who after deliveiy had four carimcnlce myrtiformes. 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 51 
 
 The internal surface of the vagina is remarkable • for the transverse 
 ridges of its mucous membrane known as rugae, which reach their 
 greatest height in the middle portion, where they form on each wall a 
 median projection bearing the name of the column, extending from 
 top to bottom, more prominent on the anterior than on the posterior 
 wall and more marked near the vulval orifice, where it is sometimes 
 double (Fig. 47), than near the uterine insertion, where it almost dis- 
 appears. These columns and rugae, probably traces of the double 
 vagina, give rise to grooves which become reservoirs for virulent 
 matter and seats of syphilitic or blennorrhagic contagion. 
 
 The average thickness of the vaginal walls is from 3 to 4 
 millimetres. The external coat is fibro-cellular and thin ; the middle 
 one is muscular and thick, formed of a superficial layer of longitudinal 
 fibres inserted below into the ischio-pubic rami, above into the 
 utero-sacral ligaments and into the uterus itself, and covers a 
 deep layer of fibres intercrossing obliquely or circularly. The inner 
 coat or mucous membrane, also thick, varying in colour according to 
 age and reflected above on to the vaginal portion of the cervix, is 
 furnished with a great number of papillae and covered with pavement 
 epithelium, which stops abruptly at the os externum and is renewed 
 throughout the whole extent of the mucous membrane with surprising 
 activity in certain pathological conditions accompanied by leucorrhcea. 
 
 It is remarkable that the vagina not only is susceptible of great expan- 
 sion and is dilated during pregnancy and delivery, but that it positively 
 hypertrophies during pregnancy, its tissues sharing with those of the 
 uterus, though to a smaller extent, the property of alternate hypertrophy 
 and atrophy, in order to meet the exigencies of their special functions. 
 
 The vagina seems to me to be without secreting organs properly so 
 called. After having passed the vulval ring or circular insertion of the 
 hymen, which is the limit of the richly glandular apparatus of the vulva, 
 we must reach the vaginal surface of the cervix before encountering 
 new secreting organs. The fluid which exudes from the vaginal mucous 
 membrane, carrying with it epithelial debris, is always acid. It not only 
 has a strong acid smell, but it powerfully reddens litmus paper. 
 
 The vulva is limited externally by the labia majora, the cutaneous 
 surface of which is covered with hairs implanted obliquely and the 
 mucous surface of which presents the orifices of numerous follicles, as 
 well as several rows of sebaceous glands.^ Below the skin and super- 
 ficial fascia is to be found a sac, which is serous, according to Broca,^ 
 and fatty according to Alph. Guerin,^ belonging to the mons veneris as 
 
 > According to C. A. Martin and Leger {Archives generates de Medecine,18G2) 
 the secreting apparatus o£ the external genital organs in woman is constituted 
 solely (with the exception of the vulvo- vaginal glands) o£ sebaceous racemose 
 glands and some sudoriparous glands which are only found on the external or 
 cutaneous surface of the labia. The muciparous follicles of the vestibule of 
 the meatus and of the urethra ai-e only mucous crypts. 
 
 ' Bulletin de la Societe anatomique, Mars, 1851. Morpain, Mtudes anato- 
 miques et pathologiques des grandes Icvres. These de Paris, 1852, No. 278. 
 He has adopted the ideas of Broca. 
 
 ' Maladies des organes gSnitaux externes de la femme, p. 243. Paris, 1804. 
 
52 
 
 INTEODUCTION 
 
 much as to the lah'ia majora, extendiDg from the external inguinal ring 
 to the level of the descending ramus of the pubis, separated above 
 
 Pig. 48. 
 
 Fig. 49. 
 
 Fig. 50. 
 
 Fig. 48, — Transverse and vertical section of the nymphse, — sebaceous glands 
 
 (after Cniveilhier) . 
 Fig. 49. — General view of the sebaceous glands of the vulva, under surface 
 
 natural size (Martin and Leger). 
 Fig. 50.— Sebaceous glands of the labia majora opening into a hair-sac, 20 
 
 diameters (Martin and Leger). 
 
 from that of the opposite side by a median sac, really serous, which 
 prevents friction of the skin on the pubis, and not passing beyond the 
 anterior half of the labium majus. 
 
 The labia majora in uniting form the anterior commissure, below 
 which is the clitoris. Behind and below they are flattened before 
 uniting to form a posterior commissure, called i\\efou7-cJieUe. Between 
 the anterior commissure, and especially between the clitoris and the 
 orifice of the vagina, is the vestibule. Between the posterior commis- 
 sure and orifice of the vagina is the fossa navicularis. The nymphae, 
 situated within the labia which they occasionally exceed in their 
 middle portion, are forked before and above, i. e. below the anterior 
 commissure, so as to form a kind of hood or foreskin for the clitoris. 
 They enclose a great number of sebaceous glands at this point. They 
 may be so hypertrophied as to exceed the labia majora to a certain 
 extent and become very troublesome under some circumstances, e. g. 
 in riding. Both surfaces are covered with mucous membrane, the 
 
ANATOMY, THYSIOLOGY AND TEEATOLOGY 53 
 
 internal having an innumerable quantity of little glands, generally 
 arranged in three or four concentric rows. 
 
 The meatus urinarius is situated 1 \ centimetres behind and below 
 the clitoris ; in virgins, as a rule^ it is a mere slit, but in lascivious 
 women it is open, owing to the erectile turgescence all round the 
 orifice. Sometimes it is half closed by a kind of inferior median ridge 
 continuous with a prominent inferior tubercle, occasionally double (Fig. 
 47), the termination of the anterior column of the vagina and serving 
 as a guide in catheterism. The meatus is generally on a line with the 
 vestibule when it is easily discovered. According to Alph. Guerin, 
 however, in women who have had precocious intercourse the vulva is 
 pushed backwards and the meatus concealed under the symphysis of 
 the pubis. Sometimes the vaginal orifice is gradually dilated without 
 any laceration of the hymen taking place. Generally, however, only 
 traces of this membrane are found after the first coitus. These vestiges 
 are known by the name of carunculse myrtiformes; they vary in 
 number, size, and form, according to the individual conditions and 
 the amount of violence used. There are generally four or five, most 
 frequently one inferior and always two lateral, at the base of which the 
 orifices of Cowper's glands are seen. The secreting organs of the vulva 
 are the sebaceous and piliferous follicles and the muciparous glands. 
 The sebaceous and piliferous follicles are excessively numerous, and are 
 only observed on the mons, on the labia majora and minora, and in 
 the genito-crural folds. The follicles of the nymphse are simply seba- 
 ceous. The muciparous glands are grouped within the nymphse, nearer 
 the entrance of the vagina. Some, already described by several 
 authors, notably by Regnier de Graaf^ and more recently by Eobert,^ 
 have been called by Huguier^ isolated muciparous follicles. The 
 others form a true gland, designated by this author as the vaginal 
 follicular body or vulvo-vaginal gland. The isolated muciparous folli- 
 cles are collected especially at three or four points round the vaginal 
 orifice ; at the vestibule, between the clitoris and the urethra (vestibular 
 follicles) ; circularly round the meatus, on the surface of the central 
 tubercle which limits this opening below {urethral follicles) ; at some 
 distance from the meatus and on its sides {urethro-lateral follicles) ; 
 lastly, sometimes on the lateral portions of the vaginal entrance, imme- 
 diately below the hymen or upper carunculm myrtiformes {lateral 
 follicles of the vaginal entrance) (JFig. 51). 
 
 The vulvo-vaginal glands described by Duverney, Bartholin, Garen- 
 geot, Morgagni, Cowper, and lately by Tiedmann* and Huguier^ are 
 
 * Traite des parties des femmes qui servent a la generation, p. 120, in 
 VSistoire anatomique des parties yenitales de I'homme et de lafemme. Bale, 
 1649. 
 
 2 De V inflammation des folUcules muqueux de la vulve. Arch. gen. de med., 
 August, 1841. 
 
 3 Memoire sur les maladies des appareils secreteurs des organes genitaux 
 externes de lafemme {Memoires de I' Academic de medecine, i. xv, p. 527, et seq.). 
 
 * Von den Duverney' sclien, Bartlwlin schen oder Cowper'schen Driisen des 
 Weibes. Heidelljerg, 1840. See also Knox, Lond. Med. Gaz., vol. xxiii. 
 
 » Op. cit. Paris, 1841. 
 
54 
 
 INTRODUCTION 
 
 conglomerate or racemose glands, situated right and left of the entrance 
 of the vagina, small before puberty, greatly developed in voluptuous 
 
 Fig. 51. 
 
 Fig. 52. 
 
 ^t 
 
 Fig. 51. — Muciparous follicles of the vulva, a, vestibular follicles ; 5, lateral 
 urethral follicles ; c, central urethral follicles ; d, lateral follicles of the 
 entrance of the vagina; e, orifice of the excretory duct of the vulvo- 
 vaginal gland. 
 
 Fig. 52. — Vulvo- vaginal gland and its excretory duct (after Huguier). a a, 
 section of the labium and nympha ; h, the gland ; c, its excretory duct ; 
 e, its orifice in the vulvo-carancular sinus, a director is introduced ; /, 
 bulb of the vagina ; g, ischio-pubic ramus. 
 
 / women, surrounded immediately by a fibro-vascular envelope in relation 
 with the transverse artery of the perineum, placed between the vagina 
 and its bulb (to which they lie close) on the inner side, the ischio- 
 pubic ramus, which is 1 centimetre to the outside, the central apo- 
 neurosis of the perineum situated behind and above, and the super- 
 ficial aponeurosis in front and below. They are bounded on all sides 
 by resistant layers, so that pus formed internally can hardly escape 
 into either the rectum or the vagina nor run together as in abscesses 
 of the labia. The excretory duct, 2 centimetres long, opens at the 
 union of the lower fourth with the upper three-fourths of the vaginal 
 orifice, beyond the hymen or lateral caruncula myrtiformes, at the base 
 of the groove which separates the external surface of these carunculse 
 from the internal surface of the nymphse, where it may often be 
 recognised by a red border. Excitation of the chtoris, the corpora 
 cavernosa and the bulb of the vagina greatly increases the secretion 
 of the vulvo-vaginal glands. 
 
 The mucus secreted by the follicles and the vulval glands is acid, 
 that which is secreted by the vestibular and peri-urethral follicles TiaT 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 55 
 
 always seemed to me more acid than that which is secreted by the 
 vulvo- vaginal gland. 
 
 Development — Comparison op the Genital Economy in the 
 
 TWO Sexes 
 
 Bevelopmeni}- takes place from different embryonic points, which are 
 more or less independent of each other in their evolution. The external 
 generative organs (the vulva and its dependencies) are developed from 
 the external layer of the blastoderm ; the internal generative organs 
 arise from the middle blastodermic layer. Hence anomalies may be 
 produced in one of these formations to the exclusion of the other. 
 There is even a point of central formation, which is neither the external 
 layer nor the intermediate blastema, but the septum estabhshed in the 
 primitive cloaca formed by the rectal cul-de-sac and the bladder which 
 has been previously derived from the latter under the form of the 
 hollow pedicle of the allantois ; the vagina is developed at this point, 
 which explains a relative independence between the anomalies of this 
 portion of the generative system and those of other parts. In short, 
 each of these portions, especially the internal one, presents in its turn 
 several centres of formation, equally endowed with a relative inde- 
 pendence each of the other, and capable of undergoing, each by itself, 
 arrests in development, alterations in type or differences of direction, 
 which multiply the number of anomalies and which may carry dis- 
 similarities in the development of different parts of the same economy 
 as far as that difference of sexual character which constitutes herma- 
 phrodism. 
 
 A few words will suffice to explain this. At the beginning the 
 development of the internal generative organs takes place around the 
 Wolffian bodies.^ These bodies atrophy towards the end of the second 
 month, leaving probably, as traces in the adult, those vestiges of 
 organs in connection with the testicles or ovaries known by the names 
 of vas aherrans in the male and the organ of Rosenmiiller in the 
 female. Whilst the Wolffian bodies atrophy, new organs are developed 
 in the same region. These are the kidneys, the ovaries or the testicles, 
 the oviducts or the spermatic ducts, &c. 
 
 I. Along the inner border of the Wolffian body there is a fusiform 
 enlargement which, increasing gradually in size and diminishing in 
 length, forms the first rudiment of the testicle or ovary. Along its 
 external border, parallel and attached to its excretory duct, but quite 
 
 • See Kiissmaul's work, Yon dem Mangel, Verhummerung und Verdoppelung 
 der Gebdrmutter, Wurtzburg, 1839 ; as well as the work of M. Lefort, Des vices 
 de conformation de I'uterus et du varjin, &c., Paris, 1863, and that of Guyon, 
 Des vices de conformation de I'urcthre chez I'homme, Paris, 1863 ; see also 
 Albers, Die weibliche Cloakbildung in Monatssclirift fiir Geburtsh, xmd Frauen- 
 Tirankheiten, Berlin, 1860, Bd. xvi, 4*^ Heft ; and Koelliker, Entwiclcelungsge- 
 schichte der Menschen und der hoheren Thieve. Leipsig, 1861. 
 
 - FoUin, Becherches sur les cori^s de Wolff. Paris, 1850. 
 
56 INTRODUCTION 
 
 independent of the tubes, there is a second organ, at first a simple 
 solid cord, later hollowed into a canal, known by the name of Miiller's 
 duct. The excretory canal of the Wolffian body and Miiller's duct 
 
 Fig. 53. Fig. 54. 
 
 Tia. 53. — Wolffian body (aftei' Coste). c v, Wolffian body ; s, excretory canal 
 o£ Wolffian body ; o, future ovary or testicle ; t, future oviduct or sperm- 
 duct called Miiller's duct ; m, future uterus ; the figure placed alongside 
 shows tbe glandular structure of these organs. 
 
 Fig. 54. — Wolffian body and internal uro-genital system of the human 
 embryo after the fortieth day (after Coste). cv, Wolffian body ; o, ovary 
 or testicle ; s, excretory canal of Wolffian body ; i, sperm-duct or oviduct, 
 Miiller's duct ; m, future uterus ; c, suprarenal capsule ; r, kidney ; u, 
 ureter ; v, bladder ; gi, large intestine, rectum. 
 
 both run into the cloaca. Now, according to Rathke and Kobelt, 
 whilst the sperm-duct is developed from the excretory canal of the 
 Wolffian body, the oviduct proceeds from Miiller's duct. 
 
 In the first period of intra-uterine life there is a time when distinc- 
 tion of sex is impossible. This confusion is owing to similarity of 
 form, which soon disappears in the internal as well as in the external 
 organs. 
 
 If Miiller's duct atrophies, Wolff's excretory duct forms a sperm- 
 duct, and is united, by means of tubes afterwards transformed into the 
 epididymis, with the germinative organ which becomes the male 
 generative organ or testicle. If Miiller's duct is developed it forms 
 an oviduct, develops at its extremity a Tallopian tube, and remains 
 distinct from the germinative organ, i. e. from the ovary. As for the 
 germinative organ, it is united to the sperm -duct by efferent vessels 
 (epididymis), or it remains isolated from Miiller's duct, with the 
 exception of the interposition of a certain number of atrophied 
 Wolffian ducts (organ of Eoseumiiller), according as it is testicle or 
 ovary. 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 
 
 57 
 
 Thus, the Wolffian body never entirely disappears either in the 
 male or female; its elements atrophy. In the male the remains of its 
 tubes, besides the part which they have taken in the formation of the 
 epididymis, frequently become small epididymous cysts, and form pro- 
 bably the corpus innominafum of Giraldes,^ the rasa aherrantia of 
 
 Fig. 55. — Figure showing the organ of Rosen miiller. Superior right angle of 
 the uterus (Ut) and portion of the hroad ligament (LI) with oviduct and 
 ovary, seen from behind ; Od, isthmus of the oviduct ; Od', largest portion 
 of this canal ; J, fimbriated extremity ; Oa, abdominal orifice of Fallopian 
 tube ; Fo, fimbriae ; 0, ovary turned downwards ; Lo, ovarian ligament ; 
 io, infundibulo-ovarian ligament ; ip, infundibulo-pelvic ligament divided 
 at its pelvic insertion ; Po, parovarium or organ of Eosenmiiller, exposed 
 to view by the ablation of a portion of the posterior fold of the broad 
 ligament ; *, vascular branch which follows the border of the ovary. 
 
 Haller. In the female the Wolffian body becomes the organ of 
 Eosenmiiller, its central tubes end in the hilum of the ovary, the 
 outer ones disappear or atrophy and remain the analogues of the 
 vasa aherrantia ; the excretory duct of the Wolffian body disappears 
 by atrophy, and is found in this state, in the cow for example, on 
 each side of the uterus as far as the vagina, where it terminates under- 
 the name of Gsertner's canal. 
 
 Therefore, according to the form of development affected by MUller's 
 ducts or the Wolffian ducts, an oviduct or sperm-duct is produced, and 
 concurrently with it an ovary or testicle. 1. One of these forms of 
 development may appear on one side, whilst another is produced on 
 the opposite side, the result of which would be a lateral hermapbrodism. 
 2. The two forms of development may appear incompletely and simul- 
 taneously on the same side (but much less frequently so, especially 
 
 ' Becherches anatomiques sur le corps innomine, Journal de Brown-Sequard, 
 t. iv, p. 1. 
 
58 INTRODUCTION 
 
 as regards the germinative organ), so that on this side there may 
 be produced a testicle and an oviduct or an ovary and a sperm- 
 duct, and even a testicle and an ovary superimposed, a phenomenon 
 to vehich has been given the name of double or vertical hermaphro- 
 dism ; only we must remember that it is easy to be led into error in 
 this case by the persistence of the Wolffian duct or of Gsertner's 
 canal. 3. Lastly, one of these forms of development may take place 
 in all the deep organs, which will be, for example, all male, whilst 
 the opposite development is effected in the superficial organs which 
 are female, the result of which would be transverse hermaphrodism. 
 As regards this transverse hermaphrodism, the independence of the 
 development of the external and internal generative organs, which 
 are produced in two fields of formation quite different from each 
 other, shows that it may occur comparatively frequently .^ 
 
 Now, in order to understand how Miiller's ducts when transformed 
 into oviducts, are developed into Fallopian tubes and uterus, and how 
 the continuity of these organs is estabHshed with the vagina and 
 external generative system, we must remember that development 
 proceeds simultaneously on the intermediate blastema and on the 
 internal and external layers of the blastoderm. 
 
 On the internal layer this development takes place early. The allan- 
 tois produced by budding from the anterior surface of the rectal cul- 
 de-sac continues attached to the rectum by its pedicle. This pedicle 
 is hollowed out into a canal (urachus), which widens at its point of 
 origin in the rectum into a reservoir (the bladder) ; so that at this 
 period the bladder and rectum form a true cloaca in which the 
 genito-urinary canals terminate, similar to that on the exterior which 
 precedes the formation of the anus and urogenital orifice. In pro- 
 portion as the uterus is formed by the apposition of Miiller^s ducts the 
 cloaca is divided, allowing the formation of the vagina either in the 
 blastema interposed by this division between the bladder and the rectum, 
 as is supposed by Eathke who thinks the lower part of the uterus is 
 developed in the same way or by the prolongation of Miiller's two 
 ducts, which themselves form a double vagina below a double uterus. 
 
 I think the most probable hypothesis to be that which limits to 
 the uterine cervix the formations depending on Miiller's ducts, and 
 which supposes the vagina to be developed from the tissue the inter- 
 position of which between the rectum and the bladder has previously 
 eflected the separation of these two reservoirs, or in its lateral borders. 
 I will give my reasons presently. 
 
 However that may be, we can in any case say with certainty that 
 Miiller's ducts, during the development of their lower portion whilst 
 approaching each other and in proportion as they descend, pass 
 through three periods characterised by — 1, complete separation and 
 division; 2, reunion in the median line; 3, complete fusion. 
 
 Eunning along the external border of the excretory canal of the 
 "Wolffian body, Miiller's duct changes its direction lower down and 
 
 ^ GeofEroy Saint-Hilaire, Traite de teratologie. Paris, 1836 ; L. Lefort, op. 
 cit., p. 174. 
 
ANATOMY, PHYSIOLOGY AND TEBATOLOQY 59 
 
 describes a half circle round this canal, coining in front and to the 
 inner side of it to meet its fellow of the opposite side to which it 
 becomes attached and united in the median line. 
 
 J. Y. Meckel observed, in embryos of from eight to nine weeks, 
 absolute equality in calibre and the absence of any line of demarca- 
 
 FiG. 56. — Development of the internal genito-urinarj organs in a human 
 emhryo older than the preceding (after Coste). c, suprarenal capsules ; 
 r, kidneys ; o, ovaries ; u, ureters ; t, Fallopian tubes ; m, uterus ; I r, round 
 ligament ; v, bladder. 
 
 tion between the rudimentary oviduct, uterus, and vagina. According 
 to Kiissmaul, however, at about three months the womb can easily be 
 distinguished from the vagina by a somewhat greater thickness and 
 consistency ; the very fine oviducts begin to become flexuous, and are 
 about a third longer than the corresponding uterine cornu. The sepa- 
 ration between the oviduct proper and the uterine cornu is marked by 
 the insertion of a fibro-muscular cord, afterwards to be known as the 
 round ligament. Meckel justly compares this organ to the suspensory 
 ligament of the testicle {guhernaculum testis of Hunter). Wrisberg 
 designates it the cremaster of the womb, and Rathke confirms the 
 analogy by the study of its development in the embryo. 
 
 Between the testicle or ovary on one side and the pubis on the 
 other extends on each side a kind of ligament, destined to become 
 more or less muscular, having connections with the inguinal canal, 
 the scrotum or labium. The presence of this organ determines, in the 
 scrotum or labium, the peritoneal prolongation known as the ijinica 
 vaginalis in man, canal of Nuck in woman, the obliteration of 
 which takes place after birth, partially in the one, completely in the 
 other. Its ulterior changes bear a relation to the displacements of the 
 testicle and ovary. The testicle, descending into the scrotum, pushes 
 before it the gubernaculum which covers it and which is transformed 
 principally into the cremaster ; the ovary, descending only into the 
 
60 INTEODUCTION 
 
 pelvic cavity, preserves its relations with this organ which, adhering 
 to the oviduct at its point of intersection with this canal and there 
 modifying the direction or the number of its contractile fibres, becomes 
 the uterine ligament of the ovary in its upper portion and the round 
 ligament of the uterus in its lower portion. The portion of the ovi- 
 duct placed above it forms the Fallopian tube, that below it the womb. 
 The two uteri are recognisable for a long time after their union by the 
 projection of the cornua of which the Fallopian tubes are a continua- 
 tion. Gradually the fundus rises slightly between these two cornua 
 but for a long time without the organ losing the traces of its primi- 
 tive duplicity. The womb at the same time becomes more volumi- 
 nous, more cylindrical, and the body may be distinguished by the 
 enlargement of the upper part. This portion, however, remains in a 
 state of comparative inferiority ; for, owing to the length of the neck, it 
 does not reach the third of the total length of the organ in a foetus at 
 term. 
 
 To sum up : two cords at first solid (Miiller's ducts), separated 
 above by the width of the vertebral column and of the Wolflian body, 
 are united below back to back. The part situated above the point of 
 union and Hunter's ligament will form the Fallopian tube, the part 
 below will constitute the uterus. Each of these cords is hollowed into 
 a distinct cavity, then the partition separating the two disappears from 
 above downwards, and the uterine canal, at first double, becomes finally 
 single. 
 
 II. Between the internal generative economy, the development of 
 which we know, and the external generative economy, the formation 
 of which we shall presently study, there is an organ of transmission ^ 
 the vagina, intermediate in function as in position. The notions 
 which we have as to its evolution are somewhat hypothetical, for they 
 are deduced partly from direct observation by embryology, partly from 
 indirect observation by teratology. We have seen that, within the 
 external fold of the blastoderm while still imperforate, there is a true 
 cloaca or cavity common to several hollow organs. This cloaca is 
 the termination at first of the rectum behind, then of the bladder (dila- 
 tation of the hollow pedicle of the allantois) before, and finally of the 
 excretory canals of the Wolffian bodies, of Miiller^s ducts and of the 
 ureters laterally. The communication between the rectum and bladder 
 is limited above by a band or elevation, indistinct at first, but which, 
 becoming more and more marked, descends from above downwards 
 under the form of a flattened membrane, and gradually separates the 
 intestinal cavity completely from the reservoir of the urine. 
 
 It is in the central blastema forming the division between these 
 two reservoirs that the vagina is soon afterwards developed ; it has 
 not been determined whether it is developed from above downwards 
 or from below upwards, but it is certainly produced from two lateral 
 canals, communicating above with the uterine necks (the probable ter- 
 mination of Miiller's ducts) and below with the vulva where may be 
 found a double hymeneal orifice, and destined, like several other pairs of 
 organs, to unite together, the absorption of the partition reducing them 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 61 
 
 to a single canal extending from the uterine orifice (which has also 
 become single) to the vulval ring developed in the midst of the 
 cutaneous formations. 
 
 Now, if the membranous band destined to separate the rectum from 
 the bladder is not formed, an abnormal communication^ (cloaca) will 
 persist between the two organs. If formed incompletely and hollowed 
 into a vagina, a double communication will remain, giving rise to a 
 double congenital fistula (vagino- vesical and vagino-rectal). If the 
 vesico-rectal septum is formed but not hollowed out, there will be no 
 vagina ; if hollowed out imperfectly, there will be a partial vagina ; the 
 superior or inferior portion may be in turn alone developed, or two 
 parts may exist simultaneously, the one superior, the other inferior, 
 between which there may be at a variable height, a transverse partition, 
 thick or thin, imperforate or perforate. Lastly, if the primitive double 
 vagina is developed normally in the vesico-rectal septum, but if 
 the development is arrested there, a double vagina will persist, co- 
 existing or not with a similar arrest of development in the uterus. If 
 the two canals are united incompletely the malformation will be limited 
 to a partial longitudinal partition between the right and left portions 
 of the vagina; if the union is complete, but if the cavity has not 
 enlarged to its normal extent, there will be a congenital narrowness. 
 
 III. The external generative economy ^q%^ not begin to be developed 
 till after the first formations of the internal generative organs, particu- 
 larly the Wolffian bodies. In an embryo of thirty-five days an accumu- 
 lation of blastema may be seen on the external tegument near the 
 caudal extremity. The result is a simple oval, central eminence, from 
 which afterwards a secondary formation of buds is seen to arise, 
 destined to form a series of appendages. This eminence is soon 
 hollowed out in the centre by a longitudinal depression which, by 
 corrosion of the tegumentary fold, soon becomes an external linear 
 orifice, getting deeper and deeper and terminating (when evolution 
 progresses regularly) by communicating with the cloaca of which we 
 have spoken and afterwards with the vesical, vaginal and rectal cavities 
 which finally become distinct and independent. Later on two rounded 
 eminences are developed from each side and towards the upper part 
 of this slit, destined to form the corpora cavernosa of the penis in 
 the male, the clitoris and nymphse in the female. They are united 
 at first by their upper or dorsal surface, leaving a lower half-groove 
 between the opposed surfaces. This half-groove persists in the forma- 
 tion of the female economy; in that of the male it is closed below 
 by a kind of raphe, which converts the primitive half-canal into a com- 
 plete one, the urethra. The malformation known as hypospadias results 
 from the arrest of development in this line of union. 
 
 Below these eminences two others are developed, which in the male 
 form the scrotum, in the female the labia. Lastly, a transverse parti- 
 tion is developed lower down, which ultimately becomes the perineum 
 separating the anus from the vulva. 
 
 ' Puech has written a good paper on the uro-genital cloaca. Montpellier 
 Medical, Jan. and Feb., 1868. 
 
62 mTRODUCTION 
 
 It is by the disappearance of the tissue situated between the rectal 
 cul-de-sac, the vagina, and the bladder on one side, and the external 
 integument on the other, that the three cavities — intestinal, genital 
 
 Fig. 57. — Development o£ the anus and external genital organs in a human 
 embryo of thirty-five days (after Coste). i, intestine, on the sides of 
 which two white masses are seen (Wolffian bodies) ; below is the section of 
 the urachiis and umbilical arteries and veins ; lower still, the cutaneous 
 fold slightly turned back over the ano-genital orifice. The latter consists 
 in a simple slit in the centre of an ovular eminence, m i, inferior mem- 
 brane ; 2> caudal prolongation. 
 
 and urinary — open externally. If this development does not proceed 
 regularly and completely on a level with the anal depression, the rectal 
 cul-de-sac will not open, and there will be an imperforate rectum. 
 When an analogous phenomenon occurs in the vaginal portion, there 
 will be a more or less extensive obliteration of that part of the vagina 
 which joins the vulval ring or simple imperforation of the hymen. 
 
 Comparison of the generative organs in the two sexes. — The reader 
 would wish me, I think, to follow up the description of the develop- 
 ment of the uterus and its appendages by some observations on the 
 independence of the different zones in which the genital economy is 
 developed, and on the analogies between the different parts of this 
 economy in the male and female. These considerations may not only 
 throw some light on the diagnosis of sexual anomalies in general, and 
 help in determining particular cases, but they may also lead to more 
 frequent and immediate applications to the various morbid states of the 
 genital organs than one would at first be apt to think. 
 
 The direct observation of the development of the embryo shows that 
 the genital economy may be divided into three zones, which must be 
 considered as three distinct seats of organic evolution, each developed 
 independently of the others, and tending to produce one system 
 destined for the accomplishment of a single function. Of these three 
 zones the two outer are principal, the middle or intermediate one is 
 secondary. The former are the internal and external genital organs, 
 the latter is the means of union between the two. 
 
 The middle zone is simple : the vagina is developed between the 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 
 
 63 
 
 vulval ring belonging to the external zone and the neck of the uterus 
 belonging to the internal zone, almost in the same way that the oeso- 
 phagus is developed between the C2il-de-sac of the stomach pierced by 
 the cardiac orifice and the cephalic cul-de-sac developed into the buccal 
 
 Fig. 58. 
 
 Fig. 59. 
 
 Fig. 58. — Development of the anus and external genital oi'gans in a human 
 embryo of from thirty- five to forty days (after Coste). o, urachus and 
 pedicle of the umbilical vesicle, the umbilical vessels of each side ; c, 
 cutaneous fold of the umbilical cord wide open ; i, intestine ; g, centi"al 
 projection produced by the development of the genital economy. If this 
 projection is seen in front, as in the annexed figure, two lateral eminences 
 will be observed above, the origin of the future corpora cavernosa ; below, 
 two smaller eminences, the origin of the future scrotum or labia. On the 
 median line above, a slit between the points of origin of the corpus caver- 
 nosum ; lower down, an opening, the uro-genital orifice ; lower still, a 
 second opening, the anus. 
 
 Fig. 59. — Development of the external genital organs in an embryo a^ little 
 older than the preceding, the sex of which, however, cannot yet be dis- 
 tinguished, p, corpus cavernosum (penis or clitoris), below which inins a 
 central groove terminating in the uro-genital orifice ; b, scrotum or labia 
 not yet united in the median line ; a, anus. 
 
 and pharyngeal cavity. The external zone is complex, but this com- 
 plexity depends only on its structure, and not on the difference of the 
 seats of evolution, its whole development being effected at one and 
 the same point in the embryo. The internal zone is more complicated 
 still, for the character of this complication exists in the multiplicity of 
 the centres of formation, the ovaries being developed along the internal 
 border of the Wolffian bodies, whilst the Fallopian tubes and the 
 uterine cornua are formed along their external border, the Fallopian 
 tubes above, the cornua below the point where the oviduct, considered 
 as a whole, crosses Hunter's ligament. 
 
 These various centres of formation are precisely the points at which 
 development may be arrested separately, or where a deviation of the 
 plastic act may be manifested. Therefore the anomaly may affect the 
 ovary, Fallopian tube or cornu on both sides or on one. It may 
 extend to several of these organs at once. The whole internal zone 
 may be affected or the intermediate or external one. The two former 
 
64 INTRODUCTION 
 
 zones may even be affected to the exclusion of the third, or the latter 
 may alone be affected ; for the two former are situated in the blastema 
 between the serous and mucous folds, and the third in the serous fold 
 transformed into the cutaneous envelope. Now, my teratological 
 studies have led me to consider these primordial embryonic folds as 
 seats in which very frequently the action of the cause which brings 
 about an arrest of development is exhausted; between these points 
 there seem to be limits which cannot be passed by any known terato- 
 logical cause.^ 
 
 As for the analogies which embryology, in concert with relations, 
 connections, structure, vascularisation, innervation and functions, 
 permits us to establish between the various portions of the genital 
 economy, male and female,^ I shall confine myself to their enume- 
 ration. 
 
 In the external economy the analogy is striking between — 
 
 The scrotum . . . , 
 The penis . . . . . 
 The bulb of the urethra 
 The glands of the urethra . 
 Co\vper's (bulbo-urethral) glands , 
 
 and the labia majora, 
 „ „ clitoris, 
 „ ,, bulb of the vagina, 
 „ those of the vulva, 
 „ Bartholin's (bulbo- vulval). 
 
 In the internal economy it is easily demonstrated between — 
 
 The testicles and the ovaries, 
 
 The cremasters „ „ round ligaments, 
 
 The vasa deferentia . . . • „ „ Fallopian tubes, 
 
 The lower extremity of the vasa defer- ( The body of the uterus, with the glands 
 entia and their vesiculge seminales . j ""^ ^^\ ™^PT^' membrane and its 
 
 (. muscular richness. 
 
 The eiaculatory ducts opening on the'^ j j-l • i • • •, 
 
 venimontanum, separated by the P^^ the cervix uteri, conical, and 
 utriculus and surrounded by the f surrounded by its glandular agglo- 
 prostate ....■:.; ^^^^'^n. 
 
 Lastly, the intermediary organ is represented by — 
 
 The membranous portion of the xu'ethra 7 j j.t- • • 
 
 i't, tyiot, c ^^"- *"6 vagina in woman. 
 
 This last analogy may seem strange without a little reflection. It 
 is, however, easily justified. The vagina, in fact, is developed in the 
 blastema between the rectum and bladder immediately above the 
 central perineal aponeurosis, by the formation, in the vesico-rectal par- 
 tition, of a canal which goes to meet the vulval slit on the one side 
 
 1 Memoire sur V absence complete du vagin, de Vutenis, des trompes et des 
 ovaires, &c., with remarks on the absence or aiTest of development of the 
 various parts of the genital economy of the female and general considerations 
 on teratological laws ; in the Memoires de V Academic des sciences et lettres de 
 Montpellier, t. ii, p. 321. Montpellier, 1853. 
 
 ^ It is curious and very interesting to pursue these researches on the analogy 
 between the various parts of the vascular system, the nerves, muscles, apo- 
 neuroses and glands, and to verify the wonderful concordance existing between 
 the elements which correspond in the male and female. 
 
ANATOMY, PHYSIOLOGY AND TEEATOLOGY 65 
 
 and tlie cervix on the other. It is identically at the same point and 
 in the same way that the membranous portion of the urethra in man 
 is formed, in front of the urethral crest (junction of the two sperm- 
 ducts), behind the groove of the penis which is soon converted into a 
 canal by an inferior line of union extending to the bulb where is also 
 found a falciform fold, the boundary line between cutaneous and inter- 
 mediary formations, and where, when catheterism is practised on the 
 male, the catheter is frequently arrested before penetrating the mem- 
 branous portion. 
 
 A consequence which results from the latter analogy seems, at first 
 sight, very paradoxical, namely, that in man there is no proper urethral 
 canal whilst there is one in woman. In man, the canal by which the 
 urine flows from the bladder is nothing but the analogue of the vagino- 
 vulval canal in woman developed in another way and put to other 
 uses. In man, the urinary passages properly so called terminate at the 
 neck of the bladder. The canal into which they open belongs, by its 
 origin and destination, to the genital economy. It is certainly, and 
 above all, the propulsor of the semen. It only lends itself to the 
 excretion of the urine which passes through it from one end to the 
 other, traversing successively its prostatic (cervix), membranous 
 (vagina), and buibo-spongiose (vestibule) portions — a new proof of the 
 differences of structure or of destination which nature can imprint 
 on organs fundamentally identical.^ 
 
 The aim of such research after analogies leading to such results is 
 chiefly to satisfy the mind and to lead it to the philosophy of science ; 
 it may, however, also lead to some practical applications. The physiolo- 
 gist does not undertake the study of organic analogies because he 
 desires to force a resemblance between dissimilar organs, but because it 
 is interesting to observe how these various parts are gradually formed 
 and differentiated from each other, although their embryonic identity 
 was such that it was impossible to predict their future condition ; also, 
 because the knowledge of these analogies leads to unexpected anatomi- 
 cal and physiological interpretations stamped with the most living 
 reality ; and lastly, because exact and useful resemblances may be 
 deduced from a pathological point of view between organs proved to 
 be anatomically analogous. 
 
 Anomalies 
 
 The majority of permanent teratological conditions in the genital, 
 as in all the other organs of the economy, represent transitory embry- 
 
 ^ In 1849 I pointed out all these analogies, developing them in a paper 
 entitled, Des diffa-ences que presente I' organisation dih corps hmnain dans les 
 deux sexes, which was published in tlie Annales cliniques de Montpellier, 1855. 
 My colleague and friend, Professor liouget, had on his side been led to adopt 
 similar conclusions, especially with reference to the cervix and prostatic portion 
 of the urethra. See his Beclierches sur le type des organes gmitaux et de lews 
 appareils musculaires. Paris, 1855. 
 
 5 
 
66 ' INTRODUCTION 
 
 onic states. Ifoerster/ Kiissmaul/ Leon Lefort/ and Klob* have 
 based the natural classifications which they have made of these mal- 
 formations on this idea. This scientific interest^ however, is not the 
 only one which leads us to say a few words on the anomalies of the 
 genital economy of woman. The cases of vaginismus, impotence, 
 dysmenorrhoea, and sterility, which are simply dependent on a tera- 
 tological condition of the genital organs, are so common that every 
 day in practice we have additional proof of the necessity there is for 
 the physician to know exactly the normal disposition of the sexual 
 organs, what I may call their physiological form, so as to be able to 
 distinguish it without difficulty from the alterations in form, size, 
 situation and relations which suffice to prevent the accomplishment 
 of their functions, and to seize easily the indications that must be 
 fulfilled in order to correct these anomalies and bring them back to 
 their normal conditions or conditions resembling their normal develop- 
 ment. With a little experience we can often guess at the existence 
 of these monstrosities by subjective signs and, if the development 
 of the sexual economy and the arrests of development to which 
 it is exposed are present to the mind, we can easily diagnose 
 them by the objective signs which are detected by methodical 
 examination. 
 
 In giving a teratological description of the various zones of the genital 
 economy in woman, I shall omit a multitude of facts which are only 
 interesting as mechanical causes of more or less serious derangements in 
 the accomplishment of their functions, while I shall place in the hand of 
 the physician a clue which will enable him easily to find his way through 
 the labyrinth of anomalies which suffice to produce the most serious func- 
 tional disorders and become the starting-point of diseases the real cause 
 of which was for long, and is even now, too frequently misunderstood. 
 
 I. General Anomalies of the Generative System 
 These anomalies may be characterised by an absence or imperfection 
 of formation, by an excess of development, or by a defect or deviation 
 of the plastic process. The first kind is equivalent to absence of sex or 
 neutrality in the individual, the second to real hermaphrodism by 
 substitution or excess, the third to an apparent hermaphrodism. 
 
 1. Neutrality. — There may be absence, rudimentary state, imper- 
 fection or arrest of development with persistence of the embryonic 
 form of all the organs constituting the three zones of the generative 
 system, or of all the organs of one of the three zones, or of some, or of 
 even one only of these organs, the consequence of which is a condition 
 which makes it impossible for the individual to accomplish functions 
 devolving on organs which do not exist, and which is equivalent to the 
 
 ^ Manuel d'anatmnie patJiologique, translated by Kaula, p. 440. Strasbourg, 
 1853. 
 
 2 Von dem Mangel, VerTcilmmerung u. Verdoppelung der Geharmutter. 
 Wiii-tzburg, 1859. 
 
 ^ Des vices de conformation de I'uterus et du vagin, p. 23 and following. 
 Paris, 1863. 
 
 * Pathologische Anatomie der weiblichen Sexualorganen. Vienna, 1864. 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 67 
 
 absolute privation of sex^ assimilating the woman so affected to tliose 
 females amongst insects (bees^ ants, &c.) designated as neiders, owing 
 to the absence, rudimentary condition or congenital atrophy of their 
 sexual economy. This condition may produce incapacity for repro- 
 duction owing to the absence of germination, and the impossibility of 
 forming a germ or ovule, or it may lead to relative impotence owing 
 to the difficulty or obstacles, sometimes quite insurmountable, which 
 alterations in form and position of the organs produced by these 
 arrests of development put in the way of coitus, of the subsequent 
 meeting of the male and female element, and of fecundation; or 
 lastly, there may be germinative impotence, impossibility of fecunda- 
 tion and incapacity for gestation, owing to the absence of the uterus 
 itself. I have seen individuals inscribed in the civil register as women, 
 some of them having the marks of a feminine organisation, but in 
 whom the generative functions, by an arrest of development affecting 
 part or the whole of the sexual economy, were so annihilated as to 
 assimilate them to those animals known as neuters. As one of many 
 interesting cases of this kind which I have seen and have been able to 
 examine, there was one on which I had to give an opinion based on 
 subjective signs alone (the subject refusing to be examined) taken 
 from what the patient herself said and from the testimony of persons 
 who knew her. I found in these signs proofs which enabled the 
 tribunals to declare nullity of marriage on the ground of error as to 
 the sex of one of the parties.^ 
 
 2. True Jiermaphrodism, common in the lower animals and in almost 
 all vegetables (under the name of gynandry or androgyny), was till 
 lately believed to be only apparent in the human kind. 
 
 Two cases, however, are now recorded, one by Eokitansky and another 
 by Heppner, which prove to a certainty that the simultaneous presence 
 of organs characteristic of both sexes may be found in the same in- 
 dividual, not only the one on one side the other on the other, but both 
 simultaneously on the same side. 
 
 There is no longer any doubt either as to the mode in which the 
 testicle and ovary, sperm duct and oviduct, are formed. Eokitansky,- 
 in 1869, presented to the Medical Society in Vienna the results of the 
 autopsy of a person named Hoffmann, in whom he found two ovaries 
 with their Fallopian tubes, a rudimentary uterus and one testicle with 
 vas deferens containing spermatozoa. This individual, who had men- 
 struated regularly, had an imperforate penis and a bifid scrotum ; there 
 was absolute sexual indifference. 
 
 Heppner,'^ of St. Petersburg, has published the interesting results 
 
 ^ Courty, Bemande en nullite de mariage, fondee sur le defaut de caracthres 
 sexuels feminins ; consultation medico -leg ale et considerants du jugenient. 
 Montpeilier medical, t. xxviii, p. 473 ; Montpellier, 1872 ; and Annates de 
 Gynecologic, t. ii, pp. 325, 410. Paris, 1874. 
 
 ^ Centralblatt filr die inedicinisclie Wissenschaften, Berlin, Union medicale, 
 3rd series, t. vi, p. 498. Quoted by Maurice Laugier, Nouveau dictionnaire de 
 medecine et de chirurgie pratique, t. xvii, p. 505. 
 
 3 Sur rherniai)hrodisme vrai dans I'esphce hwnaine, trad, par Douinic, 
 Gazette medicale de Paris, 1872, p. 29. 
 
68 
 
 INTEODUOTION 
 
 of the autopsy of a hermaphrodite of six weeks^ preserved in alcohol 
 for several years. He found in this child, together with a complete 
 internal generative apparatus (ovaries and Fallopian tubes, uterus and 
 vagina opening into the urethra), two glands which microscopical 
 examination proved most clearly to be two testicles. There was a penis 
 and a hypospadic prostate, but neither vesiculce seminales nor vasa 
 deferentia. Thus there may be excess of formation, not in the external 
 and median zones which are never double and in which a male de- 
 velopment can only be substituted for a female, or vice versa, but in 
 the inner or deep zone, where the male and female germinative organs 
 may exist simultaneously, not only the one to the right and the other 
 to the left, but both on the same side and even both on both sides, 
 which is the extreme case of bi-sexual hermaphrodism, or hermaphro- 
 dism by excess. In most cases, in place of finding male and female 
 organs on both sides or on one side, we observe male organs on one 
 side and female organs on the other, or male organs in one of the 
 zones, or in a part of one of the zones, and female organs in another. 
 
 Fig. 60.— Apparent female hermaphrodism owing to the abnormal development 
 o£ the clitoris, obliteration of the vagina and descent of the ovary into the 
 labium (after Anger). The first fig. represents the hermaphrodism before 
 the operation ; the second after, c, clitoris ; sv, sound in the vulval 
 orifice ; o, ovary ; v, urethra ; Va, vagina formed by operation. 
 
 or in a part of another zone. "When a more or less complete male 
 organism on the one side co-exists with a more or less complete female 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 
 
 69 
 
 organism on the other, this anomaly is called lateral hermapTirodism. 
 When the genital economy of one sex is developed on both sides in one 
 of the zones, and the genital economy of the other sex in another zone, 
 this anomaly is called transverse hermaplirodism. Lastly, when there 
 is co-existence on one side only of an organ of one sex in one of the 
 zones with an organ of the other sex in the same zone, or if the deep 
 zone belong to one sex and the central or superficial zone to the other 
 (case included in the preceding), it is called vertical or double Jierma- 
 pkrodism. 
 
 True hermaphrodism, therefore, may be simple or double, unilateral 
 or bilateral. From a physiological point of view it will be seen that 
 it is not possible for a hermaphrodite to effect self-fecundation nor to 
 assume the sexual functions of both sexes alternately with another 
 hermaphrodite, as do the lower animals when similarly organised ; in 
 fact, this apparent wealth is in reality poverty. When there is an 
 excess of organs in any individual this excess always coincides with a 
 
 Fig. 61. — Marie-Magdeleino Lefort. Section oE tlic pelvis sliowingtlie sjenital 
 organs, s, sound passing through the principal orifice below the clitoris ; 
 V, vagina ; o, ovary ; T, Fallopian tube ; u, uterus ; Lr, round ligament ; 
 C, clitoris ; L, labia. 
 
 defect, an imperfection or an absence of formation in these organs. 
 The arrest of development which always accompanies these singular 
 
70 INTRODUCTION 
 
 anomalies affects not only the additional organs, but also the organs of 
 the primitive or fundamental sex — all the organs, in fact, in the zone 
 in which the teratological condition is manifested, and frequently 
 those in the other zones also. 
 
 3. Apparent hermapJirodism. — In most cases the hermaphrodism is 
 apparent. If the testicles have not descended from the abdominal cavity, 
 if the penis has remained small, the two halves of the scrotum sepa- 
 rated, the bulbo-spongiose groove open and communicating directly 
 with the membranous portion, and if the urethra terminates in hypo- 
 spadias, the cryptorchis, the species of vagina of the intermediary zone, 
 and the arrest of development in the external zone which preserves the 
 appearance of a vulva, concur in giving to the whole of this sexual 
 organism a feminine aspect. If, on the contrary, the ovaries have 
 descended by the inguinal canal, as has been the case, if the bulbo- 
 cavernous groove be closed, the labia united, the clitoris hypertrophied^ 
 the beard developed and the breasts arrested in their development, the 
 woman in many respects will have the appearance of a man (Kgs. 60 
 and 61) . Lastly, while certain organs have preserved a feminine appear- 
 ance, others by union and hypertrophy may have assumed a masculine 
 character, so that the most unexpected results of apparent hermaphro- 
 dism may be presented, making the determination of sex a matter of 
 great difficulty. This is seen in the history of a certain number of so- 
 called hermaphrodites recorded in the archives of science, among others 
 in that of Marie-Mag deleine Lefort (Fig. 61). 
 
 The reflections suggested by the knowledge of these general anoma- 
 lies will naturally find their place in the history of sterility, which is 
 the usual consequence of these teratological conditions. 
 
 II. — Anomalies of the Ovaries 
 
 Absence. — Of all the anomalies of the generative organs the absence 
 of both ovaries is not only that which occurs most rarely, but also that 
 which is most frequently accompanied by other anomalies of other 
 portions of the generative system. 
 
 In two thirds of the cases in which absence of the ovaries has been 
 observed the vagina, uterus and Fallopian tubes were also absent ; in 
 the remaining third the uterus existed but was imperfectly developed, 
 presenting after puberty the characteristics of fcetal or infantile life. A 
 case recorded by Depaul is the only one which leaves any doubts as to 
 this. 
 
 Notwithstanding what has been said by Scanzoni this anomaly 
 is not marked by external signs : there is no example of the chin 
 being covered by a beard or the voice being rough and masculine. 
 It is not correct either to say that the breasts are rudimentary, although 
 Busch and Cripps have observed one case of arrested development ; they 
 were of the usual size in seven other cases. The absence of symptoms 
 indicating ovulation, with the existence of concomitant anomalies in the 
 uterus and vagina, are the only grounds we can have during life for 
 diagnosing or rather presuming on the existence of this anomaly. At 
 other times the absence occurs only on one side, generally on the left ; 
 
i.NATOMY, THYSIOLOGY AND TEEATOLOGT 
 
 71 
 
 in tins case the uterus has usually, if not always, but one cornu (Pig. 
 62), the horn corresponding to the missing ovary being also absent 
 or reduced to a cord. In twelve cases of this anomaly the ovarian 
 function was exercised normally, with regular menstruation, pregnan- 
 cies and children of both sexes. 
 
 Rudimentary develojjment. — Two features characterise this anomaly, 
 which is much more frequent than absence of the ovaries : — 1. The 
 small size of the organ. 2. The absence of Graafian vesicles at ma- 
 turity. From a physiological as well as from an anatomical point of 
 view two forms may be distinguished ; in the first the organ is in 
 outline audits structure incomplete; in the second it has the foetal 
 organisation, i. e. the form, size, and vesicles proper to that age. 
 These two forms occur sometimes with a normal conformation of the 
 uterus, sometimes with an anomaly of this organ. The anomalies 
 
 Fig. 62. — Left unicorn uterus, absence of the broad ligament, right ovary and 
 Fallopian tube, c rr, cervix uteri ; o, left ovary ; T, left Fallopian tube, 
 fimbriated extremity. The right border of the rounded uterus (u) is covered 
 with peritoneum (Klebs, Handbuch der patJiologisclien Anatomie. Berlin, 
 1873, 4« Lieferang, S. 761.) 
 
 with which they are most frequently seen to coincide are complete 
 absence of the uterus, apparent absence of this organ, infantile uterus 
 and hermaphrodism. Eudimentary ovaries, though rarely, do some- 
 times coexist with a uterus normally formed. In a preparation in the 
 Heidelberg Museum, described by Kiissmaul, a rudimentary state of 
 the ovaries is seen in a woman whose uterus is 5 centimetres long and 
 3^ broad ; the vagina is replaced by a fibrous cord 3^ centimetres in 
 length and 2 lines in width, and presenting no trace of a canal, except 
 
72 TNTEODUCTION 
 
 in the upper part. Eoubaud, in an analogous case, observed that all 
 the other genital organs were normal. 
 
 At other times only one of these organs is in a rudimentary con- 
 dition, either when the corresponding uterine horn is atrophied 
 (Granville, Mayer of Eriburg, Stolz, Forster, Rosenburger and 
 others), or when it is normally developed (Morgagni, Behling, Lalle- 
 mand, Blot, Scanzoni, Forster). The rudimentary condition of the 
 two ovaries produces the same consequences as the absence of these 
 organs ; when only one is atrophied menstruation and fecundation take 
 place as usual. 
 
 Division. — Without referring to varieties of form and size which do 
 not hinder function, we shall only mention the depressions and notches 
 which these organs sometimes present in their borders, in adults as 
 well as in infants. Sometimes single, sometimes multiple (from three 
 to six), these notches are generally superficial. At other times the 
 notch is much deeper and accompanied by a considerable separation of 
 the borders, so that in place of a slit the ovary is really divided, into 
 two segments. Klebs and Gintrac have seen cases where the two 
 segments of the ovary were united by a kind of isthmus. P. Winckel, 
 in his plates, represents an ovary divided into two almost equal parts, 
 on one of which an accessory ovary is seen retained by a peritoneal 
 fold and having a Graafian follicle; a similar accessory ovary, also 
 furnished with a serous pedicle and with a Graafian vesicle, is repre- 
 sented in another plate. Beigel has met with this anomaly eight times 
 in 350 autopsies and Winckel eighteen times in 500. In fact, the 
 ovary may be composed of two parts entirely separated, as was proved 
 by the preparation presented by Grohe, in ] 863, to the Congress of 
 Stettin / the right one was normal and well developed, whilst on the 
 left there were two small ovaries, one of which was suspended to 
 the uterus, as usual, by the ligament belonging to it, the other, 
 situated farther off, was enclosed in a peritoneal fold. The woman to 
 whom these ovaries had belonged had had three children, and the 
 three ovaries had all performed their function, as the autopsy showed. 
 
 Ectopias. — There are two kinds — lumbar and abdominal or in- 
 guinal. The lumbar ectopias described by Puech (1855)^ are arrests 
 of migration, occurring from the eighth to the tenth week of embryonic 
 life, i. e. when these organs, as well as the Eallopian tubes, occupy the 
 lumbar region normally. In the cases quoted the ovary and the 
 Tallopian tube were not in any way attached to the uterus ; in one 
 the latter organ was absent; in the other only the right horn was 
 
 1 Monatsschriftfm- Geburt&kund, &c., 1864, Bd. xx, p. 67. Since then, in 1864, 
 Klebs observed three ovaries in one woman. De Sinety and Olshausen have 
 published analogous cases, but the most remarkable has been drawn by Winckel 
 {Die Pathologie der Weiblichen Sexualorganen in LichtdntcJcabbildungen, &c. 
 Leipzig, 1872). There were three ovaries and three ovarian ligaments. The 
 third ovary and its ligament were on the anterior surface of the uterus, touch- 
 ing the fundus of the bladder, without any peritoneal inflammatory adhesion. 
 It was found in a woman of seventy-seven who, although married, had never 
 had a child. 
 
 ' Compte rendu de I'Acad. des sciences, 22 octobre, 1855. 
 
ANATOMY, PHYSIOLOGY AND TEEATOLOGY 
 
 73 
 
 wanting. Inguinal ectopias, which are much more common, may be 
 considered, on the contrary, as excesses of migration, having for prin- 
 cipal agents the various elements which concur in the constitution of 
 the round ligament. The smooth muscular fibres and those with 
 transverse striae coming from the abdominal muscles then intervene 
 and, acting in the manner of the gnlernacidum testis, drag the Fal- 
 lopian tube and ovary after the round ligament. May not the non- 
 adherence of this ligament to the oviduct where it joins the uterine 
 horn, favour this displacement ? The canal of Nuck, which has its 
 maximum of development from the fourth to the sixth month of intra- 
 uterine life, contains these organs at that time, and the descent is 
 completed by the retraction of the elements of the round ligament. 
 The ovaries may descend, hke the testicles, into the inguinal canal and 
 cross the external orifice, even reaching the labium. The persistence 
 of the canal of Nuck, the narrowness of the pelvis and the elongated 
 form of the ovaries favour this ectopia. I shall not add more now, as 
 I shall have occasion to recur to the subject in connection with hernia 
 of the ovary. 
 
 III. Anomalies of the Fallopian Tithes 
 They sometimes afi'ect the whole organ, sometimes only the body of 
 the oviduct or the fimbriated extremity. 
 
 Fig. 63. — Right unicorn uterus : absence of broad ligament, of ovaiy, and of 
 ralloJ)ian tube on left side. Matthews Duncan, Obstetrical Journal, vol. i, 
 p. 784. 
 
74 INTRODUCTION 
 
 Absence. — The complete absence of the Fallopian tubes is very rare, 
 only occurring when the uterus is entirely wanting. Unilateral 
 absence has been observed in cases of unicorn uterus, conjointly with 
 that of the ovary (Fig. 63). 
 
 Rudimentary development. — The Fallopian tubes may be represented 
 by traces only, or by more or less developed cords. In the condi- 
 tion of traces they are found under the form of muscular layers occupy- 
 ing the upper border of the corresponding peritoneal fold. One would 
 say that the Fallopian tube itself was absent, and that only traces of its 
 external longitudinal muscular tunic existed. More frequently they 
 are observed in the condition of solid cords, in whole or in part, a 
 disposition which can only be connected with arrested development, 
 for it depends on imperforation of Miiller's ducts and it coexists with 
 other anomalies of the same kind, such as complete absence of the 
 uterus, embryonic uterus, unicorn uterus with rudimentary horn and, 
 lastly, complete absence of the cavity of a uterus apparently normal. 
 In other cases the tubal canal appears well developed but is imper- 
 forate, an anomaly which coexists with the absence or embryonic 
 development of the uterus, or with the atrophy of the horn in cases of 
 unicorn uterus. In other cases congenital imperforation only affects 
 the fimbriated end. Baillie, Eeynaud, Guerard and Besnier have seen 
 cases of this kind. Lastly, there may be a striking inequality in the 
 length of the two Fallopian tubes. Puech has observed such a case in 
 a woman married for ten years and sterile ; the right Fallopian tube was 
 of the ordinary length, fourteen centimetres, whilst the left was 
 only six. 
 
 Vices of conformation. — The Fallopian tubes sometimes have an 
 apparent shortness depending on the shortness of their longitudinal 
 muscular tunic and on the more numerous and deeper folds which are 
 the consequences of it. It is not uncommon to find contractions at some 
 point of their course, and at other times dilatations, either primitive or 
 consecutive to the existence of a constriction situated below and which 
 forms, especially when obliterated by thick mucus, a more or less efficient 
 obstacle to the progress of fluids from the Fallopian tube or ovary 
 towards the uterus. But it is principally the fimbriated extremity 
 which is subject to a number of varieties ; sometimes the widening of 
 the tubal canal on a level with the abdominal extremity is slight and 
 its opening is surrounded with very short fringes; sometimes the 
 fimbriated end is greatly enlarged, and forms below a sort of canal, 
 which is in close communication with the ovary and the margins of 
 which are furnished with broad fringes. At other times supernumerary 
 fimbriae are to be seen, as described by Eichard and to which I have 
 already referred (p. 14), to the number of from one to three on the 
 same Fallopian tube, appearing always to have their seat on the upper 
 wall of the tube and presenting a single opening. Puech, in an 
 autopsy, saw two on each tube placed symmetrically. 
 
 Ectopias. — They may be lumbar or inguinal. With reference to 
 the former we have nothing to add to what has been already said of 
 lumbar ectopias of the ovary. As for the latter, considering the close 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 75 
 
 relations of the Fallopian tube and ovary there is no difficulty in 
 understanding that hernia of the ovary cannot occur without the 
 Pailopian tube accompanying this latter organ. As for hernia of the 
 Fallopian tube occurring alone, a few cases of which have been quoted 
 by Schiller, Voigt, Mayer, Scholler and Berard, they are produced by 
 a mechanism analogous to that of ovarian ectopias. 
 
 IV. Anomalies of the Uterus 
 
 The anomalies of the uterus are numerous and varied, but at the 
 same time easy of interpretation. 
 
 1. Miiller's ducts may be undeveloped or atrophied, in which case, 
 if the ovaries are also wanting, there will be complete absence of the 
 internal genital organs} 
 
 2. Want of development or atrophy may only affect the portion of 
 the two tubes destined to form the body of the uterus ; there may be a 
 vagina, Fallopian tubes and ovaries, but the uterus itself may be 
 absent — uterus dejiciens? 
 
 3. One only of the ducts may be atrophied or incompletely developed. 
 
 Fio. 64. — Unlcoi'n uterus of a child, seen from behind (after Pole), a, right 
 unicorn uterus (left half of uterus is not developed) ; h, right Fallopian 
 tube ; c, left Fallopian tube ; d, d, ovaries ; e, bladder ; /, vagina, in 
 which is seen the uterine orifice. 
 
 the other continuing its evolution ; the uterus may be only half an 
 organ and there may be only one Fallopian tube, the other half being 
 in a rudimentary condition, in fact one horn only has been developed — 
 vterus unicornis (Fig. 64). 
 
 * I have quoted a case of this kind : Memoires de I'Academie des sciences et 
 lettres de Montpellier (Section of Sciences), t. ii, p. 321. Montpellier, 1853. 
 Comptes rendus de I'Academie des sciences de Paris, 26 Sept., 1853. 
 
 ^ Cases are on record known in which absence of the uterus co-exists with 
 that of the ovaries and Fallopian tubes (Busch, Colombi, Courty, Klinkosch, 
 Quain) ; others with absence of Fallopian tubes only (Boyd, Food, Otto, &c.) ; 
 others with the presence of these organs (Burgrajve, Gintrac, Puech, Serres, 
 Ziehl, &c.). 
 
76 
 
 INTRODUCTION 
 
 4. Muller's ducts which are in contact with each other at their inser- 
 tion into the cloaca may remain separated in the whole of the portion 
 which ought to form the uterus. In this way two distinct uteri will be 
 formed, each of which^ however, will only represent the half of the 
 normal uterus. The rest of Miiller's duct is hollowed out into the 
 form of a tube greatly enlarged at its free extremity, so that there is a 
 double uterus, or rather two uteri, each having a neck and body and 
 accompanied by a Fallopian tube and an ovary — uterus duplex, diductus 
 or didelphis (Fig. 65). 
 
 5. Miiller^s ducts may be brought still closer together without, 
 however, reaching the normal type. As in the preceding case, the 
 isolated evolution of each of these ducts may take place, but their 
 union, being incomplete above, will produce a uterus the fundus of 
 which will be hollowed out by a more or less deep anterior groove 
 dividing the upper part of the organ only into two portions enlarged 
 in the form of horns — uterus bicornis (Figs. 66, 67). 
 
 Fig. 65. — Double uterus and vagina In a girl of nineteen years (after Eisen- 
 
 mann). 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 
 
 77 
 
 6. The union of the tubo-uterine canals takes place at the normal 
 point ; the fundus of the uterus, however, in place of continuing its 
 
 Fig. 66. — Double bicorn uterus, and double vagina in a girl of seventeen (after 
 
 Schrosder). 
 
 development by a median enlargement rising to the level of the ex- 
 tremity of the horns, remains depressed, as in the fourth month, and 
 
 Fig. 67. — Bicorn uterus, with single neck, in a girl (after F. C. Ntegele). 
 
78 
 
 INTRODUCTION 
 
 the fundus of the uterus is incudiform or hiangular (Pig. 68) ; or it 
 may be simply indented above like an ace of hearts and may keep 
 
 Tia. 68. — Incudiform or biangular uterus in a girl of seventeen (after Oldham) ; 
 this an-est of development recalls the form of the uterus at the fourth 
 month. 
 
 this form in spite of the absorption of the partition and the union of 
 the two cavities — uterus cordiformis (Fig. 69). 
 
 Fig. 69. — Cordiform uterus, natural size (after Kiissmaul). a, indented fundus. 
 
 7. The first part of the formative evolution (the approximation of 
 Miiller's ducts) takes place regularly. The uterus externally is 
 of normal form — litems glohdans (Figs. 70, IV) ; but the second 
 part of the work — the fusion of the two uterine canals into one 
 by the disappearance of the contiguous walls of Miiller's ducts — 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 
 
 79 
 
 is not accomplished ; the division remains intact throughout the 
 length of the organ, both body and neck — utenis sejHus, bilocularis^ 
 dipariitis {^igs.^T 0,71). 
 
 8. The lower portion of the division is absorbed, but a longer or 
 shorter part is still to be found in the fundus ; the two cavities of the 
 uterine horns, though separated above, communicate below to a more 
 or less considerable extent j the neck is single — uterus subseptus, semi- 
 partitus (EgJIi). 
 
 Fig. 70. — Double uterus and vagina, having tlie appearance of a single uterus 
 and a single vagina with partition, in a woman of twenty-eight, eight 
 days after delivery (after Spaeth). A director is passed through the cavity 
 and orifice of the left half of the uterus ; gestation took place in the 
 right half. 
 
 9. The uterus is normal in its body, but there is atrophy or absence 
 of the neck — uterus with rudimentary neck or without neck. Or the 
 neck may be normal and the body atrophied or absent, a case of which 
 I have seen — uterus without body or without fundus. 
 
 10. Lastly, the uterus may be normal in form, but arrested in its 
 nutrition or development through life, remaining an embryonic uterus, 
 uterus embryonalis (Fig. 73) or a foetal uterus, uterus fcetalis] 
 or an infantile uterus, utertis infantilis; or in the condition of a 
 
INTEODUCTION 
 
 uterus before the establishment of the menses, uterus jjiilescens p- in 
 factj a uterus in miniature, the majority of cases incorreptly designated 
 as 2iterus deficiens being properly included in this class ; or it may be 
 solid, the cavity not hollowed out, and Muller''s ducts being also solid ; 
 
 Fig. 71. — Double uterus (having the appearance of a uterus witli paiiition) 
 with, single vagina, in a state of gestation (after Cruveilhier). 
 
 at other times it is only imperforate at its vaginal orifice, uterus im- 
 perforatus. Sometimes the vaginal portion of the neck is conical, 
 cervix acuminatus (Fig. 74), and perforated by an insufficient orifice, 
 either in the centre or at the side. "When the neck is conical it is gene- 
 rally too long and may require to be partially amputated. Sometimes 
 the vaginal portion of the Deck is too short, or it may be completely 
 absent, cervix dejic'iens (I'ig. 74), or the uterus may have an abnormal 
 flexion, vestige of the foetal state, especially anteflexion, uterus flexiis. 
 In Kiissmaul there are woodcuts of lateral flexions produced by 
 foetal deviations, or by arrest of development in one of Miiller's 
 ducts. 
 
 Before closing this chapter on teratology I must give a particular 
 description of the anomahes most frequently found with regard to the 
 form and size of the vaginal portion of the cervix. Clinically, it is 
 verv important to be able to distinguish these anomalies by sight and 
 touch, to be able to i)ut the right interpretation upon them, to know 
 
 1 Puech, Annales de Gynecologie, t. i, p. 378. 
 
ANATOMY, PHTSTOLOGT AND TERATOLOGY 
 
 81 
 
 the diseases which they can produce, and to be sufficiently familiar 
 with all their varieties to appreciate a distinction between those 
 which have no result beyond that of being singular and those which 
 
 Fig. 72. — Rudimentary bicom uterus in a woman of sixty (after Eokitanski). 
 a, vulva ; h, a band of cellular tissue mixed with muscular fibres, having 
 the form of a uterus (vaginS,) ; c, c, muscular cords representing the uterine 
 comua (cervix), and terminating in enlargements, d, d, of the size of a 
 bean, hollowed out into a cavity capable of holding a lentil and covered 
 with mucous membrane (uterus) ; e, e, shrivelled-up ovaries ; /, /, oviducts ; 
 g, g, round ligaments ; h, h, broad ligaments. 
 
 disturb or prevent the accomplishment of functions, and which sooner 
 or later may become the starting point for certain diseases. Between 
 the cervix acnminatus and the cervix deficiens just referred to as 
 extremes of condition, there are many varieties of anomalies affecting 
 
 Fig. 73. — Conical neck with 
 narrow orifice (after Sims). 
 
 Fig. 74. — Absence of the vaginal poi-tion 
 of the neck ; the uterus rests upon the 
 vagina in place of projecting into it. 
 
 the size of the neck, its form and the point of its vaginal insertion, 
 or the form, size, situation of its orifice, &c. The number of anomalies 
 1 have observed is very great, but I shall omit all those which do not 
 
 G 
 
82 
 
 INTRODUCTION 
 
 cause any sensible alterations in the functions of the womb^ and shall 
 limit myself still more by only giving examples which may serve as 
 types of numerous varieties connected together by a more or less 
 striking resemblance. With reference to the size, the neck may be 
 deficient, or may be present only in the form of a projection approach- 
 ing more or less closely to the normal state, or lastly, it may be ex- 
 cessive in volume, attaining, even in nulliparae, dimensions which, 
 though seemingly characteristic of acquired hypertrophy, are sometimes 
 really caused by a relative arrest of development. This seems para- 
 doxical, but the fact cannot be doubted when we remember the large 
 size of the neck, relatively, in the foetus. The shape varies with the 
 size. Sometimes the neck is depressed at the extremity of the vagina. 
 Sometimes it projects excessively without any alteration of form, or 
 with a cylindrical shape very slightly different from the normal. Some- 
 times it is completely conical ; at other times, on the contrary, it is quite 
 the reverse, the lips being turned back like a mushroom. When the 
 lips, instead of being almost equal as in a normal condition, are un- 
 equal, they may give rise to alterations of form still further removed 
 from the primitive type, and which create new obstacles to the accom- 
 plishment of the functions. If the orifice is directed backwards, the 
 anterior lip projecting beyond the posterior, the neck, in place of 
 having the shape of a cone, assumes the -aspect of a snout, as may be 
 seen in Figure 75 drawn from nature and representing the appear- 
 ance of the cervix in a sterile woman married for eight years. The 
 anterior lip may project still more, taking the form of a beak, or 
 it may fall over the posterior lip, covering it like an apron, &c. We 
 shall see that these natural tendencies of the cervix to assume the 
 forms of a cone, mushroom, snout, &c., become exaggerated in certain 
 pathological cases giving rise to hypertrophy, when the same forms 
 become monstrous and cause so much trouble and pain to the organ as 
 to necessitate an operation. This exaggeration only serves to bring 
 
 Fig. 75. — Cervix in form of snout, the anterior lip projecting over the posterior 
 
 (from nature). 
 
 into relief the variety of abnormal configurations of the cervix. The 
 orifice is of equal importance. In place of having the aspect of a 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 
 
 83 
 
 fissure bordered by two lips, auterior and posterior, it may have the 
 form of a more or less narrow circular hole in the middle of a cylin- 
 drical neck slightly projecting, i. e. in every other respect like the 
 normal condition. It is possible that menstruation may occur nor- 
 
 FiG. 76. — Normal or linear os on 
 a depressed neck. 
 
 Fig. 77. — The same on a neck of normal 
 shape and dimensions. 
 
 Fig. 78. — The same on a voluminous 
 neck, with lips slightly turned 
 back like a mushroom. 
 
 Fig. 79. 
 
 -The same on a voluminous 
 conical neck. 
 
 mally, and even that conception may take place. Nevertheless, such 
 a tendency is sufficiently abnormal to cause some fear lest dysmenor- 
 rhoea may set in after marriage if not before, and that conception will 
 be very difficult, and, indeed, highly improbable. As a rule, a uterine 
 OS having the form of a circle or point in place of a fissure or mouth 
 (ostium uterimim) is always abnormal, and exposes the subject, sooner 
 or later, to the more or .less troublesome consequences resulting from it. 
 But there are other and more serious anomalies. The one most 
 frequently met with in nullipara3, and one which is the cause of 
 innumerable maladies, is that of a narrow, circular os coinciding with 
 an anomaly of form, principally conicity of the cervix, or with an 
 anomaly in the position of the orifice, which has become excentric in 
 one direction or another. In place of being in the centre of a cervix 
 of normal shape the utero-vaginal orifice may be situated in the centre 
 of a cervix depressed and even wanting. This case is rare and less 
 important than the others in its consequences. But whether the neck 
 projects normally or is depressed, the fact of the pin-point os is 
 serious ; therefore we must be able to diagnose it and not be misled 
 by the appearance of a fissure, the superficial character of which might 
 be overlooked till a thorough examination shows that the sound only 
 penetrates into the uterine cavity by the pin point in the centre of the 
 
,84 
 
 INTEODUOTION 
 
 apparent slit, A still more important anomaly is that of a pin-point 
 OS at the apex of a conical cervix ; it is one of the most frequent and 
 
 Fig. 80. — Abnormal 
 pin-point os on a 
 depressed neck. 
 
 Fig. 81. — The same on a 
 neck of normal shape 
 and size. 
 
 Fig. 82. — The same situ- 
 ated laterally on a 
 normal neck. 
 
 Fig. 83. — ^The same double 
 or bilateral, at the two 
 extremities of a fissure, 
 on a normal neck. 
 
 Fig. 84. — The same at 
 the apex of a coni- 
 cal neck. 
 
 Fig. 85. — The same 
 situated laterally 
 on a very coni- 
 cal neck. 
 
 most troublesome, since the narrowness of the orifice, whilst producing 
 dysmenorrhoea, is not the only cause of sterility, the conical form of 
 the cervix being still more unfavorable to conception. 
 
 In all cases in which the os is reduced to a pin-point dysmenorrhcea 
 is produced sooner or later, and whether the neck be normal or conical 
 — whether the orifice be in the centre or on the side — congestion 
 occurs, as shown in the six preceding figures drawn by myself from 
 nature or taken from Barnes. 
 
 The narrowness of the os may be complicated by its excentric posi- 
 tion, either at the extremity of a superficial fissure or at the two 
 extremities of a similar depression, having the appearance of a normal 
 linear orifice bounded by marked angles or commissures, whilst in 
 reality this depression is the vestige of that period of development 
 when Miiller's ducts are united, but when the intra-uterine septum 
 has not yet been absorbed ; therefore in making a careful examination, 
 in the first case the inclination of the sound in the cervix, in the other 
 case the possibility of introducing two sounds (one into each orifice) 
 which may or may not touch in the cavity of the organ, will lead us to 
 suspect and sometimes even to diagnose with certainty that the 
 case in question is one of unicorn uterus, or of two uteri incom- 
 pletely united. Quite lately I was able to diagnose the existence of a 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 
 
 85 
 
 right unicorn uterus : the pin-point os was to the right, the cervix 
 swollen ; whilst all the part above the right vaginal cul-de-sac, both 
 before and behind, was tumefied, probably as the result of partial 
 menstrual retention and considerable congestion of the right uterine 
 
 Fig. 86. — Pin-point orifice, on a 
 normal neck congested as a 
 consequence of dysmenor- 
 rhcea (acZ «al). 
 
 Fig. 87. — The same situated laterally. 
 
 Fig. 88. — The same situated poste- 
 riorly {ad nat. after Barnes). 
 
 Fig. 89. — The same situated on a cylin- 
 drical cervix. 
 
 Fig. 90. — The same situated on a cylindro- 
 conical cervix. 
 
 Fig. 91. — The same on a conical 
 cervix. 
 
 horn, the presence of which was traceable as far as the hypogastrium, 
 on a level with the brim, towards the iliac fossa of the same side ; 
 whilst the absence of any solid body where the left side of the uterus 
 should be led to the supposition of the absence, or at least the imper- 
 foration, of a left uterine horn. 
 
 Lastly, very frequently the narrow os, in place of being situated at 
 the apex of the conical cervix, is at some distance from it, very seldom 
 in front, more frequently to the right or left, or behind. 
 
86 
 
 INTEODUCTION 
 
 Another anomaly which occurs frequently is the semilunar form of 
 the OS ; whilst this does not cause dysmenorrhoea, it makes conception 
 unlikely. Generally the convexity is posterior, occasionally anterior. 
 In these cases there is an arrest of development with persistence of the 
 
 Fig. 92. — Semi-lunar orifice with 
 anterior concavity, from hyper- 
 trophy of the anterior lip. 
 
 Fig. 93. — Semi-lunar orifice with 
 posterior concavity, from hy- 
 pertrophy of the posterior lip. 
 
 inferior part of the central column of the arlor vita, a vestige of the 
 union of Miiller's ducts and of the central septum which primitively 
 separates the two uteri. Tliis obstacle sometimes occurs in the canal 
 or at the os internum, where it is not visible. In other women it is 
 caused by an inflammatory hypertrophy following upon previous 
 deliveries, or consecutive to a chronic inflammation. The cause varies 
 but the effect is the same. 
 
 V. Anomalies of the Vagina 
 
 Absence. — It may be total or ])artial. In cases of total absence the 
 vagina is replaced by cellular or fibrous tissue, and in both cases this 
 
 Fig. 94. — Complete ahsence of vagina, which is replaced hy a thin, flattened, 
 solid cord 12 centimetres long, formed of cellular tissue and longitudinal 
 muscular fibres ; retention of menses for seven years, puncture by rectum, 
 purulent peritonitis causing death the eighth day. V, cord, representing 
 the vagina ; z, round ligament ; L, broad ligament ; M, section of the 
 uterus and Fallopian tubes at their origin ; T, Fallopian tubes dilated to 
 the size of the little finger; o, ovaries (after Fiirst). 
 
ANATOMY, PHYSIOLOGY AND TERATOLOGY 87 
 
 defect of formation may coincide with absence of the uterus or with the 
 existence of an obliterated or embryonic uterus^ or with the existence of 
 a normal uterus (Fig. 94). The partial absence may be more or less 
 extensive ; it may be reduced to the half or quarter of the vagina, and 
 even to a kind of membranous septum, there being an insensible tran- 
 sition between this anomaly and a simple transverse septum. It may 
 coexist, like the preceding, with absence of the uterus or with a normal 
 uterus. 
 
 Arrest of development. — There are two kinds : persistence of cloaca 
 owing to defective division between the rectum and bladder, and per- 
 sistence of intra-vaginal septa from defective absorption of the elements 
 which primitively make probably a solid canal of the vagina, like Miiller's 
 ducts from which the Fallopian tubes and uterus are formed. 
 
 A. Persistence of cloaca. — I have explained (pp. 58, 60 and 61) the 
 mode in which the bladder, rectum, recto-vesical septum and vagina 
 are developed from the pedicle of the allantois. The persistence of 
 the cloaca and the consequent production of abnormal communications 
 between the vagina and the bladder or rectum are to be attributed to 
 an arrest of this development. The cloaca may be either complete 
 or incomplete. The latter may be uro-genital (with inferior perfora- 
 tion or imperforation of the vagina) or recto-genital (with vagiiial 
 communication or imperforation, or rectal communication or imper- 
 foration) ; examples of these various kinds of anomalies have been 
 observed. The former is sometimes complicated by abdominal 
 eventration, communication between the vagina and the anterior 
 abdominal wall, or extrophy of the bladder; at other times it exists 
 without any other anomaly (Sue, Velpeau, Courty). If the reader 
 wishes for further details he may refer to Puech's paper already 
 quoted, as I shall merely mention what I have seen or what has come 
 to my direct knowledge. I have seen a complete uro-recto-vaginal 
 cloaca in a foetus of eight months preserved in alcohol ; a large recto- 
 vaginal cloaca with absence of the entire septum in a newly-born child ; 
 a superior recto-vaginal cloaca with absence of anus and lower extremity 
 of rectum in a little girl just born; an inferior recto-vaginal cloaca 
 with imperforation of the vulva or rather of the lower part of the 
 vagina, the upper part of which communicated with the rectum and 
 anus, in another newly-born child ; a communication of the size of a 
 five-shilling piece between the rectum and vagina immediately above 
 the hymen and external sphincter in a girl of nineteen, and a similar 
 one with imperforation of a very thick hymen in a girl of sixteen who 
 menstruated by the anus ; lastly, an opening in the form of a fissure 
 three centimetres long in a virgin of twenty-five, in whom I dis- 
 covered at the same time a double vagina and double uterus which 
 had not been suspected, and on which I operated successfully ; it was 
 the left vagina which communicated with the rectum. Puech has 
 communicated to me two cases of congenital absence of the recto- 
 vaginal septum ; in the first, there was contraction of the rectum by a 
 membranous diaphragm, the freces being excreted by the vulva ; in 
 the second, there was at the same time absence of the rectum, and the 
 
88 INTEODUOTION 
 
 operation (performed to give exit to the meconium) was followed by 
 death. 
 
 B. Division of the vagina. — 1. There may be a transverse partition 
 more or less thick, membranous, complete, incomplete or annular. 
 This anomaly depends on an arrest of absorption at some point. The 
 persistence of the entire hymen with atresia is not included in this 
 anomaly, or rather it stands on the borderland between anomalies of 
 the vagina and vulva; it is the persistence of the partition existing 
 primitively between the genital formations of the external layer and 
 those of the intermediary layer. 2. A longitudinal partition running 
 from before backwards, and separating a right from a left vagina 
 (double vagina). One of the vaginse may be imperforate and cause 
 retention of the menses on this side.^ This longitudinal division 
 may be complete or incomplete. Both anomalies may coexist with 
 uterus bicornis, uterus septus and their varieties, or with a simple 
 
 Fig. 95. — 1, pubic symphysis ; 2, bladder ; 3, uterus ; 4, cul-de-sac of tbe 
 posterior wall of the vagina whicli is attached to the fundus of the uterus ; 
 5, OS uteri, the anterior lip of which adheres to the anterior wall of the 
 vagina ; 6, rectum (after Martini). 
 
 uterus (Maunoir). Sometimes only a vestige of this anomaly exists 
 at some point of the vagina, more frequently at one of the extremities 
 than in the centre ; I have referred to a case where the seat of 
 anomaly was at the hymeneal extremity. The coexistence of the 
 longitudinal partition of the vagina with a simple uterus is relatively 
 rare ; whilst more than 100 cases are known of the coexistence of this 
 anomaly with anomalies of the uterus, there are not fifteen of double 
 vagina coinciding with a normal uterus (Puech). 3. A longitudinal 
 septum going from right to left, separating the vagina into two secon- 
 dary cavities, one anterior, the other posterior; a very rare anomaly, 
 which only Bourjot Saint-Hilaire, Eugene Eorget and Caradec have 
 
 ' Puech, Des atresies ' complexes cles voies genitales de la fcmme ct de 
 I'liertiatometre unilateral, in Annales de Gynecology. Paris, 1875. The 
 author has collected twenty-five cases of this anomaly. 
 
ANATOMY, PHYSIOLOGY AND TEEATOLOGY 89 
 
 observed (each one case). Is it not possible that in these cases there 
 may have been an accidental septum ? or supposing the partition to have 
 been congenital, may not its direction, so different from the preceding, 
 be due to a deviation, to a kind of torsion, rather than to an absolute 
 difference of direction of the septum. 
 
 Anomalies of size. — Amongst other anomalies observed in the 
 vagina, the most remarkable are those of size. With respect to this, 
 there are great differences in women ; and in some these differences 
 exceed the normal limits and constitute teratological states. Some- 
 times the length is affected, at other times the width. As to the 
 length it is sometimes excessive, sometimes defective. The shortness 
 of the vagina often produces a marked change in the situation, the 
 relations and direction of the uterus ; this shortness does not depend 
 only on want of material ; it often results from vicious insertions of 
 the two walls, or of one of the walls of the vagina into the cervix. 
 These insertions are sometimes too low (an arrangement which may 
 simulate absence of the vaginal portion of the neck) and at other 
 times too high, causing abnormal projection of the cervix into the 
 vaginal cavity. This anomaly is especially marked when only one of 
 the walls, generally the posterior, is inserted too high ; it may even be 
 inserted into the body of the womb (T^ig. 95), which proves that the 
 vagina is not developed, like the uterus, from Miiller's ducts, but that 
 it is an intermediate formation between these canals and the external 
 genital economy. I have seen a great many examples of defect in the 
 length of the vagina with descent of the cervix as a consequence. 
 The uterus is deviated in one or the other direction according as one or 
 the other vaginal wall is the shorter. I have generally found the 
 anterior one the shorter. As to amplitude, sometimes there is excess, 
 which disposes to prolapsus ; sometimes, on the contrary, the vagina is 
 too narrow, as proved by the numerous cases described by Antoine, 
 de la Toison, Beuevoli, Plenck, Scanzoni, &c. This deformity may be 
 confined to a small part of the vagina, to a kind of diaphragm with 
 central orifice. Sometimes it extends further, giving to the vagina 
 the appearance of a funnel, broad below and narrow above. At 
 other times it extends to several centimetres, but may yield to 
 dilatation with prepared sponge, sometimes, in fact, it reduces the 
 vagina throughout its whole length to a narrow canal like the urethra. 
 It may cause serious obstacles to the accomplishment of the sexual 
 functions, especially to delivery, and may necessitate the intervention 
 of surgery. 
 
 YI. Anomalies of the Vidva 
 
 Absence. — The complete absence of the vulva has frequently been 
 observed in monstrosities, especially in acephalse, symmeles, &c. (Louis, 
 J. L. Petit, &c.). 
 
 Arrest of development may consist in a rudimentary state of all the 
 elements of the vulva, or in the partial absence of one or other of tiiese 
 elements, cither of the labia, nymphse, or clitoris ; or in a persistent 
 bifidity of this erectile organ, the corpora cavernosa of which are not 
 
90 
 
 INTEODUOTION 
 
 entirely united (Arnaud, Morpain) ; or, lastly, in an imperforation, a 
 complete atresia of the hymen, which supposes an arrest in the work 
 of absorption of this membrane, the result of which is to make the 
 external genital zone communicate with the median zone. 
 
 Excess of development may take place in the labia or nymphse, 
 which may be double or triple in number, or may acquire colossal 
 dimensions (apron of the Hottentots) ; or the hymen may be com- 
 pletely absent, which can only occur from excess of absorption ; or the 
 clitoris may assume the size of a small penis ; or there may be union 
 of the nymphse or of the two margins of the vulval groove, and even 
 of the labia, so as to present the appearance of a scrotum, in front of 
 which there would be a hypospadias surmounted by a small penis, 
 giving the most complete appearance of female hermaphrodism. The 
 resemblance becomes still more striking when the ovaries, or one of 
 them, form an inguinal hernia and descend into the sacs of the labia. 
 
 The hymen, which is between the external and median genital zones, 
 presents anomalies which are also very interesting to study, owing to the 
 connection which often exists between them and anomalies or altera- 
 tions of the internal organs. They are represented in the following 
 woodcuts, which are taken from the thesis of Roze and from drawings 
 which I myself have made from nature. 
 
 The first (Fig. 97) is imperforation of the hymen (Roze). I have 
 
 Fia. 96.- 
 
 -Hymen of normal form 
 in the virgin. 
 
 Fig. 97. — Imperforate hymen. 
 
 seen several cases, and have always operated by incision without any 
 accident. The thickness of the imperforate hymen is very variable; 
 sometimes it is very thick and formed not only of skin but of a cellular 
 layer lining it, whilst at other times it is constituted by a simple 
 epidermic layer (Courty) which tears at the slightest contact 
 without a drop of blood, as I have lately seen iji a child of six months. 
 
ANATOMY, PHYSIOLOGY AND TEEATOLOGY 
 
 91 
 
 The second (Fig. 98) is a hymen divided by a simple fissure 
 (Roze). 
 
 The third (Fig. 99) is a larger fissure giving rise to a bilabial 
 hymen with irregular borders (Ledru). 
 
 
 
 Fig. 98. — Hymen witli fissure. Fig. 99. — Bilabial hymen witli irregular 
 
 margins. 
 
 In the fourth (Fig. 100) absorption of the tissue and perforation of 
 the hymen has taken place at several points simultaneously, giving 
 it an appearance like the rose of a vratering can (Roze). 
 
 Fig. 1<)(). — Hymen perforated like rose Fig. 101. — Puckered hymen with 
 
 of a \vatcrin<r-fiin. 
 
 central orifice. 
 
92 
 
 INTRODUCTION 
 
 The fifth (Pig. 101) is a puckered hymen with a central orifice 
 (Roze) . 
 
 The sixth and seventh (Figs. 102 and 103) are hymens with a 
 circular, or rather polygonal, central orificcj with from four to six lips, 
 which are a kind of carunculae (Roze). 
 
 Fig. 102. — Hymen with polygonal 
 orifice and four carunculge. 
 
 Fig. 103. — Hymen with polygonal 
 orifice and sls caruncnlse. 
 
 The eighth (Fig. 104) is a hymen with a circular opening, but 
 with serrated edges (Ledru). It is singular that in these cases the 
 circumference of the meatus was also serrated. 
 
 
 Fig. 104. — Hymen with serrated borders. Fig. 105. — Horse-shoe hymen. 
 
ANATOMY, PHYSIOLOGY AND TEEATOLOGY 
 
 93 
 
 The ninth (Kg, 105) is a semilunar hymen, but the upper angles are 
 broader and prolonged towards the upper border of the vulval ring, 
 which has led to its being called a horse-shoe hymen (Roze). I have 
 recently seen one of these thick, resistant hymens, very broad and 
 allowing of considerable dilatation, in a virgin of thirty affected with a 
 myoma of the body of the uterus with marked descent of the anterior 
 vaginal wall (Coui'ty). 
 
 The tenth (Fig. 106) is a hymen with a circular orifice situated to 
 the left side (Roze), probably belonging to a double vagina imperforate 
 on the right side. 
 
 The eleventh (Fig. 107) is a hymen with two orifices or biperf orate 
 
 Fig. 106. — Hymen perforated at left Fig. 107. — Biperforate hymen, 
 
 side. 
 
 (Roze), tlie orifices being probably vestiges of the primitive duplicity 
 which extends from the two uterine horns to the two hymeneal orifices, 
 passing through the double vagina (Courty). 
 
 The twelfth (Fig. 108) is a hymen with two well-marked openings, 
 almost equal, observed in a young girl, who menstruated regularly and 
 without pain, in whom the inter -hymeneal septum extended from 1 to 
 2 centimetres into the vagina, being a vestige of the inter-vaginal 
 septum which had not entirely disappeared (Courty). 
 
 The thirteenth (Fig. lOD) is a biperforate hymen, one of the 
 orifices being smaller than the other, without any trace of median 
 vaginal septum, observed by myself in an old maid, and at another 
 time in a married woman of twenty-six aff"ected with membranous 
 dysmenorrhcca without any symptom of teratological condition of the 
 uterus. The septum was applied against the right vaginal wall, and 
 had a direction and position which made it certain that the left orifice 
 only had been used in copulation. She was not aware of the anomaly 
 till I discovered it (Courty). 
 
94 
 
 INTRODUCTION 
 
 Fig. 108. — Biperforate hymen with Fig. 109. — Biperforate hymen with 
 equal orifices, with prolongation unequal orifices, 
 
 of the inter-hymeneal septum 
 to 1 or 2 centimetres into the 
 vagina. 
 
 The fourteenth (Pig. 110) is the hymen with double semilunar 
 orifice, equal on both sides, forming the continuation of a double vagina 
 represented in Pig. 65 (Eisenmann). 
 
 Fig. 110. — Biperforate hymen, forming the continuation of a double vagina 
 
 and double uterus. 
 
PAET I 
 
 GENERAL SURVEY OF UTERINE DISEASES 
 CHAPTER I 
 
 DIAGNOSIS OF TTTEEINE DISEASES IN GENERAL — PEESTJMPTIVE SIGNS PUENISHED 
 BY THE SYMPTOMATOLOGY OP UTEEINE DISEASES — CEETAIN SIGNS PUENISHED 
 BY DIEECT EXPLOEATION. 
 
 It is constantly said that diseases of the uterus are far more common 
 now than formerly ; but this is an error which can be easily accounted 
 for. Our forefathers recognised these diseases less frequently because 
 they knew less about them, and because they often ascribed to other 
 causes the serious and even fatal results produced by them. Sometimes 
 they successfully treated the morbid symptoms, and so got rid of the 
 disease without being aware of its existence ; and, indeed, we know that 
 a certain class of these affections will really yield to simple hygienic 
 measures. 
 
 It is, then, of the first importance, before entering on the study of 
 individual diseases, to gain a general view of the symptoms which all 
 uterine maladies possess in common, and which may reveal or conceal 
 the true state of the case, according to the attention and skill of the 
 observer. We must point out that uterine diseases have many of these 
 common symptoms, which indeed were almost the only ones formerly 
 known ; and in certain cases it is quite possible to apply a similar, if 
 not identical, treatment to them, with reasonable chance of success. 
 We must also indicate the measures by which morbid conditions de- 
 pending on uterine diseases, as well as the diseases themselves, can be 
 ameliorated or cured. 
 
 This introduction will help us to understand how our forefathers 
 failed to recognise these diseases, and how they sometimes cured them 
 without having suspected their existence ; and it will also give us the 
 key to the errors into which several gynecologists of the first half of this 
 century fell, in supposing a simple morbid state to be the prime factor 
 in all uterine pathology. They arrived at too hasty conclusions from 
 the new means of investigation put into their hands by the inventive 
 spirit of the age, and did not see that if the ancients erred in ignoring 
 the great mass of uterine diseases, they themselves were almost equally 
 wrong in simplifying its pathology to the extent of embracing all in one 
 type of malady. 
 
 Lisfranc and his disciples found the explanation of all uterine diseases 
 in congestion, Yalleix in displacements. Those who followed Blatin 
 and Tyler Smith thought leucorrhcDca the great evil, while Recamier 
 
96 GENERAL SURVEY OF UTERINE DISEASES 
 
 and his school talked of ulcerations and granulations. The more 
 modern teachers, like Bennet^ Nonat and even Aran, although recog- 
 nising distinctions in the morbid states, were inclined to trace them all 
 to the common source of inflammation. 
 
 Prom this exclusive pathology came equally exclusive therapeutics. 
 Those who saw congestion everywhere kept their patients in bed ; those 
 who only discovered displacements applied mechanical treatment only. 
 Some directed all their attention to curing leucorrhoea as the cause of 
 any ailment, and thus concentrated their efforts on the destruction of 
 ulcerations by caustics or the actual cautery. Others, again, devoted 
 themselves resolutely to subduing inflammation by bleeding, baths and 
 emollients. 
 
 Thus it appears that uterine medicine has passed through the same 
 stages as all other branches of medical knowledge. Prom ignorance 
 and chaos emerged crude ideas, which in their turn gave birth to 
 systematic knowledge. Let us hope that by going to the root of the 
 matter, by a thorough and complete study of these diseases, we shall at 
 length reach a really scientific mastery of their various species and true 
 nature. 
 
 The false idea that, because uterine diseases had common symptoms, 
 they must also share a common nature, led to equally erroneous con- 
 sequences in identical treatment for all cases. The differentiation of 
 their various kinds will, on the contrary, teach us to treat them, not 
 all alike, but each by a special method founded on the indications 
 furnished both by the origin and manifestations of the disease. We 
 must therefore master the symptoms common to all uterine diseases, 
 not only for the sake of a general diagnosis, but that we may be on our 
 guard against analogies that are only apparent, and may recognise, in 
 spite of misleading resemblances, the true differences that characterise 
 each variety. 
 
 The interest of this general study of diseases of the womb is thus 
 intensified. Our diagnosis will not be formed simply by the considera- 
 tion of certain symptoms which indicate the presence of uterine mis- 
 chief; it will depend on a proper interpretation of these symptoms, or of 
 groups of symptoms variously arranged, as the pathognomonic expres- 
 sion of each type of disease. So also we shall not be satisfied with a 
 general line of treatment, but shall make a point of studying each 
 separate indication, so that from the character of the chief symptoms 
 we may deduce the appropriate remedies. From such simultaneous 
 study of diagnostic signs and therapeutic means we ought to acquire, 
 on the one hand, a comprehensive knowledge of uterine diseases, and 
 we shall also have prepared for ourselves a safe pathway with many 
 finger-posts, to guide us aright as to the diagnosis and treatment of each 
 particular malady. 
 
 " By their almost latent state, their great variety of symptoms (often 
 very transitory), their sympathetic effects on all parts of the economy, 
 and their immense influence on the nervous system, uterine diseases 
 are peculiarly apt to lead medical practitioners into errors of diagnosis.^' 
 Thus wrote Lisfranc, who dedicated seventy-four pages to pointing out 
 
DIAGNOSIS 97 
 
 such diagnostic errors, with illustrations from his own observations.^ I 
 have myself seen mistakes made by practitioners of excellent standing 
 which would have been simply incredible without such evidence. Tor 
 example, I remember one case where a previous pregnancy was asserted 
 while the conical cervix ought to have suggested sterility. I have seen 
 cases of leucorrhoea mistaken for blennorrhagia, and the peace of house- 
 holds consequently destroyed. 
 
 The best way of escaping such errors is to understand their cause. 
 It is certain that the majority of medical men can diagnose the diseases 
 of other organs better than those of the uterus ; and hence we may be 
 sure that there are real difficulties in the way. These are partly due to 
 the fact that the uterine symptoms are not always the most prominent, 
 that they are frequently slowly developed, and sometimes do not attract 
 the patient^s attention, while disorders of the alimentary canal or 
 nervous system demand more notice and cause more evident suffering. 
 How often is one consulted for neuralgia or hysteria; for symptoms 
 manifested in the stomach, the heart, or the liver; for digestive 
 troubles — anorexia, nausea, diarrhoea, and for all the train of evils 
 depending on poverty of blood — anaemia, chlorosis, emaciation and 
 exhaustion, but the natural and symptomatic manifestations of an un- 
 recognised uterine malady ! 
 
 The explanation lies in the fact that the uterus exercises a most 
 powerful influence over the whole economy, and that very often an 
 apparently insignificant disorder affecting this organ is felt throughout 
 the body to a quite disproportionate extent, causing troubles in neigh- 
 bouring organs, functional derangements of the various systems, and in 
 fact a result greatly exceeding its cause. Most frequently the gravest 
 effects are felt in the general health and not in local symptoms. Such 
 appearances may naturally mislead the invalid, but they ought rather to 
 put a skilled physician on his guard, and suggest to him the existence 
 of the morbid state that they only thinly veil. They should lead him 
 to ask questions which may help towards the confirmation of his 
 suspicions and the discovery of additional local symptoms, which 
 should end in the direct examination of the organs in which disease 
 really centres. 
 
 It is of importance to proceed step by step, and to pass from 
 general to local symptoms ; to ascertain the condition of the principal 
 functions and their derangements, before proceeding to investigate the 
 troubles more immediately connected with the uterine system. In 
 this way the practitioner not only provides himself with the guidance 
 of a sure clue which keeps him from losing himself in the chaos of 
 morbid conditions, gradually leads him away from mere functional and 
 symptomatic derangements, and brings him closer to the original 
 cause of all these evils ; but at the same time he is enabled to carry 
 the sufferer's mind along with his own, and to make her realise the 
 true origin of her troubles. 
 
 It is essential that the patient should be led steadily to the convic- 
 tion at which the physician has already arrived, for this conviction is 
 ' Clinique chirurgicale de la Pitie, vol. ii, p. 182. Paris, 1842. 
 
 7 
 
98 GENBEAL SUKVEY OP UTERINE DISEASES 
 
 the only means by which he can hope to make her understand the 
 necessity for a local examination and agree to submit to this painful 
 trial. This point is the more important, as a woman^s decision on 
 this matter will be entirely governed by the fact that she is or is not 
 convinced that she is suffering from disease of the womb. Women 
 are so much afraid of polypi, cancers, and ulcerations — which sum up 
 their ideas of all uterine maladies — that the reasonable terror inspired 
 by these affections will not only remove their repugnance to an exami- 
 nation, but will make them earnestly desire it. Even the less sensible 
 women will feel their instinct of modesty overborne by their desire of 
 self-preservation, and I can assert that — putting aside the members of 
 religious orders^ among whom it is often impossible to obtain any 
 examination of the genital organs — I have never yet met with one 
 woman, even unmarried, who has refused to allow an examination 
 when she was thoroughly convinced that her malady was really in the 
 womb. 
 
 Then of course the direct exploration by sight and touch reveals 
 signs absolutely pathognomonic ; and these, in combination with the 
 symptoms already noted, enable us to determine absolutely the exact 
 seat and form and usually also the exact nature of the disease. 
 
 I believe I cannot better explain the various steps towards a dia- 
 gnosis than by following exactly the order in which patients should be 
 interrogated and examined. Experience has taught me the value of 
 such a method in teaching a tolerably difficult subject. In dogmatic 
 teaching synthesis may be preferable, but in chnical instruction I 
 prefer analysis. 
 
 Let us imagine a patient of the kind most commonly met with ; let 
 us first ascertain of what she specially complains ; let us review all the 
 more general symptoms in their order of frequency, and then let us 
 come gradually to local symptoms ; then demonstrate the best modes 
 of examination, and finally enumerate the various indications which 
 we may expect to find. 
 
 All general and local symptoms related by the patient or observed 
 by the physician, without direct examination, are rational or sub- 
 jective ; they form a basis of probability or presumption. What we 
 learn by direct examination are sensible or objective symptoms ; they 
 form a basis of certainty. The latter are to be sought only subse- 
 quently to the former, unless we find in the first instance sufficient 
 reason for immediate examination. 
 
 Presumptive Signs Indicating Uterine Disease 
 
 General Symptoms. — Whenever a change of condition as well as of 
 function takes place in the womb, as at puberty, at each menstrual 
 epoch, during pregnancy, and at the menopause, there is a tendency 
 towards a morbid uterine condition which in turn will react painfuUy 
 on the whole system. A pathological change of considerable impor- 
 tance may take place, and may long remain unnoticed^ whilst the 
 
PRESUMPTIVE SIGNS INDICATING UTERINE DISEASE 99 
 
 most insignificant functional disorder is sufficient to disturb the whole I 
 economy. It is very striking to observe the disproportionate magni- 
 tude of this general disturbance compared to the insignificance of the 
 change which has produced it. 
 
 It is therefore from ignorance as well as from modesty that the 
 majority of women suffering from chronic disease of the womb complain 
 of symptoms which seem to indicate a malady in no way connected 
 with this organ. Some complain of nervous troubles, giddiness and 
 neuralgia ; others of nausea and of disorders of digestion; the majority 
 of weakness and exhaustion. In short there are almost always func- 
 tional^'disturbances of the nervous and digestive systems, which in turn 
 tend to produce various morbid cachexies, just as in the beginning of 
 pregnancy we have vomiting, dyspepsia and nervous disturbance, and 
 these are apt to be followed by anaemia, chlorosis and emaciation. 
 
 But we must remember that symptoms can do no more than sound 
 the tocsin of alarm ; we must not expect them to indicate precisely 
 the site of the lesion, and still less to explain the cause of the suffering. 
 We must therefore first ascertain whether these pathological con- 1 -^yvi/w 
 ditions are symptomatic or idiopathic. To do this we must not only I 
 assure ourselves of organic integrity side by side with functional 
 derangement, but we must endeavour to identify the original cause of 
 disturbance, and to fix upon any special indications which may enable 
 us to trace up the connection with the uterine system. In studying 
 general symptoms I will follow the usual order of their appearance. 
 
 I. Disorders of digestion. — Every practitioner must have had 
 patients who came to consult him for gastric derangement and dys- 
 pepsia, when the real source of trouble lay in the womb ; and I have 
 known such cases treated by distinguished physicians for the cure 
 of a malady that never existed. Indeed, this whole class of disorders — 
 gastralgia, nausea, dyspepsia, anorexia, perverted appetite, oesophageal 
 constriction, the globus hystericus, &c., &c. — these are of all others 
 the symptoms which most frequently accompany uterine diseases, and 
 more especially affections of the body of the womb. In such cases 
 these alone are complained of because these alone are felt. 
 
 The first and most common of such derangements is an increasing 
 difficulty of gastric digestion. This is not a true dyspepsia. There is 
 a good appetite, and the intestinal functions are healthy ; but gastric 
 digestion is slow, and is accompanied by discomfort and epigastric 
 tenderness, with distension and a sense of suffocation from the flatu- 
 lent development of gases, which lead to frequent inodorous eructa- 
 tions, obliging women to loosen their dresses and to avoid the least 
 pressure on the epigastrium. Sometimes a desire for food returns 
 very soon after a meal, but this is purely factitious. Digestive inertia 
 and pain is often succeeded by real dyspepsia of a nervous type, in- 
 volving much suffering and great delay in tlie accomplishment of diges- 
 tion, with sensations of weight and pain, swelling at the epigastrium, 
 bitter regurgitation, headache, exhaustion, incapacity for work, and a 
 sense of sinking which cannot be removed by food. This type of 
 dyspepsia is purely nervous and symptomatic of uterine disease. 
 
100 GENERAL SURVEY OP UTERINE DISEASES 
 
 while it has not the characteristics of true idiopathic dyspepsia. The 
 tongue is clean and normal, not dry, neither edged nor spotted with 
 red, and rarely furred. This in itself is an important diagnostic sign. 
 In the third stage this kind of indigestion is marked with want of 
 appetite and a tendency to nausea, sometimes with actual vomiting of 
 food, either before, during, or after meals. This symptom occasionally 
 leads the sufferer to believe herself pregnant. Digestive troubles of 
 this kind do not merely indicate uterine disease; they suggest further, 
 that it is the body and not the neck of the womb that is involved. 
 Ovarian disease is also more apt than affections of the cervix to produce 
 these digestive and nervous derangements. In addition to these we 
 may find, though more rarely, a derangement of the biliary secretion, 
 described by Bennet^ and Aran.^ This affection causes enlargement of 
 the liver and gall-bladder, and produces fits of sharp pain, which 
 begin in the hepatic region but extend over the chest, breast and 
 rio-ht shoulder. They are accompanied by bilious vomiting and diar- 
 rhoea, with excessive sensibility in the epigastric and right hypochon- 
 driac regions. These attacks occur most frequently a few days before 
 the menstrual period, and are accompanied very often by slight jaun- 
 dice. Bennet thinks they are purely symptomatic of dyspepsia, but 
 Aran considers them to be true hepatic colics, due to a biKary 
 lithiasis, which seems connected with urinary lithiasis, especially at 
 the menopause. 
 
 II. Nervous disorders may be produced by uterine disease (1) 
 directly, i. e. by sympathetic irritation of the nervous system ; (2) in- 
 directly, by means of impoverishment of the blood and general con- 
 stitutional debility. Indeed, these morbid phenomena may alternately 
 act as cause and effect, for the poverty of blood may be due to defects 
 of innervation as well as of digestion. They react both on the sensory 
 and motor functions, whether in the domain of voluntary or involuntary 
 organic life. Large account must also be taken of disorders of sensa- 
 tion, which may take the form of (1) anaesthesia; (2) visceral 
 neuralgias ; (3) neuralgia of the usual type. 
 
 (1) Ancestkesia may affect many parts of the epidermis, but is 
 especially frequent in the lower limbs. Sometimes it invades the 
 genital organs, the clitoris and vagina, which are then no longer 
 capable of being excited, and even the uterus itself, which falls into a 
 state of inertia, the sexual life of the woman being thus prematurely 
 brought to a close. I have seen several examples of this kind, where 
 sexual desire and pleasure in coitus were entirely lost after the begin- 
 ning of uterine disease. 
 
 (2) These nervous affections attack not only the bladder and rectum, 
 which are close to the uterus, but also remote organs, such as the liver, 
 the intestinal canal, the stomach, and more especially the heart, so 
 
 ^ A practical treatise on Inflammation of the Uterus, its Cervix and 
 Appendages, and on its connection with other JJteHne Diseases, 4th edition. 
 London, 1861, p. 119. 
 
 ^ Legons cliniques sur les maladies de I'lderus et de ses annexes. Paris, 
 1858, p. 141. 
 
PEESUMPTIVE SIGNS INDICATING UTEEINB DISEASE 101 
 
 that cardiac suffering and palpitation alarm the patient extremely, and 
 make her fear the existence of an aneurism or other organic lesion. 
 
 (3) Neuralgia, however, is the commonest of all these disorders, 
 not only in the lumbar and abdominal regions, where it might possibly 
 be supposed to be propagated from the uterus, but also in more distant 
 parts, and specially intercostal neuralgia on the left side, which makes 
 the patient fear that her heart is affected, and trifacial neuralgia, which 
 causes the sensation of a nail being driven into the skull in the parietal 
 region, as described by Sydenham. 
 
 Intercostal neuralgia is often associated with pain in the breast, 
 shoulder and arm of the same side, and if with lumbago sciatica and 
 facial neuralgia it may suggest to the patient the fear of hemiplegia. It is 
 not rare to find either hyperaesthesia or anaesthesia affecting one half of 
 the body only, being, in fact, a kind of hysteric hemiplegia affecting 
 sensation, as in other cases it may affect motion. 
 
 Uterine disease may also manifest itself by sympathetic pains in the 
 breast extending to the axillae and causing a feeling of swelling and a 
 particular kind of erethism often experienced during menstruation and 
 pregnancy. These sympathetic pains in the breast are very common, 
 especially during menstruation, sometimes sharp, sometimes dull, the 
 mammary glands being occasionally so swollen that it is impossible 
 to bring the arm close to the side. 
 
 Hysteria, which seems to be a natural point of transition between 
 disorders of sensation and of motion, since it includes both, is not 
 exclusively connected with the uterus or the ovaries, nor even with the 
 whole genital system. It is a chronic nervous affection characterised 
 by two kinds of symptoms ; on the one hand we have various perma- 
 nent symptoms, such as anaesthesia, or it may be hyperaesthesia, or 
 neuralgia, spasms, convulsive cough, or paralysis of different kinds; 
 on the other hand we have intermittent symptoms, attacks coming on 
 at irregular intervals, characterised by the globus hystericus, a sensation 
 of suffocation, or a loss of consciousness accompanied by various dis- 
 orders of sensation and motion, and generally terminating in a fit of 
 crying or in polyuria. This nervous affection often accompanies uterine 
 disease, but it may be developed independently of this cause; indeed, 
 physicians of great authority tell us it may be met with in men. 
 Nevertheless, it cannot be denied that the uterus or ovary, whether or 
 not in a normal condition, is most generally the starting-point, if not 
 the seat, of this affection. We need no further proof of this than the 
 extreme frequency of hysteria among women, especially among those 
 of a passionate nature who exercise self-restraint; and the same thing 
 is demonstrated by the voluptuous character of the convulsive move- 
 ments accompanying such attacks, as regards not only those of the 
 arms and eyes, but especially of the pelvis, even in the case of virgins 
 wholly ignorant of sexual relations. If, helped by the light which 
 recent researches have thrown on the physiology of the nervous 
 system, we endeavour to discover the relative share of influence 
 exercised by the nerves and by the uterus on hysteria, we must admit 
 that the disease is really a neurosis, that is to say, that it is due to a 
 
102 GENERAL SURVEY OP UTERINE DISEASES 
 
 general derangement of innervation, in which the whole nervous 
 system partakes with effects varying in form and in degree according 
 to the exciting cause and to the special idiosyncrasy in each case.^ 
 But we must remember that these symptoms, so varied in detail and 
 yet so similar as a whole, are only manifestations of the reflex action 
 of brain or spinal cord, the starting-point having been irritation in 
 some other organ, generally in the generative system. This irritation 
 and its influence transmitted to the nervous centres (analogous to the 
 O/Ura epile^tica) is often overlooked, while yet producing endless 
 phenomena of sensation or motion, affecting sometimes the whole 
 economy and sometimes only the various parts of the reproductive 
 system in which it took its rise. Thus hysteria is not properly 
 speaking a disease of the uterus or ovaries, but functional derange- 
 ments of these organs may be an exciting if not a primary cause of it. 
 I say functional derangement rather than disease ; for usually it is 
 some condition of pain, excitement, or irritation, nervous or vascular, 
 in some part of the genital organs that forms the starting point of 
 hysteria in pale, nervous and emaciated women, who already are pre- 
 disposed to it. Sometimes marriage is sufficient to develop this con- 
 dition, which in its turn produces hysteria. 
 
 On the other hand, when there is real uterine disease the patient 
 may be irritable, neuralgic and even partially paralysed, but she will 
 seldom complain of the globus hystericiis, or suffer from any really 
 serious hysterical fits or convulsions. In fact true hysteria is one of 
 the rarest of the nervous disorders occurring as general symptoms of 
 uterine disease. 
 
 Spasms, tonic or clonic, muscular rigidity, contractions or convul- 
 sions, may occur incidentally more frequently in the involuntary than 
 in the voluntary muscular system. May not vesical tenesmus, 
 vomiting, spasmodic dyspnoea, cardiac palpitations, &c., be attributed 
 to this cause ? Of such nature also is the little dry cough which 
 Ajan 2 calls '^ the uterine cough," which differs essentially from the 
 loud and noisy hysterical cough that somewhat resembles pertussis, 
 and which I think Trousseau ^ is right in attributing to the convulsive 
 motion of the muscles of the larynx and diaphragm. This uterine 
 cough is rare except in cases of great debility and exhaustion ; and 
 consequently it is a symptom which should arrest the attention of the 
 physician. He must decide whether it is nervous and merely sym- 
 ptomatic of uterine disease, or due to the commencement of pul- 
 monary tuberculosis. 
 
 ^ Coste, Be Vhysiirie consideree principalem,ent an point de vue de sa 
 nature et de ses causes. These de Montpellier, 1863, No. 6. See also Rouget, 
 Physiologie des actions reflexes, introduction to the French translation of 
 Paralysis of the Lower Limbs, by Brown- Sequard, 1864. And Brown-Sequard, 
 Arch. gen. de medecine, January, 1856 ; Causes organiques et mode de pro- 
 duction des affections dites hysteriques. Gazette medicale de Paris, 1846 ; 
 Legons sur les maladies du systeme nerveux, Bourneville, 4^ fascicule. Paris, 
 1873. 
 
 2 Op. cit., p. 146. 
 
 ^ Clinique med. de I'Sotel-Dieu de Paris, i. ii, p. 205, 2^ edit. 
 
PRESUMPTIVE SIGNS INDICATING UTERINE DISEASE 103 
 
 Motor paralysis is very rare as a nervous symptom of uterine dis- 
 ease. Aran ^ has denied its existence. It certainly must not be con- 
 founded with a numbness of the side of the body corresponding to a 
 lesion of the generative system, nor with the immobility to which a 
 patient may be driven by the intense pain occasioned by the slightest 
 movement ; nor even with more or less complete paralysis of the lower 
 limbs, which may arise from mischief in the pelvis causing compression 
 of the great nervous trunks. But besides these direct results of 
 organic lesions acting mechanically on those parts of the nervous 
 system with which they are in contact, we may have indirect and 
 sympathetic disturbance manifested in the motor nerves. 
 
 No one doubts the existence of hysterical paralysis i why may we 
 not have similar states produced by a suffering condition of the uterus 
 and ovaries which could itself develop hysteria ? I have seen two 
 very remarkable instances, one of hysterical and the other of uterine 
 paraplegia. The paralysis need not be general, nor affecting the upper 
 limbs, as Aran contends, in order to be regarded as sympathetic. 
 Indeed, a reflex paralysis, starting from the uterus, is more likely to 
 affect the lower parts of the body. Lisfranc^ mentions the case of a 
 lady suffering from paraplegia, who had been treated without benefit 
 for a supposed affection of the spinal cord, but whose condition began 
 to improve only when attention was paid to a chronic metritis, which 
 was the real cause of the paralysis. He gives another case of para- 
 plegia, where the cure of this affection kept step exactly with the relief 
 of the uterine malady. Nonat^ relates several similar cases, and shows 
 that when the uterine disease is unilateral the paralysis is so also. 
 These last cases seem to me to present some difficulties. I must refer 
 readers to his own work, and also to the theses of his pupils, 
 Esnault* and Tallin.^ Brown-Sequard^ refers to these cases, and 
 mentions having been consulted in 1855 by a young lady for extreme 
 weakness, amounting to paraplegia, at each menstrual period. Sen- 
 sibility was normal ; there were no symptoms of hysteria and no para- 
 lysis of the bladder or rectum. There was dysmenorrhoea, congestion 
 and anteflexion of the uterus, which was enlarged and very sensitive, 
 the tenderness extending to the broad ligaments, &c. The womb was 
 supported by an abdominal bandage, and in a few days there was a 
 marked improvement; in less than a fortnight the paralysis disap- 
 peared, though it had lasted for six months and had been treated by 
 strychnia, galvanism and hydropathy, as well as iron and other tonics. 
 At present I have a young girl under my care who had sufl'ered for 
 
 1 Op. cit., p. 147. 
 
 ^ Clinique chirurgicale de la Pitie, vol ii, p. 199. Paris, 1842. 
 
 ^ Traite pratique des maladies de Vuterus et de ses annexes, p. 381. Paris, 
 1860. 
 
 ■* Des paralysies symptomatiques de la metrite et du phlegmon periuterin. 
 These de Paris, 1857, No. 206. 
 
 * Des paralysies sympathiques des maladies de Vuterus et de ses annexes. 
 These de Paris, 1858, No. 33. _ 
 
 * Lessons on the Diagnosis and Treatment of the Principal Forms of 
 Paralysis of the Lower Extremities, London, 1861, p. 11. 
 
104 GENEEAL SURVEY OF UTEEINE DISEASES 
 
 more than a year from violent hypogastric pains^ sometimes associated 
 with hysteralgia and purulent vaginal leucorrhoea, and at other times 
 complicated with similar symptoms in the rectum and bladder, with 
 retention of urine, which was loaded with deposits. This condition 
 was accompanied by complete paralysis of the lower limbs, which with- 
 stood every kind of treatment, general and local, but is now disap- 
 pearing as the pelvic and uterine pains are gradually yielding to the 
 influence of atropine injected subcutaneously into the hypogastrium. 
 Not long ago I was consulted by a lady affected with paraplegia, who 
 was on her way to Balaruc ; a chronic metritis was discovered, appro- 
 priately treated and cured, the paralysis also disappearing without the 
 help of the Balaruc waters. Hunt, Romberg, Wolf, Mayer and 
 others have mentioned similar cases. Brown- Sequard asks, What 
 causes such paraplegia? We cannot admit that in the majority of 
 cases it is due to compression of the nerves of the lower limbs, 
 because the increased size of the organ is not sufficient to produce 
 such an effect. Besides, sensibility is very little, if at all, affected. 
 We must therefore conclude that the uterine disease produces the 
 paraplegia by a special action on the spinal cord, and that, therefore, 
 such paraplegia has all the characters of reflex paralysis. In such 
 cases the cure of the paralysis must depend on that of the uterine 
 malady, and our main duty is, therefore, to be able to diagnose this 
 latter disease and treat it appropriately. 
 
 III. Disorders of nutrition. — Derangements of the digestive and 
 nervous systems naturally bring about an impoverished state of the 
 blood and impaired nutrition. Anaemia, chlorosis and general 
 debility are, therefore, constantly present in women who have been 
 ill for some months, and may be taken as general symptoms of uterine 
 disease. 
 
 Chlorosis occurs specially in ill-nourished young women who have 
 probably already suffered from it at puberty and during pregnancy, 
 so that it is rather developed than originated by the uterine disease. 
 
 AncBmia is most common among older women, among those 
 suffering from serious diseases, such as cancer, fibroid tumours 
 and polypi, where repeated and profuse haemorrhages have occurred. It 
 is less a morbid affection than a direct or indirect result of the uterine 
 malady. Hepeated losses have impoverished the blood and deprived 
 the economy of needful materials for repair ; suppuration and insuffi- 
 cient assimilation have weakened the patient ; these are followed by 
 loss of colour in the skin, transparency of tissues, local cedema, a 
 frequent weak pulse, general debility and, in fact, symptoms resem- 
 bling those that follow after delivery or after some serious operation. 
 
 Chlorosis, anaemia, or chloro-ansemia are not only accompanied by 
 general debility, but by constantly increasing emaciation, until the 
 dyspepsia and uterine disease are properly treated. Even where no 
 special pain exists the patient acquires a very characteristic attitude, 
 constantly stooping forwards, the head and limbs bent in a manner 
 usually seen only in old age. The features are drawn and have a 
 look of suffering, which is all the more striking because the patient is 
 
PRESUMPTIVE SIGNS INDICATING UTERINE DISEASE 105 
 
 SO thin ; the flesh is soft and flabby, the countenance wanting in 
 expression, the complexion pale and faded, especially where there has 
 been long standing and abundant leucorrhoea ; this paleness with loss 
 of flesh and earthy complexion is different from the colourlessness of 
 ansemia, the sickly green hue of chlorosis, and the pale yeUow of 
 cancer. It is to this very characteristic appearance that we give the 
 name oi fades uterina. 
 
 Emaciation does not always exist ; on the contrary, there is some- 
 times corpulency. This is chiefly the case among those women in 
 whom amenorrhoea takes the place of leucorrhcea or hsemorrhage ; and 
 the constitution seems to get accustomed to the change. Is it pos- 
 sible that the blood which should have formed the catamenia is used 
 up in the economy to produce this unhealthy stoutness ? We cannot ■ 
 affirm that it is so, but there is no doubt of the embonpoint which 
 becomes obesity, and which leads some women to believe themselves 
 pregnant ; whilst others, when sufi^ering greatly, are forced to listen to 
 the congratulations of friends on their excellent health. As the 
 uterine disease becomes cured this unhealthy stoutness disappears, 
 and with it its various accompanying discomforts. Should the obesity 
 persist it may be treated by vapour baths, resolvents, tonics, exercise, 
 diet of roast meat and green vegetables, in addition to the admin- 
 istration oifucus vesiculosus, and these measures will generally bring 
 the body back to its normal condition. 
 
 Local Symptoms. — These are found in the neighbouring organs, or 
 in the uterus itself or its appendages. 
 
 1. In the neighbouring organs. — The rectum and bladder will 
 almost always be found affected. 
 
 A. Functional derangements of the rectum may accompany disturb- 
 ance of the rest of the alimentary canal. Though frequent they do 
 not always exist ; and sometimes instead of resulting from uterine dis- 
 ease they may produce it. If coincident, the two react upon and 
 aggravate each other. Many women who are habitually constipated 
 have diarrhoea just before the menstrual period, or during its course. 
 Tliough this symptom requires no treatment it is worthy of notice, as 
 showing the close inter-dependence of the various pelvic organs. 
 Another very important point is habitual constipation, which is so 
 common among women that in certain cases it may be looked on as 
 the cause of the uterine malady. We must therefore find out whether 
 the constipation was habitual and to what extent it existed before 
 the disease of the womb. There are cases in which it has neither 
 increased nor diminished since that period, in others it has increased 
 so much that it helps to keep up and continue the uterine disturbance 
 by the irritation and congestion which it causes in the pelvis. 
 
 Constipation does not necessarily accompany uterine disease. The 
 derangement of the digestive functions may produce diarrhoea; but 
 this is not common and is generally followed by constipation. Con- 
 stipation is all the more frequent because it may be perpetuated by a 
 mechanical cause. In prolapsus and various displacements, especially 
 retroversion and retroflexion, as well as in cases of tumours (whether 
 
106 GENERAL SURVEY OE UTERINE DISEASES 
 
 uterine, periuterine, or ovarian), the rectum suffers from pressure 
 which impedes the circulation. In cases of metritis, uterine catarrh, 
 ovarian or periuterine inflammation, congestion of the rectum is not 
 due only to blood stasis but to an extension of the inflammation, in 
 which case diarrhoea sometimes alternates with constipation. How- 
 ever, the first effect of congestion is generally obstinate constipation, 
 which is one of the most common and most serious symptoms of every 
 uterine disease. The mass of hardened scybala can be evacuated only 
 after enemata and repeated efforts, and the fseces are often coated 
 with mucus, a sign of enteric inflammation. The constipation may 
 last for two or three weeks or end in painful diarrhoea with tenesmus, 
 lasting several days ; and sometimes even this will not occur without 
 •the use of purgatives. The accumulation of fseces and consequent 
 distension of the intestine bring on a kind of paralysis, the retained 
 mass becomes partly decomposed and some of its elements may be 
 reabsorbed. The effect of this form of blood poisoning, to which 
 Barnes gives the name of Copramia, may be seen in the sallow, dirty 
 hue of the skin, the ill-smelling cutaneous secretions, in dyspepsia, 
 flatulence, pyrosis, and in fact in endless disorders of nutrition and 
 innervation. Sometimes the paralysis and obstruction of the intestine 
 go so far as to resist all treatment ; I have seen several women die 
 from simple constipation. In spite of constipation the sufferer may 
 be tormented by an urgent desire to go to stool, owing to pressure 
 being exercised on the rectum by the uterine tumour. This desire 
 becomes so strong that women make violent expulsive efforts, the 
 only result of which is the excretion of some bloody mucus, with 
 tenesmus and intolerable straining. In this way habitual constipation 
 increases uterine disease both directly and indirectly. It almost 
 always leads to hsemorrhoids, anal fissure, contraction of the sphincter 
 and violent pains during defsecation, which may persist for a long 
 time afterwards. Such violent efforts cannot be made without painful 
 reaction on the uterus, and the patient dreads the effects so much that 
 she is apt to let the constipation go on unless constantly watched. 
 
 B. Derangements in the functions of the bladder and urinary system 
 are various. The urine is often clouded, especially in the case of 
 patients who have a displacement or hypertrophy of the uterus, which 
 then presses on the bladder or urethral canal; particularly when any 
 new irritation arises in the womb, or an increase of old inflammatory 
 symptoms reacts on the bladder. Patients usually complain of 
 frequent desire for micturition, often accompanied with dysuria and 
 sometimes with strangury and hsematuria. 
 
 The bladder in fact often shares the morbid condition of the 
 uterus ; there may be congestion or even inflammation, and perhaps 
 catarrh of the mucous membrane; the urethra may be red, swollen 
 and bleeding ; the meati:^ congested and inflamed, and sometimes the 
 seat of small vascular tumours of which I shall speak subsequently. 
 Any pressure on the bladder from the abdominal or pelvic viscera is 
 very painful. The state of the urine corresponds to these morbid 
 conditions and requires examination. We find more or less viscous. 
 
PEESUMPTIVE SIGNS INDICATING UTERINE DISEASE 107 
 
 flaky, mucous, or muco- purulent deposits, which may coincide or 
 alternate with deposits of white powdery triple phosphates. These 
 muco-purulent and saline deposits are signs of vesical catarrh which 
 often accompanies uterine catarrh. Is Aran right in thinking that 
 much of the pain felt by women suffering from uterine disease is due 
 to these deposits and to the irritation caused by their presence in the 
 bladder and their passage through the urethra? Catarrh of the 
 bladder with irritation and inflammation of its mucous membrane and 
 that of the urethra is a still more likely cause of much suffering. 
 
 Sometimes the abnormal condition of the urine is due to the kidney 
 itself. The secretion may not only be very much increased under the 
 influence of violent pain or hysteria, giving rise to the excretion of a 
 large quantity of transparent " nervous^^ urine, but the secretion may 
 itself be altered, containing brick-red deposits of uric acid or urates. 
 There is sometimes a tendency to the renal lithiasis to which I have 
 already called attention as being coincident with hepatic lithiasis. In 
 these cases, it seems to me, there is a rheumatic if not a gouty 
 diathesis. 
 
 II. Symptoms in the uterus. — It is desirable to ascertain at once 
 how the various reproductive functions have been performed, especially 
 menstruation and pregnancy. As regards menstruation, we must learn 
 the date of its appearance, the character of each monthly period and 
 its frequency and duration, the quantity of the discharge, and the 
 presence or absence of pain, with any particulars relating to the meno- 
 pause. If dysmenorrhoea has existed from the first it suggests me- 
 chanical obstruction, whereas if it supervened after marriage or after 
 miscarriage it is more probably due to cervicitis. 
 
 It is important to learn everything relating \,q previous pregnancies ^ 
 as well as to each delivery. 
 
 Sterility is a fact of still greater importance in the history of uterine 
 disease. If a woman has been married for several years without having 
 become pregnant the probability is that something is wrong; there 
 may be some malformation, or the sterility may be due to functional 
 disturbance or to disease. In nine cases out of ten I have discovered 
 the cause of the sterility in a malformation, or in a morbid condition 
 of the cervix, and very frequently I have been able to remedy it. 
 Uterine symptoms are of two kinds — pain and excessive discharges. 
 Fain is the cry of the suffering organ. Of all local symptoms it 
 is the first to attract attention. It is, however, sometimes absent ; 
 but even in such cases it can be elicited by slight causes, and it is 
 always of great importance. We must study pain from three points 
 of view — 1. Its form of expression. 2. Its seat. 3. Its type. 
 When studying its form and mode of production we must distinguish 
 between spontaneous pain and that artificially elicited. 
 
 Spontaneous pain is rare if we limit the term to pain caused directly 
 by organic disease, but we ought to include pains induced by changes 
 of posture which give rise to tension. Spontaneous pain does, how- 
 ever, occur frequently enough, even when the patient is in bed with all 
 the muscles at rest and with no exciting cause dependent on neigh- 
 
108 GENERAL SURVEY OF UTERINE DISEASES 
 
 bouring organs. Such pain is almost always the symptom of acute 
 disease and generally of inflammation, such as occurs in acute hy- 
 persemia, congestion, metritis, or ovaritis (whether puerperal or not), 
 but most especially in perimetritis aud hematocele. In some cases 
 this pain persists, even after the disease has passed into a chronic 
 state ; but as a rule spontaneous pain, strictly speaking, disappears 
 at this stage, and is only excited by pressure or concussion dependent 
 on movements. Although patients generally suffer least when in bed, 
 there are instances where less pain is felt when walking or standing. 
 When the dorsal decubitus causes pain we may suspect retroversion, 
 retroflexion, a tumour, or a retro-uterine hematocele. Many patients 
 suffering from chronic metritis or congestion, or even from simple 
 hypertrophy with relaxation of the uterine ligaments, experience con- 
 siderable pelvic pain when lying down, especially if the bed slopes 
 downwards towards the foot. I have known several invalids who, not 
 content with making the bed quite horizontal, have instinctively taken 
 the precaution of placing a pillow under the nates, so that, the pelvis 
 being higher than the shoulders, the uterus escapes all pressure from 
 the abdominal viscera. The lateral decubitus, with semi- flexion of the 
 limbs, is sometimes adopted to avoid the pain referred to, but this 
 lateral position may cause other pains. If these are felt on the side on 
 which the patient is lying the lesion will be there also, whether its 
 seat be in the ovary, uterus, or connective tissue, the pain being pro- 
 duced by pressure on organs extremely sensitive from their patholo- 
 gical state and exposed by their position to pressure from neighbour- 
 ing viscera. If, on the contrary, pain is felt in the other side, it is due 
 either to the dragging of the diseased uterus on the ligaments and 
 appendages of that side, or to an inflammatory condition with abnormal 
 adhesions, in which case it may depend on dragging caused even by 
 the weight of a healthy uterus. Some patients find that the least 
 fatiguing position is that of pronation — either lying on the stomach 
 or on elbows and knees ; this is almost a certain sign of retroflexion. 
 Spontaneous pain may be felt more in sitting than in lying, as in cases 
 of uterine hypertrophy, hematocele, or perimetritis. The patient 
 cannot remain seated for long without experiencing a painful sensation 
 at the anus and perinseum similar to that caused by hsemorrhoids, 
 urgent desire to go to stool, or a disagreeable and sometimes burning 
 heat in the peringeum with a feeling of fulness and weight in the 
 pelvis. These pains sometimes become so intense that the patient, 
 not being able to remain sitting in the ordinary way, will rest in 
 Turkish fashion, or throw the weight on the heels placed below the 
 opposite tuberosities, or finally lie down to escape this discomfort. 
 Sometimes the sitting position makes the patient feel as if a hard body 
 pressed on the anus or perinseum ; at other times it is as if such a hard 
 body pressed painfully upwards on the uterus and abdominal viscera. 
 This sensation may be felt under various circumstances, especially in 
 pelvic peritonitis ; but I have often seen it when the uterus alone was 
 affected ; it is rarely absent with hypertrophy of the cervix, especially 
 when this coincides with fungous granulations or metritis. In such 
 
PEESUMPTIVE SIGXS INDICATING UTERINE DISEASE 109 
 
 cases the sufferer not only avoids sitting long, but takes great care 
 not to sit down abruptly^ knowing that by so doing she would produce 
 the pain I have just described, which may be so severe as sometimes 
 to induce syncope. 
 
 Standing seems to cause pain which neither the position nor the 
 special disease can always account for. In cases of displacement, it is 
 natural that standing, like walking, should cause a troublesome drag- 
 ging on the ligaments or painful pressure of the displaced or pro- 
 lapsed uterus on neighbouring organs; but in other cases, such as 
 leucorrhcea, one cannot connect cause and effect. Whenever the 
 uterus or the ovaries are affected, they necessarily become more sen- 
 sitive, and they are sure to suffer simply from the weight of the 
 abdominal viscera. It may be in this way that standing causes pain. 
 In walking the weight of the viscera probably comes now on one and 
 now on another part of the pelvis ; while in standing the suffering 
 uterus bears the whole pressure continuously, and consequently many 
 women prefer walking to standing. 
 
 However, in the majority of chronic uterine diseases, walking and 
 other physical exercises cause the most violent pain. It is needless 
 to add that in cases where pain is felt when the patient is at rest, it 
 becomes much more severe when she walks or otherwise exerts herself. 
 Walking so generally causes pain that many women suffering from 
 uterine disease lose the habit of walking. Others can walk in the 
 house or on a smooth flat path, but suffer as soon as they try to walk 
 on a rough road, or feel the vibration caused by a false step or even 
 by going down stairs. This is especially so in cases of metritis and 
 perimetritis, when the slightest shake is felt painfully and causes the 
 patient instinctively to put her hand on the hypogastrium. It is easy 
 to understand how much more certainly pain will be produced by 
 other and more violent exercises, such as dancing, riding, driving, &c. 
 I have seen patients suffer terribly after a little waltzing, and have 
 known others obliged to give up riding because it excited pain. 
 Travelling by railway, though better borne as a rule than driving, 
 sometimes causes great discomfort, the continual vibration producing 
 mental as well as physical excitement and uneasiness. 
 
 With other patients uterine pain is provoked by movements of the 
 arms, as in sewing or playing the piano ; these actions often caus- 
 ing a painful reaction in the hypogastric region and throughout the 
 body. ^^yjx 
 
 Coitus produces pain in many women by a complex process. The ^f*^ — 
 physical movement, shock, orgasm, all unite in bringing about the 
 result. We must ascertain whether pain is produced by intromission, 
 depending on vaginitis, fissure, spasm, or contraction of the vulva ; or 
 by the shock against the uterus causing a direct effect upon this organ 
 and the surrounding tissues. Sometimes, though no pain is felt at 
 the moment, great general fatigue, as well as throughout the pelvis, 
 is experienced the following day. As a rule these invalids avoid 
 sexual intercourse, either on account of the suffering it entails or 
 because of real uterine inertia. But besides causing pain intercourse 
 
110 GENERAL SURVEY OF UTERINE DISEASES 
 
 may become very diflBcult and in some cases impossible. Barnes ^ 
 considers this symptom of difficulty so important that he has given it 
 the name of dyspareunia, a word by which household troubles were 
 often signified by the Greeks. Dyspareunia may depend on (1) vagi- 
 nismus, i.e spasm^ either direct or reflex^ of the constrictors of the 
 vulva and vagina; (2) pain; (3) chronic nervous irritability due to a 
 first coitus having been incomplete or awkwardly performed ; (4) pain 
 caused by inflammation ; (5) embarrassment; (6) tumours; or (7) 
 malformations, imperfect development, imperforate hymen, narrowness 
 of vagina, &c., in short, whatever the cause may be the symptom is 
 one that necessitates a direct examination. 
 
 Tight dresses even v^hen worn for a short time only have their 
 influence in causing pain. Cruveilhier long ago pointed out the 
 effects produced by tight lacing on the form and position of the abdo- 
 minal viscera ; and we can easily understand how the compression of 
 these organs and their pressure on the diseased uterus or ovaries may 
 cause intolerable suffering. An abdominal belt on the contrary raises 
 and supports the viscera. Indeed, stays are often voluntarily relin- 
 quished before consulting a doctor. 
 
 We must next ascertain whether pain can be elicited artificially. 
 This is necessary with all patients in order to determine the seat and 
 exact starting point of the pain ; but it is specially important with 
 those who, from special idiosyncracy or from a hard and laborious 
 life, are not sensitive to pain. The simplest plan is to ask the patient 
 to make the movements likely to cause suffering. A woman who is 
 seated in an easy chair may assure us in good faith that she has no 
 pain whatever ; but ask her to rise and walk across the room, or lift a 
 piece of furniture, and she will be conscious of suffering immediately. 
 As a rule, it is by manual examination that we learn the seat and 
 degree of pain. Abdominal pressure, digital examination by the 
 vagina and rectum, separately or all combined, will generally elicit 
 dull latent pain. Abdominal pressure may be made when the woman 
 is either standing or lying, if standing she ought to lean forward, if 
 lying the knees ought to be well drawn up, so as to relax the abdo- 
 minal muscles ; a gentle but continued pressure must be made with 
 the tips of the fingers over the hypogastric and iliac regions as well as 
 in the groins. If pain is elicited by pressure, we ought to verify our 
 diagnosis while the patient is standing, by placing the hand trans- 
 versely on the hypogastrium above the pubis, lifting all the abdominal 
 viscera towards the diaphragm and letting them fall abruptly ; repeat- 
 ing this manoeuvre two or three times. If the patient feels relieved 
 when the viscera are lifted up and experiences pain when they fall, 
 we are able to determine the existence, seat, and often the cause of the 
 pain, and can also estimate the utility of a hypogastric belt to support 
 the abdomen. 
 
 During vaginal and rectal examination the tip of the finger may 
 press on the neck or body of the uterus, or on the ovary ; or, again, 
 on a peri- uterine tumour, to determine whether it is solid, sanguineous, 
 ^ Diseases of Women, 2nd edition, London, 1878, p. 65. 
 
PRESUMPTIVE SIGNS INDICATING UTERINE DISEASE 111 
 
 or purulent. If this pressure does not cause suffering, a slight shock, 
 as in practising balottement to diagnose pregnancy, may elicit pain. 
 At other times abdominal palpation must be associated with vaginal or 
 rectal touch before we can determine the exact seat of suffering, which is 
 sometimes in the ovary, sometimes in the uterus, and sometimes in a 
 retro-uterine tumour. In any case it is very important to elicit pain. 
 When felt it is impossible for the patient to conceal her disease or to 
 ignore its existence. It is, however, necessary to point out an error 
 into which we may fall. Some patients, especially young girls who 
 are unaccustomed to the contact of a foreign body in the vagina, partly 
 from sensitiveness, shrink with alarm and fear from the slightest touch, 
 sometimes crying out as if in pain. If this occurs just as the finger 
 touches the uterus the physician is all the more likely to be led astray ; 
 he must remember that, apart from the sensitiveness of the patient, 
 this apparent manifestation of pain may be owing to the shock or (so 
 to speak) to the surprise of the organ ; if he continues the examination 
 gently and patiently he will generally succeed in discovering the real 
 seat of pain. 
 
 There are six seats of pain — three principal and three accessory. 
 The three principal seats are — 1, the iliac regions ; 2, the loins ; and 
 3, the hypogastrium. 
 
 I. Iliac pain is the most common; it corresponds to the iliac fossa, 
 spreading towards the hypogastric and lumbar regions, but especially 
 towards the pelvic brim and cavity. This pain must not be confounded 
 with true lumbar pain, nor with intercostal neuralgia, which patients so 
 often complain of below the breast. The mistake is the more easily made, 
 as both kinds of pain are generally felt in the left side. Iliac pain is 
 described by patients as pain in the side ; as a rule this is a pathogno- 
 monic symptom of uterine disease. Aran thinks it is generally due to 
 inflammation of the ovary or appendages. Many cases may be ex- 
 plained in this way, but not all, because ovaritis is not limited to the 
 left side. I think it can be accounted for in another way; just as pain «~ 
 in the back may arise from tension of the utero-lumbar ligaments, so \ Vv-- 
 may left iliac pain be produced by tension of the broad ligament. This ] 
 may occur without metritis, ovaritis, or perimetritis. The uterus, in 
 some morbid conditions, increases in size and weight ; its normal in- 
 clination to the right being still more exaggerated, it necessarily drags 
 on the left side of the broad ligament ; this dragging is enough to 
 cause pain, and may even produce perimetritis. 
 
 %. Lumbar pain, generally called *^ backache,^' though less frequent 
 than iliac pain, is yet very common, and often very troublesome. Some- 
 times it is confined to the renal region, or it may spread to the sacrum, 
 or even to the abdomen ; at other times it extends from the loins, 
 where it reaches its maximum, down each side to the iliac regions and 
 even to the hypogastrium and pubis, encircling the abdomen with a 
 belt of pain and sometimes terminating in a violent uterine spasm. 
 Its cause is as variable as its mode of manifestation. Sometimes it 
 depends on the contraction of the utero-sacral ligaments, or possibly on 
 their distension, from the descent or retroversion of the uterus ; some- 
 
112 GENERAL SURVEY OP UTERINE DISEASES 
 
 times on congestion distending the ovarian veins and pampiniform 
 plexus J or, again, it may be due to the accumulation of leucorrhoeal 
 mucus and to the contractions provoked in the uterus in order to expel 
 it ; sometimes it is caused by cervicitis, whether simple, granular, or 
 ulcerative. Lumbar pain generally indicates disease of the cervix, 
 whilst iliac pain (especially if associated with dyspepsia) is more fre- 
 quently connected with an affection of the body of the womb or of one 
 of the uterine appendages. Sacral, like anal pain, is suggestive of 
 retro-flexion, or of a retro-uterine tumour. 
 
 3. Hypogastric pain has its seat immediately above the pubis, and 
 seems, more than any other, to have its starting-point in the body of 
 the uterus and to be dependent on an inflammation of that organ. It 
 appears when artificially elicited rather than spontaneously. Many 
 patients, also, who do not complain of it at first, feel it as soon as 
 pressure is applied to the abdomen. This symptom is never absent in 
 uterine disease. Although this pain is seldom spontaneous, it is still 
 very disagreeable to women ; it interferes with their walking, or, if they 
 do walk, they feel the necessity of supporting the hypogastrium with a 
 belt, or they keep their hands in front, ready to protect themselves 
 from the slightest shock which might occur. This pain must not be 
 confounded with the sensation of dragging at the umbilicus (associated 
 with sacral pain), which is often a symptom of retroflexion. 
 
 The three accessory seats of pain are — 1, the anus or perinseum; 
 
 2, the vagina or cervix ; 3, the cavity of the pelvis. 
 
 1. Anal or perhieal pain is, generally produced by pressure from a 
 peri-uterine tumour, from the fundus of the retroflected uterus, or 
 from the uterus itself, either hypertrophied or prolapsed. I have 
 already referred to patients affected with hypertrophy of the cervix, 
 v^ho suffered pain at the anus and perinseum, not only in walking and 
 riding, but when sitting. 2. Vaginal pain is less frequent. In cer- 
 tain acute diseases the uterine pain extends to the vagina, but it is 
 more often due to the development of peri-uterine disease, especially if 
 such disease is of an acute or inflammatory nature. In this way hema- 
 tocele, retro-uterine peritonitis, peri-uterine inflammation, or abscess, 
 sometimes produce in the vagina heat, swelling, or sharp throbbing 
 pain extending to the vulva, which may become excruciating. In 
 chronic disease this pain is often not felt unless artificially elicited. 
 
 3. Pelvic pain is usually the symptom of peri-uterine disease, or of 
 cystic or solid tumours of the ovary or uterus. In acute peri-uterine 
 diseases such pain may be violent and accompanied with throbbing 
 and a sensation of distension ; in chronic diseases it is dull and 
 heavy. 
 
 Eadiating pain is chiefly pelvic. Iliac pain extends to the groins, 
 either along the round ligament or by the ilio-pubic branch of the 
 lumbar plexus. In this case the radiation assumes a neuralgic cha- 
 racter j there is an iliac centre, an abdominal centre, and one in the 
 labia majora. Lumbar pain radiates oftenest along the course of 
 the sciatic nerve. This radiation, like neuralgic pain, is occasional and 
 intermittent ; but it may be more frequent, prolonged, and even con- 
 
PRESUMPTIVE SIGNS INDICATING UTERINE DISEASE 113 
 
 tinuous, if dependent on direct compression of one of the sciatic nerves 
 by a uterine^ ovarian^ or pelvic tumour. The hypogastric pain, like 
 the iliac, sometimes extends to the groin, but oftener to the upper part 
 of the thigh, following the divisions of the obturator nerve, or extend- 
 ing along the anterior aspect to the knee, and sometimes below it, fol- 
 lowing the branches of the crural nerve. The other pains, whether 
 sympathetic or reflex, are not simple radiations ; they have already 
 been referred to under the head of general disorders of the nervous 
 system. 
 
 Pain may be of a continuous or an intermittent type. Continuous 
 pain varies in intensity according to the individual and to the disease. 
 It is worthy of remark that the most painful diseases are not always 
 the most serious, and that certain incurable diseases, such as cancer 
 and epithelioma of the cervix, may be developed without producing 
 symptoms fitted to arouse the anxiety of patients. Hence the phy- 
 sician is almost always consulted too late to be able to do more than 
 palliate suffering; whereas if called at the commencement he could 
 have removed the diseased portion of the neck by the knife or cautery 
 and so frequently might have saved life. Cancer itself, whether of the 
 neck or of the body, does not cause suffering until ulceration begins ; 
 on the other hand, acute inflammation, neuralgia and catarrh often 
 produce most violent pain. The intensity of pain is not always pro- 
 portioned to its acuteness. There are kinds of pain which are intense 
 but dull, giving the sensation of a weight, a distension, a numbness in 
 the various regions I have described, and especially in the pelvis and 
 along the pelvic nerves. There are others of a burning or lancinating 
 character, resembling neuralgia, but less persistent, ajjpearing and dis- 
 appearing in proportion to the pressure exercised by the uterus on the 
 ramifications of the crural, obturator, or sciatic nerves, this pressure 
 depending on the posture adopted by the patient. 
 
 Intermittence of pain depends on three principal causes : — Inter- 
 mittence is often characteristic of neuralgic pain. The neuralgia 
 ■which accompanies uterine disease may, like other neuralgia, cease 
 after a certain time, or even acquire the character of periodicity. The 
 sudden attacks and exacerbations which are often observed in chronic 
 uterine diseases, especially in those of an inflammatory nature involv- 
 ing the peritoneum and accompanied by suppuration, may also explain 
 the occurrence of intermittence. Such crises are often dependent 
 on disorders of menstruation, and each monthly period may be the 
 signal for an exacerbation of the disease and of pain. Or intermittence 
 may depend on tlie very nature of the affection, and on the uterine 
 contractions which are developed in the course of the disease. These 
 contractions are painful. They are easily distinguished by the expul- 
 sive character they assume; ))atients complain of a sensation of some- 
 thing pushing downward, as in labour pains ; young girls even can 
 trace the coimeclion, when their attention has been called to the coin- 
 cidence, between tliese pains and the expulsion of a certain quantity of 
 mucus or clots of blood. They are caused by an accumulation of 
 mucus or muco-pus in cases of catarrh and leucorrhoca ; by an accu- 
 
 8 
 
114 GENERAL SURVEY OP UTERINE DISEASES 
 
 iDulation of blood in hsemorrhages ; or they may be due to stenosis of 
 the 09, or to polypi or tumours in the uterine cavity, which may 
 produce local irritability and spasm. 
 
 Another indication is afforded by the character of the dis- 
 charges from the vulva ; whether sanguineous, mucous or muco- 
 purulent. 
 
 1. Uterine hcBmorrhage is by no means an invariable symptom of 
 disease of the womb. In some cases there is little or no derangement 
 of the menstrual function ; but this is the exception. The recurrence 
 of the monthly period may be tardy, or too frequent, or there may be 
 intermenstrual haemorrhage; oftenest of all ther'e is dysmenorrhoea 
 with diminution in the quantity of blood. If the catamenia have 
 never appeared, we must learn whether general and local symptoms 
 recurring periodically may not have indicated the menstrual molimen ; 
 or there may even have been haemorrhage within the uterus without 
 any external discharge, the blood being retained from imperforate 
 hymen, obliteration or deviation of the cavity of the cervix, or an 
 occlusion of the uterine orifice. It is important to distinguish the 
 cases in which there is retention from those in which the haemorrhage 
 has never taken place, and from those still rarer instances in which 
 the uterus is wanting. I have seen an instance of the last kind, and 
 also several cases where the uterus had no external outlet owing to 
 the cicatricial obliteration of the vagina following upon gangrene after 
 delivery. I have operated on several girls for imperforation of the 
 cervix and have found menstruation subsequently take place regu- 
 larly, and I have often seen menstruation entirely or partially 
 obstructed by stenosis of the os externum or internum, or by ano- 
 malies in the position of the orifice or in the direction of the cervical 
 canal. Fortunately, amenorrboea is much oftener due to some func- 
 tional disturbance or to a morbid condition of the general health, 
 such as chlorosis or anaemia, and it must not be forgotten that 
 amenorrhosa may possibly depend on pregnancy even in a woman who 
 has never menstruated. 
 
 The next point is to ascertain whether the menstrual function is nor- 
 mally performed. In a number of uterine diseases the catamenia are 
 excessive, in others defective. It is important to ascertain whether 
 the quantity of blood habitually lost has increased or diminished. 
 Differences are relative rather than absolute ; for one woman normally 
 loses very little in comparison of another. The length of the period 
 also varies, and in this respect we must take individual idiosyncracies 
 into account. Some women may be in good health although the 
 menses only last for a few hours, whilst in other cases they continue 
 for twelve or fifteen days. The normal period of recurrence is also 
 variable though in most cases the menses return every twenty-eight 
 days ; in some women, however, the ordinary term is thirty, thirty-five, 
 or even forty days, whilst in other cases it is reduced to twenty-five, 
 twenty, or even fifteen days. We must carefully distinguish men- 
 struation from simple haemorrhage having no connection with the 
 catamenia. Although uterine hasmorrhage may sometimes be accom- 
 
PEESUMPTIVE SIGNS INDICATING UTEEINE DISEASE 115 
 
 panied by general and local symptoms which make a differential 
 diagnosis difficult, yet the menstrual flow is generally marked by 
 distinctive signs not confined to the uterus but involving the whole 
 generative system, and accompanied by an unusual sensibility in the 
 woman as well as other symptoms, varying in different individuals, but 
 habitually characteristic of each ; the whole being sufficient to prevent 
 our confusing the physiological function with the pathological pheno- 
 menon, in spite of their single common element, the loss of blood. 
 The general and local symptoms of the menstrual molimen are so 
 marked that they can easily be diagnosed even when there is no 
 haemorrhage. Sometimes we see the catamenial molimen occurring in 
 the intermenstrual period, accompanied by pain, local fatigue and 
 reaction on the general system, which is all the more intense because 
 not followed by a critical haemorrhage that would give relief (see 
 Chapter on Menstruation). It is no less important to have correct 
 information as to the quality and colour of the blood discharged. 
 Sometimes it is darker, sometimes paler, than normal. It may be so 
 dark as to be almost black, with dense viscous consistence, or perhaps 
 in a state of coagulation, being expelled probably at intervals rather 
 than continuously. All this indicates that the blood is of venous 
 rather than arterial origin, or that it is mixed with mucous secretions, 
 or that it has been long retained in the uterine cavity owing to inertia 
 or to constriction of the orifice. At other times the discharge is pale 
 and thin, of serous or sero-sanguinolent nature, leaving on the linen a 
 pale pink stain surrounded by a grey areola ; this is symptomatic of 
 chlorosis, uterine catarrh, &c. The blood may be fluid or may be 
 expelled partly in clots. The size of these clots and the presence or 
 absence of pain at the moment of their expulsion may indicate 
 increased size of the cavity of the womb with inertia of its walls, or 
 on the other hand, contraction with spasm and partial occlusion of the 
 orifices. In short, menstruation may undergo many important 
 changes. "When these derangements are marked they are designated 
 by the names of amenorrhoea, dysmenorrhoea, menorrhagia and me- 
 trorrhagia; these may be not only important symptoms in diagnosing 
 a case, but essential morbid conditions which will be described as such 
 in due time. 
 
 It must always be borne in mind that these different symptoms may 
 not only indicate uterine disease, but possibly pregnancy, abortion, de- 
 livery, &c. While no one doubts the significance of amenorrhoea and 
 haemorrhage, dysmenorrhoea is treated as of less moment, in consequence 
 of a common id^a that many women suffer at their monthly periods 
 who yet have nothing the matter with them ; but this is a mistake ; the 
 more experience we gain the more we are convinced that dysinenorrhffia, 
 especially when associated with dyspareunia and sterility, is invariably 
 symptomatic of a mechanical obstacle to the excretion of the catamenia. 
 We must learn all we can as to the history of these haemorrhages, the 
 frequency of their recurrence, whether they are spontaneous or elicited, 
 if they occur in the morning or evening, whilst the patient is at rest 
 or after exposure to fatigue, as in walking, driving, riding, and espe- 
 
116 GENERAL SURVEY OF UTERINE DISEASES 
 
 cially in coitus. A few drops of blood after congress, especially if 
 associated with muco-purulent leucorrhoeaj ought to make us suspect 
 fungous granulations of the cervix, if not a more serious organic lesion, 
 sometimes cancer. 
 
 2. Jjeucorrlma, or the various discharges from vulva, vagina, or 
 uterus, ought to engage our attention for two reasons — 1. Because 
 many patients do not mention this symptom to their doctor, thinking 
 that all women suffer in this way. 2. As leucorrhoea is always abnormal 
 its existence convinces us that a pathological change of some kind has 
 taken place in the generative system. We must find out if these dis- 
 charges are spontaneous, or if they are caused by walking, coitus, &c. ; 
 if they are insignificant or abundant, continuous or intermittent ; if 
 they cause inconvenience and are accompanied by fatigue, pain in the 
 stomach, dragging in the loins and in the middle of the back. The 
 peculiar characteristics of these discharges give us indications, and 
 often point out to us with certainty their source and even the nature 
 of the disease which produces them. 
 
 The normal secretions of the vulva, vagina and uterus are not con- 
 tinuous but intermittent, only taking place simultaneously with the 
 performance of their principal functions — coitus, menstruation, preg- 
 nancy and delivery. They may also occur normally after any fatigue 
 or excitement, whether local or general. When pathological, these 
 discharges may retain their normal character, being produced simply 
 by hypersecretion, or they may assume an abnormal nature, depending 
 on some derangement of the secretion. 
 
 Simple liypersecfetion. — The vulval mucus is transparent and viscid, 
 with acid smell and reaction, presenting nucleated epithelium with 
 fragments of pavement epithelium, the secretion being either continuous 
 or intermittent, as the case may be. The vaginal mucus is a milky- 
 white emulsion, not viscid, with acid reaction, continuous secretion, 
 and a large preponderance of solid elements, giant cells of pavement 
 epithelium predominating over the liquid elements. The uterine 
 mucus is an albuminous liquid, very viscid and stringy, sometimes 
 tenacious, closely resembling white of egg, often quite transparent, 
 secreted intermittently, with alkaline reaction, containing cylindrical 
 or ciliated epithelium with mucous globules or nucleated epithelial 
 cells; the cervical secretion the most tenacious of all, and contain- 
 ing more ciliated epithelium than the mucus of the fundus. As to 
 age, we must remember that vulval leucorrhcea is specially common 
 in children, vaginal leucorrhoea more frequent in young women, 
 uterine leucorrhoea, especially when cervical, njost common in 
 middle-aged and old women. The first is sebaceous (except the 
 hypersecretion of the vulval glands of Bartholini) ; the second, epi- 
 thelial (common or pavement) ; the third, mucous or nucleated. 
 
 Derangement of secretion. — The vulval discharge may become yellow, 
 green, purulent, or, in mixing with hypersecretion of sebaceous matter, 
 may form a magma, with strong, acid, cheesy smell, very irritating to 
 the adjoining parts, which become excoriated. The vaginal secretion 
 may become very thick, curdy, greasy (never viscid nor gluey), always 
 
PRESUMPTIVE SIGNS INDICATING UTERINE DISEASE ] 1 7 
 
 acidj or, on the contrary, very abundant, more fluid, mixed with pus, 
 yellow or green or sero-purulent, like the pathological secretion pro- 
 duced by a bhster excreted continuously, very irritating, and causing 
 excoriation of the vulva and upper part of the inner side of the thighs. 
 It is an undoubted fact that the vagina suppurates much more frequently 
 than the uterus, which is in accordance with Virchow's remark that 
 mucous membrane with cylindrical epithelium is slow to suppurate. 
 The uterine excretion may become white, grey, yellow, even green, or 
 streaked with yellow and white, of yellowish-green colour, partly 
 transparent, always alkaline, more fluid, sometimes quite serous, but 
 often tenacious, excreted intermittently and with the knowledge of 
 the patient who experiences uterine colics as soon as the contractions 
 of the organ expel the liquid, which is sometimes accumulated in large 
 quantity in the uterine cavity and then falls into the vagina or on the 
 vulva in one mass, as the white of egg would do. When the cervix is 
 affected the mucus may become so gluey and tenacious that it adheres 
 to the organ for a loag time, and is only detached from it in a half 
 solid form, similar to the cervical plug of pregnancy. To these cha- 
 racteristics, of which intelligent patients are well aware, we may add 
 those furnished to us by stains on the linen, of which I shall speak 
 when giving the diagnosis of leucorrhoea. 
 
 Mixture with another liquid, normal or pathological. — The dis- 
 charges may become serous or sanguineous, which is almost always 
 the indication of a serious derangement of the secretion, of superflcial 
 ulceration with exudation, or of the existence of an ulcer, granulations 
 or fibroma, or of some organic lesion. They may become sero-purulent, 
 purulent, ichorous, with fetid smell, the latter too often the indication 
 of a cancerous affection. I have never been mistaken as to that smell, 
 to which sufficient attention is not paid. When the utero-vaginal 
 secretion has accumulated owing to the presence of a pessary, and is 
 heated, it has a foul smell certainly, but only that of acid fermentation 
 or heated pus, which all surgeons notice on laying bare a wound when 
 an abundant suppuration has been retained by the lint dressing ; the 
 smell of suppurating cancer, on the contrary, is nauseous, stale rather 
 than ackl, somewhat similar to macerated animal matter, often noticed 
 at a distance, or as soon as the dress of the patient is removed. At 
 other times the discharges assume a character of liquid transparency, 
 and are called watery discharges, hydrorrhcea, hydrometria (See this 
 word). They may have different sources, as we shall see when we 
 come to consider leucorrhoea. These watery excretions are sometimes 
 of no moment; at other times they are symptomatic of serious dis- 
 eases, such as an ovarian cyst, epithelioma, &c. The variety of patho- 
 logical fluids is great. There are others to which I have not yet re- 
 ferred, because there is much about them of which we are still ignorant. 
 I mean those fluids produced by gaseous excretions or physometna 
 (See this word). We must beware of the rather frequent accident of 
 the introduction of air by the syringe into the vagina or uterus, or of 
 the facility with which the vagina opens and sucks in atmospheric air 
 during pronation in some women after delivery, or of the less common 
 
118 GENERAL SURVEY OF UTERINE DISEASES 
 
 accident of a recto-vaginal fistula, wliich, though too small to admit 
 the passage of the fseces, allows intestinal gases to pass ; but, apart 
 from these accidents, gas may be developed in the vaginal cavity and 
 even in the uterus so as to distend it. This symptom, called physo- 
 metria, may be caused by putrid decomposition of fragments of foetus 
 or placenta, or by decomposition of uterine secretions when abundant 
 and retained by some cause in the womb. 
 
 Lastly, discharges may produce a sensation of joain, which though not 
 common is very intense when present. I have already spoken of ex- 
 coriations on the labia and thighs; but in addition to this, there is 
 often, especially in women who have ])assed the menopause, an intoler- 
 able vulval pruritis. This pruritis is often coincident with a vaginal 
 excretion, and may be due to want of cleanliness or to a disease of an 
 inflammatory, syphilitic, pruriginous, or herpetic nature. In such 
 cases the vagina is almost always painful, covered by an erythematous 
 eruption, and sometimes excoriated. The pruritus, however, often 
 exists alone as the effect of a peculiar nervous erethism depending 
 directly or indirectly on the uterine disease, especially when not 
 accompanied by any eruption, and when it does not yield to a solution 
 of bicarbonate of soda or to local applications of tar or tannic acid. 
 
 Certain Signs Furnished by Direct Examination 
 
 By the time we have reached this stage we have often more than 
 the presumption, we have almost the certainty, sometimes we have 
 the complete certainty that the patient before us is affected by uterine 
 disease. We can easily lead her to share this certainty and to see the 
 necessity for a direct examination. Methodic interrogation has 
 enabled us to diagnose uterine disease ; a direct examination will 
 enable us to make a differential diagnosis. The means of investiga- 
 tion at our disposal are, palpation, the touch, the speculum, the 
 sound. 
 
 1. Abdominal Falpation — This is the simplest means of investi- 
 gation at our command and therefore the one we ought to . employ 
 first. It is a kind of modified touch exercised by the whole hand, or 
 part of it, through the abdominal walls. The form of the abdomen 
 should be noticed, and the patient should be made to change her 
 position so that we may ascertain if there is fluctuation. The other 
 means of external examination are percussion, auscultation, the ex- 
 ploratory puncture, mensuration, &c. 
 
 Palpation. — Palpation should be practised in two ways; when the 
 patient is standing and when lying. It matters little whether we 
 begin with the one or the other. If the patient goes to the consult- 
 ing room of her doctor, it is natural to begin with vertical palpation ; 
 if on the contrary she is obliged to keep her bed and sends for the 
 doctor he begins with horizontal palpation. In whatever order we 
 take them, the combination of these two modes of palpation in two 
 different positions, is more important than would appear at first 
 
SIGNS FURNISHED BY DIRECT EXAMINATION 119 
 
 sight ; each position helps us to discover certain symptoms which we 
 could not otherwise have made out. 
 
 The patient being in the erect posture, her back supported by a 
 piece of furniture or by the left hand of the physician, the right hand 
 is placed over the epigastric or umbilical region ; when exploring 
 these regions with the palm of the hand their temperature should be 
 observed. Gradually and methodically the hand is brought down, 
 going from right to left, any change in the form and size of the 
 abdomen being noted which may be dependent on a tumour con- 
 nected with the uterus or ovaries, or on an increase in the size of the 
 womb or its appendages, or to a fluid or semi-fluid effusion in the 
 peritoneum or pelvis, or merely to distension from a tympanitic con- 
 dition of the bowels, very common in uterine disease. Above all, 
 the size and sensitiveness of the various parts of the hypogastrium 
 and pelvic cavity should be ascertained ; and to do this, we must 
 ask the patient to lean forward, so as to relax the abdominal muscles. 
 In depressing the teguments with the tips of the fingers we often 
 elicit sharp pain immediately above the pubis, or on the inner side 
 of the left iliac fossa, at the transverse diameter of the brim. 
 These pains, together with tumefaction of this region, leave little 
 doubt as to the existence of an inflammatory disease of the uterus or 
 ovary. Any increase in the temperature of the hypogastrium ought 
 to be ascertained at the beginning of the examination as this is an 
 additional sign in favour of the supposition of chronic inflamma- 
 tion of the uterus, its appendages or surrounding tissues. We 
 should also take advantage of the upright position of the patient to 
 obtain another indication which is too often neglected, although valu- 
 able to the physician both as regards diagnosis and treatment. Instead 
 of pressing down the abdominal parietes towards the pelvis as at first, 
 "we raise the mass of viscera, so as to drive them upwards and backwards 
 towards the diaphragm ; then we let them fall down abruptly. By 
 repeating this little manoeuvre two or three times we ascertain 
 whether the pressure exercised on the uterus by the weight of the 
 viscera is a cause of pain, and consequently we can determine whether 
 an abdominal belt, preserving the uterus from this painful pressure 
 will be helpful to the patient. When on the couch the patient should 
 be on her back, the legs bent on the thighs, the thighs on the pelvis 
 and slightly apart, the head raised by a pillow so as to relax the 
 abdominal muscles. Whilst making the examination it is well to 
 speak to the patient so as to distract her attention, for many women, 
 from modesty or from sensitiveness, contract their muscles so firmly 
 when touched, that it is impossible to proceed. When the patient is 
 lying, we are able to depress the abdominal walls much more than 
 when standing, and so can better ascertain the more deeply-seated 
 changes ; not only those due to uterine tumours, fibromata, ovarian 
 cysts and pelvic tumours, but those also which have their rise in 
 disorders of other organs, such as the kidneys, the ureters, the 
 bladder, the small intestine, the crccum and the ascending colon. 
 In this way it is possible to distinguish a mass of stercoraceous 
 
120 GENEEAL SUEVEY OP UTEEINE DISEASES 
 
 matter in the sigmoid flexure, which has sometimes caused so much 
 pain as to have led to errors of diagnosis. In this investigation of 
 abdominal and pelvic tumours by palpation it is not sufficient to 
 ascertain the difterences in size, form, sensibility, and position of the 
 different organs ; we must also learn to distinguish differences in con- 
 sistency and in resistance to pressure presented by these viscera or by 
 tumours. A single finger will sometimes appreciate these differences 
 better than the whole hand. In this way may be ascertained the 
 transmission of arterial pulsation, vascular or respiratory vibrations, 
 intestinal gurgling, the depressibility and molecular mobility of the 
 contents of some tumours susceptible of displacement, the stony, 
 cartilaginous or fibrous hardness of others, the softness of a certain 
 number, the resistance of abscesses or cysts, &c. I do not mean 
 to say that palpation alone will enable us to diagnose small mobile 
 tumours, or even to elicit pain in inflamed organs, which recede 
 from pressure as the uterus does when not too large and not 
 retained by adhesions. But associated with vaginal touch palpa- 
 tion is one of the most certain and most valuable means of 
 diagnosis. When practised on the hypogastric and lateral regions 
 of the abdomen by pressing the pelvic organs down, it brings them 
 nearer to the exploring finger and sometimes indeed enables the 
 examiner to hold them between the finger introduced into the vagina 
 or rectum, and the hand which depresses the abdominal parietes. 
 The fundus, the Fallopian tubes, the ovaries, mobile pelvic tumours, 
 the posterior side of the uterus, would escape investigation if vaginal 
 and rectal touch were not complemented by abdominal palpation and 
 even exceptionally by another mode of examination to which I shall 
 afterwards refer under the name of rectal palpation. 
 
 One last remark : before abdominal palpation is practised the 
 bowels should be evacuated by an enema or laxative, and the bladder 
 naturally or by catheter, otherwise it will not give us the certain 
 information that we require. 
 
 The complementary means of external examination are : percussion, 
 quest for fluctuation, change of posture, auscultation, observation as 
 to the appearance and shape of the abdomen, an exploratory puncture, 
 and mensuration. These are practised when the patient is lying. 
 
 Peraissio7i of the different regions of the abdomen, and especially 
 in those parts where there is abnormal tumefaction, enables us to detect 
 the presence of foreign bodies, whether gaseous, solid or liquid, and to 
 determine the exact limits of a tumour of the uterus or ovary (left 
 undecided by palpation), to discover their inequalities, and recognise 
 other complications, &c.^ 
 
 ' E.g. percussion enables us to perceive tympanitic resonance of the intestine 
 at the highest part of the abdomen near the umbilicus, or on the contrary at its 
 most dependent parts the flanks, an essential distinction in diagnosing between 
 ascites and an encysted tumour ; it limits the bounds of a solid or fluctuating 
 tumour ; it enables us to ascertain the presence of dulness in the most depen- 
 dent parts (ascites), or above the pubis, uniformly in the centre, with fluctua- 
 tion, (vesical tumour, retention of urine), or in the In'pogastrium sloping 
 downwards with irregular surface, &c. (pregnancy, hypertrophy of the uterus, 
 
SIGNS FUENISHED BY DIRECT EXAMINATION 121 
 
 Examining for fluctuation is not less important in some cases ; it 
 enables us to discover efl'usions which may be in the lower part of the 
 peritoneal cavity and helps us to diagnose an ovarian cystj and to ascer- 
 tain whether it is simple or multilocular, partly liquid and solid, 
 whether complicated with ascites, &c. The association of percussion 
 and even auscultation with this mode of examination leads us to dis- 
 cover the characteristic hydatid thrill, and so distinguish an acephalo- 
 cystic tumour of the pelvis or omentum from any other kind of tumour. 
 In certain cases palpation must be associated with digital examination 
 in order to discover fluctuation, the finger of one hand resting on the 
 most dependent part of the vaginal tumour, while the other hand de- 
 presses the hypogastrium firmly. Short taps on this region made by 
 a finger of the same hand are transmitted by the liquid to the tip of 
 the finger within the vagina. 
 
 Changes of posture and shocks given to the abdomen are useful 
 after percussion and palpation in giving additional information. 
 In order to discover dulness, resonance, fluctuation and the various 
 sounds which are recognised by auscultation we must examine the 
 patient, not only when she is standing and lying, but also on the 
 back on each side in pronation, and even on elbows and knees, as 
 Bozeman does for the operation of vesico-vaginal fistula. Nothing is 
 so useful as these changes of posture in displacing peritoneal 
 effusions and solid tumours attached to the broad ligaments or to the 
 mesentery, or in changing the relationships of organs or abnormal 
 products. 
 
 When these changes of posture are not sufficient to enlighten us 
 as to the weight and consistency of organs and as to the presence of 
 solids, liquids and gases in the abdomen, we may be able to throw 
 light on the diagnosis by concussion, which communicates a balotte- 
 meiit, more or less considerable, to all the abdominal viscera. This 
 balottement, as well as changes of posture, may help us greatly in 
 diagnosing the case, not only because of the impressions transmitted 
 directly to the physician, but because of the new sensations which it 
 causes to the patient. 
 
 Auscultation is especially useful when we have to distinguish between 
 pregnancy and a uterine or ovarian tumour. When the uterus contains a 
 living foetus we can generally hear the foetal heart as well as the uterine 
 souffle. The existence of the heart sounds in an abdominal tumour, 
 more or less lateral and not dependent on the uterus, which is rela- 
 tively defective in development, ought to lead us to diagnose extra- 
 uterine pregnancy. This question should always be determined before 
 forming a diagnosis of an abdominal tumour. In auscultating cases 
 of ovarian tumours or of uterine fibromata compressing the aorta or the 
 iliac arteries, a souffle can almost always be perceived on one side analo- 
 
 fibi'oraa, &c.), or on one side of the pelvis extending to a more or less elevated 
 part of the iliac fossa (tuiiionrs of the broad ligaments or ovaries), or at the 
 most elevated part of the abdomen, with or without Hnctuation and with 
 tympanitic resonance in the ilanks (cysts, cystosarcomata, solid tumours of the 
 ovary). 
 
122 GENERAL SURVEY OP UTERINE DISEASES 
 
 gous to what is called the uterine souffle. This sound is often 
 perceived on the surface of the tumour and evidently arises from 
 the great vessels which traverse it, whether it be due to an ovarian 
 cyst or to the distension of the uterus by an enormous fibroma ; 
 it depends probably on the compression which the volume of the 
 tumour exercises on these vascular trunks at some point, and is an 
 indication of their great size. Auscultation also enables us to dis- 
 tinguish intestinal gurgling, tympanitic resonance, peritoneal friction 
 sounds, &c. 
 
 The external appearance of the abdomen gives the physician an 
 opportunity of receiving impressions which palpation alone would not 
 have afforded. We not only note the changes in colour and appear- 
 ance of the abdomen, the umbilical depression, the pigmentation of the 
 linea alba, presumptive signs of a commencing pregnancy, the vibices 
 due to the distension of the belly by a previous pregnancy, ascites, or 
 a tumour, wrinkles, cicatrices, marks of chafing, &c., but it enables 
 us also to detect the slightest change in the form of the abdomen. 
 The patient ought alternately to be standing and lying, especially lying 
 on the back. In this position we can easily distinguish the general 
 swelling due to meteorism ; the peculiar tumefaction of the sigmoid 
 flexure, colon or csecum, due to constipation ; the vesical tumour 
 caused by retention of urine; the uterine tumour of pregnancy; the 
 more limited protuberance of a solid tumour, of the womb, ovary, or 
 broad ligaments ; the prominent tumour, raising the umbilicus and 
 even the xiphoid cartilage, caused by the enormous distension of an 
 ovarian cyst ; the iliac or hypogastric puffiness accompanying peri- 
 metritis ; lastly, the increased size of the belly in the flanks and in 
 the iliac regions due to ascites. 
 
 The exploratory puncture is of the same utility in diagnosing tumours 
 of the genital organs as of other parts of the body. It determines the 
 consistency and nature of the contents of the tumour by the issue of a 
 drop of liquid or of a solid particle. It may be applied not only to the 
 abdomen and to the external organs of generation, but also to the 
 vagina, to the posterior vagino-uterine cul-de-sac, to the uterus, or to 
 tumours of its cavity. 
 
 As the complement of palpation, tapping is even more useful than 
 an exploratory puncture. Evacuation of the tumour helps us in the 
 same way that evacuation of the bowels and bladder does. I do not 
 say that this is necessary in order to diagnose the existence of an 
 ovarian tumour, but it is impossible to ascertain the peculiarities of 
 its form and composition, the complications and adhesions, unless the 
 evacuation of the cyst permits the examination of the empty sac and 
 its appendages by means of palpation (associated with touch), the 
 abdominal parietes being now as easily depressed as they were distended 
 i^ormerly. 
 
 Mensuration frequently repeated is useful in determining the 
 changes of size. We must measure the circumference of the abdomen 
 carefully with a tape, and always from the same points, using the 
 precaution of taking measurements from several points, in difl'erent 
 
SIGNS FURNISHED BY DIEECT EXAMINATION 123 
 
 directions (horizontally and vertically), before and after practising 
 the exploratory puncture. 
 
 2. Digital touch. — All practitioners agree in giving to digital touch 
 the first place as a means of examination ; it is all the more valuable as 
 being the one which causes least distress to the patient, owing to our 
 being able to employ it without uncovering her. I insist on the capital 
 importance of digital examination for two reasons. The first is because it 
 has been neglected since the discovery of the speculum. Now, I have 
 seen so many women affected by serious uterine or peri-uterine disease 
 which their physicians, nevertheless, had failed to discover, because they 
 had only examined them with the speculum, that I cannot too strongly 
 warn practitioners of the danger of abandoning touch for the spe- 
 culum, which can do no more than correct and complete the informa- 
 tion given by the touch. The second is my hope of persuading 
 young practitioners to practise this mode of examination. Now, in 
 order to be able to do so, or indeed to make any other examination 
 profitably, it is not only dexterity that is required, we must also have 
 an exact knowledge of the sensations due to a normal and an 
 abnormal condition of the organs explored -, this knowledge is only 
 acquired by habit, and I can assure all young practitioners who wish 
 to perfect themselves in this mode of investigation, that they will be 
 surprised to observe what constant progress they make. Digital 
 touch, hke abdominal palpation, is practised when the patient is 
 standing or lying ; in England the usual position is on the left side. 
 In most cases it is indispensable to examine the patient by touch 
 when she is standing. It is often the only means of reaching the 
 cervix in girls, as with them the uterus is generally very high up. 
 It is the same with tall women who are stout, because the cellular 
 adipose tissue, which lines the perineum, shortens the examining 
 finger ; the vertical position is sometimes insufficient to enable us to 
 reach the cervix, unless the patient makes an expulsive efi'ort which 
 forces the uterus downwards. The vertical position facilitates exami- 
 nation of the cervix of a pregnant woman, as well as that of a uterus 
 containing a fibroid tumour ; in both of which cases the womb rises 
 above the pelvis as Simpson has pointed out. This mode of exami- 
 nation also helps us to practise balottement and to appreciate the 
 weight of an inflamed or hypertrophied uterus which may be an 
 important element of diagnosis. Lastly, this alone can give exact 
 information as to elevation, descent, displacements or flexions of 
 the womb ; for all these displacements are modified by the horizontal 
 position. When making the vaginal examination in the erect posture 
 the patient ought to have her back against a piece of furniture, the 
 legs slightly apart, the body leaning forward so as to relax the 
 abdominal muscles, the hands on the back of a chair. The physician 
 on a low seat, or on his knees, introduces the right hand under the 
 dress of his ])atient, having previously anointed the index finger, so as 
 to preserve it from infection, as well as to facilitate its introduction. 
 He follows the line of the right thigh and tries to reach the posterior 
 commissure of the labia, endeavouring to avoid the anus behind and 
 
124 
 
 GENERAL SURVEY OF UTERINE DISEASES 
 
 the clitoris in front in order to save the patient the annoyance of 
 having these sensitive organs touched. Contrary to the advice given 
 by some authors the other fingers ought not to be bent on the palm 
 of the handj as doing so shortens the index finger nearly an inch. 
 They ought on the contrary to be left in extension and as far as 
 possible from the index, the thumb directed forwards towards the top 
 of the vulva, on one side of the clitoris, resting on the labium, whilst 
 the three other fingers, directed backwards, should rest on the 
 perineum and anus, raising them if necessary, so as to shorten the 
 vagina and bring the uterus nearer the index finger. We must learn 
 to execute this little manoeuvre in spite of the resistance offered by the 
 coccyx and adipose tissue of the perineum ; for in certain cases 
 we could not otherwise reach the uterus, its appendages, or peri- 
 uterine tumours situated high up in the pelvis. When the index 
 reaches the posterior commissure of the labia it depresses the four- 
 chette and insinuates itself easily into the vagina. The finger is 
 made to feel its way all along the posterior wall of the vagina towards 
 the cervix, taking note of the condition of the mucous membrane, its 
 temperature, observing whether it is dry or moist, whether its surface 
 is smooth or rough, &c. Having reached the cervix, it first examines 
 the two lips and the os and then carefully examines the fundus of the 
 
 Fig 111. — Vaginal toucb associated with aMominal palpation. 
 
 vagina. Then it makes its way back to the vulva, now exploring tlie 
 anterior wall of the vagina in the same way as the posterior was pre- 
 
SIGNS FURNISHED BY DIEECT EXAMINATION 125 
 
 viously examined. Sometimes^ in place of one finger we may have to 
 introduce two or even four when we have to ascertain the presence, 
 form and consistency of a tumour, its connections with the uterus, 
 whether pediculated, &c. The vagina should next be explored whilst 
 the patient lies on her back ; only by this means are we able to 
 ascertain certain pathological conditions, the existence and limitation 
 of ovarian or peri-uterine tumours, the distinction between these 
 tumours and the uterus itself when deviated or flexed. Vaginal 
 touch associated with palpation may give to our diagnosis a certainty 
 which could not be acquired by any other means. It is the best of 
 all modes of examination for enabKng us to judge as to the integrity 
 of the uterus, the ovaries and the Fallopian tubes. Having asked the 
 patient to flex the lower limbs and open them slightly, the physician, 
 without uncovering her, proceeds to practise the touch with the same 
 precautions as he employed in the vertical position. I think it is 
 better for him to pass the hand under the thigh nearest him ; it is 
 more convenient, there is less risk of touching the clitoris, it allows 
 the finger to penetrate further, and above all forces the patient to keep 
 her thighs well flexed, which facilitates the examination. After 
 having acquired experience in this mode of examination, in using the 
 other hand simultaneously for palpation and in depressing the various 
 parts of the hypogastrium, there are very few lesions which can escape 
 our investigation. 
 
 In England it is usual for the patient to be placed on the left side 
 when examined. It is also the custom in that country for women to 
 be delivered in this position. The knees are drawn up, the head and 
 shoulders directed obliquely across the couch, whilst the nates are 
 brought near the edge of the bed. In this position the vulva is easily 
 penetrated without uncovering the patient, but it is difficult to practise 
 palpation, or to appreciate uterine displacement and the relative situa- 
 tion of the various organs as exactly as in the dorsal position ; the 
 only advantage of the lateral decubitus is that it sometimes reveals to 
 us the mobility of a tumour or the existence of adhesions attaching the 
 uterus and its appendages to the pelvis. Scanzoni and other writers 
 have proposed that in the case of virgins we should content ourselves 
 with the information furnished us by rectal touch, as if this mode of 
 examination were not far more repugnant to the delicacy of girls than 
 the vaginal touch itself. We can persuade a young girl as well as a 
 married woman of the necessity of a vaginal examination, and it is easy 
 to practise this without injuring the hymen — the physical sign of vir- 
 ginity. The precautions to be taken are these : the patient should be 
 requested to bring her thighs close together in place of separating 
 them, as this puts the hymen in a state of tension unfavorable to the 
 entrance of the finger into the vagina. The index finger (well 
 greased) should then be placed on the fourchette, and rest there for 
 a few seconds, till the spasm caused by the contact of a foreign body 
 has passed ; then let it glide gently forwards, depressing not only the 
 fourchette, as in the case of a married woman, but also the inferior 
 border of the vulva and the hymen attached to it. Bringing the thighs 
 
126 GENERAL SURVEY OF UTERINE DISEASES 
 
 together makes this membrane depressible, just as bringing the fingers 
 together malies their commissure depressible. It is only after having 
 ascertained the depression of the hymen that the finger should be 
 slowly insinuated into the vagina, when it will penetrate without paiu 
 or difficulty. I have often practised the vaginal touch under these cir- 
 cumstances, and have never caused suffering or haemorrhage, nor torn 
 the hymen, which is often more or less obliterated in these young girls 
 owing to the leucorrhoea Vt^hich so often accompanies uterine diseases 
 in virgins. It is not so much the hymen as the sphincter of the vulva 
 which it is difficult to pass, but it can always be managed by going 
 slowly and gently. Fmally, whatever may be the age of the patient, 
 the condition of the genital organs, or the position in which we prac- 
 tise the touch, we must endeavour to make the examination as short as 
 possible, remembering that it is always disagreeable and often painful. 
 On this account we must, above all, learn to practise the vaginal touch 
 methodically ; we must know beforehand all that we ought to seek 
 for and all that we can find by its assistance, observing every indica- 
 tion given to us as we go along. Having already explained how it 
 ought to be practised, I will now point out the valuable information 
 which it gives to the physician as he proceeds from the vulva to the 
 uterus, and from the uterus to the vulva. In the first place this ex- 
 amination may disclose to us, or at least give us reason to suspect, 
 some malformation. I refer the reader to the description given in 
 another place of these abnormalities. Next, the condition of the labia 
 and the orifice of the vagina should be observed, the contraction which 
 this latter and the vagina itself may have undergone after the meno- 
 pause being sometimes so great as even to make the entrance of the 
 finger difficult. The presence of tumours, cysts of the labia, of the 
 vulva, of Cowper's gland, of the posterior vaginal wall, tumours of the 
 rectum perceptible through this wall, distension of the bowels due to 
 the presence of faeces, which are depressible, and which nevertheless 
 have sometimes been taken for real tumours, may be determined by this 
 mode of examination. In withdrawing the finger we ascertain the 
 state of the mucous membrane and the existence of any cysts, polypi, 
 or vegetations which may be found on the anterior wall of the vagina. 
 Vesical catarrh, cystitis, stone, gravel, may be recognised by the 
 pain caused by pressure of the finger on the anterior wall ; inflamma- 
 tion of the urethra, blenorrhagia, vascular or fibro-yascular tumours 
 of the urethra and meatus are brought to light by compressing the 
 inferior part of the anterior vaginal wall against the pubic arch. The 
 finger, before reaching the cervix, may discover in the vagina a tumour 
 originating in the uterus; this is often a polypus, a fibrous tumour, 
 elongation of the vaginal portion of the cervix or of one of the lips, 
 rarely retroversion of the uterus. It is important to discover the con- 
 nection of this tumour with the cervix and fundus. At other times 
 there may be an encysted tumour in one of the vaginal walls, or 
 a solid tumour in the portion of the broad ligament which runs' 
 along the lateral part of the vagina, and which may be an inflammation 
 of the lymphatics. Having reached the cervix we must first note the 
 
SIGNS FURNISHED BY DIEECT EXAMINATION 127 
 
 mobility or immobility of the uterus, distinguishing the mobility of 
 the cervix due to flabbiness from that of the organ as a whole. When 
 the uterus moves freely on its axis the finger is able not only to dis- 
 place the cervix, but in so doing to perceive by the resistance offered 
 the inclination of the fundus in the opposite direction. Mobility is an 
 important sign of the integrity of the uterus and surrounding organs; 
 it IS destroyed by adhesions following peri-uterine inflammation ; it is 
 diminished by diseases of the ovaries and Fallopian tubes, and even by 
 uterine disease, or by the tumefaction, hypertrophy, and chronic in- 
 flammation of the organ. Even when the uterus is mobile the finger 
 may find the cervix changed in position, above, below, behind, or in 
 front of the normal position. When the cervix is placed forwards and 
 high up, as if resting on the pubis, there is reason to suspect the ex- 
 istence of a tumour forcing it in that direction. At other times the 
 direction of the cervix is changed. It may be inclined forwards owing 
 to retroversion, but this is rare. More frequently it is directed back- 
 wards, the consequence either of an anteversion or of tumefaction of 
 the anterior lip. In order to discover this deviation the finger must 
 follow the posterior wall of the vagina till its tip can pass beiiind the 
 cervix. In this case the anterior lip is first reached and can be 
 examined. The posterior lip may have become inaccessible, and may 
 only be discovered after much seeking, and with difficulty be forced 
 into the axis of the vagina So as to allow the finger to penetrate into 
 the ])ostenor cul-de-sac. At other times, though less often, the cervix 
 is inclined to the right or left, according to the position of the fundus. 
 This position can only be ascertained by a careful examination as to 
 which side the os is directed ; unless this is done we should be apt 
 to be deceived by the difference of size between the two lips. The 
 form of the cervix, its temperature, its hardness, softness, irregularity 
 of surface, &c., ought to be carefully investigated by the touch. The 
 neck may be conical in place of being round. This cone may hang 
 freely in the vagina, may even be hypertrophied in a longitudinal direc- 
 tion, occupying the centre of the canal, or may be compressed against 
 one of its walls whilst preserving its mobility like the rest of the 
 uterus. When compressed against one side constantly to the front and 
 to the left the finger discovers on the opposite side, i. e. behind and to 
 the right, an enormous vaginal cul-de-sac, the size being due to the 
 penis habitually slipping over the conical cervix and lodging there 
 during coitus. This state of things is sometimes made worse by the 
 position of the os being on the side in place of on the summit of the 
 co)ie, and is a cause of sterility, all the more important to diagnose 
 because it can be remedied by partial amputation of the cervix. This 
 abnormally exaggerated conical cervix must not be confounded with 
 the slightly conical one often found in virgins, and which is quite 
 normal. The cervix may, on the contrary, be fiattened like a mush- 
 room, the lips turned back, forming a circular border, which projects 
 beyond the upper part of the neck. There may also be a ditl'erence of 
 size between the two lips ; the posterior one is generally the longer, the 
 anterior the thicker. The anterior lip often becomes hypertrophied 
 
128 GENEEAL SUEVEY OF UTEEINE DISEASES 
 
 and engorged ; the posterior more painful, owing to granulations or 
 ulceration- I have already described the varieties of form presented 
 by the vaginal portion of the cervix in treating of congenital anomalies. 
 The temperature of the cervix and also of the vagina may be higher 
 than in a normal state. This is an almost certain sign of metritis or 
 of peri-uterine inflammation. The consistency is variable also. Some- 
 times the cervix is hard as in hypertrophy ; when there are follicular 
 cysts or commencement of cancer the surface is irregular. At other times 
 it is soft, being easily indented by the finger. If this softening is 
 accompanied by ascent of the organ and balotteraent it may be only 
 a sign of pregnancy ; but if coincident with increased size, high tem- 
 perature, disposition to haemorrhage, &c., it may be a sign of 
 congestion, inflammation, catarrh, or of fungous growths. 
 
 The position, form, size, penetrability of the os, are all important 
 elements in the diagnosis. The os may look in various directions, 
 owing either to natural causes or to deviation of the organ, flexion of 
 the cervix, or lastly, to a difference in the size of its lips, e. g. one of 
 them may be so much swollen or hypertrophied as partly to cover the 
 other, which has preserved its natural size. The os externum is most 
 frequently a transverse fissure ; sometimes it is a more or less circular 
 orifice. In a woman who has had children the fissure is more marked, 
 larger, and somewhat gaping ; in the angles of the fissure are hard 
 cicatricial marks, perceptible to the touch. Sometimes, even in 
 virgins, the orifice is large enough to admit the end of the finger. 
 Unless there is pregnancy this indicates an abnormal dilatation due to 
 catarrh, chronic inflammation, congestion, or the presence of a 
 polypus, or other intra-uterine tumour, causing contractions in the 
 body of the uterus, which tend to open the neck. The surface of 
 the lips often present sensible irregularities. Sometimes we find 
 bleeding granulations, sometimes nodules, tubercles, irregularities, 
 point to the development of little tumours. The lips may also be the 
 seat of ulcers and fungous vegetations, or of real tumours, vascular, 
 follicular, or fibrous, more or less pediculated, as well as of cancer. 
 Through the gaping neck the finger may enter the cervical and even 
 the uterine cavity, and discover a clot of blood, a conception, an inter- 
 stitial tumour, sessile or pediculated, polypi, fungous vegetations, 
 cancers, &c. It is important to ascertain whether, if the touch pro- 
 duces pain, in what way and at what points it is elicited. Sometimes 
 pain is caused by a movement communicated to the uterus, by an 
 attempt, successful or otherwise, to displace it ; it then indicates a 
 morbid condition of the appendages, adhesions between the uterus and 
 the peritoneum, the ovaries or Fallopian tubes. Sometimes it is caused 
 by pressure of the finger on the neck or body of the uterus, and is 
 then dependent on increased sensitiveness of this organ; it is felt most 
 when recourse is had to bimanual palpation. This sensitiveness may 
 be confined to one limited point in the organ. It indicates general or 
 partial metritis, or irritation symptomatic of commencing organic 
 lesion. It occurs most frequently in the posterior lip, wliich seems 
 more disposed to inflammation and ulceration than the anterior one. 
 
SIGNS FURNISHED BY DIRECT EXAMINATION 129 
 
 wliich^ on the other hand, has a tendency to tumefaction and hyper- 
 trophy. At the same time it is easy to recognise whether the size of 
 the organ has increased, not only the size of the neck, but that of the 
 body. Tumefaction sometimes attacks both parts of the womb at once ; 
 at other times only the body is affected, the neck seeming to be normal, 
 but above it can be felt, through the vaginal cul-de-sac, a rounded 
 tumour, very similar to the form of the uterus in the beginning of 
 pregnancy. The regularity of outline, the elastic and moderately firm 
 consistency of the tumour, as well as its mobility, should help us to 
 distinguish it from a fibrous tumour, a flexion, an ovarian tumour, a 
 heematocele, or from a peri-uterine inflammation. The immobility of 
 the uterus greatly facilitates this differential diagnosis. Whether the 
 uterus be flexed or not, it loses its mobility if it contracts adhesions 
 with neighbouring organs, either in front or behind ; but even though 
 no adhesions are formed, if there be peri-uterine inflammation, inflam- 
 matory tumefaction of the uterus or surrounding tissues, there will be 
 a relative immobility owing to the severe pain which any movement 
 produces. If the inflammation has produced an effusion into one of 
 the peritoneal cul-de-sacs or in the broad ligaments, the uterus is not 
 only rendered immobile, it is displaced. Sanguineous effusions pro- 
 duce the same results ; retro-uterine hsematocele, for example, displaces 
 the uterus, forces it forwards and upwards behind the pubis, whilst the 
 tumour projects into the posterior vaginal cul-de-sac. In this case the 
 womb is as immovable as if fixed in the centre of a mass of plaster 
 which had hardened around it. 
 
 In conclusion, the careful examination of the vagina all round the 
 cervix furnishes us with the most valuable information. In a normal 
 state the cul-de-sac is smooth and easily depressed by the finger in 
 either direction, the uterus rising when this is done ; but it may un- 
 dergo various changes. I have often found it as if glued to the pelvis, 
 as the result of adhesions caused by peri-uterine inflammation; at other 
 times it is diminished in size by peri-uterine inflammation, a hsemato- 
 cele, or by some other tumour situated behind, before, or on one side 
 of the cervix. Sanguineous effusions and peri- uterine inflammatory 
 tumefactions do not always project into the vagina, but they always pre- 
 vent our being able to depress it indefinitely ; they offer a more or less 
 determined resistance to pressure in lieu of the sensation of empty 
 space due to the displacement of mobile organs. At other times they 
 form a more or less prominent border all round the cervix, or more 
 especially on one side (corresponding to one of the broad ligaments), 
 or in the posterior cul-de-sac (corresponding to Douglas's space). The 
 touch may also disclose to us in this cul-de-sac behind, and either to 
 right or left of the uterus, the presence of very sensitive globular 
 tumours, due to ovaritis or abscess of the Fallopian tube ; whilst behind, 
 and more especially at the base of the broad ligaments, we may also find 
 inflamed and indurated glands which are very painful. By the touch 
 we also recognise tumours formed by the uterus itself when flexed. We 
 must learn not to confound these various tumours. Peri- uterine 
 tumours can be distinguished from ovaritis by rectal touch, and 
 
 
 
130 GENERAL SURVEY OF UTERINE DISEASES 
 
 flexions from other tamours by the sound-; it is also most important to 
 be able to appreciate not only the size of these tumours, but also the 
 sensibility of the peri-uterine tissues. Let us always remember that 
 when the peritoneum^ the peri-uterine cellular tissue and the appendages 
 are in a normal state, the examining finger should find the surface 
 everywhere smooth and depressible. 
 
 Having completed the thorough investigation just described, we 
 ought to observe whether the finger has brought away any blood or 
 mucus (milky-white, glairy, or purulent) , pus, ichor, cancerous matter, 
 &c. Note should be taken of any hsemorrhage which may accompany 
 or follow the examination in the case of bleeding fungosities, cancer, 
 epithelioma, &c. 
 
 Rectal touch cannot supply the place of vaginal touch ; it is as 
 repugnant to the modesty of women and it gives us less information. 
 It is often necessary but ought only to be employed when requisite to 
 complete a doubtful diagnosis. If we asked our patient^s permission, 
 we should expose ourselves to an almost certain refusal ; therefore it is 
 better to practise it immediately after the vaginal touch, just as if it 
 were usual and the natural complement of the other examination. 
 Hence it follows that the patient should be in the same position as 
 when examined j)er vaginam,^ the only precaution necessary being to 
 have advised the patient to take an enema a few hours previous to the 
 examination. After having passed the sphincters, the finger having 
 penetrated about two inches, comes upon a resisting and rounded 
 tumour in front, which is the neck of the uterus pressing more or less 
 on the anterior wall of the rectum in proportion to its size, its 
 position, and its deviation towards the sacrum. Above the protuber- 
 ance of the cervix the index discovers the body of the womb, and 
 passes over its posterior surface but rarely over the fundus, unless it 
 be inclined towards the concavity of the sacrum owing to a retrover- 
 sion or retroflexion. On depressing the abdomen with the other 
 hand and forcing the uterus downwards, i.e. combining palpation 
 with rectal touch, we can better explore the posterior surface, the 
 fundus, the outlines of the womb and the various tumours which may 
 be found behind or on its sides. This mode of examination helps us 
 not only to recognise flexions, deviations, tumours of the posterior wall 
 of the uterus, such as fibroma, phlegmons, the results of pelvi-perito- 
 nitis, inflammatory or cystic tumours of the ovaries and Fallopian 
 tubes, extra-uterine pregnancies, &c., but it also allows us (especially 
 when associated with abdominal palpation) to judge as to the size, the 
 consistency, the mobility, the sensibihty of these difi'erent tumours, 
 and to obtain a precision in diagnosis which vaginal touch failed to 
 afford. We must take care to raise the perineum as much as 
 possible, for its thickness in stout women makes rectal as well as 
 vaginal touch more difiicult. Rectal touch is the only means we have 
 of ascertaining the absence of the uterus. In this case it must be 
 combined not only with palpation and vaginal touch but also with 
 catheterism of the bladder. In short, rectal touch, alone or asso- 
 ciated with vaginal touch, is necessary in order that we may judge of 
 
SIGNS FURNISHED BY DIHECT EXAMINATION 
 
 131 
 
 the condition of the recto-vaginal septum, its tumours, abscesses, per- 
 forations, fistulse, &c. Recamier used to insist on the necessity of 
 introducing two fingers of one hand, the index and middle finger, one 
 in the rectum the other in the vagina ; or the thumb in the vagina 
 the index in the rectum ; or the index of one hand in the vagina and 
 that of the other in the rectum. This is the only way to diagnose 
 small retro-uterine tumours. Touch is not even always sufficient ; we 
 must sometimes inspect the mucous membrane of the posterior 
 vaginal wall, forcing it through the vulva by a kind of artificial recto- 
 cele, or we may have to examine the anterior wall of the rectum, 
 pressing it down through the anus by fingers introduced into the 
 vagina. This little manoeuvre has often been of great use in helping 
 to diagnose lesions of the recto-vaginal septum and in facilitating 
 necessary operations. 
 
 Rectal palpation. — I cannot give this any other name to distinguish 
 it from the touch properly so-called, and to express the nature of this 
 far too rough method of examination, which has been too often 
 resorted to, on the authority of Simon, of Heidelberg, who was the 
 first to practise it.^ It is certainly possible to introduce, not only 
 
 Fig. 112.— Rectal combined with abdominal palpation (after Simun). 
 
 one or two fingers, but the whole hand into the rectum especially of 
 women when under the influence of chloroform, after having forcibly 
 but gradually dilated the sphincter. The patient being placed on her 
 back, the lower limbs and the head are flexed on the abdomen, which 
 
 1 Ueber die Erweiterring des Anns und Bectttm, &c., Archiv. fur Klinische 
 Chirurgie herausgegcben von Langenbeclc, Billroth uvd Ghtrlt, Band xv, 
 Heft 1, p. 99, 1872 ; Gazette hebdomadaire. 3 Janvier, 1873. 
 
132 GENEEAL SUEVEY OF UTEEINE DISEASES 
 
 is thus shortened as much as possible whilst the surgeon introduces 
 first two fingers, then two more, then the thumb, then the whole hand 
 well greased through the anus with the same precautions as are used 
 in introducing it into a narrow vagina or into the uterus for the 
 purpose of turning or for the removal of the placenta, making small 
 incisions when requisite round this orifice. In spite of the great dis- 
 tension of the anal orifice, mere intra-rectal exploration does not 
 relax the sphincter; cases requiring incision are followed by fsecal 
 incontinence for ten or twelve days. When the hand has penetrated 
 into the rectum as far as the promontory of the sacrum, it is possible 
 to reach the sigmoid flexure with three or even four fingers, and 
 owing to the mobility of the rectum we can palpate (through its 
 walls) the whole of the abdominal region as far as the kidneys and 
 umbilicus, and so gain much information. In two cases of ovarian 
 cyst Simon was able to determine the breadth and length of the 
 pedicle, the absence of adhesions, and the existence in the fundus of 
 the uterus of two fibromata of the size of a cherry-stone. Unless the 
 patient is very stout, we can in this way examine the ovaries even 
 when they are healthy and in a normal position. It appears from the 
 researches of Simon that the greatest circumference of the rectum is 
 at 6 or 7 centimetres above the anus, and may reach at this point 25 
 to 30 centimetres. In the upper part of the middle third it is only 
 from 20 to 25 centimetres, and diminishes rapidly beyond that, being 
 only from 16 to 18 centimetres in the middle part of the upper third 
 of the rectum. The narrowest point corresponds to the beginning of 
 the sigmoid flexure. Weir, in summing up these measurements, con- 
 cludes that a hand measuring less than 26 centimetres in circumfer- 
 ence can without danger penetrate from 17 to 19 centimetres but not 
 farther. It is superfluous to remark that in this exploration, which is 
 only allowable in very serious cases, a small hand is very useful, and 
 that the greatest gentleness should be observed in the manoeuvre, 
 especially if there is reason to suspect contraction of the intestine. 
 Several deaths have already occurred as the result of this method. 
 Heslop, of Birmingham ('Lancet,^ May 11th, 1872), relates two 
 cases of death due to rupture of the intestine near or at the seat of a 
 contraction. Three other cases of death are reported by Ptobert Weir 
 ('Medical Record,' New York, May 20th, 1875, p. 201) occurring 
 in the practice of Sands, Sabine and Weir, aU three due to laceration 
 of the intestine. 
 
 When an operation necessitates penetration far into the rectum we 
 may have recourse to rapid dilatation of the anus and intestine ; often 
 rupture of the sphincter is sufficient ; if not we can resort to lateral 
 incisions, or, better still, to a posterior one, with or without ablation 
 of the coccyx. The introduction of instruments is greatly facilitated by 
 posterior linear rectotomy as practised by Verneuil, without haemor- 
 rhage, by means of the thermo-cautery, and in this way operations are 
 made possible vvhich would not otherwise be practicable; but these 
 operations are rarely required for diagnostic purposes. Lastly, when 
 ocular inspection is associated with touch, various kinds of specula 
 
SIGNS FURNISHED BY DIRECT EXAMINATION 133 
 
 (the two best being the univalvular and Fergusson's) may be intro- 
 duced, and furnish us with new and valuable elements of diagnosis, 
 not only for rectal diseases but for those of the uterus and its 
 appendages. 
 
 Vesical touch. — I must not omit noticing this new mode of examina- 
 tion, recommended by Noeggerath,i which may be exceptionally used ; 
 it is the association of vesical with rectal or vaginal touch. The 
 urethra being dilated the index finger is introduced whilst another 
 finger is in the rectum or vagina, the uterus in the meantime being 
 drawn down by a fine tenaculum hook. 
 
 3. The Speculum. — The speculum is a mirror reflecting light on the 
 neck of the uterus and the distant parts of the vagina, whilst the vulva 
 and rest of the vaginal walls are dilated by it.^ The one for habitual use 
 should be one easily handled and, above all, easily cleaned. In these 
 respects there is none superior to the cylindrical speculum, slightly 
 conical, of Recamier (1814), or of Dupuytren (1816) ; but this spe- 
 cujum is by no means sufficient for every case ; indeed, as applicable to 
 the largest number of cases, the duck bill is preferable. In enumerating 
 the various instruments of this kind which are manufactured I will 
 mention those which I use most frequently, as well as those to which I 
 have recourse only in exceptional cases. The tubular metal speculum 
 is, as I have said, most necessary to the gynecologist. He should 
 have several sizes and all as long as possible. More than once I have 
 failed to reach the cervix owing to the shortness of my speculum. It 
 is well to have five sizes on account of the variable dimensions of the 
 vulva and cervix in different women. It is not enough that a speculum 
 enters the vulva ; it must also fit the neck of the womb. If the large 
 size is most convenient for examination it is not so for the application 
 of leeches to the cervix, because if this organ is not exactly encircled 
 by the speculum the leeches may fasten on the vagina in place of on 
 the cervix. 
 
 Fig. 113. — Cylindrical speculum fitted with a plug. 
 
 The gynecologist should also have several sizes of Fergusson's glass 
 tubular instrument, silvered and coated with vulcanite; it is more 
 easily introduced into a narrow vagina, and is also more convenient for 
 
 ' American Obstetrical Jov/rnal, May, 1875. 
 
 ^ Verhncs, MonograpJiie stir le dioptre ou speculum. These de Paris, 1848. 
 
134 
 
 GENERAL SUEVEY OF UTERINE DISEASES 
 
 reaching a retroverted cervix. Unfortunately it is very fragile. The 
 manufacturer ought to try to make it stronger by adding to the thick- 
 ness of the glass.^ 
 
 Charriere's trivalvular speculum owes its great success to want of 
 
 Fig. 114. — Fergusson's speculum. 
 
 skill in the ordinary practitioner. However, the smallest size may be 
 useful in examining a virgin. This instrument has another advantage ; 
 
 Fig. 115. — Charriere's trivalvular speculum, fitted with a plug. 
 
 by removing one of the valves it can be turned into a duck-bill, which 
 allows the vaginal wall to be examined. These valvular expanding 
 specula have, moreover, a further advantage, owing to their conical 
 shape when shut they can be easily introduced into a narrow contracted 
 vulva or where there are fissures, while they dilate the vagina when 
 open. They were invented by Jobert (1838) and Eicord (1834), and 
 have undergone various modifications, one of the most important 
 (due to Eicord) being that of having the hinge on a level with the 
 vulval orifice, so that when the blades diverge the circumference of the 
 instrument is not increased at this point — an arrangement which pre- 
 vents laceration of the vulval orifice. This bivalve speculum is useful 
 in examining a large cervix, but it does not sufficiently protect the 
 vagina when applications have to be made to the cervix^ and it also has 
 the inconvenience of allowing folds of a large vagina to get between 
 the valves. 
 
 ^ As for the opaque glass speculum of Mayer, of Berlin, it neither possesses 
 the advantages of Fergusson's nor of the simple boxwood instrument. It is 
 certainly necessary to have a speculum which can protect the vagina from heat 
 when the actual cautery is used, and which is not affected by acids and caustics ; 
 hut I greatly prefer the simple boxwood speculum on account of its cheapness 
 and strength, or those of Leiter, of Vienna, in vulcanite, which are both strong 
 and light. 
 
SIGNS FURNISHED BY DIRECT EXAMINATION 135 
 
 Charriere has made a new bivalve speculum for Cusco and Yeiss, of 
 Paris, and for Tyler Smith, of London ; whilst preserving a constant 
 
 Fig. 116. — Segalas's quadrivalve speculum. 1, a, shut with its plug ; 2, b, open. 
 
 Fig. 117. — Ricord's hi- Fig. 118. — Chairiere's quadrivalve speculum, 
 valve speculam. c, p, its ping. 
 
136 
 
 OENEEAL SUEVET OP UTERINE DISEASES 
 
 diameter at its vulval extremity, it allows the practitioner to separate 
 the two blades widely at their uterine extremity, so as to expose the 
 cervix to view without allowing the mucous membrane of the vagina 
 to be caught between the valves. Tyler Smith's is of the usual size. 
 Cusco's is shorter, so as to avoid pushing the cervix back when it is 
 
 Fig. 119. — Cusco's bivalve speculum. 
 
 low down, and to allow of its being examined nearer. Its only incon- 
 venience is that it sometimes dilates the lips of the cervix, so as to cause 
 ectropion, which may lead the practitioner into error as to the position 
 of the OS externum. 
 
 The univalvular speculum is indispensable for the examination and 
 treatment of diseases of the vagina, and especially for vesico-vaginal 
 fistula for which it was invented. Lallemand used a simple speculum 
 of this kind for such cases. For a long time I have used similar 
 instruments that I made myself of zinc or that I had made in wood, 
 when I have had occasion to perform operations in the remote parts 
 of the vagina. Hergott, of Strasburg,^ was accustomed to use a 
 cylindrical metal speculum, a great part of which he removed so as to 
 leave only a spoon fastened to a handle, having the desired size and 
 
 Fig. 120. — One of Jobert's lateral blades. 
 curve. Jobert ^ used long ago a very ingenious contrivance for dilat- 
 
 * Perfedionnements recents apportes a I'operation de la fistule vesico- 
 vaginale. Sti-asboui-g, 1863. 
 
 2 Traits de chirurgie plastique. Paris, 1849. 
 
SIGNS FUENISHED BY DIRECT EXAMINATION 
 
 137 
 
 ing the vagina in the treatment of fistula; he had four blades of 
 different shapes, one of which he applied to the anterior wall, another 
 to the posterior, and the two remaining ones laterally. I have several 
 times found them of great use. But all these instruments are inferior 
 
 Fig. 121.- 
 
 -Duck-bill specula, for the operation for vesico-vaginal fistula by the 
 American method. 
 
 to the duck-bill specula invented by the Americans to be used in 
 operating for vesico-vaginal fistula. In Marion Sims's instrument ^ 
 the same handle carries two blades of different sizes. Bozeman ^ has 
 exaggerated the breadth and curvature of these blades; there may, 
 however, be cases where the large dimensions of his instrument may 
 be useful. Neugebauer was in the habit of simply using two long 
 
 Fig. 122. — Neugebauer'.s speculum modified by Barnes. 
 
 metal blades regularly curved, one being inserted along the anterior, 
 the other along the posterior wall, so that the two formed a bivalve 
 speculum ; the uterine extremities of the blades may be more or less 
 
 ' Silver Sutures in Surgery. The Anniversary Discourse before the New 
 York Academy of Medicine. New York, 1858. 
 
 ^ Follin, Examen de quelques nouveaux procedes operatoires powr la gueri- 
 son des fistulas vSsico-vaginales, Reviie critique {Arch. gen. de med., 5*^ serie, 
 t. XV, pp. 457, 584). Paris, 1860. 
 
138 
 
 GENERAL SURVEY OP UTERINE DISEASES 
 
 separated, while the vulval extremities serve as handles. Barnes has 
 made various alterations in the curve and size of the valves ; in giving 
 to each of the four extremities a different curve we have specula with 
 different valves, and by associating two together we have four addi- 
 tional specula. 
 
 What I find most convenient is to have four of Sims's valves of 
 different sizes, and two handles; as each of these valves fits on to one 
 
 Fig. 123. — Speculum made for my own use with four valves and two handles. 
 
 of the handles, we can when necessary use two valves at the same 
 time, one to draw down the posterior vaginal wall, the other to raise 
 the anterior wall. I have had such a speculum made for myself and 
 use it every day : the smallest blade is a very narrow one for virgins, 
 the largest a very broad one useful for operations ; by making use 
 of two handles and two blades simultaneously my univalvular spe- 
 culum is transformed into a bivalve of variable dimensions. I have 
 similar valves made in wood, others in vulcanite, useful when acid 
 applications are made, or when the actual cautery is employed. In 
 fact this instrument can when necessary replace all other specula, 
 whilst none can replace it. Therefore it is the most fitted for daily 
 use when we do not wish to be cumbered by too many instruments. 
 
SIGNS FURNISHED BY DIRECT EXAMINATION 
 
 139 
 
 It is very easily introduced ; all that is required is to push the well- 
 oiled blade along the side of the index finger of the other hand, the 
 tip of which touches the cervix. The position of the uterus depends 
 on whether the decubitus of the patient be dorsal^ ventral, or lateral, 
 
 ' ! "\l ^ 
 
 Fig. 124. — Two univalve specula, used as a bivalve. 
 
 the position chosen being important not only for diagnosis (which is 
 greatly facilitated by the examination of the two cul-de-sacs, impossible 
 with any other speculum) but also for treatment. If the patient is in 
 the pelvi-dorsal position we find the cervix opposite and quite near us ; 
 if she is on the left side, she is in a less strained position, and the cervix 
 is very mobile, a condition favorable to the exploration of the vagina 
 and to the performance of operations on it; if she is in the ventral 
 position, the uterus is far off, dragged down by the weight of the 
 viscera, which are propelled towards the umbilicus by the entrance of 
 air into the vagina when the speculum is introduced ; but though the 
 cervix is far off, its position is at the same time very convenient when 
 applications have to be made. I should like to take this opportunity 
 of warning young practitioners against making use of any mechanical 
 contrivances for fixing the speculum either to the pelvis of the patient 
 
140 
 
 GENEEAL SIJRYET OF UTEEINE DISEASES 
 
 or to the operating table ; the patient is thereby exposed to serious 
 injury when she instinctively but involuntarily shrinks back from the 
 operating instrument. Surely the hand of an assistant is preferable in 
 every respect. 
 
 The introduction of the cylindrical and bivalve speculum is less easy 
 than that of the simple univalve; the difficulties are^ to avoid giviug 
 pain when the instrument passes the vulval sphincter, and to find the 
 cervix. Pain will be avoided if care is taken to depress the fourchette 
 before passing the speculum, which should be well oiled. An inex- 
 perienced practitioner, when using a cylindrical or valvular instrument, 
 will find it advantageous to make use of a wooden plug with rounded 
 extremity projecting beyond the speculum, which will glide gently 
 between the labia into the vagina, and can be removed as soon as the 
 instrument is in place. The bivalve must be introduced transversely 
 and not perpendicularly, for the anterior and posterior vaginal walls 
 touch, as shown in Pig. 46, p. 50. It is not sufficient to be acquainted 
 with the normal direction of the vagina and position of the cervix ; 
 before applying the speculum we must always ascertain the exact 
 
 Fig. 125. — Ventral position. 
 
 Posterior vaginal wall raised by univalve 
 speculum. 
 
 situation in each case by vaginal touch. The speculum as well as the 
 touch can be used in the case of virgins without injury to the hymen, 
 care being taken that the legs are completely flexed on the abdomen 
 and kept close together, so as to relax the hymen and make it de- 
 pressible. Of course only instruments of the smallest size must be 
 used. 
 
 The speculum should be oiled and shghtly warmed before its intro- 
 duction, otherwise the sudden contact of the cold metal with the 
 sensitive genital organs might cause contraction of the vulva and spasm 
 
SIGNS FURNISHED BY DIRECT EXAMINATION 141 
 
 of the vagina, sometimes even sharp pain. The patient being in an 
 upright position by the edge of a bed, sofa, or table, we ask her to lie 
 back, when we raise the feet, flexing the legs gently on the abdomen, 
 begging her (if no assistant is present) to keep them in this position 
 by passing her hands under the knees. The ischiatic tuberosities 
 ought to project as much as possible over the edge of the couch on 
 which the patient is lying. I have learned by experience that women 
 prefer this position (in which it is not necessary to uncover the patient), 
 as being more modest than the one generally used in Prance, in which 
 the patient has to open her knees and place her feet on two chairs 
 before her, at a considerable distance from each other; besides, the 
 patient being occupied in holding her knees, has her attention some- 
 what distracted from the examination. It is, moreover, the only suit- 
 able position for applying a speculum to a virgin; the legs being close 
 together the hymen and fourchette are relaxed and so laceration is 
 prevented. Let me advise all my readers to follow my example in 
 preferring a simple couch, ottoman or table, to all those ingenious 
 mechanical arm-chairs, which only frighten patients. 
 
 The physician, separating the labia and nymphse with two fingers 
 of his left hand, examines the colour of these organs, the state of the 
 hj-men and carunculse and of the meatus, ascertaining whether there 
 is any pus or leucorrhceal discharge. He depresses the fourchette with 
 the index finger of the right hand, to judge as to the rigidity of the 
 tissues. Then taking the speculum between the thumb and three first 
 fingers of the same hand, he places the narrow end flat on the four- 
 chette, lowering the hand so that the uterine extremity of the instru- 
 ment looks upwards. He then depresses the fourchette, vulval 
 sphincter, or hymen (if there is one), gradually bringing the axis of the 
 speculum into the axis of the vulva, and by a see-saw motion, executed 
 slowly and carefully, he inclines it more and more towards the sacrum^ 
 as in practising the touch. He must beware of letting the upper 
 border of the speculum come against the meatus, as this might cause 
 pain and bleeding. The vulva once passed, he slides the instrument 
 tc^ards the cervix, following the direction pointed out by the previous 
 examination. This organ is usually situated behind, the os looking 
 towards the concavity of the sacrum ; the easiest way of reaching it, 
 therefore, is to follow the posterior vaginal wall. 
 
 Daylight is always preferable to any other; I have, however, often 
 been able to examine and even operate by artificial light. Collin's 
 reflecting lamp is the best; but a good moderator or even a candle is 
 sufiicient, if an assistant with his hand, or, better still, with a silver 
 spoon, reflects the light into the speculum. As the speculum slowly 
 penetrates the vagina the surface of the latter ought to be carefully 
 inspected. We may flnd not only redness, granulations or erosions, 
 but ulcers, vegetations or polypi, as well as mucus, blood, pus, &c., 
 excreted by the uterus. If the cervix when reached is not in the 
 axis of the speculum, it must be brought into view with the tenaculum 
 hook or sound, and wiped with a pledget of cotton wool. If the 
 mucus is too adherent to be got rid of by this method it should be re- 
 
142 
 
 GENERAL SUEVEY OF UTEEINE DISEASES 
 
 moved by injecting tepid water, and if this is insufficient we must use 
 an emulsion of jolk of egg, as Pajot^ advises. We shall then be able 
 to determine the positionj size, colour and external appearance of the 
 cervix. In short, the speculum confirms some of the information 
 
 already furnished by touch, whilst it adds 
 some new facts. If the os is directed back- 
 wards (anteversion) the speculum only dis- 
 closes the anterior lip ; and in such a case, 
 to bring the os into the axis of the specu- 
 lum we must not only have the patient's 
 legs well flexed on the abdomen, but we 
 must ask her or an assistant to depress the 
 abdomen whilst we use the sound. In this 
 way the fundus is lowered whilst the cervix 
 is raised. If the os looks forwards (retro- 
 version) we must direct the speculum behind 
 the pubis, and with the sound try to draw 
 the uterine orifice backwards. I have some- 
 times found it useful to place the patient on 
 elbows and knees or on her side, in order to 
 cauterise the cervix, which I could not 
 otherwise have reached. We can judge as 
 to the volume of the cervix by the difficulty 
 of including it in a cylindrical speculum, or 
 by being obliged to have recourse to a 
 bivalve. The inequalities, the consistency, 
 the relative size of the two lips are visible, 
 or can easily be ascertained by exercising 
 pressure on the organ as a whole or on each 
 of its lips. 
 
 The principal facts revealed by the spe- 
 culum are : the nature, abundance, and 
 origin of morbid secretions, the form of the 
 orifice, the colour of the cervix, its ulcera- 
 tion or enlargement, whether due to hypertrophy or the existence 
 of vegetations. If the cervix is dry it is well to squeeze it with 
 the speculum, pressing the uterus at the same time through the 
 abdominal walls, to see if by this means we can express a drop or 
 even a flow of clear, milky, or purulent mucus. It is important to 
 ascertain the form of the orifice; it may be a round hole or a 
 transverse fissure, all but closed or widely open ; it may be con- 
 tinued by secondary fissures, sometimes bordered by cicatricial tissue 
 in multiparge; or there may be ectropion of both hps, exposing to 
 view the cervical cavity ; there may even be inversion, or, if one may 
 so say, eversion of the mucous membrane of the cervix. The colour is 
 important ; it may be pale pink, dark red, or even violet. The violet 
 colour of the vulva, vagina and cervix is not exclusively a sign of preg- 
 nancy. It exists to some extent for a few days before and after men- 
 ' Annales de Gynecologie, t. t, p. 464. Paris, 1877. 
 
 Fig. 126.^Collin's lamp, 
 with reflector and re- 
 fracting lens. 
 
SIGNS FURNISHED Bi^ DIRECT EXAMINATION 
 
 143 
 
 struation. This change of colour is so marked and is coincident with 
 such equally important changes in the size, weight and consistency of 
 the organs, that I make it a rule not to examine a woman for the first 
 time before the eighth day after menstruation, i. e. if I wish to make 
 an exact diagnosis of the condition of the uterus. Eruptions, erosions, 
 ulcers of various kinds, are best seen at this time, and cannot be 
 diagnosed with precision by any other means. The 
 same may be said with regard to slight granulations <^ 
 
 and those that are confluent, as well as fungous ^ 
 
 growths and small follicular cysts. 
 
 What has been said in respect of other modes 
 of examination is especially true of the speculum ; it 
 is not only a means of diagnosis but of treatment. 
 It alone allows of various applications being made to 
 the cervix or to the uterine cavity. But we must bear 
 in mind that this instrument ought not to be unneces- 
 sarily used, as it may irritate the urethra, vagina and 
 cervix, and like all applications it fatigues the organ 
 when used too often. 
 
 4. The Uterine Sound. — The sound is our chief 
 resource in making an examination of the uterine 
 cavity. In the last century Levret ^ used one made 
 of whalebone for measuring the womb. In 18iJ8, 
 Lair ^ introduced Larrey^s probe into the cervical 
 cavity curving the extremity like a catheter, and in 
 order to facilitate its entrance into the body of the 
 womb he withdrew the speculum one third and de- 
 pressed the handle of the probe as much as possible. 
 It is, however, only recently that the sound has come 
 into general use as a means of diagnosis and treat- 
 ment, thanks to Simpson, Huguier, Yalleix and 
 Kiwisch. The circumstances under which this in- 
 strument was invented indicate its chief uses. Val- 
 Jeix, engrossed with uterine displacements, wanted 
 like Kiwisch and Simpson to find an intra-uterine 
 sound that would straighten the flexed uterus ; whilst 
 Huguier, having discovered hypertrophic elongation 
 of the cervix, invented the same instrument (calling 
 it a hysterometer) to enable him to measure the 
 cavity. To these uses we may add that of determin- 
 ing deviations in the cervico-uterine ca)ial, and above 
 all, the increased capacity of the uterine cavity 
 interstitial fibroma, polypi, &c. When the os is 
 situated in a cervix which is conical and deviated from its normal 
 position, the only means of ensuring the entrance of the sound is to 
 
 ' Sur un allongement considerable qui survient quelquefois cm col de la 
 matrice ; Journal de medecine et de pharmacie de Moux, Octobre, 1773, t. xl, 
 p. 352. Quoted by Stoltz, Gazette hebdomadaire, 1860. 
 
 '■' Nouvelle methode de traitement dcs ulcerations de la matrice. PariK, 
 
 1828. 
 
 Fig. 127. — Intra- 
 uterine sound 
 v.'ith stem slid- 
 ing into the 
 handle and mov- 
 able index. 
 
 associated with 
 very small, and 
 
144 GENERAL SURVEY OE UTERINE DISEASES 
 
 introduce it through the speculum. But after an entrance is secured it 
 penetrates more easily without the speculum than with it. The reason 
 of this is, that the axis of the uterus is not that of the vagina ; that 
 there is also often a slight anteflexion between the neck and body of the 
 womb ; besides, there may be abnormal flexions or tumours causing 
 curves and angles in the uterine cavity. The uterine extremity must 
 follow these various curves, consequently the handle must be inclined 
 in a contrary direction. Therefore, after the sound has entered the os 
 the speculum ought to be withdrawn and the handle of the sound 
 depressed towards the rectum, so as to allow the bulb to enter the body 
 of the uterus. When it is desirable to introduce the sound without the 
 speculum, the patient ought to be on her back or on the left side. 
 After examining by touch, the tip of the flnger is placed close to the os, 
 and the sound is introduced by the other hand (its concave side being 
 always directed forwards) ; guided by the index finger the os is easily 
 reached and entered. The finger ought then to be placed behind the 
 cervix, raising it slightly, whilst the sound is pushed gently forwards 
 25 or 30 millimetres. The operation so far is very easily performed, 
 unless the orifice is circular and very narrow, as is often the case in 
 virgins and nulliparse ; usually no pain is felt, unless the patient is 
 suft'ering from metritis or neuralgia. If difficulty is experienced in 
 passing the arhor vita, it will be overcome by moving the sound very 
 gently from side to side ; but it often is not easy to pass the os internum 
 without causing a little bleeding. The narrowness of the orifice, its 
 natural occlusion owing to the median columns of the cervix fitting 
 tightly into each other, the spasmodic contraction of the sphincter, the 
 flexion of the body on the neck, all conduce to make it difficult to pass 
 the OS internum. Indeed, sometimes it is impossible to do so ; occa- 
 sionally, however, it is passed very easily and without causing any pain. 
 Force must never be employed in order to enter the uterine cavity, by 
 pressing very gently in the probable direction of the orifice, raising the 
 neck or body with the finger, according to the mutual relationsliip of 
 these two parts as indicated by vaginal touch, depressing the handle 
 for an anteflexion, raising it for a retroflexion, or inclining it to the- 
 side in the case of a lateral flexion, we at last experience the sensation 
 of resistance overcome, whilst the patient at the same moment expe- 
 riences more or less acute pain. The instrument penetrates to a 
 distance of 60 to 80 millimetres, and can be moved easily, especially in 
 a lateral direction. When it impinges against the fundus it sometimes 
 causes a peculiar sensation of discomfort and suffering, which " goes 
 to the heart,^' as patients say. I have seen some women suffer very 
 acute pain, accompanied by hysterical spasms and nervousness, which 
 lasted for some hours. As the sound follows the direction of the canal 
 the uterus is replaced in proportion as the instrument penetrates, so 
 that flexions disappear, being sometimes transformed into versions, 
 whilst at other times the whole organ is brought back to its normal 
 position. It is then that the mobility of the sound in the uterine 
 cavity can be observed, and that it can be made to describe circles more 
 or less extensive; and, at the same time, before its withdrawal care 
 
SIGNS FURNISHED BY DIRECT EXAMINATION 145 
 
 Fig. 128. — Use of the sound in retroflexion. 
 
 should be taken to move the index slide to a level 
 with the cervix in order to measure the exact length 
 of the organ. 
 
 In the case of a uterine fibroma, anteflexion^ &c., 
 the introduction of a sound is very difficult and 
 painful. In place of the ordinary instrument it is 
 better to use Sims's small flexible silver or copper 
 one. If we cannot reach the fundus with this instru- 
 ment we must use a very small gutta-percha bougie, 
 because in such a case it is of great consequence to 
 measure the exact length of the uterus. 
 
 We must not persist in forcing the sound onwards 
 when we experience great resistance ; it is better to 
 make a second or third attempt, or to delay it till 
 another day. As a rule it is more prudent to use 
 this instrument in the middle of the intermenstrual 
 period, when the congestion which precedes and 
 follows menstruation is not present ; however, if we 
 cannot succeed then, we may take advantage of the 
 menstrual period or the day following (when the 
 orifices are dilated) to penetrate into the cavity and 
 to dilate the os internum ; but in doing so we must 
 use extra precaution. 
 
 The use of the sound may be contra-indicated ; 
 for instance, by pregnancy. To avoid all risks the 
 
 »■ 
 
 Fig. 129.— a a, 
 arc of a circle 
 described in the 
 uterine cavity 
 by the bulb of a 
 sound moving; 
 round a fixed 
 point B h, at the 
 OS externum. 
 JU 
 
146 GENERAL SURVEY OF UTERINE DISEASES 
 
 practitioner should never use the sound without receiving an assurance 
 that the patient has had no coitus since her last monthly period^ and 
 having satisfied himself that the usual presumptive signs of pregnancy 
 are absent. The use of this instrument is also contra-indicated at the 
 menstrual period, especially when menstruation is abundant and painful 
 and associated with considerable congestion, as well as in an inflamma- 
 tory condition of the uterus, in suppuration of the mucous membrane, 
 in acute catarrh, in ovaritis, in acute pelvic peritonitis, in an organic 
 disorder such as cancer or softening of the tissues of the body of the 
 uterus, or in the few weeks following delivery. Care must also be taken 
 not to use force in pressing the bulb of the sound against the uterine 
 walls for fear of lacerating or perforating them. Such accidents have 
 occurred, and although they have seldom been followed by serious con- 
 sequences we must remember there is a great difference among women 
 as to sensitiveness. Several cases of death^ have been recorded as the 
 result of the imprudent use of this instrument. Unless the uterus is per- 
 fectly mobile it ought never to be lifted up by the sound, nor should 
 abdominal palpation be combined with the use of this instrument, for 
 in pushing it against the fi^ngers which depress the hypogastrium we 
 run the risk of perforating the uterus. 
 
 "Whilst admitting that the sound requires to be used with great care, 
 I think all gynsecologists will agree with me in considering it indis- 
 pensable in the diagnosis of a certain number of uterine diseases. If 
 we remember that normally the uterus is slightly anteflexed, that the 
 relative lengths of neck and body are anatomically determined, that 
 in a state of health, especially in the nullipara, a cavity of the body 
 cannot be said to exist, the two walls, being in close juxtaposition, 
 only allowing shght lateral movements to any instrument that may be 
 introduced, and, lastly, that the smooth mucous membrane protected 
 by epithelium is not liable to be torn by a blunt instrument nor to 
 bleed unless there is congestion, we may conclude that examination by 
 the sound will be of great use in giving us necessary information on 
 the following points : — 1. The dimensions and entire length of the 
 uterus, and consequently its volume. 2. The relative dimensions of 
 the cavity of the body and neck, the latter being sometimes short, 
 whilst the former is long and' inflamed ; at other times the neck only 
 is long, being more than three quarters of the whole length, presenting 
 thus a true hypertrophic elongation. 3. The differences of size in 
 other directions, the dilatation of the uterine cavity being easily per- 
 ceived by gently moving the sound. 4. Irregularities of the surface, 
 alterations in the form of the cavity, fibromata, polypi, vegetations, 
 fungous growths, and the hsemorrhage which accompanies them. 5. 
 The absolute and relative position of the uterus and of its two segments 
 with regard to each other, deviations, flexions, and the dift'erential 
 diagnosis between these displacements and polypi, fibromata, whether 
 interstitial or pediculated, utero -peritoneal adhesions, extra-uterine 
 tumours, peri-uterine abscess, hsematoceles, ovarian cysts, &c. 6. 
 Stenosis, deviations, and spasmodic contractions of the uterine orifices. 
 ' L. E. Dupuy, Progres medical, pp. 109, 171, 195. Paris, 1873. 
 
SIGNS FDENISHED BY DIRECT EXAMINATION 
 
 147 
 
 7. Lastly, the accumulation of fluids in the uterine cavity, which can 
 be diagnosed by means of the hollow sound, which at the same time 
 affords a means of ascertaining the comparative dilatation of this 
 cavity. 
 
 II. Cowplementary means of exploring the Uterine Cavity. — 
 The greater part of these are means of treatment as well as of 
 diagnosis. I will, however, describe them here, because though 
 
 Fig. 130. 
 
 Fig. 131. 
 
 Fig. 133. 
 
 Fig. 130. — Joljevt de Lamballe's intra-uterine speculum. 
 
 Fig. 131. — Mathieu's small speculum or uterine dilator. 
 
 Fig. 132.— Bivalve uterine dilator (Lemenant-Deschenais). 
 
 Fig. 133. — Trivalve uterine dilator (Busch, modified by Huguier). 
 
148 
 
 GENEEAL SUEVEY OP UTEEINE DISEASES 
 
 there is only one way of using them when they are employed as a 
 means of diagnosis^ their use varies^ on the contrary, according to 
 the exigencies of the case when they are employed as a means of 
 treatment. 
 
 T/ie hitra-nterine speculum is, I think, the least useful of all instru- 
 ments. There are various kinds, one of them (that of Desormeaux) 
 being really a speculum, ^. e. a mirror enabling us to see different parts 
 of the intra- uterine mucous membrane; the others serve also as dila- 
 tors. I may mention those of Atthill,^ Jobert, Mathieu and Blatin, 
 the bivalve of Lemenant-Deschenais, the trivalve of Busch modified by 
 Huguier, &c. Peaslee'^ has also invented a somewhat similar instru- 
 ment. It is a silver tube, 7 to 8 millimetres in breadth, 5 to 6 cen- 
 timetres in length, with a conical end, through which are three 
 openings, which not only afford a view of the fundus, but also allow 
 of the introduction of the very finest instruments, of vegetable or 
 metallic threads, &c. 
 
 The dilator is more useful. I may mention Aussandon's instru- 
 ment, made of prepared wood or ivory, which, when placed in the 
 uterus, swells to double its size. Dilatation, however, is effected 
 
 «Basz2aa2£2M^>— 
 
 Fig. 134. — Aussandon's uterine dilator. 
 
 more surely and safely by means of ordinary 
 bougies or by Simpson''s metallic stems (of 
 tin, silver, or aluminium) of gradually in- 
 creasing size, terminating in a bulb, which 
 supports the cervix. But the best of all 
 means of dilatation are tents of prepared 
 sponge or laminaria, which expand so slowly 
 and gradually that the dilatation of the uterine 
 cavity and orifices is attended by no danger, 
 and very often by no suffering. 
 
 1. Sponge tents should be prepared in the fol- 
 lowing way : — Take a piece of sponge of conical 
 shape, soak it in a strong solution of gum, fix it 
 on a central stem, and compress it as forcibly 
 as possible by binding it round with string ; dry 
 it thoroughly, remove the string, file off any 
 roughnesses, and cover it with lard or wax to 
 facilitate its introduction, which is efl'ected by 
 inserted in the centre of the sponge, or simply 
 
 Fig. 135. — Simpson's 
 large intra-uterine 
 pessary. 
 
 means of a stem 
 
 » Dublin Journal of Medical Sciences, January, 1873, p. 73. 
 ' Intra-uterine Medication : its Uses, Limitations and Methods, by M. D. 
 Peaslee. New York Medical Journal, July, 1870, p. 481. 
 
SIGNS FURNISHED BY DIRECT EXAMINATION 149 
 
 by the uterine forceps. These tents should be made of different 
 sizes, varying in diameter from 2 to 10 millimetres and in length 
 
 Fig. 136. — Sponge tent with introducer. 
 
 from 2 to 7 centimetres. Before introducing one I cover it with 
 belladonna ointment (Ext. Bellad. gr. xv, lard gr. Ix). After its 
 insertion I pour two spoonfuls of glycerine into the vagina, and then 
 place a plug of cotton wool to keep the tent in its place. The 
 glycerine, whilst determining a very abundant serous secretion, dis- 
 infects this leucorrhceal discharge entirely. The tent is left for 
 twenty-four hours, when the patient can remove it herself by means 
 of a thread attached to it, and which is long enough to hang out- 
 side the vulva. The dilatation generally takes place without suffering ; 
 sometimes, however, the patient has pains like those of menstrua- 
 tion. If the sponge is left for more than twenty-four hours, it is 
 generally expelled spontaneously into the vagina, probably from 
 pressure of the mucus secreted above, aided by uterine contractions. 
 However, if it is pushed high up into the cervical cavity, so that the 
 OS externum closes over it, extraction may be necessary, especially if 
 the thread breaks, as sometimes happens. The sponge itself may tear, 
 a part being retained for months adhering to the mucous membrane. 
 After having withdrawn the sponge the patient ought to take an 
 emollient bath for an hour, injecting water from the bath into the 
 vagina all the time. A second sponge may be introduced immediately 
 afterwards, but it is more prudent to allow the patient to rest for one 
 or two days. The vaginal injections ought to be made very slowly, 
 for I have sometimes seen the occurrence of uterine colics, evidently 
 caused by the fluid penetrating into the uterus. 
 
 By taking these precautions, occasionally making an examination by 
 speculum, and suspending the dilatation as soon as any signs of irrita- 
 tion appear, we may in a few weeks — sometimes in a few days — dilate 
 the cavity sufficiently to be able to explore its surface thoroughly with 
 the finger, and even with instruments. During this time the ])atient 
 ought to remain in bed and take an emollient bath every day. When 
 the OS externum is too narrow to allow of the entrance of a tent, 
 incision of the orifice must be practised, but even after this incision 
 has been made it is often necessary to use tents to dilate the cervix 
 and OS externum. If M-e have any reason to suspect cancer we cannot 
 exercise too much care in dilating and examining the uterus, lest the 
 substance should be torn and the wall perforated, as in a case I 
 have seen. 
 
 2. Laminaria digitata is soft, flexible, and loses much of its 
 
150 GENEEAL SURVEY OF UTERINE DISEASES 
 
 diameter when dried. Its structure being cellular, it dilates greatly 
 under the influence of moisture, reaching a volume of five or six times 
 its original size. The mucous secretions are generally sufficient to 
 effect thiSj but simple injections may be used if necessary. The young 
 stems are the best, the size varying according to the case. The rind 
 should be retained, and one end should be pointed, whilst the other 
 has a thread attached to it. The tents before being used should be 
 well washed and then damped and dried successively several times. 
 Laminaria tents act as efficiently and quickly as prepared sponge 
 
 (^^ 
 
 Fig. 137. — Laminaria tent polisBed and perforated. 
 
 and are better in some respects ; they are more easily introduced when 
 the OS is very small, and they cannot break. They can be used indefi- 
 nitely if care be taken to wash them in a solution of permanganate of 
 potash, they are more quickly and easily prepared, they are abundant 
 and cost almost nothing; but in spite of these advantages they cannot 
 as a rule replace sponge tents beneficially. Sometimes the constricted 
 OS is very unyielding, and prevents the laminaria from dilating to its 
 full size at this point, as it does higher up, so that the tent is firmly 
 retained, and cannot be withdrawn without incision of the orifice. 
 Although incision of the os externum is not attended with danger, it is 
 different with the internal orifice, incision of which is dangerous, and any 
 attempt to withdraw the laminaria without incision is more dangerous 
 still. 1 have seen a case where attempts at extraction produced pro- 
 lapsus of the uterus, with evident laceration of the peritoneum, which 
 brought on acute inflammation and almost caused death. Nothing of 
 the kind is to be feared with sponge tents, therefore it is clear that 
 they should have the preference. 
 
 Artificial prolapsus of the vterus is another means of diagnosis that 
 ought not to be omitted. This can be effected without danger, and 
 even without pain, by seizing the cervix or one of its lips with the 
 uterine forceps or a fine tenaculum hook, and exercising moderate but 
 continuous traction till the os is on a level with the vulva. If the 
 cervix has been naturally dilated by a tumour or artificially by a sponge 
 tent, the finger may then be introduced into the cervix, and even into 
 the body of the uterus, in order to examine it thoroughly. The same 
 means ought often to be employed for treatment, to facilitate the 
 ablation of polypi as well as for several other operations practised on 
 the uterus. 
 
CHAPTER II. 
 
 XEEATMEXT OF UTERINE DISEASES IN GENEEAL — INDICATIONS TO BE FULFILLED 
 IN THE TEEATMENT OF UTEEINE DISEASES — METHODS OF TEEATMENT 
 AND TAEIOUS MEDICATIONS IN UTEEINE DISEASES — MEANS OF FULFILLING 
 INDICATIONS IN THE TEEATMENT OF UTEEINE DISEASES. 
 
 To institute a rational treatment, it is necessary first of all to 
 lay down the indications and contra-indications ; afterwards to 
 seek the best means of fulfilling these indications. I have con- 
 siderable difficulty with regard to the indications, because of their 
 infinite variety in diseases of the womb. If it is difficult to describe 
 them correctly, it is more difficult still to lay down exact treat- 
 ment. In practice it is of the first importance to remember that 
 it is our patients whom we have to treat and not abstract diseases. 
 However exact our descriptions and precepts may be, they can only 
 represent types undergoing modifications which it is impossible to 
 foresee ; therefore, in applying general rules to any individual case, a 
 large margin must be left to the judgment of the attending physician. 
 In spite of these difficulties we can place some finger posts which will 
 help to keep us in the right road. In considering the question from 
 this point of view I shall lay down some general principles to serve as 
 a basis for a system of therapeutics as apphed to uterine diseases in 
 general, from which can be deduced the special treatment most suitable 
 to each particular case. 
 
 1. The first indication is the necessiti/ for treatment. It may seem 
 superfluous to make this remark, but it is not really so. There are so 
 many acute and even chronic diseases cured by nature that it is neces- 
 sary to point out how different uterine diseases are in this respect. 
 In their case the expectant method is deplorable, although very useful 
 in many other circumstances. Experience teaches us that diseases of 
 the womb have no tendency to spontaneous cure. Nothing can be 
 hoped, even from the changes and evolutions which the uterus under- 
 goes at dilTerent periods of life in passing from childhood to puberty, 
 from puberty to the period of sexual activity, and from that to old 
 age. Neither menstruation nor the menopause has any tendency to 
 cure uterine diseases. Menstruation, on the contrary, brings a great 
 many. The menopause certainly has a tendency to lessen some dis- 
 eases by the cessation of periodical ovulation with its accompanvin" 
 fluxion and hasmorrhage ; but habitual fluxions do not always cease ; 
 on the contrary, they sometimes seem to assume a character of greater 
 intensity from having lost their regulator. It is the same with passive 
 congestions which no longer have their periods for disappearing in 
 
152 TEEATMENT OP UTEEINE DISEASES IN GENERAL 
 
 the normal alternations of uterine plethora and depletion. Besides, 
 various constitutional affections are apt to show themselves at the 
 climacteric period, so that if one danger is removed another is brought 
 on. As for the changes occurring in the sexual period, they are 
 hurtful in place of benig favorable to uterine diseases, often helping 
 to perpetuate, hardly ever to cure them. Beware of hoping that 
 marriage will cure a uterine disease. At the most it can only regulate 
 or increase defective menstruation, and will certainly aggravate any 
 real morbid condition ; for one disease that pregnancy has ameliorated 
 or cured (supposing the retrograde evolution of the womb to have been 
 well directed) it has aggravated a thousand. It is of consequence to 
 have clear ideas on this point, that the physician may be able to con- 
 vince his patients of its importance, so as to make them willing to 
 continue treatment as long as is necessary. We must, however, 
 remember that every functional disturbance or displacement of an 
 organ is not a disease. This term should be reserved for those changes 
 in the generative system which are accompanied by functional disturb- 
 ance, abnormal phenomena, or pathological processes in this system or 
 in the general economy incompatible with the free exercise of special 
 or general organic functions, or with the continuance of life. Such 
 are the limits beyond which we ought not to venture in pursuing a 
 vigorous treatment, which cases recently reported (especially with 
 regard to displacements) show not to be exempt from danger. 
 
 2. Under certain circumstances we must content ourselves with a 
 palliative cure and not continue treatment when a perfect cure is im- 
 possible, as unfortunately is too often the case. Por example, how 
 can we hope for the radical cure of interstitial and multiple tumours, 
 pediculated subperitoneal tumours, of ovarian cysts when sufficiently 
 tolerated by the organ not to necessitate extirpation, in short, of all 
 material changes which are the starting point of functional troubles 
 which art is powerless to remedy, or at least which it cannot attempt 
 without exposing the patient to greater dangers than those of the 
 disease itself ; therefore we are often obliged to limit ourselves to a 
 palliative cure, simply regulating the functions of the sexual organs 
 and of the general economy. By venturing further and employing 
 more energetic means we expose ourselves to terrible reactions and 
 even to an exacerbation of the disease itself; or if we succeed in sup- 
 pressing it we may determine serious disturbance of the whole economy 
 or the appearance of a dangerous disease such as phthisis, which till 
 then was latent, in another organ. It is all the more important that 
 we should restrict ourselves to palliative measures in certain cases, 
 as the perfect integrity of the uterus and its appendages is not abso- 
 lutely indispensable to the exercise of sexual and general functions. 
 Experience teaches us that women may be affected by organic dis- 
 orders of this system without being greatly inconvenienced by them. 
 These disorders are often not only compatible with the free exercise of 
 the general functions, but even with the accomplishment of the special 
 functions of the sexual economy. Pibrous tumours and ovarian cysts 
 do not always prevent conception nor induce abortion. 
 
INDICATIONS FOE TEEATMENT 153 
 
 Very often we must limit our aim to the disappearance of functional 
 disorders, pain, hgemorrhage, leucorrhoea, and other morbid phenomena 
 with the restoration of the general health. In morbid conditions 
 characterised by functional trouble, such as disorders of menstruation, 
 or by pathological processes unaccompanied by neoplasm, functional 
 restoration usually coincides with the radical cure of the disease, the 
 treatment having attained both ends at the same time. In displace- 
 ments and deviations, as well as in diseases characterised by the 
 existence of neoplasm or organic alterations, it is possible to regulate 
 function without restoring integrity of the structure or the position of 
 the organs ; and treatment need not be prolonged after the first of 
 these results, a palliative cure, has been obtained. 
 
 3. When we consider how seldom it happens that the uterus is for 
 a long period the seat of morbid processes without its organic tissue 
 becoming more or less seriously affected and how little tendency 
 uterine diseases have to spontaneous cure, we must see the importance 
 of another indication : viz. the necessity of always associating general 
 with local treatment. 
 
 In general affections of the organ and in purely diathetic diseases, 
 especially when the localisation is multiple, or when the accompanying 
 material change is insignificant, it will be readily understood that not 
 only are general means of treatment the most important, but that 
 usually they are of themselves sufficient to produce a definite cure ; 
 in the same way local treatment may suffice for traumatic lesions, 
 changes of position, or the development of neoplastic tumours, 
 whether homeomorphous or not, and even when produced by the 
 localisation of a diathetic afi'ection. But although local suffering may 
 be relieved and the general health improved by one-sided treatment, it 
 is very seldom that a permanent cure can be effected without combin- 
 ing general and local means of treatment. The one or other may 
 require most attention according to the case; but they cannot be 
 separated, nor can the one be sacrificed to the other. Aran^ has 
 made the same remark, and it is strikingly illustrated in the diS'erence 
 between our private and hospital practice. In private practice patients 
 often refuse local treatment, either because of the pain which they 
 fear as a consequence of energetic measures or from repugnance to sub- 
 mitting to the frequent applications and various little operations which 
 may be necessary. On the other hand, they are most willing to carry 
 out any general treatment either internal or external, even baths and 
 hydropathy when advised. Under the influence of such a regimen I 
 have often seen the appetite restored, digestion regulated, nutrition 
 increased, flesh gained, strength recovered. But the uterine pain 
 never disappears, a real cure is never effected ; in short, the temporary 
 improvement does not last more than a few months, when the patients 
 fall back into their former state of ill-health and all has to begin over 
 again. Hospital patients, on the other hand, are obliged to undergo 
 local treatment, all necessary operations are performed, dressings made, 
 &c. But it is seldom that general treatment is carried out with 
 
 1 Op cit., p. 162. 
 
154 TREATMENT OF UTERINE DISEASES IN GENERAL 
 
 necessary regularity. Some patients consider all drugs poison, and 
 often manage to throw their medicine away, whilst baths, mineral 
 waters, food and ventilation are often also defective owing to the 
 limited resources of the hospital. In these cases I have noticed 
 that the local symptoms — pain, tumefaction, granulations, ulcers, 
 leucorrhoea — may disappear temporarily, but if the general health 
 does not improve proportionately with the local disorders the latter 
 soon re-appear. 
 
 4. An appropriate treatment should be applied to every disease. — 
 It may seem superfluous to point out this indication, but whilst it 
 certainly would be so in reference to any other class of diseases, it is 
 not so with regard to uterine pathology ; this is only explicable by the 
 relative ignorance of our predecessors as to the variety of diseases of 
 tbe womb. We must remember that in uterine pathology, as in the 
 pathology of any other organ, there are species and varieties differing 
 so much from each other as to require differences of treatment. The 
 most. characteristic feature of the progress of uterine pathology in our 
 day is the tendency to distinguish the different diseases of the uterus 
 as we distinguish different diseases of the lungs or heart, by their 
 symptoms, their organic lesions and their nature. The most practical 
 application of this nosological distinction is, without doubt, the 
 general indication to vary the treatment according to the case, and 
 to distinguish the special indications arising from the differential 
 diagnosis of the various diseases. I meet so many medical men who 
 have kept up the habit of treating all uterine diseases in exactly the 
 same way (the treatment varying, not with the patient but with the 
 doctor) that I must take this opportunity of warning young practi- 
 tioners against all uniform and stereotyped therapeutics. Lisfranc did 
 not escape this error. His opinion as to the frequency of engorge- 
 ment, which he looked on as the basis of all uterine pathology, 
 necessarily led him to prescribe for the majority of these diseases a 
 common treatment, which we find reproduced almost word for word 
 in his consultations. The chief points of this treatment were as 
 follows : — Eest on the sofa, baths twice a week, conium internally, 
 bleeding from the arm once a month ; lastly, the gradual reduction of 
 food to the minimum quantity required to sustain life, with the idea 
 that organic resolution is promoted by abstinence — ciira /amis} 
 Nonat has also adopted this mode of treatment, though not so ex- 
 clusively. Others have made almost all uterine pathology to consist 
 in replacing the womb, whilst others insist far too much on antiphlo- 
 gistics. Some wear out the uterus by continual applications ; others 
 limit themselves to the use of general means. One practitioner in- 
 variably gives hot baths, a second cold baths ; some prescribe hip- 
 baths, others general baths. Now, we cannot guard ourselves too 
 carefully against any exclusive treatment of uterine diseases in general, 
 or of any special means in particular. Disease varies in form and 
 nature in the uterus as in other organs ; treatment ought to vary 
 likewise. 
 
 ' Bulletin dc VAcademie de Medecine. 
 
INDICATIONS FOR TEEATMENT 155 
 
 5. It is very important to consider the nature of the disease. — 
 Uterine diseases are very seldom of a reactionary nature ; on the 
 contrary, tbey may be classified as affective diseases, i. e. dependent on 
 a general state. It is not that the general condition from which they 
 derive their nature has always been the determining cause of their 
 development ; but it impresses its character on the disease whether 
 primarily or not. They may arise in two ways, either following the 
 development of a general affection or being produced by a disease 
 originally local. The diathetic affection exists; it has already given 
 proof of its existence, though it has not yet attacked the uterus. 
 However, it is not long before it fixes itself there, because this organ 
 is more disposed than any other to be affected, owing to its position, 
 its inclination, its monthly congestion, the increased vitahty developed 
 in it by pregnancy and the traumatism determined by an abortion or 
 by delivery. The diathetic affection manifests itself spontaneously; 
 at most it only awaits a favorable opportunity for taking possession. 
 At other times the uterus is predisposed to disease. Menstrual 
 troubles, sexual excess, over-fatigue, a miscarriage or difficult labour 
 cause congestion, engorgement, hypertrophy. Disease is established. 
 That would be of no consequence if the woman were healthy and 
 strong; all would then disappear with a few simple precautions. If, 
 however, a diathetic tendency be present the tendency becomes a 
 localised affection, it fixes on the uterus, impressing its special 
 character on the already existing disease. What occurs to a man 
 suffering from blenorrhagia or engorgement of the prostate happens 
 to the woman affected by uterine disease. These illnesses when recent 
 and uncomplicated are easily cured in vigorous individuals. But 
 given the existence of a special diathesis, these maladies open 
 the door to the inroads of an affection tiU now latent, and cure is 
 difficult. 
 
 6. That we may perceive, therefore, the leading indication, it is 
 necessary first of all to determine the diathetic affection which is the 
 essential cause of the malady. Any constitutional disease may become 
 localised in the uterus; it is certainly so with cancer, rheumatism, 
 gout, herpetism, scrofula, syphilis, &c. I do not think that any 
 practitioner can doubt the correctness of ray statement with regard to 
 the majority of the affections just named. I myself for a long time 
 retained doubts as to gout; but lately I have seen a case which seems 
 to me sufficiently conclusive to force conviction. 
 
 Case. — A lady, aged forty-five, is mother of two grown up children in good 
 health ; her father is gouty, her mother comes of a gouty family, and her 
 brother is asthmatical. She has at various times suffered from pain and 
 swelling of the joints, especially of the small articulations, several of which 
 are defoi-med. The urine is often charged with brick-red deposit. She suffers 
 to a small extent from haemorrhoids, but her digestive functions are in good 
 condition. She has repeatedly had serious attacks of pulmonary congestion, 
 haemoptysis, &c. Tor some time back the lungs have been healtliy, but the 
 uterus is affected with chronic congestion, occurring apparently without cause ; 
 twelve da^'s after the catamenia there is an exacerbation causing acute pain and 
 rendering walking impossible. This state is accompanied by serious general 
 
156 TEEATMENT OF UTERINE DISEASES IN GENEEAL 
 
 disorder ; in a few days there is an improvement allowing the patient some 
 days' rest before the return of the monthly period. This is ushered in with 
 gi-eat pain, a condition which never existed previously ; after two or three days 
 the pain ceases and the haemorrhage is more abundant than before the uterine 
 disease. I have sometimes known this patient for five or six months to have 
 hardly any suffering or congestion, and then begin to suffer anew. These 
 pains and the morbid conditions developed successively in the limbs, chest, and 
 uterus, keep her extremely thin, and produce a great tendency to perspiration 
 and a general weakness in spite of an excellent appetite and good digestion. 
 I do not know whether I have given a sufficiently exact description of this case 
 to convince my readers that this succession of morbid conditions, so serious and 
 at the same time so variable, can only be explained as attacks of visceral gout, 
 
 I do not think any one can doubt as to the influence of catarrhal, 
 chl orotic, herpetic and scrofulous affections on uterine diseases. 
 
 7. Inflammation dXso plays a great part in the production of uterine 
 diseases. Sometimes it constitutes the basis or even the essence of the 
 disease ; at other times it plays only a secondary role to the diathetic 
 affection. In the first case the uterine disease may be called re- 
 actionary; in the second, as in the case just cited, affective. Thus, as 
 the result of traumatism or of causes which may be called traumatic, 
 such as sexual excesses, fatigue during menstruation, abortion, difficult 
 labours, operations performed on the genital organs, acute inflamma- 
 tions are often developed which are, to speak correctly, reactionary, 
 such as metritis, ovaritis, peritonitis; these inflammations become 
 chronic if they are too aggravated to undergo natural resolution, or 
 too slight to terminate in suppuration or gangrene, and the disease 
 retains the inflammatory nature with certain modifications. 
 
 At other times the disease has begun with inflammatory symptoms 
 but is evidently kept up by a diathesis retaining nothing of an in- 
 flammatory character but the form or a state of special complication. 
 Nevertheless, at a given moment, under the influence of unforeseen 
 accidental causes or even of normal processes, such as menstruation, 
 this condition may produce an increase in the inflammatory element 
 which will now occupy the first place among the existing morbid 
 phenomena, owing to the danger it involves. But whether inflamma- 
 tion form the basis of the uterine disease or be only an element of 
 secondary importance subordinate to the diathesis, or an accidental 
 coincidence more or less serious, it always presents important indica- 
 tions. In the one case the leading indication is to subdue it, in the 
 other this is -of secondary importance — secondary, that is to say, to 
 that of the diathesis; but in all cases it deserves the most serious 
 consideration. 
 
 8. Another important source of indications is the asthenic nature of 
 the majority of uterine diseases, no matter what part inflammation 
 plays in them. If we consider the condition of the vital forces, i. e. 
 the* resistance which the economy is capable of making in this struggle, 
 we can assuredly say that generally there is not a sufficient power of 
 resistance. Occasionally it may exist in acute uterine disease and in 
 inflammatory attacks, which give a new character and nature to the 
 disease. But generally the reverse holds good. As a result of the 
 chronic state of the malad}', of the sympathetic disorders of digcs^''^*^ 
 
INDICATIONS FOE TEEATMENT 157 
 
 and innervation, and of the consequent impoverishment of blood, there 
 is a state of general debility wliich not onlj takes from patients the 
 tone which gives energy and activity to the whole system, but also 
 deprives them of what the ancients called motor force. Besides the 
 atony with which the muscular system and the whole of the organism 
 is affected, we may say that the majority of uterine diseases are 
 characterised by asthenia. Therefore, after having subdued inflamma- 
 tion or congestion by blood-letting or otherwise when necessary, we 
 must hasten to overcome the diathesis which has a share in the disease, 
 and above all to raise the strength by enriching the blood, soothing 
 the nervous system, facilitating digestion, stimulating nutrition, and 
 by giving an impetus to the repairing processes in all the organs. 
 
 9. The chronicity of uterine diseases is also an indication of con- 
 siderable importance. A small number of uterine diseases have an 
 acute course. Such are those diseases which may be called trau- 
 matic, as well as those having a sthenic character and tending to 
 inflammation, and those consequently which participate in the nature 
 of reactionary affections, such as cases of metritis, ovaritis, haemato- 
 celes at their commencement, peritonitis, inflammatory attacks of pelvic 
 peritonitis or peri-uterine inflammation, active hsemorrhage, &c. But 
 the majority, on the contrary, are chronic in character ; there is some- 
 thing slow in their manifestation and a natural tendency to last indefi- 
 nitely. This chronic character depends on two causes : primarily, on 
 the influence of the diathesis, or at least on the asthenic nature of the 
 malady. All diathetic affections are difficult to cure. They are deeply 
 rooted in the whole economy ; the whole mass of the tissues needs to 
 be gradually modified, a requirement which necessitates a long and 
 uninterrupted treatment. Even when a uterine disease cannot be 
 attributed to a diathesis, its asthenic nature calls equally for reconstitu- 
 tion of the blood and restoration of the whole system. Secondarily, 
 it depends on special causes peculiar to the uterus, which keep up the 
 disease by bringing obstacles in the way of its cure. The womb is not 
 only placed below all the abdominal viscera, which by their weight 
 tend to keep up the congestion as well as to cause pain mechanically ; 
 not only is it subject to the troublesome and repeated excitement of 
 conjugal relationship, but every month it is the seat of a normal san- 
 guineous discharge, which to a great extent undoes the good derived 
 from previous treatment, giving at the same time new life to the 
 disease. Those patients are fortunate who escape with only a monthly 
 periodical flow, many having a recurrence every fortnight. These 
 periodical discharges, besides tending to perpetuate the disease by the 
 accompanying congestion, haemorrhage, pain and other pathological 
 conditions, are troublesome from their necessitating, in the majority of 
 cases, an interruption to treatment, which delays cure. Therefore we 
 must expect to lose every month part of the good we have already 
 gained, and must content ourselves with a very slow and gradual 
 improvement. 
 
 As the chronicity of the disease cannot be altered, an appropriate 
 treatment should be adopted, which can be prolonged indefinitely. 
 
158 TEEATMENT OF UTERINE DISEASES IN GENERAL 
 
 If a suitable treatment, local as well as general^ is applied, patients 
 soon obtain marked relief. Leeches, a purgative, baths and douches, 
 with tonics, when rightly employed, seem to rid them of all their pains 
 and discomforts. They think themselves cured. But the physician 
 must not deceive himself; the relief is only temporary. The organs 
 have not sufficient tone to preserve them from a relapse ; the diathesis 
 still exists ; the uterine discharge will soon recur, forcing us to dis- 
 continue treatment, and taking possession of the organ will throw it 
 back into its original condition. Therefore, I repeat, as the disease 
 is chronic the treatment must be so also. 
 
 10. More is needed: we must j)reveni relapses. Treatment must 
 be continued for a considerable time after an apparent cure, even 
 after a real cure. The causes of the chronicity of uterine diseases are, 
 at the same time, causes of relapse, and if we would destroy their 
 power we must give tone and strength to the whole economy, and 
 especially to the diseased organs, in order to preserve them from 
 relapses. 
 
 11. T/ie elementary nature and form of the uterine disease is 
 another source of indications which must not be neglected in treat- 
 ment. The various elements which contribute by their union to give 
 the disease its form, physiognomy, and special appearance, may com- 
 bine in different ways or be associated with such or such a disease as 
 primary or secondary element. In this way fluxion, congestion, hae- 
 morrhage, leucorriioea, ulceration, pain, engorgement, hypertrophy, 
 displacement, may be alternately principal or accessory elements of 
 the disease, and become the source of primary or secondary indications. 
 Many of these elements are not mere alterations of tissue or modifica- 
 tions of local life, but morbid processes of the whole economy, having 
 the uterus for their starting point or goal, and passing for simple 
 affections. These affections may remain simple or become compli- 
 cated by several other pathological elements. This remark applies 
 especially to the most common of these elements — -jiiixion. Whether 
 it be an original element of the disease or a later complication, fluxion 
 is the morbid process against which we have to struggle with most 
 persistency in the treatment of uterine disease. We have to contend 
 not only with imminent or established pathological fluxion, but even 
 with the periodical physiological fluxion, at least in its derangements, 
 and to prevent the consequence of its baneful influence on the malady. 
 I cannot too strongly recommend the excellent treatise of Bartbez on 
 this subject (' Traitement Methodique des Fluxions^). The distinc- 
 tion made between the fluxion that is imminent and the one that is 
 established is very practical. The precept to use revulsives to prevent 
 the first from becoming fixed and to employ derivatives to arrest the 
 second is excellent. 
 
 Congestion or vascular fulness of the organ is often only an estab- 
 lished fluxion. It may then be called active congestion, and hidicates 
 the necessity for revulsives or derivatives. When it is passive it is 
 none the less an important and frequent source of indication, which is 
 best fulfilled by depletion. 
 
INDICATIONS FOR TBEAT.MEXT . 159 
 
 Engorgement, or the presence of interstitial plasma^ which is some- 
 thing between oedema, congestion and hypertrophy, naturally indicates 
 the use of resolvents. 
 
 Hypertrophy, or increase of the uterine tissue by excess of assimila- 
 tion or defect of decomposition, indicates reabsorption. When this 
 hypertrophy is localised on some point of the organ and some portion 
 of one of the tissues, and has given birth to granulations, fungous 
 growths, polypi, fibromata, &c., it may become the source of special 
 indication, that of the local destruction of abnormal tissue by ablation 
 or otherwise. 
 
 The discharges themselves are sources of therapeutic indication, 
 only these are often of minor importance, subordinate to others arising 
 from the morbid condition, whether diathetic or otherwise, on which 
 these discbarges depend. For example, fluxion, congestion, organic 
 alterations, in reference to heemorrhage ; catarrh, chlorosis, herpes, 
 scrofula, with respect to leucorrhoea, furnish indications to be fulfilled 
 primarily, being of greater importance than those even of the hsemor- 
 rhage or leucorrhcea. Ulceration and the consequent more or less 
 serious loss of substance, whether granular or fungous, becomes in its 
 turn a source of indication. Subordinate as it is to the treatment of 
 the diathesis on which the ulcer often depends, the indication to bring 
 about cicatrisation is not the less urgent. 
 
 Pain is one of the most important sources of indication ; it may 
 exist in the uterus or around it, or sympathetically in distant parts. 
 It may be transitory or persistent; it assumes difl'erent forms — hyper- 
 esthesia, neurosis, or neuralgia — and may be idiopathic, symptomatic, 
 or sympathetic. It must be subdued whenever it appears, for pain 
 increases the fluxion and all the elements of the malady, and is sufh- 
 cient to bring them back if we have been fortunate enough to get rid 
 of them. We must attack it at every period of the disease, and even 
 after its cure, for it sometimes persists after the organ has returned to 
 a satisfactory state of health. 
 
 Lastly, the position of the uterus, the condition of its suspensory 
 ligaments, the changes in its normal relationships, all become sources 
 of indications. Only we must had out whether the morbid symptoms 
 really depend on the displacement or are independent of it. When 
 the disease is confined to a deviation or displacement, even then the 
 indication may be complex — 1. To prevent the abdominal viscera, by 
 means of rest, attitude and supporting belts, from increasing the dis- 
 placement of the organ and causing pain. 2. To render the displace- 
 ment bearable by palliative treatment or by the use of mechanical 
 support, y. LasUy, to obtain a radical cure by attacking directly the 
 causes of the displacement or deviation. 
 
 1£. Special indications arise from ntighhonring disorders accom- 
 panying uterine disease. The condition of the urine ought to be 
 examined. In acute as well as in chronic diseases we often find this 
 excretion abnormal. Lithiasis, concentration, deposits of various 
 kinds, are all sources of indication, as well as tenesmus, inflammation, 
 catarrh, frequent or difficult micturition, mechanical compression of 
 
160 TREATMENT OF UTEBINE DISEASES IX GENEEAL 
 
 the bladder or urethra by uterine tumours, kc. Then we have dis- 
 orders connected with the rectum, diarrhoea, tenesmus, hsemorrhoids, 
 glairy, mucous or bloody discharges, and, above all, constipation, the 
 most common and hurtful of all complications, keeping up as it does 
 pelvic congestion. 
 
 13. What can be said of the sympathetic reaction of uterine diseases 
 on the nervous system and digestive economy but that the consequent 
 functional disorders are sources of indication ? Let me, however, 
 remark that the majority of the indications arising from these dis- 
 orders are already fulfilled by the means employed in combating 
 asthenia, raising the tone of the whole economy, soothing pain, regu- 
 lating the nervous system, improving the condition of the blood, 
 increasing nutrition, renewing the whole constitution. 
 
 14. What can be said too of the very serious complications which 
 sometimes increase the severity of uterine diseases and prevent a con- 
 tinuance of the treatment, but that these complications are new 
 sources of indications ? From the point of view of preservation of 
 life or of general health they may take precedence of those arising 
 from the disease of the womb, they may even oblige the physician to 
 respect the uterine disease, as a sort of natural revulsive guaranteeing 
 the general health against the rapid and disastrous evolution of the 
 coexisting disease. This may be the case where pulmonary tubercu- 
 losis is coincident with leucorrhoea or uterine ulceration. It is often 
 imprudent to insist on the cure of uterine diseases in phthisical 
 patients. If it is wise, as Bennet^ says, to modify uterine symptoms 
 when they become oppressive, we must respect the kind of equilibrium 
 established between the uterine affection and pulmonary phthisis when 
 the symptoms are bearable ; all the more so as in these cases the use 
 of energetic means is not always without danger. We must remember 
 in this case, as in that also of haemorrhoids, rectal fistula, gouty 
 deposits in the small articulations, &c., that there are diseases which it 
 is dangerous to cure ;^ and that the aphorism of Hippocrates^ is 
 equally true with reference to diseases as to treatment : — "Aug wovwv 
 ajua yivofxevwv fii] Kara tov avrov tottov, 6 (r^ocpoTepog afiavpoi 
 
 TOV tTSpOV. 
 
 METHODS OF TREATMENT AND VARIOUS MEDICATIONS IN UTERINE 
 
 DISEASES. 
 
 Having enumerated the indications, the question arises, what 
 method should be employed in the treatment of uterine diseases, and 
 what medicatiotis wiU suitably fulfil the indications for this treatment ? 
 
 The ?nedicatioti is the direct answer to the indication : it is an 
 impression produced on the organs by a means or the association of 
 several means, and intended to modify the economy in one sense or 
 
 ' Bulletin general de therapeutique, t. Ixix, p. 49. Paris, 1865. 
 ^ Raymond de Mai-seille, Traite des maladies qu'il est dangereiuc de guerir. 
 Paris, 1816. 
 
 ^ Section 2, aphorism, 46. 
 
METHODS OF TREATMENT AND MEDICATIONS 161 
 
 another. The method is the order to be followed in the use of the 
 medications, and of the means by which they are carried out : it is 
 simply a help which we give nature when she tends towards cure; or 
 a way indicated to her, an impulse given to her from different points 
 all directed to one end; or a rule imposed on her without apparent 
 reason, but which experience has proved to be wise. 
 
 Methods of treatment according to Barthez ^ may be divided into 
 natural, analytical, and empirical. It is needless to say that we can 
 seldom in the treatment of uterine maladies limit ourselves to natural 
 methods, because these diseases rarely have any tendency to sponta- 
 neous cure. On the contrary^ we must often have recourse to analy- 
 tical methods ; for these diseases are usually the product of one or 
 more elements of one or more essential affections, and of several 
 simpler diseases existing as complications. They are almost always 
 complex ; at least they are complicated with all the morbid conditions 
 consequent on the special structure and functions of the womb. 
 Therefore we must simultaneously treat the diathetic affection, which 
 often gives to the disease its character, and the morbid processes which 
 give to it its form or which determine its exacerbations, its relapses 
 and its chronic nature, or sometimes the simple disorders of men- 
 struation which keep it up or increase it. In this way inflammation, 
 engorgement, hypertrophy, granulations, ulcers, necessitate the use of 
 certain means, at the same time that the diathesis is treated by an 
 appropriate medication. Haemorrhage, congestion, simple fluxion are 
 treated as they arise according to their relative importance ; e.g. if 
 fluxion is defective, the use of attractives is indicated ; if excessive, 
 then depletion or derivatives are indicated. Lastly, we must some- 
 times have recourse to empirical methods ; for the disease, even when 
 capable of being analysed, may resist the ordinary means of treatment, 
 showing no tendency to be cured, or it may be kept up by a specific 
 affection the cure of which can only be effected by a specific medicine 
 which experience has pr'oved to be efficacious. This happens in many 
 chronic diseases, especially when neuroses or local indolent engorge'- 
 ment predominate ; in such a case an acute attack may bring about a 
 change which may become the starting-point of a favorable impetus 
 towards cure. 
 
 Medications. — The methods of treatment suitable to uterine diseases 
 having been determined, we must carry out the treatment in the order 
 indicated by the use of the general and local means at our dis- 
 posal. Here also we find a medium between the method and treat- 
 ment. Every means of treatment produces several results, some- 
 times the one, sometimes the other, successively or simultaneously; 
 on the other hand, the association of several means may be necessary 
 to produce a single impression on the economy, just as the concur- 
 rence of several processes is necessary to accomplish a single function. 
 The means therefore cannot be applied directly without an inter- 
 mediary in answer to the indication. 
 
 ' Preface du Traite des maladies goutteuses, 1819 ; V., Nouveaux Mements 
 de la science de I'homme, &c., 3', ed., t. ii, p. 282. Paris, 1858. 
 
 11 
 
162 TREATMENT OF UTEEINE DISEASES IN GENERAL 
 
 The association of various general and local means constitutes 
 a medication : and it is by the help of medications that we respond 
 to the indications. The true answer to the indication is not the 
 medicine but the medication or medications. One or several medica- 
 tions answer to one or several indications. Sometimes a single medi- 
 cation suffices for one indication^ but it may include several medicines 
 or kinds of medicines. Sometimes two or more medications must be 
 associated to respond successively or simultaneously to two or more 
 indications. The distinction is so essential between medicines, i. e. 
 the means and methods of treatment, and medications, i. e. the manner 
 of responding to an indication by the effect which such remedies pro- 
 duce, that it is as impossible to group these medicines by medications as 
 by indications. The combination of several means is necessary for one 
 medication, and^ on the other hand, the same means may serve in several 
 medications or may carry out several indications at the same time. 
 Bleeding, for example, is a depletive, derivative, revulsive, debilitant ; 
 purgatives are not only evacuants, they are derivatives, revulsives, 
 resolvents ; hydropathy is at the same time sedative, tonic and revul- 
 sive ; vaginal irrigation may be refrigerant, sedative, astringent, &c. 
 The same medication makes use of various means according to the 
 case ; thus, resolvent medication utilises evacuants, revulsives, altera- 
 tives, hydropathy, starvation, &c. ; the choice depends on the patients, 
 on the disease, on the constitution, on the remedies at our disposal. 
 We must therefore postpone reviewing the means to be employed in 
 the treatment of uterine diseases, contenting ourselves with grouping 
 them according to their natural affinities. As for the medications, 
 they are arranged naturally like the indications to which they are 
 intended to respond. When I set out in quest of the indications I 
 simply followed the order we adopt in practice to discover them and 
 to determine the disease, and by enumerating successively their different 
 sources I showed how they arise. But the indications, when once 
 found, ought to arrange themselves in our mind according to their 
 various degrees of importance, according as they are common or 
 special, local or general, major or minor, primary or accessory. 
 The medications respond so directly to them with regard to the cura- 
 tive effects which we hope to obtain from them, that we cannot but 
 arrange them in this essentially therapeutical order. There is the 
 same difference between the order in which the indications present 
 themselves and that in which the medications appear, as between the 
 way of making a diagnosis and that of instituting a treatment. There- 
 fore I distinguish between common and special medications. 
 
 Common medications are those which respond to common indica- 
 tions, i. e. indications which may arise in every uterine disease. I 
 have already said that the various processes which go to make up men- 
 struation are almost invariably sources of indication in uterine patho- 
 logy. By their simple presence, by their absence, excess, derangement, 
 by the pains accompanying them, they may of themselves constitute 
 morbid states, and in the majority of cases be added to the disease as 
 cause, effect, or complication; or they may hinder the treatment or 
 
METHODS OF TEEATMENT AND MEDICATIONS 163 
 
 retard the cure indefinitely. "We must be able to increase or diminish 
 the flow, dissipate the congestion, relieve the vascular system, or 
 deviate the blood which flows towards the organ by directing it to- 
 wards a distant organ. To each of these indications there is a corres- 
 ponding medication, attractive, depletive or evacuant, derivative, 
 revulsive. Sometimes we wish to attract the sanguineous flow to- 
 wards the uterus by the help of rubefacients, vesicants, leeches to the 
 labia, groin, anus, or cervix , by hot, aromatic, or mustard foot-baths 
 or sitz-baths, by stimulating purgatives, enemata, or suppositories, 
 by hydropathy, electricity, &c. At other times we empty the uterine 
 vascular system by leeches to the cervix, scarification, cupping, pur- 
 gatives, &c. Sometimes in cases of fluxion and congestion we deviate, 
 i. e. derive the blood, by applying leeches or blisters to the groins, 
 hypogastrium, or loins, or we may cup. Sometimes we turn away or 
 divert this current and the movement which produces it by blood- 
 letting from the arm, cupping the breasts, administering a purgative, or 
 even an emetic, or by directing the fluxion to the surface of the whole 
 body by means of vapour baths and other hydropathic operations, &c. 
 I will explain afterwards that it is not enough to be able to use these 
 medications ; we must learn how to apply them opportunely. 
 
 Special medications correspond to indications which do not occur 
 in every case, but which vary according to the nature of the afl'ection, 
 the pathological form assumed, and the organic alteration produced by 
 it. Some are local. Por example, medication consisting of appli- 
 ances which are reducing and supporting, for the treatment of dis- 
 placements, deviations, &c. ; atrophic or hypertrophic in cases of 
 uterine hypertrophy or atrophy; substitutive and modificatory in 
 cases of superficial alterations of vitality and fluxion, of granula- 
 tions or ulcers; destructive by the knife, caustics or fire, in cases 
 of more profound organic alterations, or considerable tumefaction, or 
 formation of new elements and of homeomorphous or heteromor- 
 phous tumours. Other medications are general, or both general and 
 local : antiphlogistic, directed against inflammation, no matter where 
 the seat or what the extent may be ; resolvent, with which the atrophic 
 medication is often associated, against engorgement or other causes 
 of permanent increase of volume ; anti-diathetic, whether simply altera- 
 tive or specific, against general aff'ections, the localisation of which 
 keeps up the morbid state ; sedative and narcotic, against pain, 
 whether it be an essential element or a complication; antispasmodic, 
 against spasm and nervous erethism; tonic, against weakness, want of 
 tone, and strength ; restorative, against digestive troubles, disorders of 
 nutrition, impoverishment of blood, chlorosis, &c. 
 
 Opportuneness of treatment. — This is another great principle in 
 general therapeutics, which is specially applicable to uterine diseases. 
 A brief explanation of it will form the natural connecting link between 
 the enumeration which I have just made of the principal medications 
 used in uterine therapeutics and that which I am about to five of th 
 
 &' 
 
 16 
 
 means by which we realise these medications. In the cure of uterine 
 diseases, next to precision of diagnosis, opportuneness of treatment 
 
164 TREATMENT OF UTEEINE DISEASES IN GENEEAL 
 
 is the best guarantee of success. The treatment, medication and 
 means must all be employed at the right moment. Treatment may be 
 useless in a few cases, indispensable in almost all^ but hurtful at one 
 time, beneficial at another. It is the same with medication and the 
 means employed. Very often the same end may be reached by 
 several medications, the same medication by several medicines and 
 means ; in short, there are different ways of treating a patient. There 
 is opportuneness with regard to the disease, the medication and the 
 means, but especially with regard to the patient ; for the various 
 parts of the economy are not in a good condition, the constitution is 
 often enfeebled, the blood impoverished, the nervous system affected, 
 all the functions languid. 
 
 I cannot too carefully impress on my readers the necessity of exam- 
 ining all the organs attentively. It is not enough to examine a patient 
 for purposes of diagnosis; we must also examine with reference to 
 treatment. By carefully investigating the various functions, systems 
 and organs, we sometimes had disorder where we least expected it. But 
 that is not all. In treating disease it is necessary to make an impres- 
 sion on certain organs by means of medicines. Only there are different 
 ways of producing this impression, different means of arriving at the 
 same end. True art consists in being able to choose the best, the one 
 most appropriate not only to the disease, but to the patient. That is 
 why we must interrogate every function, examine every organ to learn 
 if we can and should act on the stomach, the intestines, the kidneys, 
 the skin, &c. How often after having made a careful examination do 
 we find another disease counter-indicating treatment ! How often 
 do we find the condition of certain organs such that treatment would 
 do more harm than the disease ! Supposing, however, that the patient 
 bears the treatment, and that it is applied at the right time, it is not 
 enough unless the medication and the means are used opportunely. It 
 is of more importance to be able to seize the opportune moment in 
 treating uterine than other diseases. The recurrence of menstruation 
 introduces such important changes into the condition of the organ, 
 that we must not only suspend the usual treatment during the whole 
 of the monthly period, but we must utilise this time by employing new 
 means, which are only efficacious when used at the right moment. I 
 have seen many patients who had undergone treatment which they 
 assured me had aggravated their disease, and yet the very same means 
 were most successful when used by me at an opportune time. 
 
 Let us take an example. One of the means which gives the most 
 marked and rapid relief in the treatment of uterine disease is the appli- 
 cation of leeches to the cervix. Struck by my success, all my pupils 
 have adopted this practice ; but sometimes I have been called on to 
 rectify their error, and to repair the troublesome consequences of 
 treatment clearly enough indicated, but inopportunely or insufficiently 
 carried out. This practice, though less frequently adopted than it 
 deserves to be, is yet common enough to have allowed me to see a 
 certain number of patients from different parts of Europe who had 
 undergone this little operation in their own country. With several I 
 
METHODS OF TREATMENT AND MEDICATIONS 165 
 
 have been obliged to have recourse again to the same means, and 
 sometimes have had considerable difficulty in overcoming the opposi- 
 tion of my patients, who remembered that a previous application had 
 increased their pain and all other symptoms, and had even developed 
 new troubles. It is very easy to explain these differences, and I have 
 laid down rules calculated, I hope, to prevent accidents resulting from 
 an inopportune application of leeches, whilst retaining so valuable an 
 agent in uterine therapeutics. Leeches may be applied to the cervix 
 during any part of the intermenstrual period, with the exception of the 
 last week, provided they draw a sufficient quantity of blood. If not, 
 they must be applied again and again if necessary, because after an 
 insufficient flow of blood we always see an aggravation of symptoms, 
 especially of pain. The reason is this : — The suction of the leeches 
 has determined a flow of blood towards the organ which has not been 
 evacuated. The vascular system is more gorged than before, hence 
 the marked aggravation of all the symptoms and of the disease itself. 
 The only remedy is to make a fresh application of leeches, and if re^ 
 quisite another, till an abundant hsemorrhage has caused depletion of 
 the blood-vessels. Leeching the cervix during the week preceding 
 menstruation may be indicated by the absence or insufficiency of the 
 fluxionary movement accompanying the recurrence of the monthly 
 period. In this case it acts as an attractive inducing fluxion towards 
 the uterus. As this indication, however, generally occurs in young 
 girls, and as it can be responded to almost as well by leeching the 
 groins or the labia, this latter operation should be preferred. If, how- 
 ever, we have to do with another disease, metritis for example, or 
 uterine congestion, for which the application of leeches to the cervix 
 is clearly indicated (as a depletive, not as an attractive), we must 
 beware of making the application during the days which precede men- 
 struation^ especially if we have to do with a hsemorrhagic congestion. 
 The flow of blood towards the uterus commences a few days before the 
 periodical discharge takes place. The organ, under the influence of 
 this continuous fluxion, becomes gradually congested, and this con- 
 gestion produces disease if the natural haemorrhage, which is the crisis 
 and the third act of this morbid drama, does not arrive in time or is 
 insufficient. If, then, the organ is suffering from simple congestion or 
 an inflammatory condition or is the seat of haemorrhages which, in 
 place of relieving, add to the morbid condition, it is evident that the 
 application of leeches will only increase pre-menstrual congestion and 
 consequently all the accidents produced by the pathological congestion 
 or inflammation. The natural congestion preparatory to menstruation 
 is of itself a troublesome occurrence, and we know that in the majority 
 of uterine diseases the return of the monthly period is coincident with 
 the return and aggravation of all the princi|)al accidents. What then 
 will happen if this natural congestion is increased by the application 
 of leeches, which will add to the usual afflux of blood preceding men- 
 struation ? Even if the flow of blood were to be abundant it would 
 not prevent the pre-menstrual congestion from being increased and all 
 the symptoms from being aggravated, because it would come too soon 
 
166 TEEATMENT OP UTERINE DISEASES IN GENERAL 
 
 to be the crisis^ and would not prevent menstruation from taking place 
 at the usual time, within a few days of the application of leeches ; nor 
 could it prevent the manifestation of all the usual symptoms, intensified 
 in consequence of the attraction which has been followed by insufficient 
 or useless depletion. 
 
 These theoretical explanations are only the deduction of facts 
 learned by observation, for I have seen serious accidents produced by 
 inopportune leeching. Therefore, as a general rule, the cervix ought 
 not to be leeched in the week preceding menstruation. 
 
 In the week following menstruation, on the contrary, the conditions 
 are quite different. The organ remains congested, especially if the 
 critical haemorrhage has been insufficient ; but the fluxion which has 
 preceded the hsemorrhage and determined the natural congestion has 
 been extinct for some days. Any depletion at that time will be 
 beneficial to the uterus. The suction of the leeches will not reawaken 
 the fluxionary movement which has just ceased, and which will only be 
 reproduced normally in a month. We can, therefore, without fear 
 apply leeches to the cervix at this time. If the flow of blood is in- 
 sufiicient it will not be followed on that account by any accident : the 
 organ will be soothed, though incompletely. If, on the contrary, it is 
 abundant and capable of causing disgorgement of the vessels of the 
 uterine system, the amelioration will be as complete as rapid, and the 
 effect produced will sometimes exceed all our expectations. To obtain 
 this result we must not fear to apply leeches again the following day 
 if the first application has been insufficientj and to follow it up by 
 purgatives, which are often found to be the necessary complement to 
 this method of depletion. Practice is rewarded by a success exceeding 
 the anticipations of theory. Therefore, as a general rule, the cervix 
 should be leeched the day following menstruation, or at latest during 
 the week following it. 
 
 What I have said as to the opportune application of leeches could 
 be said with regard to other means — douches, sitz-baths, irrigations, 
 purgatives, ergot, &c. But no example seemed to me so striking as 
 that of leeches, and I have so often seen the difference in the effects 
 produced by their application at different periods, that I cannot have 
 a doubt as to the importance of the time chosen to make use of this 
 and other means. 
 
 MEANS OF FULFILLING INDICATIONS IN THE TREATMENT OF 
 UTERINE DISEASES 
 
 It is not enough to state the general way of preparing and admin- 
 istering these means, the modus faciendi ; we must also determine the 
 manner and the time of employing each one of them under given 
 circumstances in order to realise the medication indicated. It is the 
 only way of successfully applying to other cases the means which have 
 answered in any given case. To know why these means have suc- 
 ceeded, is to know what medication they have realised and to what 
 
METHODS OF TREATMENT AND MEDICATIONS 167 
 
 indication this medication has responded. The means of fulfilling the 
 indications are general and local. 
 
 I. General Means 
 
 The general means are hygienic or medicinal. 
 
 1. The hygienic means are : posture, rest or exercise, regimen^ &c. 
 
 Itest is often indispensable. The postwe that ought to be adopted 
 by the patient is generally neglected unless the physician makes it his 
 business to give precise instructions with regard to this important 
 though small detail^ and sees that they are attended to. In serious 
 cases, always in acute and often in chronic diseases, the patient ought 
 to remain in bed. She should lie horizontally, the pelvis on a level 
 with the shoulders or higher, the head resting on a pillow, the legs 
 and thighs flexed and supported by pillows under the thighs ; in short 
 the muscles relaxed by semiflexion. The bed ought to be hard so that 
 the pelvis does not sink in it; if the mattress is not of hair it is well to 
 put a hair pillow under the pelvis. Spring mattresses combine resist- 
 ance with elasticity. Feather beds must be forbidden absolutely. 
 
 This prescription is indispensable, not only in acute diseases when 
 the patient feels the necessity of rest and semi-flexion, but in all cases 
 of haemorrhage whether occurring at the menstrual period or not, and 
 in several chronic maladies, especially where there is a risk of hsemor- 
 rhage, as in polypi, fibromata, &c. ; or in inflammatory cases, as in 
 ovaritis, metritis, &c., absolute rest in the position of semi-flexion and 
 on the back, are often the most important elements of success. In 
 certain cases^ e.ff. retroflexion, the contrary position, i.e. pronation, 
 must be prescribed. 
 
 When the disease is chronic, it is not generally necessary to confine 
 the patient to bed. She may be on the sofa during the day if she 
 takes care (when necessary) to keep in the position 1 have just indi- 
 cated. In spite of the great importance which I attach to rest, I do 
 not agree with Lisfranc and his school, in thinking it ought to be 
 invariably prescribed in chronic diseases. Absolute rest for any 
 length of time, especially in bed, is weakening and leads to loss of 
 appetite and impoverishment of blood which play so important a part 
 in the existence of uterine disease. 
 
 We must therefore recommend exercise in these cases ; but the 
 exercise must be moderate, in proportion to the strength of the 
 patient, and of a kind not likely to excite pain. Therefore we must 
 sometimes content ourselves with carriage exercise on a smooth flat 
 road, making the horses if necessary walk, the patient lying in the 
 carriage and being protected from shaking by air-cushions. When 
 the patient can take active exercise without suffering it is much 
 better; in such cases she should be advised to walk, taking the pre- 
 caution to choose a smooth road and stopping as soon as she feels any 
 pain. She should gradually increase the length of her walks, but it is 
 better to take several short ones than one that is too long, and she 
 ought to lie down immediately afterwards. A hypogastric belt is 
 often of great use by supporting the weight of the abdominal viscera 
 
168 TEEATMENT OF UTEEINE DISEASES IN GENERAL 
 
 and so preventing pain when walking or standing. Sitting is some- 
 times very injurious, as it has a tendency to cause pelvic congestion. 
 When patients are obliged to sit, they ought to choose a hard seat or 
 an air or water cushion, which should be flat. Those which are 
 excavated in the centre are injurious to women suffering from uterine 
 diseases or from hsemorrhoids. They spare the patient the pain 
 caused by direct pressure on the hsemorrhoids or on the uterus ; but 
 they congest the anus and lower part of the rectum, by the circular 
 pressure exercised on the seat. 
 
 The physician ought to prescribe the physiological rest of the organ 
 in addition to the mechanical rest. This rest is indispensable not only 
 in acute cases but in the great majority of other diseases. Engorge- 
 ments, deviations, prolapsus, do not always counter-indicate sexual 
 intercourse. But whenever there is pain or fluxion, inflammation, 
 haemorrhage, or a great tendency to the recurrence of any one of these 
 morbid elements, coitus must be absolutely forbidden, and the patient 
 advised not to share her husband^s room. This rule cannot be too 
 strictly enforced ; unfortunately, it is too often infringed as relapses 
 testify. It is often difBcult to get our instructions carried out by the 
 poorer classes ; indeed, they are not always attended to by the rich. 
 In such cases it is well to advise patients of the former class to go to 
 a hospital, and those of the latter to go to a hydropathic estabhsh- 
 ment or to mineral waters when expedient, with the double object in 
 view of undergoing treatment and of being separated from their 
 husbands. When there is only engorgement, congestion, or general 
 symptoms without local inflammation and a long time is required to 
 complete the cure, intercourse ought to be allowed at distant intervals, 
 for there are patients of a passionate nature for whom it is necessary. 
 Only I advise them, as I advise men affected by diseases of the pros- 
 tate, to accomplish the act quickly. Unsatisfied erotic desires which 
 keep up a fluxion, a nervous excitement, a persistent orgasm, are 
 infinitely more injurious than coitus when quickly performed. It is 
 therefore better in some cases to submit to the inconveniences of con- 
 jugal relationship than to enforce abstinence ; but it must be on con- 
 dition that the patient is spared the fatigue of a prolonged state of 
 erethism. 
 
 Coitus may have to be forbidden for another reason : in order to 
 avoid the possibility of pregnancy, which occasionally though rarely 
 occurs before a cure has been obtained. If the physician considers 
 that pregnancy will have an unfavorable influence on his patient he 
 has no other course to take. 
 
 The regimen in acute uterine diseases is the same as in all acute 
 diseases. In chronic uterine diseases, atony, impoverishment of blood, 
 debility of constitution, indicate the necessity of tonics and restora- 
 tives. The best tonic is a good regimen; the best restorative 
 generous diet. We must therefore prescribe roast meat, green veget- 
 ables, ripe fruit, wine, &c. Parinaceous food must be forbidden, but 
 green vegetables and fruit allowed to prevent constipation. When 
 the state of the digestive functions will not allow the use of beef and 
 
METHODS OF TREATMENT AND MEDICATIONS 169 
 
 mutton, we must content ourselves with white meat, chocolate and 
 milk. I often prescribe partial milk diet to patients whose digestive 
 mucous membrane is in an irritable state : in such cases the milk 
 should be drunk warm and taken from the same cow or goat, which 
 ought to get from half an ounce to an ounce of salt or iodide of 
 potassium daily. If there is difficulty in digesting the milk it may be 
 mixed with lime water or a little Vichy water or soda-water. Milk 
 and water in equal proportions answers as a laxative with some 
 women. There are various ways of improving the appetite and diges- 
 tion, preventing constipation, &c., without having recourse to medi- 
 cines, to which I will afterwards refer when treating of tonics and 
 restoratives. 
 
 We must also pay attention to the clothing, dwelling and climate. 
 It is often desirable that flannel should be worn next the skin. Resi- 
 dence in a dry warm cKmate is very beneficial, especially to patients 
 who are accustomed to a damp cold climate. According to Donne,^ 
 M'ho lived long enough in Montpellier to be able to judge of the 
 climate, it is superior to any other town in France. I have seen a 
 considerable number of women affected by uterine diseases cured there, 
 who had been treated unsuccessfully elsewhere by physicians of high 
 reputation. I have often observed that the same means which had 
 been used in other latitudes without any beneficial results produced a 
 decided improvement after a few weeks' trial in Montpellier, and very 
 seldom more than one winter is required to effect a cure. 
 
 II. Tlie medicinal means are : bleeding, purgatives, hydropathy 
 (including mineral waters, baths of all kinds, with injections), resolvents, 
 tonics and restoratives, sedatives and irritants. 
 
 1. Bleeding may be practised by different methods — by the lancet, 
 by leeching, cupping or by scarification. It is depletive, derivative 
 or revulsive. General bleeding has been recommended by Lisfranc and 
 his school. Nonat still has recourse to this method frequently. It 
 is usually practised in the arm. Sometimes a considerable quantity of 
 blood is drawn — from eight to ten ounces — so that the operation may 
 have a depletive effect on the whole system. It is in such cases said 
 to be spoliative ; but more frequently a much less quantity is drawn — 
 five to six ounces ; it is then said to be revulsive. It is practised 
 immediately before menstruation to diminish the flow of blood towards 
 the uterus, or during menstruation or immediately afterwards, to divert 
 the flow in another direction. As a rule, I consider spoliative bleeding 
 as counter-indicated ; if it has the advantage of increasing absorption it 
 has the serious drawback of weakening the patient. On the other 
 hand, bleeding from the arm as a revulsive may be of great use in cases 
 of metrorrhagia, but especially in active menorrhagia; also in cases of 
 imminent or acute fluxion, or fluxion of long standing previously set 
 in motion by other means ; or of amenorrhcea, of vicarious menstrua- 
 tion with consequent congestion of other organs, such as the lungs. 
 It is very seldom that bleeding from the foot is indicated. This little 
 
 ^ Gonseils aux, families sur la nianicre d'elever les enfants, p. 300. Paris, 
 1864. 
 
170 TREATMENT OF UTERINE DISEASES IN GENERAL 
 
 operation only increases fluxion towards the uterus. It may, how- 
 ever, be indicated in cases of amenorrhoea with disordered menstrua- 
 tion, when the fluxionary movement is directed towards the head or 
 the chest. As an attractive it may be resorted to in place of leeching 
 the uterus or vulva. It may even act as a derivative of fluxion 
 localised on the uterus and previously diverted by local depletion. 
 This is, perhaps, the only case when it is indicated in uterine diseases. 
 Leeching and cupping are, on the contrary, often indicated. They may 
 be applied round the pelvis or close to the uterus, or to the cervix 
 itself. In the case of girls suflering from amenorrhcea, or when men- 
 struation has been suddenly suppressed by some physical or moral 
 excitement, they may be applied to the upper part of the thighs, to the 
 groins or to the labia. In this way fluxion is directed towards these 
 points and to the uterus, whose vascular system is in direct communica- 
 tion with that of those regions ; they play the part of a direct and 
 powerful attractive to the blood circulating in these vessels, and are 
 very efficacious. At other times, in applying them to these parts, 
 especially after having practised direct depletion of the uterine vessels, 
 we succeed in diverting the current of blood which is directed too in- 
 tensely or persistently towards the uterus. This derivative medication 
 is effected still more efficaciously in certain circumstances vrhen 
 applied to the hypogastrium, to the iliac regions or to the loins. In 
 some patients this application acts like a charm, intense pain disap- 
 pearing at once. In these cases cupping is preferable because more 
 powerful, especially in cases of ovaritis or of peritoneal or peri-uterine 
 inflammation. 
 
 But of all the modes of applying leeches the one I practise most 
 frequently and successfully, especially in cases of persistent and long- 
 standing congestion, chronic metritis, perimetritis, ovaritis, peri-uterine 
 hsematocele or pelvic inflammation, is that of applying them to the 
 cervix. It is the best way of practising local depletion, or of deter- 
 mining a derivation by means of the uterus and the community of 
 circulation existing between this organ, the Fallopian tubes and the 
 ovaries. Whether known to Zacutus Lusitanus and Nigrisoli of 
 Perrara, or not, the application of leeches to the cervix in our days 
 was introduced by Guilbert^ and adopted by Scanzoni and Aran. 
 During the many years that I have had recourse to this means it has 
 invariably produced good results. Only the slight difficulties attending 
 this little operation and the necessity of watching the results ought to 
 prevent the physician from delegating it to others. However, with a 
 little management on our part, this mode of applying leeches is not 
 more disagreeable than any other. The patient is placed on the edge 
 of the bed in the usual position for examination by speculum, the legs 
 close together and flexed. After the cervix has been discovered and 
 embraced by a long cylindrical speculum and the mucus carefully 
 removed we put seven medium-sized leeches in the instrument (a 
 larger number would not have room for sucking), directing them to 
 the uterus, where they are kept in place by a large plug of cotton 
 
 ^ Considerations pratiques sur certaines affections de I'uterus. Paris, 1826. 
 
METHODS OF TREATMENT AND MEDICATIONS 171 
 
 wopl^ pushed into the speculum to prevent their escape. "When that 
 is done a table or high chair may be brought for the patient to rest 
 her feet on, whilst she is entirely covered by her dress. The physi- 
 cian, however, must carefully hold the speculum pressed against the 
 cervix, never letting it go for one moment^ so as to prevent any of the 
 leeches from insinuating themselves between this instrument and the 
 vagina, and sucking the latter in place of the uterus, or escaping 
 altogether, as I have often seen happen. I have never seen pain caused 
 by the suction except when the cervix has been ulcerated or the os so 
 open as to allow the entrance of the leeches, or when it is the seat of 
 hypersesthesia and neuralgia, which not only prevent the extremity of 
 the sound from- being introduced, but will not even permit of the 
 uterus being touched by the finger (in these cases the pain caused by 
 the leeches may be excruciating, leading to hysteria or fainting). This 
 last case cannot always be foreseen, but in the first two cases it is easy 
 to prevent pain by placing a little cotton wool in the half-open os, and 
 by covering the ulcer with collodion. 
 
 The patient does not usually feel the leech-bites, but often expe- 
 riences a peculiar sensation when they suck with most activity, or 
 rather at the moment when, under the influence of suction, the blood 
 flows towards the cervix and commences to flow. It is a sensation of 
 dragging, of traction, which appears to be exercised from the hypo- 
 gastrium, iliac region or kidneys towards the vagina ; often the 
 starting-point of this sensation of suction is in the diseased organ, the 
 body of the uterus or the ovary, and specified exactly by patients. 
 About twenty minutes afterwards, and most frequently after the patient 
 has felt the peculiar sensation to which I have just referred, the blood 
 is seen to ooze out round the cotton wool. This must then be 
 removed and the speculum inclined downwards, so as to allow the clots 
 of blood to escape ; if we wait a quarter of an hour the leeches will 
 follow. We must count them, so as to be sure that none have re- 
 mained behind ; if necessary we must search for them with the forceps 
 at the bottom of the speculum, or after having withdrawn it we can 
 discover them with the finger in some corner of the vagina and bring 
 them out. The whole operation does not last more than half an 
 hour. 
 
 If the leeches have taken well and the sanguineous flow be sufficient 
 we shall see the cervix, which was swollen and dark red or purple, 
 become pale and diminish in size ; and the patient often at once expe- 
 riences an agreeable sensation of depletion ; sometimes she says that 
 the leeches have taken away her malady. 
 
 The haemorrhage generally lasts for some hours. The patient must, 
 therefore, stay in bed ; if the haemorrhage is too great, a plug of cotton 
 wool must be introduced into the vagina, which will moderate it by 
 causing coagulation, and the patient should be advised to lie on her 
 back, her legs together and flexed, and she should take some beef tea 
 to keep up her strength. The physician ought not to leave her without 
 being assured that the blood does not flow too abundantly. If the 
 haemorrhage is excessive, as is sometimes the case, we must have 
 
172 TEEATMENT OF UTERINE DISEASES IN GENERAL 
 
 recourse to vaginal injections of vinegar and cold water, and not leave 
 the patient till the haemorrhage is stopped. The surest way of doing 
 so is to introduce the speculum again, to pour a little water into 
 it so as to liquefy the blood, to remove the clots, find out from which 
 point the hsemorrhage comes, to introduce a tampon saturated with 
 a solution of perchloride of iron (1 in 30), and then plug. If, on 
 the contrary, the bleeding is insufficient, leeches must be applied 
 again the same evening or the next day, so as to obtain the requisite 
 depletion. 
 
 Scarification of the cervix may also be employed. Scanzoni^ and 
 Mayer have had scarificators made for this purpose. The ordinary 
 scarificator may be used, or a lancet may be employed by means of 
 Savage's uterine forceps. The scarifications must not be made too 
 deep for fear of wounding vessels of considerable size. But, as a rule, 
 the hsemorrhage obtained from scarification is insufficient, and leeches 
 have always seemed to me preferable. I make use of scarification 
 when it is necessary to deplete a large cervix before cauterising it. 
 The difficulty of obtaining a sufficient depletion by scarification of 
 the cervix led to the invention of a cupping glass suitable for this 
 organ, which induces a flow of blood from the little wounds made by 
 the scarificator. Collin invented an instrument of this kind which he 
 calls a uterine leech, and Simpson used a somewhat similar one. 
 
 I do not like to finish the history of bleeding without summing up 
 in a few words the medications which it reaUses and the indications 
 which it fulfils. In the first place it is evident that recourse ought 
 not to be had to bleeding except when the blood plays an important 
 part in the existence of a uterine disease, either in producing fluxions 
 by the impulse given to it, or in congesting the organ by the dis- 
 tension of its vessels, or lastly, in helping to keep up inflammation. It is 
 therefore evident that it can only be depletive, derivative, or revulsive. 
 With reference to it, therefore, we must follow the rules laid down 
 for the Methodic treatment of fluxions, and for the use of depletion, 
 derivation, and revulsion in general. In this respect, what I have to 
 say with regard to bleeding will be applicable to other evacuants, to 
 other derivatives, to other revulsives. 
 
 We cannot do better than take the treatise of Barthez on the 
 methodic treatment of fluxions2 for a guide whenever we have to apply 
 this great principle of general therapeutics to any special case. 
 Now, fluxion may be imminent, or recent, or fixed. On the other 
 hand, the inverse movements which we can produce on the blood, 
 on fluxion, or on congestion, by means of bleeding, evacuants, 
 blisters, attractives, hydropathy, &c., are depletion, which consists in 
 directly subtracting from too full an organ, derivation, which con- 
 sists in diverting in another direction, and before its arrival, the fluid 
 which would otherwise have been carried to this organ where it would 
 
 ^ Lehrhuch der Krankheiten der weiblichen sexual Organen, dritte Auflage. 
 Wien, 1863, p. 38. 
 
 ■•^ Nouveaux MUments de la science de I'liomnie, 3* edit., t. ii, p. 339. Paris, 
 1858. 
 
METHODS OF TREATMENT AND MEDICATIONS 173 
 
 have caused congestion, and revulsion, which turns aside the current of 
 this fluid in order to direct it towards, and if necessary to fix it in 
 another organ more or less distant, the organ which thus becomes 
 itself the seat of the fluxion relieving the other which has kept 
 
 Fig. 138. 
 
 Pig. 139. 
 
 Fig. 140. 
 
 Fig. 138. — Mayer's scarificator for the cervix. 
 
 Fig. 139. — Cupping-glass witli exhauster for the cervix. 
 
 Fig. 140. — Collin's uterine leech. 
 
 up the disease it is our business to cure. When fluxion is imminent, 
 revulsion in turning the course to quite a difl'erent point may prevent 
 its fixing itself on the organ which we wish to protect, e.g. bleeding 
 from the arm, emetics, dry cupping of the breasts, sinapisms on 
 
174 TEEATMENT OF UTEEINE DISEASES IK GENEEAL 
 
 the arms in the case of imminent uterine fluxion, whether congestive 
 or hgemorrhagic. When fluxion is fixed and has determined recent 
 congestion of the organ, the current of blood may be diverted in 
 another direction to a point more or less near the seat of congestion, 
 e. g. by leeching or cupping the vulva, anus, groins, hypogastrium, 
 loins, in case of recent uterine congestion following an excess of 
 fluxion with insufficient menstrual haemorrhage. When fluxion is 
 fixed and of long standing, and cure difficult owing to habit and to 
 the loss of reaction of the distended vessels, neither revulsion nor 
 derivation are eff'ectual. We must resort to evacuation or depletion 
 in order to diminish the excess of vascular fulness, e. g. by leecliing 
 the cervix in congestion and chronic metritis. I omit details given 
 by Bartliez, and will also avoid going into them myself in the way 
 of applying these fundamental principles to particular cases. But 
 there is one point which this great physician seems to me to have 
 neglected, and that is the necessity of associating revulsion or deri- 
 vation with depletion in cases of chronic congestion, and associating 
 them in an inverse order from that which we adopt when using them 
 against imminent or recent fluxion. In short, depletion alone will not 
 effect a cure ; it will remove the excess of fulness, but not the habit 
 of fluxion. The bad effect is only destroyed for the moment and 
 will soon be reproduced, for the cause remains. We must not there- 
 fore be satisfied with having emptied the excess of fulness : we 
 have not destroyed the fluxion, we have only mobilised it. We 
 must quickly take advantage of this circumstance to divert it by 
 derivation, directing it to another point by revulsion, doing it 
 thoroughly and during a sufficient length of time for the uterus to 
 lose the habit of being the seat of attraction to this fluxion. 
 
 In such cases we must almost always begin by leeching the cervix 
 once or twice ; but after the fluxion has been mobilised by this deple- 
 tion, and if necessary by another as a derivative, or by the appKcation 
 of a blister to the neighbouring parts, we must take advantage of this 
 mobility to uproot it, and by revulsion turn it aside in the direction of 
 other organs. A purgative given the day after an application of 
 leeches fulfils this indication perfectly in certain cases, and some 
 patients from this moment are cured, or think themselves so ; but in 
 most cases the disease is of too long standing to be so quickly uprooted ; 
 the action must be kept up by cutaneous and intestinal revulsions of 
 different kinds, especially by hydropathy, the best of all revulsives, 
 not neglecting tonics, sedatives, &c., nor local applications, which are 
 generally required to ensure success. 
 
 2. Evacuants or purgatives. — Purgatives are used with a twofold 
 aim : as a cure for constipation or as a revulsive. It is absolutely 
 essential to the success of treatment that constipation should be over- 
 come. Neglect in this matter is followed by increased suffering, dis- 
 tension of the belly, hypogastric pain, dull aching in the back and at 
 the anus, swelling of the epigastrium, headaches, &c. Eegularity of 
 the bowels is also necessary to keep up the appetite, prevent dys- 
 pepsia and increase nutrition ; in fact, it is one of the most important 
 
METHODS OP TREATMENT AND MEDICATIONS 175 
 
 points in the treatment of uterine diseases. It is best to begin with 
 simple enemata, cold rather than warm ; if these are not sufficient medi- 
 cinal enemata should be tried, laxative rather than purgative, a decoc- 
 tion of lettuce with four spoonfuls of olive or castor oil in an emulsion 
 of yolk of egg, or the same quantity of honey, manna, treacle, or gly- 
 cerine, in two or three glasses of water, with occasionally an infusion 
 of half an ounce of senna in two pints of water, &c. &c.; if necessary 
 three or four pints should be prescribed, the patient lying on her back 
 and using a thick and very long gutta-percha tube. A long tube is 
 of great service in allowing the enema to penetrate high up into the 
 intestine, and enabling the patient to retain it for a long time. Some- 
 times the uterus or a peri-uterine tumour presses on the rectum and 
 makes it as difficult for the enema to enter as for the faeces to be ex- 
 pelled. Enemata ought to determine a real evacuation of the bowels. 
 To secure this the long gutta-percha tube ought to be used, and the 
 enema should be laxative, cold or tepid, and copious. Attention must 
 also be paid to diet, which should be partly composed of brown bread, 
 milk, spinach, prunes, &c., and if necessary mild laxatives must be 
 taken in addition, such as whej', vegetable broth, magnesia, alone or 
 mixed with a little jalap or rhubarb, castor oil, &c. I often prescribe 
 equal parts of rhubarb and magnesia (enough to cover a sixpenny- 
 piece) in the first spoonful of soup, or a teaspoonful of castor oil in a 
 cup of acorn coffee. 
 
 To determine revulsion these means are not enough; purgatives 
 must be employed. I have already said that purgatives are generally 
 indicated after leeching the cervix; mild laxatives, frequently repeated, 
 are the best resolvents in chronic metritis and perimetritis. Drastics 
 ought to be avoided; scammony, jalap, aloes, gamboge, which make 
 up the pills so commonly used under the names of Anderson, Morrison, 
 Frank, Bontius, &c., have the disadvantage of congesting the lower 
 part of the intestine and the uterine system. It is only exceptionally 
 and in very small doses that I allow their use, and then not as pur- 
 gatives, but to prevent constipation. There is no danger in occa- 
 sionally giving a little podophyllin or gr. 1^ of aloes with gr. f of 
 rhubarb, so long as their use does not become habitual. But the best 
 purgatives are oils, salts or tonics. Of oils, half an ounce of castor 
 oil, alone or with the addition of one drop of croton oil, is quite 
 sufficient, especially if the patient has taken a laxative enema the 
 evening before. The salines most generally used are an ounce of 
 Glauber's or Epsom salts, Seidlitz, Hunyadi Janos, and other natural 
 purgative mineral waters. On account of the abundance of the serous 
 excretions which they determine they cause a revulsion very favorable 
 to the relief of the uterine system, and to the resolution of the diseased 
 organ ; it is a kind of white bleeding. If castor oil is counter-indicated 
 by the coated tongue, and saline purgatives by atony with tendency to 
 irritation, especially if there is a bilious condition which requires pur- 
 gation as an evacuant as well as a revulsive, rhubarb, senna, and tonic 
 purgatives generally may be resorted to. In such circumstajices I am 
 accustomed to give : — Infusion of coffee, one ounce ; senna and rhubarb. 
 
176 TREATMENT OF UTERINE DISEASES IN GENERAL 
 
 of each one sixth of an ounce ; aniseed, fifteen grains in half a pint of 
 water, adding two thirds of an ounce each of Epsom salts and manna. 
 In obstinate constipation, kept up by a nervous condition (a kind of 
 spasm of the intestine), and in the case of patients whose stomachs 
 cannot tolerate the purgatives just referred to, belladonna pills are very 
 successful (Sapon. Med., 5tj Pulv. Bellad., gr. viii ; Ext. Bellad., gr. 
 viii. Misce; divide in pil. 50. Sig. one pill every night at bedtime). 
 Sometimes gr. -^-ho or gr. -^ of strychnia may be added, or pills of 
 sulphate of zinc. Lastly, on rare occasions emetics may be indicated, 
 as a means of revulsion in fluxion or uterine haemorrhage, or as a means 
 of perturbation. In this case we may have recourse to antimony, 
 in the dose of |- to 1-|- grains, or to ipecac, 15 grains, paying atten- 
 tion, of course, to the indications and counter-indications to the use 
 of these medicines. 
 
 3. Batks — Injections — Hydropathy — Mineral Waters. — Under this 
 heading I include the use of water in every form. 
 
 A. — Hot or tepid baths are usually bad in the treatment of chronic 
 uterine diseases. They must not, however, be absolutely forbidden 
 because they have been abused. In acute inflammation with nervous 
 erethism of the uterus or neighbouring organs they soothe pain and 
 act as a sedative in a remarkable way, especially if used long enough 
 at a time, and rendered medicinal with bran, starch, hemlock, poppy- 
 heads, belladonna, &c. ; they should be taken hot, and vaginal irriga- 
 tion should be made the whole time. They act as sedative fomenta- 
 tions, and in certain chronic diseases, such as cancer, they form with 
 emolhent plasters the only treatment possible. 
 
 General tepid baths, whilst soothing in acute disease, are weaken- 
 ing, therefore they cannot be continued for long. Sitz-baths, at a 
 temperature beginning at 80° to 85° Eahr., and gradually lowered 
 every day, are often very useful taken for fifteen or twenty minutes at 
 a time. Cold baths are often more useful than hot. I do not mean 
 baths of a very low temperature; but in the majority of uterine 
 diseases it is well to take baths at a temperature below that of the 
 body ; the bath may be tepid when the patient enters it (if a reactive 
 effect is not required), the temperature being gradually reduced till it 
 is cool or even cold. I know nervous women who cannot take general 
 baths except at a temperature of from 10° to 15° below that of the 
 body, and who can remain for half an hour in the water. I speak 
 especially with reference to sitz-baths; if hot sitz-baths are open to 
 criticism, it is not the same with reference to cold ones, which ought 
 almost always to be accompanied by vaginal irrigations. 
 
 B. — Injections are internal local baths. Eew medicinal applications 
 have varied as much as these in composition, form, and mode of 
 administration. I think they may be turned to good account, but 
 on condition that we understand the effects produced better than has 
 hitherto been done. I will relate my experience on the subject, I 
 distinguish three ways of applying liquids to the vaginal cavity : 
 injection, lotion, irrigation. 
 
 a. Injection consists in the introduction of a liquid intended to 
 
METHODS OF TREATMENT AND MEDICATIONS 
 
 177 
 
 modify the vaginal mucous membrane in whole or in part, and in the 
 prolonged contact (of varying duration) of this liquid with the parts 
 on which it is to act. 
 
 When the physician wishes to obtain from an injection all that he 
 is entitled to hope from it, he ought to make it himself. An ordinary 
 syringe of medium size may be used if a straight uterine tube is affixed 
 to it. The patient should be on her back in the position described for 
 examination by speculum, care being taken that the pelvis be slightly 
 raised. Another way is to use an ordinary syringe, introducing the 
 tube into the vagina and holding it pressed against the vulva, adding 
 cotton so as to close the vaginal orifice. A third way consists in 
 using a gutta-percha syringe without a tube, the same size as the 
 penis or larger ; that is to say, exactly filling the vaginal orifice. The 
 extremity should be rounded and pierced with holes ; it should reach 
 the further end of the vagina, but in proportion as the piston is pushed 
 to expel the liquid, the syringe ought to be partially withdrawn to 
 make room for the injection, which can be retained in the vaginal 
 cavity as long as desirable by simply keeping the instrument in the 
 entrance of the vagina so as to close it. 
 
 h. Lotion is really washing the vaghial mucous membrane by the 
 repeated passing of a liquid over the whole extent of it. It is an 
 excellent way of cleansing not only the vaginal walls but the cervix. 
 It is generally, though incorrectly, called injection. Fortunately 
 patients can generally make use of this means themselves. Of all the 
 instruments for this purpose the one I prefer is the liydroclyse, because 
 
 Fig. 141. 
 
 Fig. 142. 
 
 Fig. 141.— Ricord's vaginal injection syringe. 
 
 Fig. 142.— Hydroclyse or small pump, for vagino-uterine lotions. 
 
 it can be put in any recipient, can be used for almost any kind of 
 liquid, and its mechanism is not easily put out of order. The patient 
 being seated on a bidet in which is the liquid for the lotion, places the 
 hydroclyse in the narrow part of the bidet, and slowly introduces the 
 straight tube^ well oiled, pushing it towards the back to the further 
 extremity of the vagina ; she then has only to pump for a few minutes 
 
 1 It is very important for patients to use straight tubes of a large diameter, 
 the advantages of which are detailed by Delioux de Savignac {Bulletin tie 
 ilUrapeutique, t. Ixxxv, p. 159). 
 
 12 
 
178 
 
 TEEATMENT OF UTERINE DISEASES IN GENEEAL 
 
 to secure that the whole of the liquid shall pass over the vagina several 
 times. Most frequently after a lotion of simple water or soap and 
 water, I order a medicinal one for ten or fifteen minutes, which then 
 acts as a good injection. Lotions are indispensable in all diseases 
 causing vaginal secretions; they often require to be made several 
 times a day. The temperature is variable. In acute inflammation of 
 the uterus or vagina, in cancer, and in certain cases of hypersesthesia, 
 the lotion ought to be tepid. In chronic inflammation, in leucorrhoea, 
 engorgement, hypertrophy, deviation, &c., it ought to be cold. The 
 nature of the injection also varies ; the most generally useful are soap, 
 carbolic acid, the alkaline carbonates, vinegar, alum, tannin, different 
 preparations of iron, especially permanganate of iron, aluminate of 
 iron, perchloride and peroxychloride of iron, &c. In using lotions the 
 two following precepts ought to be attended to : 1. Only use deter- 
 gents, astringents, cathartics ; caustics ought only to be employed as 
 injections or as direct applications. 2. See that the medicinal lotion is 
 preceded by one of pure water, which will cleanse the mucous surfaces 
 of the secretions which cover them. 
 
 c. Irrigation is nothing more than a prolonged lotion. It is an 
 internal bath given to the vagina, the cervix, and organs contained in 
 the pelvic cavity. Most frequently this internal bath may be given 
 
 simultaneously with a sitz or 
 general bath; in this case the 
 vaginal irrigator may be used, 
 but the hydroclyse is better. 
 
 This irrigation may be pro- 
 longed indefinitely, but ought 
 not to last less than from a 
 quarter to half an hour, and it 
 ought to be repeated twice ; but 
 I have often been obliged to 
 continue it for several hours and 
 to renew it after a short interval, 
 in order that patients may derive 
 the full benefit from a means 
 the skilful use of which can 
 produce most beneficial results. 
 Such continuous irrigation, after 
 cauterisation or any other trau- 
 matic lesion, is an excellent way 
 of producing a sedative efi'ect on the uterus and uterine system, and 
 of preventing a fluxionary movement. 
 
 When the patient is confined to bed the double vaginal irrigator 
 must be used. This ingenious apparatus allows of the cervix and 
 vagina being kept constantly bathed for several hours by a liquid at a 
 fixed temperature, without the bed or dress of the patient getting wet. 
 The pipe which brings the liquid terminates in a tube which discharges 
 it near the cervix. The pipe which carries the liquid away takes it up 
 near the vulval orifice, letting it simply run into a bucket placed near 
 
 FiQ. 143. — Vaginal irrisfator. 
 
METHODS OF TREATMENT AND MEDICATIONS 
 
 179 
 
 the bed. Both tubes open into the vagina, the orifice of which must 
 be perfectly closed or the apparatus will not work. In Maissoneuve^s 
 instrument this is effected by the swelling of an air pessary. In Aran's 
 it is managed simply by a metaUic plate from the surface of which a 
 metallic cone arises enclosing the two tubes. 
 
 Fig. 145 
 
 Fig- 144. 
 
 Fig. 146. 
 
 Fig. 144. — Maisonneuve's double vaginal irrigator. 
 Fig. 145. — Vulvo-vaginal extremity of Aran's double irrigator. 
 Fig. 146. — Leroy's double canule pessary which can be used as a tube for the 
 double vaginal inigator. 
 
 c. — Kydropathy is one of the most powerful means in the treatment 
 of uterine diseases. It comes to the aid of so many medications, 
 sedation, tonification, revulsion, resolution, without enumerating 
 others. Unfortunately it is often used blindly. Hot and tepid baths 
 have been abused as well as bleeding, rest, &c. Probably it will be 
 the same with cold water. By the side of patients who have been 
 completely cured, are there not others who have been victims to 
 hydropathy which has been made fashionable by empirical success and 
 recommended too indiscriminately in the works of some skilful phy- 
 sicians ? If we would enable hydropathy to render great services in 
 the treatment of uterine diseases (and it can render great services), we 
 must determine the nature of these services, at the same time pointing 
 out the cases in which it may be injurious, for it is a two-edged 
 instrument. 
 
 Cold water is efficacious in uterine diseases as in all chronic dis- 
 eases, even in inflammations, but under certain conditions : for 
 example, if acute attacks have ceased; if the hydropathy be employed 
 according to the strength of the patient, according to her sensitive- 
 ness, and to that of her womb ; if reaction be deteriikined in different 
 ways to suit different patients, by walking or other exercise, moist or 
 dry heat, friction, &c., according to general strength and to the 
 
180 TREATMENT OF UTERINE DISEASES IN GENERAL 
 
 special susceptibility of diseased organs, for sometimes the slightest 
 exercise is followed by inflammatory attacks. 
 
 Physicians who are at the head of hydropathic establishments must 
 always remember that cold water, like any other medicine, must be 
 variously applied, the modes of reaction modified, and the whole 
 system of treatment suited to the patient and to the disease. The 
 chief aim of hydropathy is the cooling and the return of heat to the 
 skin, the impression made on the organism and the reaction of the 
 latter, concentration and expansion. Cold water and hot air : these 
 are, according to Tleury,^ the bases of hydropathy. These alternations 
 of concentration and reaction are effected by means of cold water, i.e. by 
 an agent which strengthens the economy without exciting it, and which 
 acts on the organ which has the greatest extent of surface, i.e. the 
 skin, at the same time that it stimulates the functional vitality and 
 energy of all the viscera. The result is, that a frequently repeated 
 natural revulsion is determined on the largest possible surface of the 
 body J and that it has a resolvent action like everything which stimu- 
 lates nutrition, repair and decomposition, absorption and excretion. 
 This treatment is pre-eminently tonic for the diseased organ as well as 
 for the whole economy, and constitutes a medication which Aran ^ has 
 designated by the original expression of remontement general. Lastly, 
 it may be made sedative in certain cases, by prolonging the impres- 
 sion of cold or moderating it so as to avoid reaction. Sometimes one 
 or other of these efl^ects is required from hydropathy, sometimes a 
 combination of all. Generally it is employed to terminate a cure 
 initiated by the use of other medicinal agents but which could not be 
 effected by them alone. 
 
 There are cases in which artificial sweating has to be resorted to, 
 when there is a difficulty of reaction in a patient, or when a powerful 
 cutaneous revulsion is necessary. Artificial sweating may be deter- 
 mined by vapour baths, by dry heat, or by wet packs, during which 
 the patient should drink an infusion of lime-tree flowers with a few 
 drops of acetate of ammonia, and when sweating begins a glass of cold 
 water every quarter of an hour. This sweating may either precede or 
 follow refrigeration. This means has the drawback of weakening 
 patients ; but it is very powerful, and there are occasions when it is 
 most beneficial. The sudden impression of cold may be produced by 
 friction with a sponge soaked in cold water, a dripping sheet, wet 
 compresses, cold enemata, affusions, immersion in a bath, in a river or 
 in the sea ; by sitz- baths (which may be of running water), rain baths, 
 and douches of all kinds. The temperature of the latter ought to be 
 from 45° to 50° Pahr. 
 
 The majority of these means can be employed at home under the 
 direction of a physician. Great attention, however, must be paid in 
 making applications. I am accustomed to begin by prescribing dry 
 frictions : these frictions should be made morning and evening with a 
 
 ' TraiUinatiqueetraisonned'hydrotlierapie. Paris, 1'^ edit., 1852 ; 2eedit., 
 1857. 
 
 2 Op. cit., p. 261. 
 
METHODS OP TEBATMENT AND MEDICATIONS 181 
 
 piece of flannel, a hair glove, or better still a brush soaked in cam- 
 phorated ammonia, alcohol or tincture of bark. After a while this 
 maj be changed for cold sponging or the dripping sheet. A wet 
 compress may be used also. This is soaked in cold water, then 
 wrung out and wound round the pelvis with dry flannel and oil silk 
 over it; this is worn for eight or twelve hours without being changed. 
 They are very sedative, but should only be used in summer. Enemata 
 of cold water taken at bedtime and retained all night are also very 
 sedative and refreshing. By-and-by cold sitz-baths may be taken. 
 They are either merely revulsive or they become sedative according to 
 their duration. The temperature must not be too low, especially if 
 they are of running water, and care must be taken to elfect a good 
 reaction. 
 
 The most beneficial applications, however, are cold affusions and 
 douches ; in them refrigeration is combined with titillation or more or 
 less energetic percussion by means of which reaction is more certainly 
 produced. The douche may be given at home with a common garden 
 hose, or better still with a pump having an air reservoir like those of 
 Charriere or Mathieu, in which the force of projection exercises a 
 more efficient percussion. These douches ought to be general; seldom 
 local, on the sides, loins or hypogastrium ; never on the cervix nor into 
 the vagina. A single jet may be used, or it may be broken by a rose. 
 The latter is preferable as a rule. Patients ought to breathe freely 
 while being douched. In order to secure this, care should be taken 
 after having struck the feet with the column of water, to make it 
 mount upwards by the legs, pelvis and loins, where it should be kept 
 for a few seconds, then to diverge obliquely to the shoulders, first to one 
 side, then to the other, without striking the spine, which always 
 causes a feeling of sufl^ocation. The patient ought to move and rub 
 herself under the douche in order to facilitate the return of heat. It 
 is enough to have the douche once a day on rising, or during the day 
 three or four hours after a meal. It ought not to last more than a 
 minute at first; but may by degrees be prolonged to five minutes. In 
 order to make it effective, we must commence by determining heat to 
 the skin, by means of friction, sweating, or best of all by walking or 
 other exercise ; this is what is called action. When the body is well 
 warmed the patient gets her douche. Immediately afterwards she is 
 dried, rubbed, and then she walks again till she perspires ; this is what 
 is called reaction. 
 
 In hydropathic establishments there is the advantage of having 
 very strong douches, of being able to have two daily and to multiply 
 the means of action and reaction ; in short, of employing the whole 
 day in treatment of some kind. The continued regularity of the treat- 
 ment under a good doctor greatly hastens the resolvent effects of 
 hydropathy. Hot and cold douches may also be given alternately, 
 and often produce great effect. In many establishments treatment is 
 not even interrupted at the monthly periods, but it is more prudent to 
 do so for at least two or three days, and especially to discontinue cold 
 sitz-baths. Aran mentions a case in which serious accidents occurred 
 
182 TREATMENT OF UTERINE DISEASES IN GENERAL 
 
 because this precaution was not taken. Before terminating^ let me 
 repeat once more that hydropathy ought never to be employed in 
 cases of acute disease, nor even in chronic diseases which preserve an 
 acute character, nor in which inflammatory attacks are liable to occur; 
 these must be subdued by antiphlogistics, blood-letting, rest, general 
 baths, purgatives, &c. In short, we must not expect the impossible 
 from hydropathy, but it can do much; indeed, without it I 
 think it would be difficult to effect a cure in the majority of uterine 
 diseases. 
 
 D. Mineral Waters and Medicinal Baths — Mineral waters in baths, 
 irrigations, douches, as well as artificial mineral or medicinal baths, 
 produce excellent effects if applied opportunely and according to the 
 indication. We must remember that mineral waters vary greatly in 
 character ; some are resolvent, such as the alkaline waters of Yichy, 
 Andabre, Vals, Boulou j others are revulsive and slightly stimulating, 
 e.g. the sulphur waters of Luchon, Saint Sauveur, Cauterets, Vernet; 
 others tonic and more or less stimulating, e.g. the iron waters of 
 Lamalou, Sylvanes, the saline waters of Balaruc, sea-bathing, the 
 Bourbonne waters, &c.); lastly, some are sedative (Bigorre, Ussat, 
 Neris, &c.). 
 
 We must remember that these waters, besides possessing the pro- 
 perties just enumerated, have a specificity (if I may use the expression) 
 which makes them valuable in diathetic affections, impoverishment of 
 blood, dyspepsia, and all the general conditions on which uterine 
 disease is often dependent. We must be guided by these two 
 principles in choosing a watering place for our patients, remem- 
 bering that mineral waters may be even more prejudicial than 
 hydropathy if employed prematurely before acute symptoms are 
 extinct. 
 
 Sea-bathing produces very different effects according to the length 
 of the bath, the climate in which it is taken, the season of the year, 
 and the temperament of the patient. It may be tonic and stimulating, 
 or it may exercise a very energetic resolvent action on a scrofulous affec- 
 tion, or on swellings dependent thereon. An intense or prolonged 
 chill is to be avoided in women exhausted by a long uterine disease, as 
 well as in persons whose power of reaction is weak ; hence the inestim- 
 able value of the Mediterranean for delicate and enfeebled constitutions. 
 The body hardly cools in the water, and reaction is quick on coming 
 out of the sea into an atmosphere warmed by the rays of a burning 
 sun. The burning sand is also of great value in bringing back heat 
 to the extremities. The Atlantic is for the strong who can support 
 the cold, it gives them renewed strength ; the Mediterranean is for the 
 weak and chilly, for the lymphatic, for those who have neither strength 
 nor heat to lose.^ 
 
 The waters of Balaruc, Bourbonne, and other saline springs possess 
 
 the same qualities j they are purgative, they are also very efficacious 
 
 in the treatment of paralysis, especially of essential paralysis, as well as 
 
 of nervous hysterical paralysis. I have seen a case of paraplegia of 
 
 1 Uounc, op. cit., p. 317. Paris, 1864. 
 
METHODS or TEEATMENT AND MEDICATIONS 183 
 
 this kind in a young lady, which had lasted for two years, depriving 
 the legs, bladder and rectum of all power of contraction, completely 
 cured by the Balaruc waters. As a rule, however, saline waters are 
 too exciting, and therefore contra-indicated in the treatment of uterine 
 diseases. 
 
 On the other hand, we have the sedative waters of Bigorre, Assat 
 and Neris, which have a great reputation, and to which some physi- 
 cians send all their patients indiscriminately. They are absolutely 
 inert in the majority of uterine diseases, but they have a sedative 
 effect similar to that produced by a series of tepid baths of ordinary 
 water. 
 
 The alkaline waters of Yichy, Vals, Boulou, Andabre, Plombieres, 
 are perhaps those which produce the most satisfactory results. They 
 owe their success to the influence they have on digestive troubles and 
 to the resolvent action which they exercise on engorgements. I have 
 had some remarkable instances of success, especially in associating 
 them with hydropathy. Villemin^ has wisely pointed out that their 
 use is absolutely contra-indicated where inflammatory symptoms 
 exist. 
 
 The iron waters of Lamalou, Sylvanes, Schwalbach, Bussang, Oreza, 
 &c., are often of great service also in curing chloro-ansemia and dys- 
 pepsia; they enrich the blood and strengthen the constitution, but 
 sometimes have the drawback of being too exciting. The consider- 
 able amount of carbonic acid contained in the Lamalou waters deter- 
 mines a temporary hypereesthesia of the skin, which is afterwards 
 followed by the revulsive effect produced by the absorption of carbonic 
 acid, i. e. a marked sedation of the nervous system. 
 
 Lastly, the sulphur waters of Luchon, Saint Sauveur, Cauterets, 
 and especially Vernet, are indicated in women who are lymphatic, scrofu- 
 lous, leucorrhoeic and affected by catarrh or rheumatism. In addi- 
 tion to the sedative effects of some springs and the stimulating effects 
 of the great majority, they have a revulsive and resolvent action, by 
 which remarkable results are produced in a great number of patients, 
 as I can testify. Yernet is especially to be recommended ; it is habit- 
 able all the year, and hydropathy may be combined with the use of the 
 springs, which vary greatly in temperature and composition. 
 
 Medicinal haths are often useful in acute uterine diseases, or in very 
 painful chronic diseases, such as cancer, or in cases of great debility 
 associated with the lymphatic temperament. They are generally com- 
 posed of narcotic or sedative plants — poppy-heads, hemlock, belladonna, 
 henbane, aconite; or of emollient substances — linseed, bran, glue, 
 mallow ; or infusions of aromatic plants — lime-tree flowers, orange 
 leaves, thyme, lavender, rosemary, sage. 
 
 An aromatic bath is prepared by pouring boiling water over two 
 handfuls of aromatic herbs and covering the bath witii a blanket, the 
 patient waiting till the temperature is sufficiently low to allow of her 
 taking the bath comfortably. When aromatic herbs cannot be had 
 
 ^ De I'emploi des eaux de Vichy dans les affections chroniques de I'uterus, 
 pp. 126, 244. Paris, 1857. 
 
184 TEEATMENT OF UTERINE DISEASES IN GENERAL 
 
 they may be replaced by the preparation of Pannes. For emollient 
 baths_, from 4 to 16 ozs. of glue or starch is dissolved in water, or a 
 canvas bag containing 2 lbs. of bran is put in the bath, or a decoction 
 of mallow or linseed. For sedative baths a decoction made from 1 oz. 
 of the leaves of narcotic plants and poppy-heads mixed together 
 may be poured into the bath. For a sitz-bath with irrigation one 
 half or one third of the quantity required for a general bath is 
 sufficient. 
 
 Mineral baths may be prepared in many ways. I think the simplest 
 are the best : — 1 or 2 lbs. of common kitchen salt for saline baths ; 
 as much black soap or from 7 to 10 oz. of carbonate of soda for alka- 
 line baths; from 3 to 4 oz. of sulphide of potassium, previously dis- 
 solved in water, for sulphur baths. As for chalybeate baths, I think 
 Lambossy's recipe is the best : — Take five or six quart bottles filled 
 with vinegar, add three or four handfuls of iron filings to each; leave 
 them open and exposed to the air ; when the liquor has the taste of 
 ink it is ready for use. One bottle is enough for a bath. The iron 
 is left at the bottom of the bottle, which can be refilled with vinegar. 
 The same water may serve for several baths if an additional half 
 bottleful is used each time. 
 
 4. Resolvenfs, including all the agents used in the same medica- 
 tion, solvents, alteratives, and special stimulants, such as electricity, 
 are often indicated after antiphlogistics and bloodletting, and simulta- 
 neously with purgatives, baths, hydropathy or mineral waters. Dry 
 rubbing or with hartshorn, alcohol, bark or benzoin, hydropathy and 
 purgatives, are all powerful resolvents when wisely used, but not 
 sufficient of themselves to dissipate engorgement, hypertrophy, or the 
 remains of products of inflammation, especially when these morbid 
 states are kept up by the existence of a diathesis. In these cases 
 we must have recourse to resolvents, properly so called, and to anti- 
 diathetics. 
 
 One of the most powerful resolvents that can be used on account 
 of its antiphlogistic character is mercury ; it diminishes the plasticity 
 of the blood, increases the absorbing power of the lymphatic vessels 
 and stimulates reabsorption. I generally prescribe it on the abdomen 
 and groins. I add to the uuguentum hydrarg. one tenth of its weight 
 of extract of belladonna, an excellent sedative. In acute disease the 
 application is repeated every six hours, placing over it a large, hot 
 and very moist cataplasm. Another mode of application is to spread 
 a thick layer of this ointment on a piece of linen large enough to 
 cover the whole abdomen, and leave it there for three or four days, taking 
 care to cover it with a sheet of cotton wool and oil silk which keeps 
 the skin moist and conduces to the absorption of the ointment as well 
 as to the subduing of the inflammation ; the whole should be kept in 
 place by a bandage, or, better still, by a pair of knitted swimming 
 drawers. 
 
 ^. Ung. Hydrarg. 
 
 Ung. Simplic, aa 5! ; 
 
 Tinct. Opii, IT^v to x ; 
 
 Ext. Bellad., <rr. i to gr. f . 
 
METHODS OF TREATMENT AND MEDICATIONS 185 
 
 When the use of mercurial frictions is prolonged care must be taken 
 to prevent salivation by occasionally giving a glass of Seidlitz or Pullna 
 water and telling the patient to be particular to wash the mouth 
 
 Fig. 147. — Instrument for injecting ointment into the rectum. 
 
 frequently, adding a little carbolic acid, tincture of bark or guaiacum 
 to the water. She should also use a solution of chlorate of potash as 
 a gargle. One of the best preparations when mercury has to be given 
 internally is a pill containing | of a grain each of calomel, extract of 
 hemlock, extract of dulcamara and white soap; one to four 
 daily. 
 
 In diseases, however, which have become chronic, iodine and its 
 compounds are more frequently useful. Iodide of potassium taken 
 internally has a very powerful resolvent action. It is well to begin 
 with 1^ grains daily, which may be gradually increased to 45 grains, 
 and then diminished, the whole treatment lasting for about three 
 months. Sometimes it is better to give this medicine as an enema : — 
 Prom 3 to 30 grains of iodide of potassium with a few drops of lau- 
 danum or a little belladonna or chloral in from 1 to 3 ozs. of water. 
 Simpson^ used to prefer the bromide to the iodide because he con- 
 sidered it a sedative and tonic as well as a resolvent. The sedative 
 properties of this salt have induced all practitioners to adopt it.^ I 
 do not sj)eak of the other preparations of iodine, such as the tincture, 
 the iodide of iron, &c., which ' are less frequently used in these cases, 
 but which sometimes render great service, provided they are not contra- 
 indicated by the state of the digestive organs. As to the external use 
 of this drug, I sometimes paint different parts of the hypogastrium 
 and even the vagina and cervix with tincture of iodine, which acts as 
 a revulsive as well as a resolvent. Sometimes I prescribe frictions, to 
 be made in the evening, with an ointment composed of 
 
 ^. Ung. Simp., 3Ji ; 
 
 Plumb. lodid., gr. xlvj ; 
 Pot. lodid., gr. xxx, 
 
 or it may be applied in the same way as the mercurial ointment. 
 
 Preparations of gold are very useful when mercury and iodine are 
 contra-indicated. They are especially useful in cases of scrofulous 
 diathesis. I have used them with great success for several years ; 
 under their influence I have seen three ovarian cysts disappear, and 
 the development of two others arrested. Chloride of gold and sodium 
 
 1 Clinical Lectures on the Diseases of Women. London, 1872, p. 385. 
 - Giibler, De la puissance sedative clu bromure cle potassium, dsLws \e Bulletin 
 tjeneral de therapeutique, t. Ixvii, pp. 5, 49. Paris, 1861. 
 
186 TREATMENT OE UTEEINE DISEASES IN GENEEAL 
 
 is given by rubbing it into the tongue, beginning with gr. ^, and 
 gradually increasing the dose by an additional gr. ^^ every ten days 
 till gr. -jio is taken ; or it may be given in solution or in pills from 
 gr. J-o to gr. f daily. 
 
 I have also found arsenic of great benefit when the uterine disease 
 seemed to be under the influence of a herpetic diathesis. It improves 
 the condition of the blood and stimulates nutrition. I generally pre- 
 scribe a solution of gr. f of arseniate of sodium in 7 oz. of water, a 
 tablespoonful twice a day. The dose may be increased by adding gr. | 
 every week till 44- grains are taken in the week. 
 
 Alkaline or sulphur waters, tincture of colchicum^ and Bonjean's 
 dialysed preparations ought not to be neglected in cases of rheumatic 
 or gouty tendency; but the indication for the two latter drugs is much 
 less frequent than for the others. 
 
 Electricity may become a powerful resolvent by the special excite- 
 ment produced in the uterine tissue. 
 
 I must also mention ergot of rye, which may act, though in an in- 
 direct way, as a powerful resolvent on this organ. It causes contrac- 
 tions of the muscular tissue of the uterus. Owing to its special action 
 on the uterus, as well as to its haemostatic properties, it not only arrests 
 hsemorrhage, but it determines a continuous contraction of the organ, 
 which is transformed into an expulsive effort when a polypus or other 
 foreign body is contained in it, and into a resolvent action when this 
 contraction operates on the organ itself, on the liquids which engorge 
 itj or on the plastic elements interposed in its tissue, and which 
 increase its size and density. Ergotine may be used or ergot of rye 
 in powder in the same way as to induce delivery, but in smaller doses, 
 3^ to 7 grs. every day. 
 
 Lisfranc, Nonat, and others recomuuend abstinence or the gradual 
 diminution of food (the Arabic treatment), as stimulating the absorp- 
 tion of plastic products and promoting resolution. Nothing is more 
 logical, and I admit that there are cases where this treatment should 
 be resorted to. But these cases are very rare. The cura /amis requires 
 very great prudence on the part of the physician for two reasons : the 
 first is, that impoverishment of blood and debility of constitution 
 generally accompany chronic disease ; the second is, that whilst it is 
 true that the resolution of chronic phlegmasia is promoted in propor- 
 tion as the patient is weakened, we are also assisting the diathesis to 
 profit by the daily increasing debility of constitution to make fresh 
 inroads on the organism. 
 
 5. To7iics and restoratives are, on the contrary, absolutely indicated 
 in the majority of cases. We can even obtain from them some of the 
 beneficial effects of the cura famis, such as the diminution of the un- 
 healthy stoutness of some patients, at the same time that we improve 
 the condition of the blood and fibre, the tone of the muscles, the 
 strength and resistance of all the organs. A generous diet is the best 
 tonic; abstinence from farinaceous food and from milk, and almost 
 from bread, the constant use of roast meat with green vegetables and 
 fruit, associated with vapour baths, frictions, hydropathy, exercise and 
 
METHODS OF TREATMENT AND MEDICATIONS 187 
 
 alteratives will strengthen the constitution as well as determine the 
 resolution of hypertrophy or tumours formed by the plastic products 
 of chronic phlegmasia. In order to derive the full benefit of a 
 generous diet we must, as a rule, stimulate digestion and also give 
 medicines of a tonic character or which act on the blood, such as the 
 chalybeates. When digestion cannot be stimulated by a change to the 
 country or sea- side, by the action of mineral waters and hydropathy, 
 we must have recourse to anti-dyspeptic medicines. When the principal 
 agent of digestion is wanting, we must resort to pepsine, alone or 
 associated with diastase, lactate of soda (3 grains of each), morphia, 
 strychnia and bismuth taken immediately after meals, as recommended 
 by Corvisart.^ When the secretion of the gastric juice requires to be 
 stimulated we should give a bitter or aromatic infusion, a little ice or 
 alkalines ten minutes before meals, as advised by Blondlot,^ Corvisart,^ 
 and Longet.* The preparations which I have seen most successful in 
 this case are the following : — A wineglassful of Yichy water (Source 
 de I'Hopital), or a pinch of bicarbonate of soda in a little water, a 
 cupful of infusion of quassia, alone or with a little rhubarb, or a tea- 
 spoonful of absinth liqueur ; they should be taken ten minutes before 
 meals, and be varied from time to time. At other times I give one or 
 two of Gallard^s pills^ during meals. When there is nausea with ten- 
 dency to vomiting, natural or artificial effervescing drinks should be 
 taken at meal times — seltzer water or St. Galmier, Condillac, Vergeze, 
 or Lamalou water, &c. ; or the following powder may be prescribed in 
 a little orange-flower water : — Calumba root and calcium carb., each 
 gr. 3|^ with belladonna, gr. -5%. If one dose is insufficient a second 
 and a third may be taken at two hours'* interval. If the tone and re- 
 action of the stomach are defective, an infusion of bark mixed with 
 wine should be drunk at meals, or tar water, or the alkaline chalybeate 
 waters of Lamalou, Boulou, Yals, A^ichy (Celestin), Andabre, Bussaug, 
 Orezza, &c. ; or sometimes even cold sulphur waters, or artificial pre- 
 parations, simple iron water, carbonate of iron, or the peroxychloride 
 of iron. When there is habitual diarrhoea, Yichy water should be 
 taken before meals, and a large compress of flannel and oil silk should 
 be worn over the abdomen, or the abdomen may be rubbed with croton 
 oil. Small enemata, with a few drops of laudanum, are sometimes 
 useful, or chalk mixture, bismuth, &c. Lastly, morphia in solution 
 
 ' Sur la dysjospsie et la consomption et sur I'ushge de la pepsine. Pans, 
 1854. See also O. Eeveil, Formulaire raisonne des medicaments nouveaux et 
 des medications nouvelles, p. 92. Paris, 1864. 
 ' Traite analytique de la digestion. Paris, 1843. 
 
 3 De la secretion du sue gastrique sous Vinfluence directe des aliments, 
 des boissons et des medicatnents. Paris, 1857. 
 ■• Traite de plujsiologie, t. i, -p. 184. Pai-is, 1861. 
 * j^ Piperis, 
 
 Pulv. Myristic, aa gr. xv ; 
 Pulv. Cinnamon, 
 Pulv. Car^'ophylli, aa gr. xxx ; 
 Assafoitid., gr. Ix ; 
 Ext. Tarax, q. s. 
 Miscc, divide in pil. 50, silver. Sig. 1 or 2 at meal times. 
 
188 TREATMENT OF UTERINE DISEASES IN GENERAL 
 
 (I of a grain in 30 minims of laurel water), or laudanum, or tincture 
 of nux vomica, either of which may be taken in doses of from 
 1 to 6 drops, may be of great use in calming pain or exciting 
 contractions when pain or inertia of the stomach are the causes 
 of dyspepsia. 
 
 As for tonics properly so called, in cases of chloro-anaemia we must 
 have recourse to one of the numerous preparations of iron. One of 
 those I use most frequently is a modification of Biaud^s pills made by 
 my father: R. Mass. Pil. Blaud, gr. ijJ-; Pulv. Ehei, gr. |. M. 
 Pt. pil. 1 to 4 before each meal. This preparation of iron is soluble, 
 and the rhubarb prevents constipation. I often add valerian to the 
 pills. When we wish to associate a fattening ingredient with the iron, 
 cod-liver oil mixed with syrup of iodide of iron should be ordered. 
 
 Lastly, the various preparations of bark, alone or mixed with milk, 
 are excellent tonics and restoratives. 
 
 6. The importance of sedatives cannot be overrated with regard to 
 the various indications which they fulfil in the treatment of uterine 
 diseases. The element of pain is the one we have most frequently to 
 fight against, especially when localised in the uterus or in some nerve. 
 Local or general hypersesthesia, neuralgia of the uterus or of one of 
 the sensitive nerves, e.g. the sciatic nerves, the ilio-pubic, an inter- 
 costal, or a branch of the trifacial, are the most frequent manifestations 
 of pain ; they indicate tbe use of ansesthetics and anodynes. The 
 preparations of opium are the best narcotics ; they may be associated 
 with belladonna and given in various forms. In metritis itself, when 
 an element of excessive pain is added to the inflammation, opium 
 should be given internally, -f of a grain every four hours or every hour 
 if necessary, or -jV of a grain of hydrochlorate of morphia every six 
 hours till the pain ceases. Narcotics may be also administered in an 
 enema or bath. I prefer giving 15 or 30 drops of laudanum by 
 the rectum in an ounce of water to making a uterine application ; or 
 the groins may be rubbed with laudanum, or a suppository of opium 
 and belladonna may be introduced by the anus, or, better still, a 
 sedative pommade may be injected by means of the rectal syringe (fig. 
 147, p. 1S5). Sitz-baths are often of great use, made of a decoction of 
 60 grains each of benbane and belladonna leaves to 10 quarts of water. 
 Sometimes a cold sitz-bath with irrigation for several hours is sufficient 
 to cause the cessation of this excessive hypersesthesia, especially when 
 brought on by traumatism. Yarious sedatives may be appKed to the 
 cervix itself, belladonna, laudanum, &c. As to the application of cold, 
 chloroform, and carbonic acid, it is better to apply them to the hypo- 
 gastrium than to the cervix ; the first is followed by a painful reaction 
 and the two others induce congestion. 
 
 Subcutaneous injections of atropine, or hydrochlorate of morphia, or 
 even of chloroform, succeed wonderfully in neuralgia,^ and I always 
 advise their use if anodyne frictions have no effect. I know a lady 
 veho has given herself some hundreds in the iliac and crural regions to 
 
 1 Des injections narcotiques sous-cutanees dans le traitevient desnevralgies. 
 Montpellier medical, t. iii, p. 289, 1859. 
 
METHODS or TREATMENT AND MEDICATIONS 189 
 
 soothe the excruciating pain caused by compression of the crural nerve 
 by a fibroma of the broad ligament. They can be made in the hypo- 
 gastrium^ in the sides, thighs, &c. ; I do not think there is any advan- 
 tage in making them into the uterus. If the hquid is injected into 
 the uterine cavity, how can the dose be measured ? how can we know 
 that a single drop will be absorbed ? If it is injected into the tissue 
 itself the puncture causes a little haemorrhage, which carries away a 
 part of the solution with the blood. I confess that though I 
 have been in the habit of performing this little operation, I have 
 never been satisfied with the way in which it was done nor with its 
 results. 
 
 The other element depending on the nervous system is spasm ; it 
 necessitates the administration of antispasmodics under all forms. 
 Sometimes the spasm is confined specially to the uterus under the 
 form of cramp ; sometimes it is general, and may even give rise to 
 hysterical attacks. Laudanum given in an enema is often sufficient to 
 alleviate these colics. Cold water in many circumstances acts as an 
 antispasmodic. Infusions of lime tree flowers, orange leaves, balm, &c. 
 are also useful ; but when there is constriction of the throat, nausea, 
 convulsive or tetanic movements, angesthesia, &c., we must employ 
 stronger remedies. Inhalations of ether or chloroform often succeed ; 
 or these medicines may be administered by the mouth in the form of 
 capsules; when these remedies are not sufficient, ammonia, camphor, 
 galbanum, ambergris, valerian, musk, or castoreum may be tried. 
 Ambergris and musk are so costly that I generally use valerian and 
 castoreum associated with laudanum and sulphuric ether; I mix these 
 four substances in equal parts, and prescribe 15 to 30 drops in half a 
 tumbler of water with a spoonful of orange flower water, to be taken 
 in spoonfuls every five minutes. These antispasmodic drops generally/ 
 give immediate relief, and it is a convenient preparation for patients to/ 
 have beside them. When, however, the symptoms assume a still more} 
 serious aspect, assafoetida should be given in pills or in an enema' 
 (assafoetida gr. Ix, tr. opii min. xv, mixed with the yolk of an ^^^ in! 
 3 oz. of water), and sinapisms applied to the extremities, the pul- 
 monary, epigastric, and cardiac regions. The use of electricity under 
 the form of the continued current may also render great service in the 
 treatment of uterine pain and spasm. 
 
 7. Epispastics and exulories may be employed, especially in the 
 treatment of chronic diseases. They act as derivatives rather than as 
 revulsives, for example in mucous discharges; and sometimes as 
 resolvents, for example in the treatment of engorgements and chronic 
 peri- uterine phlegmasia. Exutories may be used in cases of diathesis, 
 but I confess I dislike this mode of treatment, especially for young 
 women, and prefer revulsion towards the skin by means of hydropathy, 
 not only because it is less repugnant, but because it is much more 
 natural, being exercised on a large surface, and consequently more 
 efficient and energetic than the best exutories. I reserve them for 
 serious cases, where complications such as phthisis prevent the use of 
 hydropathy. 
 
190 TREATMENT OF UTERINE DISEASES IN GENERAL 
 
 Epispastics properly so called (blisters) have a double action, being 
 derivative as well as resolvent when applied near the seat of evil. In 
 cases of chronic metritis, peri-uterine inflammation, ovaritis, engorge- 
 ment, hypertrophy, they should be applied to the loins and even to 
 the sacral region, to the abdomen, hypogastrium, or one or other of 
 the iliac regions ; they ought to be proportioned to the extent and 
 duration of the inflammation. For an extensive but recent inflam- 
 mation, pelvic peritonitis for example, a large bhster is apphed, 
 covering the greater part of the abdomen or one of the iliac regions ; 
 it should be left for about twenty-four hours till the blister is well 
 formed. It is then gently punctured with a needle to allow the escape 
 of the serous fluid, care being taken not to remove the skin; it is then 
 covered with cotton wool which is kept in place by a tight bandage to 
 prevent friction. For a long standing but circumscribed inflamma- 
 tion or for an engorgement or hypertrophy it is better to apply a 
 number of small blisters (the size of a crown piece) successively ; the 
 first in the centre, the others round about it. 
 
 Blisters may also be applied to the cervix. I have seen them cure 
 obstinate leucorrhcea. They are also useful in cases of perimetritis, 
 and in all those cases where it is desirable to relieve the uterus by 
 means of a serous discharge, or to produce a rapid and temporary 
 vicarious action. These applications are made as follows : after 
 removing all mucus from the uterus, a blister rather smaller than the 
 cervix is applied to it, and kept in place by pledgets of cotton wool ; 
 after inserting a number of small ones a large one ought to be intro- 
 duced. These precautions are absolutely necessary to prevent the 
 blister from touching the vagina which would cause intense pain. 
 After remaining for a few hours or a day it should be withdrawn, 
 when a very abundant serous secretion takes place which generally 
 lasts for a few days. It is useless to apply any dressing, but emollient 
 irrigations should be made morning and evening. 
 
 2. Local means 
 
 Local or topical means are of three kinds : mechanical appliances, 
 medicated applications and surgical operations. 
 
 1. The mechanical means applied externally are : various kinds of 
 abdominal belts and perineal pads. The former act on the abdominal 
 viscera, the latter on the uterus. We must distinguish between two 
 kinds of belts : abdominal belts, the object of which is simply to 
 support or compress methodically; and hypogastric belts, which only 
 act on the viscera in the way of supporting them so as to protect the 
 uterus indirectly. 
 
 Abdominal belts may act either on the whole of the abdominal walls 
 or on its lower part. The object of the former is to compress the 
 abdomen methodically when too much distended by adipose tissue, 
 when the size of the belly becomes troublesome, or when tlie parietes 
 (enfeebled by distension caused by previous pregnancies or ascites) are 
 relaxed, hanging down over the pubis, and requiring to be supported 
 in order not to hinder exercise and cause fatigue. This methodic 
 
METHODS OF TREATMENT AND MEDICATIONS 191 
 
 compression may be exercised with advantage on distension produced 
 by ovarian cysts during their development, after evacuation of the 
 fluid by puncture, or even after the removal of the cyst. I have seen 
 such striking examples of the efficiency of abdominal belts, that I 
 
 \ 
 
 \ i / 
 
 Fig. 148. — Bourjeai^rd's abdominal Fig. 149. — Courty's belt for methodic 
 
 belt or suj)port. compression. 
 
 cannot but recommend their use. The introduction of india rubber 
 into the materials used for this compression allows of a great degree 
 of precision being attained in the application of these belts, and at the 
 same time renders them impermeable, which makes them of great ser- 
 vice when it is desirable to maintain a moist heat round the pelvis. 
 In this respect I cannot too highly recommend Bourjeaurd's elastic 
 belts} The difficulty of exercising a sustained and regular compres- 
 sion when the abdomen presents inequalities or contains an irregular 
 tumour, or during the evacuation by paracentesis of the fluid of an 
 ovarian cyst or of ascites, led me long ago to invent a hell exercising 
 metJwdic compression. It is simply composed of a dozen little straps 
 of girth webbing alternating with a dozen little buckles, both being 
 fastened to a single piece of strong ticking which forms the lumbo- 
 sacral part of the belt. In buckling the straps alternately right and 
 left, beginning either from above or below and increasing the con- 
 striction proportionally, the whole of the antero- lateral abdominal 
 parietes are compressed in the most regular manner. In paracentesis 
 this belt obviates the necessity of having assistants. 
 
 Hypogastric belts, as their i^me indicates, concentrate their action 
 on the hypogastrium. Their essential part consists of a strong pad, 
 very thick, sometimes elastic, but more frequently not, hard, resistant, 
 stuff'ed with horsehair, lined with strong chamois leather on the hypo- 
 gastric side, and supported by a broad metallic plate outside. These 
 are not intended to compress the uterus in any way, still less to render 
 it fixed, but only to raise and support the abdominal viscera, in 
 order to prevent them from weighing painfully on the diseased womb. 
 These belts ought to have the opposite effect from the corset. The 
 corset pushes all downwards ; hypogastric belts ought to raise all up- 
 
 ' Gazelle des hopitaux, 24 Janvier, 1857. 
 
192 
 
 TEEATMENT OF UTERINE DISEASES IN GENERAL 
 
 wards; hence the uterus is protected. The principal part of the 
 apparatus therefore is an elastic pad, or a plate supporting a strong 
 pad of horsehair, to which a key has been adapted which allows of 
 variation in the slope. As for the way in which the pad is maintained 
 in place, sometimes a broad band is used, like the soft belt for sup- 
 porting the hypogastrium in pregnancy ; or a stronger band, like 
 that used in the bandage for hernia (E-aynal^s system). Sometimes 
 
 Fig. 150. — Bour- Fig. 151. — Hypogastric belt with 
 jeaurd's hypo- springs and articulations, and pad 
 gastric belt. with key. 
 
 Fig. 152. — Bour- 
 jeanrd's belt for 
 anal or nterine 
 prolapsus, with 
 peiinaeal pad. 
 
 elastic springs are used, having their point d'appui behind on the 
 sacrum, which by means of double articulation allow movements in all 
 directions without displacing the pad (Charriere's and Mathieu's belts 
 are like these). Whichever belt is applied, the band or springs ought 
 always to pass under the crest of the ilium. In cases where median 
 compression would be painful for bladder or uterus, it is replaced by 
 bilateral compression, exercised by means of two pads on the right and 
 left of the Unea alba, leaving a little space between them. 
 
 The perineal pad acts on the uterus, but it acts externally, not in- 
 ternally like pessaries, and in that respect is often superior to them 
 because better borne. It is indicated in cases of prolapsus, and even 
 in cases of hypertrophic elongation of the cervix. It consists of a large 
 pad of hair, india-rubber, gatta percha, or even wood, pressed against 
 the perinseum by means of straps fastened to a good belt. Sometimes 
 the pressure that is necessarily exercised causes a dragging on the 
 thighs, which would let the belt slip if ^ot kept in place by shoulder- 
 braces like Demarquay's.^ 
 
 It has been proposed to introduce mechanical supports into the 
 rectum, with the view of removing uterine retroversion by distending 
 the rectum with one of Gariel's pessaries.^ It is introduced into the 
 intestine in a flaccid state, and then distended with air by means of a 
 syringe, or pledgets of lint may be introduced of a gradually increased 
 size.^ Every one, however, must foresee that these means must be very 
 
 ' Gazette des Mpitaux, 1860. 
 
 ^ Favi'ot, Revue medico -cliirurgicale, novembre, 1851. 
 
 ^ Huguier, De VHysUrometrie, p. 3B8. Paris, 18fi5. 
 
METHODS OF TREATMENT AND MEDICATIONS 
 
 193 
 
 troublesome, causing a constant desire to go to stool, irritating the 
 intestine, and tending to produce tenesmus. 
 
 Fig. 153. — Velpeaii's pessary, having the form of the vagina. 
 
 Fig. 154. — Sponge filling the vagina 
 and serving as pessary. 
 
 Fig. 155. — Gariel's globe air pessary 
 filling the vagina. 
 
 2. Internal mechanical supports are known as Vaginal pessaries ; 
 they are very numerous, but in this case we may say, as in that of every 
 other therapeutical problem which is apparently distinguished by the 
 variety of ways in which it can be solved, that this seeming wealth 
 only conceals real poverty. They may be distinguished according to 
 the parts which they support and those which they take for their point 
 d'appui. Some support the uterus by filhng the vagina and taking 
 its shape, like Eecamier's emollient or aromatic bags, or the pessaries 
 of Velpeau or Cloquet ; others distend the vagina in every direction 
 like the globe pessaries (of wood, ivory, or metal), or fine sponge (fig. 
 154), which is the simplest of all pessaries, in spite of the drawbacks 
 pointed out by Lisfranc, or like Gariel's air pessary (fig. 155), which 
 is very easily introduced when empty (fig. 156) and which can be 
 afterwards inflated (fig. 157). 
 
 Others, in place of taking the shape of the vagina or distending it 
 in every direction, only distend it in one zone, exercising excentric 
 pressure on its walls in a circular manner, the edge of the inferior strait 
 
 13 
 
194 TEEATMENT OF UTEEINE DISEASES IN GENEEAL 
 
 serving as a point d'appui, which allows the uterus to rest on this 
 artificial floor (Figs. 158, 159, 160). They are supported by the bones 
 of the pelvis. These ring pessaries are either made of hard substances. 
 
 Fig. 156. — Gariel's globe pes- 
 sary empty. 
 
 Fig. 157. — Gariel's globe pessary distended 
 with air. 
 
 such as wood, metal, or vulcanite, or of India rubber distended by air 
 (Pigs. 162, 163, 164). They are generally perforated in the centre to 
 
 Fig. 160. 
 
 Fig. 161. 
 
 Fig. 158. Fig. 159. 
 
 Fig. 158. — Circular ring pessary. 
 Fig. 159. — Elliptical ring pessary. 
 Fig. 160. — Pessary in form of figure of 8. 
 
 Fig. 161. — Funnel-shaped pessary, hollowed out in front and applied in cases 
 of retroversion. 
 
 allow the uterine secretions to escape. These pessaries have been used 
 not only for prolapsus but also for deviations, especially retroversion 
 or retroflexion, by making their two opposite segments very unequal, 
 for example, the posterior very large and the anterior very small 
 (Figs. 161 to 16-1). The greatest improvement that has been made is 
 their reduction to a simple ring, which is very light, and distends the 
 
METHODS OF TREATMENT AND MEDICATIONS 195 
 
 upper part of the vagina, being kept in position by its own flatness. 
 
 Fig. 162.— India- 
 rubber ring pes- 
 sary inflated. 
 
 Fig. 163. — India-rubber ring 
 and air pessary intended for 
 cases of retroversion. 
 
 Fig. 164. — Air pessary 
 excavated in front. 
 
 Tliese modifications have originated the pessaries which go by the 
 names of Meigs, Dumontpallier, and Gairal de Carignan.^ 
 
 Fig. 165. Fig. 167. 
 
 Fig. 165. — Meigs's watcb-spring ring pessaiy covered with gutta percha, it has 
 recently been imitated by Dumontpallier. 
 
 Fig. 166. — Gairal's ring pessaiy, differing from Fig. 165 in the ring being flat 
 instead of round, which prevents its slipping after being placed in the 
 upper part of the vagina which it is intended to distend. 
 
 Fig. 167.— Method of introducing the pessary into the upper part of the vagina. 
 
 Other pessaries distend the vagina in a straight line, or in an axis 
 the extremities of which seem to be the two ends of a lever supported 
 
 ' All these pessaries are considered useful in anteversion (preventing the 
 cervix from inclining towards tlie posterior wall of the vagina) and in retro- 
 version (preventing the fundus from falling backwards). But it is sometimes 
 necessary to place the posterior side in front, which proves that they act less in 
 redressing the uterus than in supporting it. 
 
]96 
 
 TREATMENT OF UTERINE DISEASES IN GENERAL 
 
 simply by the pressure which the stretched vaginal walls exercise on 
 them. Sometimes they distend the upper part of the vagina across, or 
 from one side to the other, before or behind the uterus. The most 
 primitive of these instruments is the simple spring to which Kilian 
 
 Fig. 168, — Zwanck's Hysterophore. 1, when being introduced ; 2, kept open 
 
 in the vagina. 
 
 has given the pompous name of elytromochlion (vaginal lever) ; others 
 consist of two wings, which are closed whilst the instrument is being intro- 
 
 Fm. 169.- 
 
 -Schilling's hystero- 
 phore. 
 
 Fi&. 170. — Zwanck's hysterophore 
 modified by Savage. 
 
 duced and opened when it is in place. They are kept in position by a 
 screw fitted into one of the stems (as in Zwanck's hysterophore); or by 
 a simple hook at the end of one of the stems into which the end of the 
 other fits (as in Weiss^s hysterophore) ; or by a vice common to the 
 two stems, regulating the degree of divergence (Schilling's) ; or by an 
 elastic ring (Eulenburg's) ; or better still by an india-rubber tube 
 split at the top, which is attached to both wings, keeping the stems 
 closed in the vagina (Savage's), which is the simplest and therefore 
 the best (Figs. 168 to 171). Sometimes they distend the vagina from 
 
METHODS OF TREATMENT AND MEDICATIONS 
 
 197 
 
 before backwards as well as support the uterus. Such are the excavated 
 pessary for retroversion, the battledore pessary of Hervez/ the trian- 
 gular one of Simpson and Priestley, which rests on the vagina on one 
 
 Fig 171. — Zwanck's hysterophore modified by Eulenburg : 1, shut ; 2, open. 
 
 side and on the perineum on the other. Such, too, are Hodge's lever 
 pessary and Graily-Hewitt's cradle, which rest on the posterior cul- 
 
 FiG. 172. — Hervez' battledore Fig. 173. — Simpson's and Priestley's 
 pessary. triangular pessary. 
 
 de-sac on the one side and on the anterior wall of the vagina on the 
 other. 
 
 I have modified the latter pessaries, adapting them to the cure of 
 
 Fig. 174. — Hodge's horse- 
 shoe pessary, silver gilt. 
 
 Fig. 175. — Hodge's lever pessary of 
 silver, gutta percha or tin. The 
 same in aluminium (Sims). 
 
 retroflexions by hollowing out the posterior part of the ring so as to 
 push back the cervix instead of passing behind it and pushing back the 
 
 ' De quelques deplacements de la matrice et des pessaires les plus conven- 
 ables pour y remedier, Memoires de VAcademie de medecine, t. ii, p. 319. 
 Paris, 1833. 
 
198 
 
 TREATMENT OF UTERINE DISEASES IN GENERAL 
 
 vagina. It is a good plan to try them first in each patient, choosing 
 them of the size and shape best suited to each, and on the first appli- 
 cation to use rings of tin or lead, which take any form given to them. 
 
 Fig. 176. — Hodge's pessary in position Fig 177. — Hodge's pessary modified 
 for retroflexion. by Conrty, so as better to maintain 
 
 the reduction of tlie retroflexion. 
 
 Afterwards they should be made on this model in aluminum, a light 
 and unalterable metal, which is so well tolerated by patients that it 
 
 Fig. 178.— Graily-Hewitt's 
 cradle pessary. 
 
 Fig. 179. — Graily-Hewitt's pessary mo- 
 dified by Courty, so as better to main- 
 tain the reduction of the retroflexion. 
 
 does not hinder the accomplishment of any function, not even of 
 coitus. 
 
 Lastly, there are pessaries which have an external as well as an 
 internal poi7it d'appui. The external fulcrum varies. It may be the 
 
METHODS OF TREATMENT AND MEDICATIONS 
 
 199 
 
 straps which pass under the thighs crossing at the vulva (I'ig. 181), in 
 which case it is distributed to the four opposite points of the belt, 
 
 GALANTe 
 
 Fig. 180.— Cup-and-ball 
 pessaiy having an ex- 
 ternal fulcram. 
 
 Fig. 181. — Bourjeaurd's air pessary, 
 supported by india-rubber straps 
 crossingf under the vulva. 
 
 which is onlj the more firmly fixed for being drawn downwards by the 
 tendency of the uterus to prolapsus. It may be the plate of a hypo- 
 gastric belt (Fig. 182), an arrangement which is much better for the 
 patient, but which requires more skill in the construction. 
 
 Fig. 182. — Roser's hysterophore, modi- 
 fied by Scanzoni and Charriere. 
 
 Fig. 183. — Scanzoni's pessary 
 with ball-and-socket joint. 
 
 The internal fulcrum varies also. Sometimes it is the vagina, the 
 anterior cul-de-sac being supported against the pubis, so as to raise at 
 the same time all the rest of the organ and the uterus itself, unless 
 there be great relaxation of the posterior wall, rectocele, retroversion, 
 &c. (Figs. 182, 183). Sometimes it is the cervix which is directly 
 supported by means of an india-rubber, ivory, or metallic ring (Figs. 
 180, 181). The only means of making this pessary bearable is to 
 adapt a system of elastic articulations or supports to its stem, which 
 allow free movement to the patient without danger of displacing the 
 pessary or causing pain. 
 
 3. Intra-uterine mechanical sxipports are also known by the name of 
 redressors ; that of uterine director, however, would be more correct. 
 The first and I think the best (Fig. 181) of these instruments was 
 invented by Simpson. It is a hollow metallic stem Cgeuerally made of 
 two dififerent metals in order to produce a current of electricity), and 
 
200 TEEATMENT OF UTERINE DISEASES IN GENERAL 
 
 terminates in a hollow bulb ; tbe stem is introduced into the uterus, 
 the bulb remaining in the vagina where it is kept in position by a large 
 
 Fig. 184. — Simpson's intra-uterine stem 
 pessary or galvanic director. 
 
 Fig. 185. — Stem pessary of alumi- 
 nium for dilating the os. 
 
 tampon saturated with glycerine. It is made of various sizes in order to 
 serve as a dilator in cases of constriction (Pig. 185). This instrument 
 has the advantages of not straightening the uterus violently, of acting 
 on the flexion without acting on the version at the same time, and of 
 leaving the uterus mobile, thus avoiding irritation of this organ or the 
 surrounding parts, which are more frequently inflamed than we imagine. 
 Kiwisch invented an intra-uterine stem pessary composed of two 
 branches, which opened after being introduced, and so fixed it more 
 firmly in the uterus. In order to fix it more firmly in the vagina 
 Detschy associated it with a hysterophore, whilst Yalleix attached it to 
 an external support. All these professed improvements have only 
 created new dangers which have led to its proscription. In order to 
 introduce it anew and to procure from it ail the benefits that it alone 
 can give, I have had on the contrary to free it from all these pre- 
 tended aids and reduce it to its simplest form. 
 
 II. Topical remedies. — Before describing local remedies and the 
 way of applying them, I must not omit to mention the best kind of 
 forceps for making such applications. Those which I use have short 
 blades, and are consequently very strong and useful for dilating the 
 uterine orifice ; they are straight or curved, and grooved so as to hold 
 a needle or crush the pedicle of a polypus, with a catch or screw near 
 the handles to graduate the pressure. 
 
 Tojoical remedies are solid, liquid, or gaseous. 
 
 1. Among solid applications I give the first place to tampons of 
 cotton wool or lint, and to the little operation of plugging, which must 
 be done in a methodical manner, whether it be to arrest a haemorrhage 
 or to maintain various medicaments in contact with the cervix, or to 
 prevent the cervix from coming in contact with the vagina, or the op- 
 posite walls of this canal from touching. 
 
METHODS OP TREATMENT AND MEDICATIONS 
 
 201 
 
 It has lately been proposed to substitute for plugging with lint or 
 cotton wool the introduction of an india-rubber bag (GarieFs pessary), 
 which is to be distended with 
 air or cold water when in the 
 vagina; but the use of this 
 pessary is painful, it does not 
 allow of the convenient appli- 
 cation of medicines, and, more- 
 over, it is not always at hand 
 like cotton or lint. I also find it 
 inconvenient to plug by means 
 of a compress previously intro- 
 duced into the vagina, and 
 serving as a receptacle for the 
 cotton ; because, whatever may 
 be said, it is not possible to 
 withdraw all at the same time ; 
 that is, if the plugging has 
 been sufficient to distend the 
 vagina. 
 
 The simplest and most effi- 
 cient way is the following : The 
 vagina having been cleared of 
 the clots it contains, and washed 
 with cold water or an astrin- 
 gent liquid, the speculum is 
 introduced, after which a large 
 pledget of lint charged with 
 some medicinal substance (alum, 
 tannin, perchloride of iron, io- 
 dine, or any caustic) is placed 
 in contact with the cervix. Af- 
 terwards a number of tightly 
 rolled balls of cotton wool are 
 added, which by means of long 
 uterine forceps we try to place 
 in the farthest corners of the 
 vagina, so as to stretch it and 
 to surround the cervix. Pajot^ 
 tells us Dubois proved by expe- 
 riments that pledgets of charpie 
 mixed with pieces of agaric are 
 more efficient even than cotton 
 in opposing an insurmountable 
 barrier to the blood. The spe- 
 culum is gradually withdrawn 
 
 in proportion as the vagina is filled, and in this way the whole space 
 is filled by a multitude of little pledgets till the vulval orifice is 
 
 ' Archives generales de medecine, fevrier, 1867. 
 
 Fig. 186. — Conrty's straight uterine for- 
 ceps. A, the same, curved. 
 
202 TEEATMENT OF UTEEINE DISEASES IN GENEEAL 
 
 reached, on which is laid a larger one, supported by a graduated com- 
 press firmly fixed by a T-bandage. It is necessary to remove some 
 of the cotton wool a few hours afterwards, in order to allow of the 
 patient passing water or to catheterise her ; the next day, or the day 
 after, the rest is removed by degrees, care being taken to make re- 
 peated injections. By means of the fingers and the long forceps the 
 greater part of the cotton wool is easily extracted ; as for that which 
 is in contact with the cervix and which ought to be left a little 
 longer, its extraction is facilitated by frequent injections made on the 
 bidet. 
 
 When the plugging is intended merely to maintain a medicament in 
 contact with the cervix it may be reduced to two tampons, the first 
 applied to the cervix and a second much larger one to keep the first 
 in position. To keep the vaginal walls from touching one is suffi- 
 cient ; this may be charged with a medicament such as alum or tannin, 
 or it may be saturated with a solution or covered with an ointment ; or 
 it may be replaced by a bag containing inert powders for absorbing 
 the liquid secretions, or medicated powders, emollients, tonics or 
 astringents, to modify the diseased surfaces as well as to absorb the 
 secretions. In the acute stage cataplasms are substituted for bags. 
 Linseed ferments easily, therefore it is better to use starch, rice or 
 bread ; glycerine is better still. Take as much fine cotton wool as the 
 hollow of the hand will hold, soak it in tepid water, and after squeez- 
 ing it out saturate it with glycerine and introduce it into the vagina.-^ 
 It possesses the properties of absorbing moisture, disgorging the tissues 
 with which it is in contact, and of being in some degree disinfectant. 
 Lastly, it facilitates the absorption of medicines mixed with it under 
 the name of glyceroles.^ 
 
 The drawbacks of plugging are so considerable that it has been 
 proposed to substitute for it the introduction of inert poivders into the 
 vagina. Eecamier used them frequently, Aran also, and they may 
 always be resorted to when there is an indication to dry the vagina by 
 the absorption of fluids accumulated in its cavity. Starch powder 
 may be used, or lycopodium, or rice flour or common flour ; starch is 
 most frequently used. The bivalve speculum is introduced, and after 
 aU the mucus is removed, from 5J to 5J of starch powder is thrown 
 into the cavity of the instrument, then the speculum is withdrawn, and 
 if the vulval orifice is too large to retain the powder a large plug of 
 cotton wool must be introduced. After twenty-four or thirty-six hours 
 the patient makes a vaginal injection to moisten the starch and bring 
 it away. When the disease is at the vulva it is sufficient for the 
 patient to open the labia and powder the parts exposed. 
 
 Before introducing the starch it may be moistened with laudanum 
 or some other medicament, whichj owing to the starch taking the form 
 of the vagina, is kept in contact with the parts better and more gently 
 than by means of cotton. I do not contest the utility of this application, 
 
 1 Sims, Clinical Notes on Uterine Surgery. Loudon, 1866, p. 70. 
 ? Demarquay, cle la Glycerine et de ses applications a la chirurgie et a la 
 tnedecine, 2« edit. Paris, 1868. 
 
METHODS OF TEEATMENT AND MEDICATIONS 203 
 
 but I am not in favour of leaving foreign bodies in the vagina in 
 contact with the cervix unless in exceptional cases. 
 
 Lastly, in place of inert powders, we may apply oak bark, catechu, 
 powdered cinchona, or even more active substances, such as alum, 
 tannin, sulphate of zinc, calomel, bismuth, &c. As a rule these active 
 substances should be mixed with an inert powder in variable propor- 
 tions, according to the effect which it is desirable to produce ; or they 
 should be applied in the centre of a light plug of cotton wool. One 
 of the best powders for modifying diseased surfaces is the subnitrate 
 of bismuth. 
 
 Plugging hy ice has been recommended by Aran^ as preferable to 
 the refrigerating mixtures employed in cases of cancer by Arnott, to 
 whom we owe various experiments on the ansesthetic action of cold. 
 It consists in bringing into contact with the cervix a greater or less 
 quantity of ice broken into little bits, which may either be simply left in 
 the vagina or may be renewed as it melts. In both cases the cervix 
 is exposed by means of a speculum, of wood, if we only wish to act on 
 the cervix and in a moderate way, of metal, if we wish to act more 
 energetically ; the quadrivalve speculum is convenient for this applica- 
 tion. When the ice is not to be renewed, we must take care to retain 
 it by means of a large pledget of lint introduced when the speculum is 
 withdrawn : reaction is then less rapid and less disagreeable. The refri- 
 gerative action is much more marked when a metalhc speculum is used -, 
 it is exercised on the whole of the vagina as well as on the cervix. 
 With the exception of temporary colic in the abdomen anaesthesia is 
 complete in a few minutes j by continuing the application of ice from 
 a quarter of an hour to an hour the action exercised on the circulation 
 and sensibility of the pelvic organs may be so great for several hours 
 as to lead patients to think they have been freed from all their troubles, 
 and to allow of their walking and attending to their various duties. 
 Aran said that the reaction was insignificant; he renewed the applica- 
 tion every day or every two days eight or ten times in the course of 
 treatment. 
 
 Whilst admitting that plugging with ice may be of great use in 
 cases of hsemorrhage, cancer, hyperaesthesia, neuralgia, inflammation 
 and congestion, in which it was especially used by Aran,^ I must say 
 that the indication for it has never seemed to me so marked as to lead 
 me to have recourse to it. It cannot be denied that it exposes the 
 patient to too energetic reactions, and that it is an inconvenient appli- 
 cation, as well as being sometimes impossible, from the difficulty of 
 getting ice. In most cases cold irrigations with refrigerating applica- 
 tions to the abdomen are sufficient. 
 
 Paint'mg the cervix with collodion. — Mitchell^ has introduced this 
 means as a substitute for nitrate of silver in the treatment of ulcera- 
 tion of the cervix. This organ having been wiped, collodion is applied 
 with a camel's hair brush ; twenty minutes is allowed for the medicine 
 
 ' Op. cit., p. 220. 
 
 2 Ibid., p. 379. 
 
 ^ Dublin Medical Press, October, 1848. 
 
204 TREATMENT OF UTERINE DISEASES IN GENERAL 
 
 to dry, and one or two additional layers are then applied in the same 
 way. This application must be renewed in forty-eight hours because 
 the secretion which accumulates under this varnish detaches it. In 
 the case of simple abrasion, three applications were sufficient. If the 
 disease is more obstinate, if there are large granulations, this physician 
 uses in the first instance nitrate of silver, acid nitrate of mercury, or 
 solution of caustic potash, applying the collodion above. 
 
 I think that the application of collodion ought to be confined to 
 two kinds of cases : elastic collodion for very superficial erosions and 
 excoriations of the cervix ; pure collodion in cases of engorgement or 
 oedema to obtain a reduction in bulk of the organ under the influence 
 of the contraction which the collodion undergoes in drying. 
 
 The majority of solid medicated topics are ointments, varying in 
 consistency from that of suppositories to almost liquid preparations. 
 
 Vaginal suppositories, like suppositories introduced into the rectum, 
 were used by the ancients in remote times. Their use has been revived by 
 Simpson under the name of medicated pessaries. They are conical, cylin- 
 drical, or ovoid, the latter being the best form for enabling the patient 
 to push them to the farthest end of the vagina, and also for increasing 
 the chance of retention. In size they must not exceed one inch in length 
 by half an inch in width. They are made of wax and lard or cacao butter 
 in suitable proportion to give them a proper consistency ; they contain 
 a certain quantity of some medicinal substance, sedative, astringent, 
 or resolvent ; such as mercurial ointment, iodide of lead, extract of 
 belladonna, &c. The patient introduces them into the vagina in the 
 evening, pushing them back as far as possible ; they melt in a few 
 hours, and a tepid injection made the following morning removes 
 whatever has not been absorbed. We must not count too much on 
 the action of these pessaries ; in the first place they do not always 
 melt well however carefully they have been made; in the second 
 place the power of absorption of the vaginal mucous membrane is not 
 great, especially for oily bodies. When rapid and energetic action is 
 desirable, whether sedative or resolvent, it is better to introduce them 
 into the rectum. The ointments which I use most frequently are the 
 ordinary mercurial ointment with the addition of a tenth part of the 
 extract of belladonna, or ointments containing calomel, red oxide of 
 mercury, iodide of lead, potassium, &c. I apply them to the cervix 
 simply on a pledget of cotton wool and withdraw the speculum, or I 
 put a thick layer of ointment on a little round mat of coarse thread, 
 the size of the cervix, which the patient could crochet or knit in a few 
 minutes, and which forms a little cup for holding the uterus. I apply 
 this to the cervix, keeping it in position by means of a large pledget 
 of cotton wool. 
 
 When it is necessary to make applications to the uterine cavity I 
 use special instruments, which I wUl afterwards describe along with 
 intra- uterine caustic holders. ^ 
 
 2. Liquid applications are easily applied to the cervix and vagina. 
 
 » See p. 336. 
 
METHODS OF TREATMENT AND MEDICATIONS 205 
 
 I often use them to modify the vaginal surface in place of prescribing 
 injections or lotions for the patient. After having cleansed the vagina 
 it is easy to apply a liquid to the whole of its surface by means of a 
 brush whilst the speculum is being withdrawn. In this way great 
 effect is produced, and we are surprised to see vaginal leucorrhoea, ero- 
 sions, even ulcers cured in a few days or a few weeks, which had been 
 treated for months past by injections without any result having been 
 produced. There are various modes of applying liquids : sometimes 
 the medicament is poured into the speculum followed by an inert 
 powder which absorbs it and forms a magma round the cervix. When 
 the action is to be limited to the cervix it is poured into the speculum, 
 and after being left in contact with the cervix allowed to escape by 
 lowering the speculum; or it may be applied by means of a pledget of 
 lint or a cameFs hair brush. When caustics are used the surface 
 touched should generally be washed as soon as the desired action has 
 been produced and before withdrawing the speculum. The liquids 
 most frequently used are sedatives, astringents, solvents, stimulants, 
 cathartics. Laudanum is useful not only as a sedative but to induce 
 cicatrisation. Solutions of alum and tannin may be applied by means 
 of a large brush to the whole of the utero-vaginal mucous membrane. 
 The other liquid astringents are solutions of acetate of lead, solutions 
 of peroxychloride of iron, ddute tincture of iodine, &c. The principal 
 cathartic liquids, which may be either resolvent or stimulating, are : 
 tincture of perchloride of iron, especially in cases of diphtheria, a 
 saturated solution of chlorate of potassium, pure tincture of iodine, 
 iodoform, a solution of corrosive sublimate, and above all the solu- 
 tion of nitrate of silver, or a cameFs hair brush dipped in water and 
 then applied to the solid crayon may be used. Several of these liquids 
 may be advantageously used mixed with glycerine. Glycerine as an 
 emollient may be employed alone in cases of erosions and superficial 
 ulceration. There are very few of these substances which do not affect 
 metal; therefore, as a rule, I use a wooden, glass, or gutta-percha 
 speculum for all liquid applications. When irritant or caustic 
 liquids are used care must be taken to remove with a little cotton 
 wool all that may remain on the cervix or vagina, lest it should 
 touch the lower part of the vagina or the vulval orifice which are 
 extremely sensitive. 
 
 Lastly, it must be remembered that however important local treat- 
 ment may be it must not be abused, especially with patients who do 
 not tolerate it easily. 
 
 3. The only gaseous applications that have been used in the treat- 
 ment of uterine diseases are chloroform and carbonic acid. Carbonic 
 acid was first used as a local anaesthetic by Ingenhousz. In 1884 
 E/Ozier injected it into the vagina of women suffering from cancer of the 
 uterus; it was also recommended by Mojon in injections to alleviate 
 pain and to induce the catamenial flow. It was introduced into use 
 in Scotland by Simpson and into France by Follin and Broca. 
 Demarquay and Monod, who have also tried it, think that vaginal 
 injections of carbonic acid produce good effects when the mucous 
 
206 
 
 TREATMENT OP UTERINE DISEASES IN GENERAL 
 
 membrane is denuded, whilst no effect is produced when the tissues 
 are whole. 
 
 Different apparatus may be used : the simplest is an ordinary 
 bottle furnished with a conducting tube (Simpson); but the most 
 convenient is that of Fordos. The canula is first introduced into the 
 vagina, then the apparatus is charged. An ounce of tartaric acid 
 in large crystals is first put into the carafe, then 3 oz. of bi- 
 carbonate of soda in powder ; half a pint of water is then poured 
 in and the carafe is filled up with a tin tube containing fragments 
 
 of marble and pieces of sponge, 
 which filter the gas as it is libe- 
 rated, freeing it from the saline 
 and acid particles that are me- 
 chanically swept out. By satura- 
 ting the pieces of sponge contained 
 in the tin tube with chloroform 
 we have the anaesthetic action of 
 its vapours in addition to that of 
 the carbonic acid, and we avoid 
 the current of air produced in the 
 vagina by the injection of chloro- 
 form fumes alone. 
 
 Charles Bernard^ has mentioned 
 cases of cerebral accidents caused 
 by these injections ; but they must 
 happen very seldom, and do not 
 contra-indicate the use of this 
 means. A more serious drawback 
 is that carbonic acid, like chloro- 
 form, whilst soothing pain pro- 
 vokes congestion of the diseased 
 parts, which ought to lead to its 
 rejection in cases of fluxion, con- 
 gestion and metritis, its use being 
 reserved for hypersesthesia and ute- 
 rine neuralgia. 
 
 Chloroform has been adminis- 
 tered by Hardy (of Dublin) in 
 vaginal injections in the form of 
 vapour. The apparatus invented by this surgeon is composed of a 
 small metallic cylinder, in which is placed a sponge saturated with 
 chloroform. A tube is adapted to one extremity of this cylinder, 
 communicating with an india-rubber bag distended with air. Another 
 
 ^ ArcMv gen. de med., 5^ serie, t. x, p. 529, 1857. 
 
 Scanzoni, Beitrdge zur Geburtskunde und Gyndhologie, 1858, t. iii, p. 181, 
 has mentioned a case of death after the injection of carbonic acid into the cer- 
 vical cavity. Death took place in one hour and three quarters. It made a great 
 sensation in Grermany, and led to Breslau's and Vogel's experiments on pregnant 
 rabbits. See Wiener medizinische Woclienschrift, 11 Sept., 1868. The Gazette 
 hebdoofnadaire, 1858, p. 741, gives an abridged account of the article. 
 
 Fig. 187. — Hardy's india-rubber in- 
 sufflator with double valve and 
 
 reservoir. 
 
METHODS OF TREATMENT AND MEDICATIONS 207 
 
 tube is attached to the other extremity of the cylinder, termina- 
 ting in a long india-rubber canula, which ought to reach the cervix 
 when introduced into the vagina. By compressing the india-rubber 
 bag it is emptied of the air which it contains, and this air in 
 passing through the cylinder is charged with anaesthetic fumes which 
 are introduced into the vagina by means of the canula. A valve 
 allows the re-admission of air into the bag from which it is again 
 driven through the cylinder. This apparatus, with slight modifi- 
 cations, has also been utilised for the insufflation of medicated 
 powders into the vagina and uterus, but it is better to use a camel's 
 hair brush. 
 
 III. Operations are of two kinds. The first are small operations 
 analogous to dressings, only differing from them in the nature of the 
 substances used; for when there are caustics the danger incurred 
 necessitates great care and prudence. The second class includes 
 special operations for special diseases, in performing which the obser- 
 vance of the ordinary rules of surgery is required. I will describe all, 
 entering, however, into more minute details when treating of those 
 which occur most frequently. 
 
 The posture which the patient ought to adopt in order to facili- 
 tate the different operations which have to be performed on the uterus 
 and vagina, with or without speculum, varies. In each case we must 
 take care to resort to the one which theory and practice teach us 
 is the best. These postures are : — 1, Supination on the back as for 
 lithotomy ; 2, lumbo-sacral supination (the first exaggerated), so as 
 to raise the vulva more ; 3, right or left lateral pronation ; 4, pro- 
 nation on elbows and knees; 5, pronation on the edge of the bed, 
 the feet touching the ground, the chest, head and arms on the bed. 
 The three last postures are sometimes very convenient after dilatation 
 of the vagina, owing to the introduction of air, as well as to the 
 projection of the uterus towards the hypogastrium and of the intes- 
 tines towards the umbilicus. This projection exposes the posterior 
 vaginal cul-de-sae very clearly, and the horizontal position given to 
 the cervix is favorable for applications. 
 
 Most of these operations are facilitated by the use of tenaculum hook 
 forceps. These are of two kinds: — 1. The converging tenaculum 
 forceps, made to glide so as to seize at different heights the part re- 
 quired to be held, and to disarticulate so as to make two very fine 
 single hooks ; 3. the diverging tenaculum forceps, which is an excellent 
 instrument of prehension and distension. 
 
 A. General operations. — The small operations requiring to be re- 
 peated frequently like dressings are : the application of electricity, of 
 the actual or potential cautery, intra-uterine injections, &c. 
 
 1. Electricity may be employed as a sedative, stimulant, or resol- 
 vent. Under the form of the continued current it exercises a sedative 
 action on the uterus as on other organs or on nerves affected with 
 rheumatic neuralgia. Under other forms it stimulates the vitality of 
 the tissue, accelerates absorption in cases of engorgement and hyper- 
 trophy, excites muscular contraction, thus reducing the size of the 
 
208 TREATMENT OF UTERINE DISEASES IN GENERAL 
 
 congested organ, and by strengthening the relaxed tissue corrects 
 flexions, &c. 
 
 Fig. 188. Fig. 189. 
 
 Fig. 188. — Converging and sliding tenaculum hook forceps : a, forceps when 
 shut; B, one of the branches of the forceps open, sliding on the articula- 
 tion ; c, one of the branches separated from the other serving as a simple 
 tenaculum hook. 
 
 Fig. 189. — Diverging tenaculum hook forceps : a, shut ; B, open. 
 
 2. Caute?'isation of the cervix. — This is one of the most useful and 
 therefore one of the most frequent operations. At the same time the 
 indications for it are somewhat difficult to determine, for it may be 
 resorted to in the treatment of several diseases. It is not surprising 
 that it should have been, and still is, the means most frequently 
 abused. 
 
 I can affirm, as the result of long experience, that when suitably 
 applied it renders greater services perhaps than any other means in 
 the treatment of uterine diseases; but, on the other hand, when em- 
 ployed in spite of certain definite contra-indications very commonly 
 misunderstood, and especially when used as a universal panacea for all 
 uterine diseases, it has done as much harm as good, in aggravating or 
 perpetuating a number of maladies which would have been cured but 
 for it. The most serious consequences are the producing of constric- 
 tions and obliterations of the cervical canal, and the setting up of sup- 
 
METHODS OF TREATMENT AND MEDICATIONS 209 
 
 puration from its application when applied to patients suffering from 
 peri-uterine inflammation which has passed unnoticed. The potential 
 as well as the actual cautery may be used. 
 
 Potential cauterisation. — The caustics used may be liquid or solid. 
 
 The liquid caustics most frequently used are the acids^ especially the 
 acid nitrate of mercury. Next to it we may place the perchloride of 
 iron, the tincture of iodine, which acts as a caustic when applied to 
 bleeding or ulcerated surfaces, and the saturated solutions of the solid 
 caustics, which may be either catheretic or caustic, according to the 
 degree of saturation and the condition of the surface to which they 
 are applied. 
 
 The acid nitrate of mercury.^ recommended by Recamier and em- 
 ployed by Lisfranc and several other physicians in preference to other 
 caustics, has been in very general use. It is very much in vogue even 
 now, enjoying, as it seems to me, an undeserved reputation among the 
 profession. It is employed in cases of granulation and simple ulcera- 
 tion, pure or diluted, according to the indication. A brush made of 
 lint, or a small piece of sponge cut in the shape of a cone is applied to 
 the ulcerated surface. Immediately afterwards cold water is poured 
 into the speculum to prevent any stray drops of the caustic from 
 spreading in the vagina. In addition to the drawbacks which it has 
 in common with other liquid caustics, it has another which alone 
 should cause its rejection : in some women it induces an inconvenient 
 and obstinate salivation. 
 
 This, although at first disputed by some writers, is now an esta- 
 blished fact. Therefore I prefer nitric, sulphuric, hydrochloric and 
 chromic acids, pure or diluted with water, in variable proportions, or 
 alkaUne solutions, like potash, creasote, or better still, perchloride of 
 iron, the saturated solution of nitrate of silver or tincture of iodine. 
 These last named, however, are catheretic rather than caustic. When 
 real liquid caustics are used care must be taken to wipe the wet brush 
 before applying it, so that only the part requiring to be cauterised may 
 be acted on and not the surrounding tissue. 
 
 But whatever precautions are taken, liquid caustics will always have 
 two serious drawbacks. 1. It is difficult to determine the depth to 
 which they penetrate. 2. It is still more difficult to prevent them 
 from spreading beyond the point desired and to be certain that the 
 healthy surfaces will escape their action. Therefore I have almost given 
 up using them, only em])loying catheretics, which, infiltrating all the 
 sinuosities of a denuded or ulcerated surface, help cicatrisation. In 
 all cases where cauterisation is necessary I have recourse to the actual 
 cautery, or to a solid caustic like canquoin, or any other that is 
 deliquescent or pulverulent. 
 
 Of solid caustics canquoin is one of those I use most frequently. I 
 do not understand Gendrin's preference for the Vienna paste; its 
 advantages ought to be great to compensate for the difficulties in 
 applying it. It is true that these difficulties are overcome in the ])re- 
 paration made by Tilhos ; but even with it there is great uncertainty 
 as to the extent and depth of the scar, besides the necessity of using 
 
210 TEEATMENT OP UTEEINE DISEASES IN GENEEAL 
 
 quantities of water in washing the surfaces, and the possibility that in 
 spite of all precautions some of the caustic may remain. All these 
 disadvantages present such a striking contrast with the simplicity of 
 the actual cautery, that in spite of the high authority of Gendrin's 
 practice and of Henry Bennetts recommendation, I cannot understand 
 how the use of Pilhos's caustic has come to be adopted. Besides, we 
 know that all these alkaline caustics produce soft scars, make the blood 
 diffluent, and induce haemorrhage.^ 
 
 Therefore when I find that the actual cautery will not produce 
 sufficiently deep scars, especially on hard, friable, bleeding tissues, like 
 cauliflower excrescences, and that it is not followed by that modifica- 
 tion of the surrounding surfaces which seems to be effected by certain 
 caustics, I never have recourse to any other caustic than chloride of 
 zinc, so highly recommended by Bonnet, of Lyons, and which I had 
 previously used repeatedly with success. Chloride of zinc hardened 
 with a variable quantity of flour and spread on linen in layers of vary- 
 ing thickness forms what is called canquoin plaster, its caustic strength 
 depending on the relative quantity of the chloride and on the thick- 
 ness of the layer of paste. Nothing is easier than to cut a little circle 
 of this plaster and place it on the cervix, or to roll it up and introduce 
 it into the ragged cavity of the cancerous organ, or to cut it in small 
 arrows to be inserted into the tumour, according to Maisonneuve's 
 plan, keeping it in place by plugging. This is the least painful and 
 least dangerous mode of applying this caustic. If the piece of plaster 
 is not very thick, and if the portion of the organ which has to be 
 destroyed is considerable, the application may be left for twenty-four 
 hours, otherwise it may be removed in a few hours. Copious injec- 
 tions of tepid water must then be made, after which it may be 
 advisable to introduce tampons, either dry or covered with cold cream, 
 at least into the farthest extremity of the vagina, to prevent any frag- 
 ments of the causlic that may be softened and brought away by the 
 suppuration from destroying the corresponding part of the vaginal 
 walls. I have frequently seen considerable destruction of the vagina 
 result from an awkwardly made application of this caustic, which is 
 really dangerous in inexperienced hands. When the scar falls a second 
 application can be made when necessary. 
 
 I often use dehquescent chloride of zinc, over which I pass a wet 
 cameFs-hair brush, which is then applied to the parts needing cauteri- 
 sation. At other times I have recourse to Rousselot^s red arsenical 
 powder, or that of Friar Come, which is better still. It contains more 
 arsenic, and is as efficacious in ulcers of the cervix as in those of the 
 face, to which it is generally applied. 
 
 Chromic acid is also a valuable caustic, provided it is not applied 
 over too extensive a surface, so as to produce poisoning characterised 
 by vomiting. 
 
 Nitrate of silver, which is the most used of all, is not essentially 
 destructive. It acts as a simple modificator when used in solution ; as 
 catheritic when a wet brush is saturated with this salt by being passed 
 ' Philippeaux, Traite pratique de la cauterisation. Paris, 1856. 
 
METHODS OF TREATMENT AND MEDICATIONS 
 
 211 
 
 over the crayon several times ; as a protector of the ulcerated surfaces 
 by the coagulation of mucus and the precipitation of chloride of silver 
 acting almost in the same way as collodion ; in repressing exuberant 
 granulations when the crayon is applied. Lastly, in modifying as well 
 as destroying tissue when the powder or crayon is left in the uterine 
 cavity, a method to which I will afterwards refer when treating of 
 intra-uterine cauterisation. 
 
 The actual cautery. — It is specially suitable as an application to the 
 cervix, for this organ is almost insensible to the action of fire — at least 
 to the pain which this action produces on other tissues. 
 
 There is no better mode of applying fire to diseased surfaces than 
 by means of red-hot iron. 
 
 Although this means has been employed for long, it has probably 
 never been used with method and discrimination till our own time. 
 Larrey^ gave all the necessary operative details, but it was Jobert^s^ 
 works that popularised this operation in gynecological practice. As I 
 believe that additional information on this subject would be welcomed, 
 I will relate what a long practice has taught me. 
 
 Several kinds of cautery are necessary, according to the use for 
 which they are intended. I use two kinds especially ; the first are 
 very fine, with a reservoir for heat for ignipuncture ; the others spear- 
 
 FiG. 190. — Cauteries for ignipuncture. 
 
 shaped, straight or curved, for ignilysis or section by fire. I have also 
 conical cauteries of every size down to that of a grain of corn, others 
 
 Fig. 191. — Cauteries for scarifications, sections and excisions by fire. d, 
 
 straight ; E, curved. 
 
 cylindrical, nummular, &c. ; I even had a cup-shaped one made for 
 
 ' Clinique cMrurgicale, t. ii, pp. 114, 829. Paris, 1830 — 183G. 
 
 " Plaies d'armes a feu, Memoire sur la cauterisation. Paris, 1833. 
 
212 TEEATMENT OF UTERINE DISEASES IN GENERAL 
 
 destroying an irreducible inverted uterus, and I used it afterwards for 
 cauterising a cervix enormously engorged or hypertrophied. I have 
 found nothing better for heating the cauteries than the eolipile 
 spirit lamp which solder ers generally use. I think this lamp and 
 these cauteries are to be preferred for this purpose even to the thermo- 
 cautery, although I admit the superior advantages of the latter in 
 other circumstances. 
 
 The operation of cauterisation is performed in the following man- 
 ner: after introducing a speculum of wood or of glass, the uterus is 
 seized firmly and the speculum pressed against it so that it cannot 
 escape, the operator being on his guard against any movements that 
 the patient may make; the cervix is then well wiped with cotton 
 wool ; if it is bleeding the cotton ought not to be withdrawn till an 
 assistant has brought the cautery, which must be at white heat. 
 Whilst the left hand holds the speculum the right apphes the cautery 
 to the uterus, and, according to the object in view, the uterus is barely 
 touched, or the iron may pass lightly over different points of its sur- 
 
 FiG. 192.— Eolipyle spirit lamp for heating cauteries. 
 
 face, or may be left in contact with some point for a few instants, and 
 when necessary be replaced by a second cautery ; or, lastly, it may 
 even be introduced into the cervical cavity, care being taken to pro- 
 tect the healthy part by one of Eecamier's large curettes. In most 
 cases, however, the operation is much simpler, being limited to one or 
 more punctures varying in depth from 5 to 15 millimetres, in one or 
 other of the lips of the cervix. At other times excision of the diseased 
 part may be performed by making use of a univalve in place of a 
 cylindrical wooden speculum, and fixing the cervix by means of fine 
 tenaculum hook forceps. 
 
METHODS OF TREATMENT AND MEDICATIONS 
 
 21; 
 
 Immediately the cautery is withdrawn cold water should be poured 
 into the speculum several times ; this instrument may then be with- 
 drawn, when the patient is placed in 
 bed in the dorsal decubitus with legs 
 and thighs flexed. Cooling applications 
 may be made to the hypogastrium, 
 vulva, and upper part of the thighs, 
 of vinegar and water, the ice-bag, &c. 
 
 Serious accidents may happen affer 
 cauterisation. They rarely occur unless 
 the patient is suifering from metritis, 
 ovaritis or perimetritis. However, the 
 freedom from pain during the operation, 
 the superficial action of certain slight 
 cauterisations and the absence of trou- 
 blesome consequences after imprudences 
 committed by some patients subsequent 
 to this operation, have inspired some 
 practitioners with too blind a confidence 
 in the innocuous nature of this means, 
 and a blameable temerity in its use. I 
 have seen patients who had actually 
 been cauterised by a doctor in his con- 
 sulting room ! I have also seen the de- 
 plorable consequences of such impru- 
 dence. Although the cervix is not 
 sensitive to pain, there is none the less 
 a reaction after the traumatism that has 
 been undergone. An inflammation 
 of elimination is necessarily developed 
 round the scar; this inflammation if 
 neglected may pass the limits within 
 which it ought to be confined, and ori- 
 ginate very serious pathological pheno- 
 mena. Therefore, in order to avoid 
 all accidents every possible precaution 
 should be taken, not only by avoiding 
 cauterisation even with nitrate of silver 
 during the week preceding the cata- 
 menia, but also by insisting on the 
 patient remaining in bed for several 
 days, the hypogastrium being covered 
 with cooling or emollient applications. 
 She should take an emollient bath every 
 day, remaining in it for an hour at least, 
 and making vaginal injections all the 
 time ; or if this cannot be done, vaginal 
 irrigations should be made several times 
 a day with some disinfectant. Thanks to these precautions, I have 
 
 Fig. 193. — Ignipnnctnro of 
 the cervix, which is kept 
 fixed by the divers^ing 
 tenaculum hook forcep.s. 
 
214 
 
 TEEATMENT OF UTEEINE DISEASES IN GENERAL 
 
 never seen any accident follow the numerous cauterisations I have 
 performed, but on the contrary they have always produced good 
 results. 
 
 When the cervix is very much engorged or when considerable folli- 
 cular hypertrophy exists, I follow the excellent advice given by 
 Huguier, making a number of scarifications before cauterising. 
 
 The cervix may be cauterised even during pregnancy if the precau- 
 tions are taken which I have just detailed. I need hardly say that 
 the redhot iron is not to be applied to the cervix of a pregnant 
 woman who is merely suffering from simple granulations, not exceed- 
 ing the limits often assumed by this morbid condition during preg- 
 nancy, and giving no cause to fear a miscarriage. When, however, 
 the cervix is seriously affected recourse may be had to cauterisation 
 without misgiving; the operation being practicable from the end of 
 the first month to the end of the sixth. There need be no anxiety as 
 to causing abortion ; on the contrary, one of the advantages of this 
 little operation in such a case is, that it increases the chances against 
 the occurrence of this accident.^ Eacts have proved to me not only 
 the immunity of the actual cautery,^ but also that its application in 
 
 Fig 194. — Apparatus for cauterising with gas. 
 
 the case of pregnant women is followed in due time by a safe and 
 normal delivery.^ 
 
 1 Mauny has puhlished five cases of persistent vomiting during pregnancy, 
 cured by cauterisation of the cervix with nitrate of silver or with acids. 
 Paris, 1869. 
 
 2 Annales cliniques de Montpellier, 25 aout, 1853. 
 
 3 Ibid., 10 avril, 1854. 
 
METHODS OF TREATMENT AND MEDICATIONS 
 
 215 
 
 I have also cauterised the cervical cavity when its mucous mem- 
 brane was the seat of follicular or granular hypertrophy. Great care, 
 however, must be taken to cauterise only the fungous and exuberant 
 parts, protecting the rest from the action of the heat. Otherwise we 
 should run the risk of causing scars, which might obliterate or at 
 least narrow the orifices, as unfortunately too often happens. 
 
 Nelaton has recommended using the flame of a gas-jet in place of 
 the red-hot iron. The advantages of this cautery are, that it does not 
 frighten the patient, who need not even be aware of the kind of 
 operation about to be performed; it allows the cauterisation to be 
 defined as exactly as if done with a pencil, and above all it permits of 
 a more energetic action, as the gas flame can be kept in contact with 
 the diseased part as long as necessary. It is therefore superior to the 
 red-hot iron in many ways. In other respects, however, it is inferior. 
 It only acts on surfaces, it cannot be used for cauterising the cervical 
 x;avity, for removing an excrescence, for scarifications, nor for deep 
 
 Fig. 195. 
 
 Pig. I'.M) 
 
 Fig. 196. — Galvano-thermo-caustic battery. 
 
 Fig. 197. — g, platinum bistoury ; L, cautery in fcirm of a knife ; i\ 
 cautery ; o, cylindrical cautery. 
 
216 
 
 TREATMENT OP UTERINE DISEASES IX GENERAL 
 
 ignipunctureSj which in my opinion are the most useful application 
 that can be made of the actual cautery to the uterus. 
 
 The galvanic cautery is applied by means of a galvano-caustic 
 handle or knife, and has been popularised by Middeldorpf. Electro- 
 lysis has been recommended by Ciniselli and adopted by some sur- 
 geonSj who consider it very valuable ; they believe that in performing 
 a section by means of the negative pole around which the alkaline 
 elements arrange themselves, the scar will be soft, and the subsequent 
 cicatrix non-retractile (which remains to be proved ; in my opinion 
 cicatricial tissue is always cicatricial tissue, i.e. retractile). The diffi- 
 culty of keeping galvanic and electrical apparatus in order will always 
 prevent their coming into general use. 
 
 Paquelin's thermo-cautery has not the same drawbacks. At my 
 request Collin has succeeded in making spear-shaped cauteries, some 
 curved others conical, but as yet he has not been able to make any 
 sufficiently pointed to serve for ignipuncture of the cervix. This 
 apparatus though much simpler than electrical machines requires con- 
 siderably more attention than the eolipyle lamp. Therefore this lamp 
 and the ordinary cauteries seem to me preferable to all other instru- 
 ments for cauterising the uterus. 
 
 Fig. 197. — Paquelin's thermo-cauteiy. 
 
 To understand the harmlessness of the actual cautery when applied 
 to the uterus with the precautions indicated, we must remember that 
 the fibro-plastic nature of the tissue, the tendency to hypertrophy, the 
 remarkable facility with which the mucous membrane of the uterus is 
 renewed, this instability of a tissue which I have described as being 
 constantly in process of organisation, must greatly facilitate the pro- 
 cess of repair in an organ like the uterus, when destruction has only 
 
METHODS OF TREATMENT AND MEDICATIONS 217 
 
 extended to a small part of its mucous membrane, and especially when 
 this destruction has been limited to pathological excrescences. Not 
 only is cauterisation of the uterus not invariably followed by the for- 
 mation of a cicatrix, but the cauterised cervix which previously was 
 hard becomes soft. There must, therefore, have been a work of 
 absorption going on, perhaps the production of new elements ; but 
 not, strictly speaking, the formation of cicatricial tissue. There is 
 frequently even partial renovation of the mucous membrane. The 
 oritice is the only part we must always treat carefully. 
 
 Only a short time since I had a new proof of the wonderful facility 
 with which repair of the uterine tissue takes place. It was a chronic 
 case of complete inversion of the womb ; reduction was impossible, 
 and it seemed to me that the only indication was the ablation or de- 
 struction of the organ by the actual cautery. The ordinary cauteries 
 seeming to me insufficient, I had one made expressly of a large piece 
 of iron, forming therefore a much larger reservoir of heat than our 
 largest cauteries, and slightly excavated on the surface so as to mould 
 itself to the convexity of the uterus. I applied it at white heat to the 
 mucous membrane, leaving it long enough to lead me to hope I 
 had effected destruction; but with the exception of a very limited 
 spot, the whole of the mucous membrane resisted, or rather was 
 renewed so effectively, that after making fourteen cauterisations (which 
 were much more painful than those of the cervix) I had to renounce 
 further attempts. In proportion as the scar was detached healthy 
 granulations appeared underneath, and after a few weeks I found the 
 surface covered, not with hard and retractile cicatricial tissue, but with 
 a soft membrane resembling the mucous membrane of the uterus in 
 appearance. It is certain that the red hot iron does not produce so 
 deep a scar as one would think, nor as that caused by chloride of 
 zinc. The rapid drying of the surface prevents the action of the fire 
 from extending, so that the tissues underneath are modified rather 
 than destroyed. 
 
 I only know one contra-indication to the use of the cautery, whether 
 actual or by caustics, and that is the e^^istence of inflammation, and 
 especially of peri-uterine inflammation. I catinot repeat the caution 
 too frequently that it is very imprudent to cauterise, especially inter- 
 nally, in cases of parenchymatous metritis, and even of inflammation of 
 the mucous membrane, a disease all the more dangerous because it may 
 simulate a simple catarrh or be coincident with it, and pass unper- 
 ceived in a superficial examination. In order to arrive at a correct 
 diagnosis we must have recourse to inspection, touch and the 
 uterine sound ; for cauterisation performed in such circumstances 
 has led to serious suppuration in the uterus and its appendages ending 
 in death. 
 
 At present I am attending a patient suffering from serious uterine 
 and peri-uterine inflammation, developed after an inopportune cau- 
 terisation, made, however, by a Trench surgeon who justly enjoys a 
 great reputation. I am convinced, from knowledge of the special 
 antecedents of this patient, that the inflammation existed before cau- 
 
2J8 
 
 TEEATMENT OF UTERINE DISEASES IN GENERAL 
 
 terisation, tliat it passed unnoticed because the patient was only exa- 
 mined with the speculum unaided by touch and palpation, and that it 
 was deplorably aggravated by the operation. 
 
 The scar generally falls between the tenth and 
 fifteenth day. Cicatrisation should be hastened, 
 and therefore, besides continuing the general treat- 
 ment of baths, irrigations, and (when indicated) 
 astringent and detersive injections, medicated 
 applications should be made to the cervix at 
 variable intervals. I may mention the following 
 as particularly useful : laudanum, when all that 
 is necessary is to promote the natural tendency of 
 the wound towards cicatrisation; the solution of 
 nitrate of silver, when it is desirable to stimulate 
 the healthy granulations ; basic peroxychloride of 
 iron/ when the wound has a tendency to bleed, 
 and when vascular fungous growths seem ready 
 to reappear on the surface; the concentrated 
 aqueous solution of tannin, or even the crayons 
 of tannin invented by Becquerel, for a lesion not 
 extending beyond the cervical cavity, when the 
 catarrhal condition and aqueous infiltration seem 
 to have caused the development of granulations 
 (I have a case of slight catarrhal granulations 
 where the application of these craj'ons sufficed 
 to effect a cure) ; iodoform and the tincture of 
 iodine, when the engorgement of the cervix and 
 the size of the granulations seem to indicate a 
 scrofulous diathesis; the tincture of iodine and 
 the perchloride of iron, when the mucous secretion 
 is very abundant, or when the wound is pale or 
 diphtheritic, and requires to be stimulated or mo- 
 dified, or when it threatens to bleed, &c. 
 
 3. The cauterisation of the uterine cavity is 
 performed in a different way. Everything here 
 contra-indicates the use of energetic caustics ; 
 liquid or solid caustics cannot be blindly applied 
 to diseased parts without risk of causing great 
 injury; the red-hot iron must not on any account 
 be used, it would burn the orifices and the cervical 
 walls before reaching the part requiring cauteri- 
 sation ; and yet we cannot doubt the existence of 
 fungosities and granulations on the mucous mem- 
 brane of the body, less frequently, but still as 
 decidedly, as on that of the neck ; nor can we 
 deny that the means which succeed best in the 
 treatment of these diseases would be applicable 
 to the mucous membrane of the body as well as 
 ^ Montpellier ^medical, 1858. 
 
 do 
 
 Fig. 198. 
 Two graduated ute- 
 rine sounds of dif- 
 ferent calibre. 
 
METHODS OF TREATMENT AND MEDICATIONS 
 
 219 
 
 to that of the neck. Leucorrhcea itself, a morbid condition of the 
 glands of this mucous membrane, seems to require the intervention 
 of active applications. Might we not hope that astringents, cathartics, 
 caustics would effectually help the action of general treatment as well 
 as in analogous diseases of the vagina and cervix ? This conviction 
 has suggested the idea of applying liquid modifications and even 
 caustics by means of injections. 
 
 The intra-uterine injections practised by Melier, Yidal (of Cassis),^ 
 Scanzoni and Aran, and met with disapproval by Hourmann, Nonat, 
 &c., must be ranged among the most energetic means of modifying 
 the tissues, but also the most dangerous that can be employed, if not 
 practised according to the rules about to be laid down. 
 
 We must begin by cleaning the uterine cavity from the mucus 
 which covers it, either by injections of pure water, or by painting it 
 
 Fig. 199. — Canula on whicli a fine india-rabber sound may be screwed, and 
 wbich is fixed at the other end to the small injection syringe. 
 
 Fig, 200. — Small graduated syringe for making uterine injections. 1, syringe 
 in its metal case, the canula enclosed in the stem of the piston ; 2, syringe 
 ready for use, which may be fitted to the metal sound or to a gum-elastic 
 sound by means of the canula. 
 
 with yolk of egg to form an emulsion with the mucus and thus to 
 expel it more easily. Then a caustic injection is made. The use of 
 the uterine sound greatly facilitates the operation. Whether we use 
 a fine india-rubber sound introduced by means of a wire in the interior, 
 which is withdrawn immediately afterwards, or a hollow uterine sound 
 made after the model of Simpson's, it is in any case useless to have 
 one with a double canula, as the liquid should be able to flow back 
 round about the sound, which ought to move freely in the orifice. As 
 for the instrument of propulsion, whether the india-rubber bag of 
 Hardy (of Dublin) be used, or the graduated syringe which Collin 
 has made at my request, the process is the same, and consists in first 
 introducing the sound, then adjusting the syringe to its extremity and 
 ' Essais sur le traitement methodique cles maladies uterines. Paris, 1840. 
 
220 TEEATMENT OF UTEEINE DISEASES IN GENERAL 
 
 propelling the liquid very slowly, so as not to distend the cavity of the 
 uterus, lest the sound by filling the orifice should prevent the free 
 return of the liquid into the speculum. The speculum is always indis- 
 pensable when a caustic liquid is used, to prevent the cauterisation of 
 the vagina by the liquid as it issues from the uterus. 
 
 Nothing could be simpler or more efficacious than these injections 
 if the susceptibility of the mucous membrane, the narrowness of the 
 cervico- uterine canal, and the permeability of the Fallopian tubes were 
 not the source of dangers, all the greater that they are sometimes not 
 foreseen, and that the greatest skill and prudence have not always suc- 
 ceeded in preventing them.^ As for myself, I have often made these 
 injections without any bad result; but although I have never had 
 occasion to deplore the death of a patient, I have sometimes seen the 
 instantaneous occurrence of such formidable accidents after injections, 
 that I have resolved never to make another caustic injection, or even 
 one of simple water, unless assured of a free passage through the cervico- 
 uterine orifice, allowing of the easy reflux of the liquid into the vagina 
 as soon as it. has filled the uterine cavity. In this case there is nothing 
 to fear. We may, therefore, without misgiving follow this rule : 
 to make an injection into the uterus when the orifice is sufficiently wide 
 to allow the excess of liquid to flow hack through the cervix ; in all 
 other cases to abstain from this mode of treatment.^ This operation, 
 moreover, must only be performed in the middle of the intermenstrual 
 period. 
 
 The liquids used are : simple water, solutions of tannin, alum, sul- 
 phate of zinc, nitrate of silver, acid nitrate of mercury, tincture of 
 iodine, perchloride of iron, and even of chloride of zinc. 
 
 1 must, however, repeat that every liquid caustic may become 
 dangerous : (1) because it touches all parts of the mucous membrane, 
 and so may cause too extensive a destruction, or excite an irritation in 
 the mucous membrane, followed by inflammation dangerous in itself, 
 and which may spread to the mucous membrane of the Fallopian tubes 
 and to the peritoneum ; {;Z) because the uterine cavity is so small that 
 all the liquid may not flow back by the orifice, and, even when it can 
 return freely, part of it may penetrate the orifice of the Fallopian 
 tube and cause fatal inflammation. Therefore I restrict intra-uterine 
 injections, in those rare cases which absolutely require them, to simple 
 water used as a lotion, or to a very small quantity of catheretic rather 
 than caustic liquid : — tincture of iodine, perchloride of iron, nitrate of 
 silver, beginning with a very weak solution and increasing very gra- 
 dually ; and I never make thetn when there is any cause to fear that, 
 owing to a flexion, a deviation of the cervico-uterine canal, a constric- 
 tion of the orifice, or any other obstacle, the liquid injected cannot 
 return easily from the uterine cavity into the vagina. This is no doubt 
 
 ^ Nseggerath has related a case of death resulting from caustic injections 
 into the uterus {Neio YorTc Journal of Medicine and Gazette med de Paris, 
 1861, p. 190). 
 
 2 Gantillon, du Catarrhe uterin. These de Paris, 1868. Guyot, des Injec- 
 tions intra-uterines. These de Paris, 1868. 
 
METHODS OF TREATMENT AND MEDICATIONS 
 
 221 
 
 equivalent to a half condemnation. In fact, I hardly ever perform 
 this little operation since I recognised its attendant dangers, and espe- 
 cially since I ascertained the entire freedom 
 from injurious results of the introduction 
 into the cavity of the uterus of a small 
 quantity of solid or pulverised nitrate of 
 silver. There are, however, cases of obsti- 
 nate haemorrhage and abundant leucorrhoea, 
 where injections of tannin, iodine, &c., have 
 been of great use. 
 
 Intra-uterine cauterisation ought only to 
 be practised with nitrate of silver. Any 
 other caustic seems to me dangerous, except 
 in cases of serious alteration with suspicious 
 vegetation of the whole mucous surface, 
 when nitric or chromic acid, in solutions of 
 varying strength, or even chloride of zinc 
 may be indicated. 
 
 Nitrate of silver may be applied to the 
 uterine cavity in various ways. It may be 
 introduced by a brush dipped in a concen- 
 trated solution of the caustic, or the wet 
 brush may be rolled in powdered nitrate of 
 silver, or a sponge tent may be covered 
 with wax and rolled in the powder, according 
 to Gillespie^s plan {Lyon medical, 20 
 aout, 1871). We may even with the 
 brush, which presents none of the dangers 
 of injections, apply other caustics, such as 
 the aqueous solution of tincture of iodine, 
 perchloride of iron, and even chloride of 
 zinc, as I have done several times. 
 
 The mode I adopt is as follows : I com- 
 mence by introducing the sound into the 
 cavity so as to learn the direction to be 
 given to the instrument, taking care always 
 not to cause hsemorrhage. Immediately 
 after withdrawing it I insert a fine camePs- 
 hair brush, mounted on a long handle and 
 soaked in a strong solution of nitrate of 
 silver, or rolled in the powder, and repeat 
 the application a second and even a third 
 time if the os internum remains sufficiently 
 open to allow of it. Whilst this is being done 
 I fix the cervix by means of the converging 
 tenaculum hook forceps. In most cases this 
 application repeated once a month three or 
 four times is quite sufficient to produce the 
 desired effect ; but in some rare cases, where a more powerful action is 
 
 Fig. 201. — Cauterisation of 
 the uterine cavity by 
 lueans of a brush. 
 
222 
 
 TEEATMENT OF UTERINE DISEASES IN GENERAL 
 
 necessary, it has been suggested that the crayon should be introduced 
 and applied to the mucous membrane lining the cavity in the same 
 way as to ulcers of the cervix, or to the proud flesh of an external 
 wound. Till lately, however, practitioners feared the danger that 
 might be incurred by a fragment of the caustic being broken off and 
 remaining in the womb. Having assured myself not only of the 
 harmlessness, but even of the good results consequent on this accident, 
 and having considered the advantages which might accrue from leav- 
 ing a fragment of nitrate in the cavity of the womb provided its use 
 was indicated, and that precautions were taken to avoid troublesome 
 consequences, I have not hesitated to try this means of cure for obsti- 
 nate leucorrhoea and fungous growths. Experience has answered my 
 expectations in the most satisfactory way, and at present the introduc- 
 
 FiG. 202. — Uterine caiis- 
 tic-holdei'. a, sound ; 
 b, stylet. 
 
 Fig. 203. — Extremity of different uterine caustic- 
 holders. 1, large sound with two large orifices 
 for ointment ; 2, 3, smaller sounds for passing 
 solid or pulverulent caustics into the uterus. 
 
 tion of nitrate of silver into the uterus is not only one of the little 
 operations which I perform as frequently as cauterisation of the cervix 
 or of the cervical cavity, but it is a recognised application in gyneco- 
 logical therapeutics. I perform it in the following way : I choose a 
 crayon of varying length, according to the size of fragment I intend to 
 leave in the uterus ; generally a very small crayon is sufficient. I 
 
METHODS OP TEEATMENT AND MEDICATIONS 223 
 
 round and point the extremity, rolling it between the fingers in a 
 piece of coarse wet linen, so as to facilitate its introduction ; then I fix 
 it in an ordinary platinum caustic-holder with a long handle, or seize 
 it with the uterine forceps, or place it in the end of Braun's sound. 
 After having introduced the sound in order to learn the direction of 
 the cervico-uterine canal, but very gently so as to avoid causing spas- 
 modic contractions of the orifice, I apply the crayon to the uterine 
 cavity ; then, in place of trying to withdraw it intact, I try to push it 
 in by partly opening the forceps, or to break it by inclining the 
 caustic-holder abruptly, or I thrust it in by means of the gutta-percha 
 sound invented by Braun of Vienna^ for this purpose; immediately 
 afterwards I introduce into the vagina a large tampon, soaked in salt 
 water, so as to neutralise the nitrate of silver which, as it dissolves, 
 issues from the uterine cavity, and to protect the vagina and cervix. I 
 keep this plug in place by a larger dry one, and then withdraw the 
 speculum. In addition to these the same precautions are taken to 
 prevent the development of inflammation as are used after the actual 
 cautery. 
 
 I may say that I do not know a more heroic means of treatment 
 than leaving a fragment of crayon in the uterine cavity in those cases 
 of large fungous granulations fo r which Eecamier invented his curette, 
 and above all in cases of chronic and obstinate leucorrhoea, which 
 cause despair to patients and physicians alike. It seldom happens 
 that this little operation is required a second time. 
 
 I have never seen serious accidents follow this mode of treatment. 
 The cauterisation of the vagina is prevented by the introduction of the 
 plug soaked in salt water; inflammation of the uterus or of its mucous 
 membrane by baths, vaginal irrigations and absolute rest; and pain, 
 spasm or nervous erethism, which are the most common accidents, by 
 an antispasmodic draught or an opiate enema. 
 
 I have only once seen excruciating pain alleviated neither by baths, 
 antispasmodics, nor narcotics. It was owing to expulsive efforts and 
 uterine contractions produced by a considerable swelling of the cervix 
 which caused a temporary occlusion of its orifice. . This morbid condi- 
 tion, which prevented the expulsion of the mucus abundantly secreted 
 under the irritating influence of the nitrate of silver, being the sole 
 cause of these pains, a cause purely mechanical, I incised the cervix a 
 few hours after the operation to facilitate the expulsion of the mucus, 
 as well as of the nitrate of silver itself. The symptoms ceased imme- 
 diately, and the good eflects of the cauterisation were produced all the 
 same. In all my other cases, the pain, which has occurred more 
 frequently than after cauterisation of the cervix, and which has some- 
 times been severe, has always yielded to general and local antispas- 
 modics, and to baths asiociated with continuous vaginal irrigation. 
 
 Besides, if the nitrate is only left in the uterine cavity when the 
 
 ' Since then a year never passes without a new instrument heing invented 
 for precipitating a fragment of nitrate of silver into the uterus, which is the 
 best refutation of the objections made to my method, i.e. before having tried 
 it experimentally. 
 
224 TREATMENT OF UTEEINE DISEASES IN GENERAL 
 
 orifices are gaping, tlie mucus, which is abundantly secreted imme- 
 diately after the operation, is easily expelled under the influence of 
 uterine contractions, and it rarely happens that these contractions are 
 painful. Sometimes the orifices are so patent that the crayon is 
 expelled with the mucus. As it is not always necessary to introduce 
 a large fragment, I often use ordinary open sounds furnished with a 
 piston for propelling a small bit of nitrate, or simply the powder or an 
 ointment. 
 
 The contra-indications to this little operation are very clear. The 
 first and most absolute is the existence of an inflammatory state of the 
 uterine system. This rule alone would prevent many accidents. 
 Another important contra-indication is never to leave the crayon in the 
 uterine cavity when the secretions would have any difficulty in escaping. 
 Consequently I never do so in cases of flexion, deviation of the uterine 
 canalj or constriction of the orifices. 
 
 I must now explain what takes place through the agency of this 
 mode of cauterisation, and also account for its innocuity. The chief 
 cause of its harmlessness is that the mucous membrane of the womb 
 does not experience the direct and immediate action of the caustic. In 
 fact the nitrate of silver cannot be brought into immediate contact with 
 the mucous membrane, nor can it produce an energetic cauterisation on 
 any part of it. The presence of the crayon causes hypersecretion of 
 mucus, which protects the membrane, the crayon being enveloped with 
 the mucus which coagulates around it from the first; afterwards it is 
 only through this envelope that an exchange can be effected between 
 the caustic and the secretions of the uterine cavity. We know this 
 from seeing the crayon as it escapes seven or eight days afterwards, or 
 rather its form, for it is strangely altered, decomposed, softened and 
 foliated. It is evident that it has been greatly modified by its sojourn 
 in the uterine cavity ; it is evident also that it has not dissolved as it 
 would have done in a glass of water. A series of successive exchanges 
 have been made between the elements of which it is composed and 
 those of the mucus secreted by the membrane lining the uterus. The 
 impression, therefore, made on the organ by the caustic must have been 
 very gradual. This action difl'ers, without doubt, from cauterisation 
 properly so called ; we can understand also that, if some parts are more 
 aft'ected than others, it must be the superficial ones, the granulations, 
 the exuberant fungosities, the hypertrophied follicles. In short, we 
 can understand that this modification of the uterine cavity is prefer- 
 able to that produced by injections which penetrate further, reaching 
 all the recesses of the mucous membrane, even of the Fallopian tubes, 
 and presenting dangers the existence of which is proved both by 
 experience and theory. 
 
 4. Eecamiev^s uterine curette is a metallic stem in steel, twelve inches 
 in length, of the thickness of an ordinary goose quill, cyHndrical in 
 the middle, presenting at each of its extremities a curve, which allows 
 of its being more easily adapted to the axis and direction of the uterus. 
 Its curves are disposed inversely with regard to each other. Their 
 concave sides are excavated in deep grooves of unequal length, the 
 
METHODS OF TREATMENT AND MEDICATIONS 
 
 225 
 
 edges of which, although blunt, are very fine, like those of a rasp, 
 and capable of removing exuberances of the mucous membrane by 
 friction. After introducing the instrument into the uterine cavity 
 
 Fig. 204. 
 
 4y 
 
 Fig. 205. 
 
 pi 
 
 i 
 
 ^4^ 
 
 Fig. 206. 
 
 Fig. 204. — Eecamier's uterine curette. 
 
 Fig. 205. — Sims's curette, eifecting abrasion by the external border. I have 
 
 had one made which abrades with the internal border. 
 Fig. 206. — Button-hook curette, diilering from the other two in not being 
 
 closed, so that it can be used for the removal of a polypoid excrescence. 
 
 The stems of these instruments not being tempered, they can be inclined 
 
 to suit the direction of the cervico-uterine canal. 
 
 Recamier used to impart to it light movements of circumduction as 
 well as in a vertical direction, so as to explore successively every part 
 of the mucous membrane. If he found that some points were 
 especially exuberant, he scraped the mucous membrane with one 
 edge of the groove, and when both of the walls seemed sufficiently 
 smooth he withdrew the instrument, taking care to turn the groove 
 upwards, so as to bring away the fungosities just abraded. I have 
 often in this manner extracted fungosities, which were the only cause 
 
 15 
 
226 
 
 TEEATMENT OF UTERINE DISEASES IN GENEEAL 
 
 of metrorrhagia which ceased after abrasion by the curette. Eecamier 
 sometimes repeated the operation several times at intervals of a few 
 days. Each scraping was followed by cauterisation with nitrate of 
 silver and bathing of the uterine cavity. 
 
 This operation has been severely criticised by some and too much 
 praised by others. To say thatMarjolin, Robert, Trousseau, Nelaton, 
 Maissonneuve, Nonat, &c., have practised it several times with success 
 is a sufficient justification of the use of the curette. When there are 
 no fungosities it cannot do very great harm to pass the curette 
 lightly over the mucous membrane, and when there are it alone can 
 remove them quickly and surely. It is, therefore, undoubtedly of 
 great value. I specially recommend its use for the abrasion of a little 
 polypus or fungosity clearly diagnosed by means of the sound. In 
 such a case it may be necessary to have recourse to Sims's curette, 
 which is broad, or to mine, which I have left open on one side in the 
 form of a button hook. 
 
 It cannot be denied that in cases of softening of the uterine tissue 
 the curette may have produced perforations which, though cured in 
 some cases, have in others had a fatal result. The danger of this 
 accident, which is very rare and always easy to avoid, ought always 
 to be present to the mind of the surgeon, who will 
 /\ use every precaution and even abstain from abra- 
 L^ sion in all cases where flexion 'of the uterus or 
 I'* J softening of its tissue would facilitate the penetra- 
 tion of the curette through the uterine walls. 
 
 5. Simpson's infra-uterine dry cupping instrument 
 is a hollow sound perforated with holes at the terminal 
 extremity, whilst the other end is screwed on to a 
 little aspirating pump, by means of which a vacuum 
 can be made. The diameter of the sound is suffi- 
 cient to fill the cervico-uterine orifice when the 
 rounded extremity is in the cavity of the womb. 
 In proportion as a vacuum is made in the body of 
 the pump a kind of aspiration is exercised on the 
 uterine mucous membrane which comes in contact 
 with the little openings of the sound. After repeat- 
 ing this application several days running, at the 
 time when the catamenia ought to appear, there is 
 a flow of blood towards the mucous membrane, and 
 at last there may be a little oozing of blood from it. 
 Simpson used to have recourse to this little opera- 
 tion for amenorrhoea, but it has not been adopted by 
 the profession. It is a complement of the intro- 
 duction of the galvanic stem and of the dilatation of 
 the orifice by stem pessaries of gradually increasing 
 diameter. 
 B. Special operations. — The operations which remain to be men- 
 tioned are so entirely special that the description of them cannot well 
 be separated from the history of the diseases for which they are indi- 
 
 Fig. 207. 
 Intra - uterine 
 sonnd for drj- 
 cupping the ute- 
 rus (Simpson). 
 
METHODS OF TREATMENT AND MEDICATIONS 
 
 227 
 
 Fig. 208.— Simpson's simple Fig. 209.— Mathieu's Fig. 210.— Division of the os ex- 
 hysterotome. double liysterotome. ternum with the blunt-pointed 
 
 1, open ; 2, shut. concealed bistoury and diver- 
 
 gent tenaculum hook forceps. 
 
 cated. Some of tliem, though offering no apparent difficulty, and 
 though devoid of all real gravity, are not on that account unaccom])anicd 
 by dangers, occurring either from ignorance of the exact anatomical 
 knowledge required, or from induced hccmorrhage, or even from serious 
 
228 TREATMENT OF UTERINE DISEASES IN GENERAL 
 
 accidents consequent upon them, such as the putrefaction of pus, the 
 entrance of air into a purulent or sanguineous centre, the decomposi- 
 tion of liquids contained therein and the purulent or y)utrid absorp- 
 tion which may be one of these consequences. Others take their 
 place among the most serious operations of surgical art, and neces- 
 sitate special knowledge as well as an experienced hand and a mind 
 familiar with all the accidents and all the resources of general 
 surgery. 
 
 6. Amongst the first class we may include division of the cervical 
 orifices ; perforation of the hymen, vagina or uterus, in cases of atresia 
 of these organs ; puncture of peri-uterine, uterine, or ovarian tumours, 
 whether by the vagina or the abdomen ; injections of various kinds into 
 centres, the contents of which have previously been evacuated. 
 
 The division of the cervical orifices indicated in cases of constric- 
 tion, of mechanical and even of membranous dysmenorrhoea, sterility, 
 or even of intra-uterine tumour (to facilitate means of access), is 
 performed by means of simple instruments such as scissors, bistouries, 
 sharp- or probe-pointed, with a director, &c., as on any other part of 
 the body, with this difference that these instruments must be long 
 enough to reach the uterus. Sometimes it is more convenient to 
 use special instruments or hysterotomes, the concealed blades of which 
 are made to spring out from their sheath wh^n required. They may 
 be either single or double-bladed like lithotomy knives, which they 
 resemble in this respect. The simple hysterotome invented by Simpson 
 is one of the most useful. Those which are double-bladed are 
 preferable in some circumstances, owing to the rapidity with which 
 they allow of the operation being performed. Or short-bladed 
 straight scissors may be used. Kiichenmeister has invented a pair, 
 the external blade of which is furnished with a point which fixes 
 it firmly in the uterine tissue; others have blades with teeth like 
 a saw to prevent hsemorrhage. As for myself, I prefer fixing 
 the cervix by means of diverging tenaculum hook forceps introduced 
 into its cavity and stretching the os so as to facilitate its incision to 
 the required depth by a simple bistoury v^'ith a fine concealed blade, 
 like that of Blandin. Sometimes simple division is not enough, it 
 being impossible to preserve a sufficiently large opening without really 
 performing autoplasty of the orifice. There is a great difference between 
 division of the os externum and the os internum as regards the 
 gravity of the operation. Iq performing the last great care must be 
 taken not to pass beyond the uterine tissue. My reason for preferring 
 the simple tenotomy knife or Simpson^s hysterotome to the double- 
 bladed one is that I generally make a superficial incision, dilating 
 afterwards with sponge tents. It should always be remembered that 
 this operation must never be performed at the menstrual period, or 
 even within a week of the time. 
 
 I shall simply refer, as a means of treatment, to dilatation of the 
 cervix by bougies, stem pessaries, sponge tents, or other dilating 
 bodies, about which I have already spoken in detail as means of 
 diagnosis. 
 
METHODS OF TREATMENT AND MEDICATIONS 229 
 
 Punctures are generally made with trocars of various forms, straight 
 or bentj and of different sizes, from the exploratory trocar intended for 
 capillary punctures in supposed abscesses of the Fallopian tube or 
 peri-uterine abscesses to the large one with which an ovarian cyst is 
 punctured, especially in ovariotomy, in order to hasten and facilitate 
 the escape of the thick fluid often contained in it. These different 
 kinds of trocars, as well as the apparatus annexed to them either for 
 increasing the orifice in cases of hematocele or retro-uterine abscess or 
 for retaining the walls of the cyst and preventing effusion of the fluid 
 into the peritoneum during ovariotomy, will be described with each of 
 these diseases and the operations which they necessitate. 
 
 Deep injections, generally more injurious than useful unless simply 
 detersive, are made into the various peri-uterine centres or into ovarian 
 cysts, as into every other enclosed cavity, by means of a syringe 
 fitted on to the canula of a trocar. I have sometimes been able with 
 great advantage to substitute for these injections real lotions made 
 with a double canula sound to which a small hydroclyse has been 
 fixed. 
 
 7. The second class of these special operations comprises antoplasty 
 and the more or less serious operations necessitated by the partial or 
 total absence of the vulvo-uterine canal, the excision or amputation of 
 the cervix, the ablation of polypi by ligature or bistoury, the reduction 
 of displacements, the taxis for the reduction of uterine inversion, the 
 extirpation of pediculated or interstitial fibromata, and, lastly, amputa- 
 tion of the ovary and of the uterus — an operation revived in our times 
 with great success. 
 
 The operations necessitated by extensive vaginal imperforations or 
 obliterations are very serious, their success being very variable and 
 depending on the conditions under which they are performed. Their 
 great difficulty arises from the necessity of performing autoplasty of a 
 canal without having a sufficient extent of mucous membrane. Hence 
 the danger of encroaching on neighbouring organs (bladder or rectum) 
 whilst making a way by incision, dilatation, tearing, &c., in the narrow 
 space which separates them. Hence also the imperfection of the 
 results obtained,' owing to the impossibility of lining the new canal 
 with true mucous membrane, at least to the extent required, whilst 
 almost all the benefit of the operation is lost owing to the formation 
 of retractile cicatricial tissue. 
 
 Amputation of the cervix, indicated in cases of conicity, elongated 
 hypertrophy, or incurable organic alteration of this segment of the 
 uterus, is performed by means of long curved bistouries or scissors 
 while the organ is pulled down ; in cases of hypertrophy of the supra- 
 vaginal portion a long and troublesome dissection is required, necessi- 
 tating great precautions against hcemorrhage. Consequently it is 
 better, as a rule, to perform the operation with the thermo-cautery. 
 
 The same remarks are applicable to the removal of polypi. To the 
 methods already mentioned we may add avulsion and torsion for small 
 vascular tumours, and the ligature, especially the elastic ligature, used 
 as in former times to effect strangulation and slow detachment by 
 
230 TREATMENT OF UTERINE DISEASES IN GENERAL 
 
 sloughing. Later on we shall consider the respective indications for 
 these different methods. 
 
 The reduction of chronic uterine inversion and the extirpation of 
 the tumour are operations of the most serious description, but fortu- 
 nately are very seldom necessary. 
 
 The extirpation of fibromata, although easy when the tumours are 
 small, presents great difficulties in the contrary case, and has led to 
 the invention of a most ingenious method of operation, consisting in 
 the division of the tumour in situ, and the extraction of it in fragments. 
 These extractions necessitate long forceps furnished with claws and 
 instruments of prehension of various kinds, in the fabrication of which 
 great perfection has been attained during the last few years. The 
 increase in size of fibrous myomata may be an indication for the partial 
 or total extirpation of the uterus by abdominal section. 
 
 Lastly comes ovariotomy, the most serious of all these operations, 
 so serious that it has not yet been generally adopted. The minute 
 details necessary and the various rules laid down by the enterprising 
 minds who have most frequently performed this conquest of modern 
 surgery must be reserved till we come to the description of ovarian 
 cysts and serious alterations of the uterus. 
 
 Gynecological Apparatus 
 
 My pupils have very frequently asked me to furnish a list of the in- 
 struments most necessary for examining women affected with uterine 
 diseases, for making the applications and performing the various 
 operations which these diseases may necessitate. Now the instruments 
 which serve in diagnosing diseases of women have the exceptional 
 advantage pointed out by Barnes, viz. that of serving for treatment as 
 well as for diagnosis. I divide gynecological instruments into three 
 categories : 1. Those which the gynecologist ought always to have 
 with him, i.e. those that are necessary for examination, for applica- 
 tions, and even for unforeseen and extemporaneous performance of 
 small operations. 2. Those which are often employed, but the use 
 for which is neither unforeseen nor indispensable. 3. Lastly, those 
 intended for performing more important operations, whether on the 
 genital organs or on other parts of the body. 
 
 The first class alone constitutes the gynecologist's apparatus. The 
 second forms what I may call the special arsenal of the gynecologist. 
 The third is what the gynecologist borrows from general surgery. 
 
 1. — The Gynecologist's Apparatus 
 
 1. Two sizes of Sims's speculum as modified by Courty, i. e. two 
 blades with handles made to screw off and on. They have this great 
 advantage, that they suffice for any ordinary diagnosis or application, 
 whilst any other may possibly be useless owing to the narrowness 
 of the vagina, the abnormal direction of the cervix, the presence of a 
 tumour, &c. 
 
GYNECOLOGICAL IXSTRTTMENTS 231 
 
 2. One or two pairs of Courly^s dressing forceps (one pair straight, 
 one curved) with short blades and blunt points, equally suitable for 
 making applications, seizing the pedicle of a tumour, holding a needle, 
 a piece of sponge, &c. 
 
 S. A female catheter, and by preference a sigmoid catheter. 
 
 4. A uterine sound made to slide into its handle. 
 
 5. Two silver sounds perforated at the point, the other end being 
 made to fit into a syringe'. 
 
 6. Two fine india-rubber sounds of small calibre, also made to fit 
 on to the syringe by means of a conical cauula with a screw. 
 
 7. Blandin^s long-bladed concealed bistoury. 
 
 8. Three pairs of long scissors with short pointed blades ; one pair 
 straight, another curved, the third elbowed. 
 
 9. Convergent and sliding tenaculum hook forceps. 
 
 10. Divergent tenaculum hook forceps with catch. 
 
 11. Two fine camePs hair brushes on long handles. 
 
 12. Two long canulas with movable piston, one an intra-uterine 
 solid caustic holder, the other an ointment holder like those of Braun 
 and Barnes. 
 
 13. Two of Piecamier's curettes, one narrow, one broad. 
 
 14. A small syringe for intra-uterine injections fitting on to the 
 sounds. 
 
 15. A larger syringe for washing the cavity of the uterus before 
 and after cauterisation. 
 
 To this list of instruments 1 will add a short one of medicaments 
 which the gynecologist wall find it useful to have beside him ; — cold 
 cream, glycerine, laudanum, tincture of iodine^ perchloride of iron, a 
 nitrate of silver point in a glass tube, powdered nitrate of silver in a 
 glass stoppered bottle, chloride of zinc in crystals in a similar bottle, 
 canquoiu plaster, Priar Come''s red arsenical powder. I need not say 
 that I have only mentioned the most necessary, passing over a very 
 large number of most useful drugs, such as chlorate of potash, alum, 
 tannin, &c. 
 
 2. — The Gynecologist's Special Arsenal 
 
 1. Collin's reflecting lamp wath refracting glass. 
 
 2. The two large blades of my speculum. 
 
 8. Two of the same in wood, to be used when the potential or actual 
 cautery is applied. 
 
 4. Cusco's folding bivalve speculum. 
 
 5. Three sizes of Ferguson's glass speculum. 
 
 6. Eolipyle spirit lamp with stand for cauteries. 
 
 7. Four cauteries for ignipuncture, the points and bulbs of varying 
 sizes. 
 
 8. Three spear-shaped cauteries, one straight, the others more or 
 less curved ; and one very narrow in the form of'a kniff 
 
 9. Six prepared sponge tents of different sizes. 
 
 10. Four Courty's galvanic stem pessaries, different sizes. 
 
 11. Sims's bistoury with reversible blade. 
 
232 TEEATMENT OF UTEEINE DISEASES IN GENERAL. 
 
 13. Three of Startin's hollow needles, one straight, one curved in 
 the axis, and a third (Courty's) curved perpendicularly to the axis like 
 that of Deschamps, all furnished with Mathieu's threader. 
 
 13. Long but fine forceps with short claws and catch, straight and 
 elbowed. 
 
 14. Two long fine tenaculum hooks with handles, one single the 
 other double, 
 
 15. A long blunt hook.. 
 
 16. Two curettes, cutting the one on the convex (Sims's), the other 
 on the concave side (Courty's). 
 
 17. A curette in the form of a button-hook (Courty). 
 
 18. A long and fine serre-noeud for extemporaneous ligature, and 
 one very small for vascular tumours of the urethra. 
 
 19. Gooch's canula as modified by Courty. 
 
 20. Naudinat's large size hydroclyse, with straight tubes varying in 
 length and thickness. 
 
 31. A supply of iron wire, silver wire, waxed thread, fine whipcord, 
 india-rubber thread, fine india-rubber tubing, cotton wool, &c. 
 
 3. — Instruments common to the Gynecologist and the 
 General Surgeon. 
 
 I. A set of bistouries with long handles and short blades, pointed 
 or blunt, straight, curved on the flat, or elbowed at the level of the 
 blade. 
 
 3. MacClintocFs corkscrew or vice for removing polypi; Aveling's 
 polyptribe ; Simpson's polypotome. 
 
 3. Very strong single or double tenaculum hooks open or concealed, 
 
 4. Chassaignac's radiating, convergent, or divergent tenaculum 
 hooks. Courty's semi-tenaculum hooks of the same make. 
 
 5. Strong polypus forceps, straight or curved, with lock. 
 
 6. Museux's strong tenaculum hook forceps, some very concave, for 
 seizing strong tumours (Robert's pattern), others sliding (Green- 
 halgh's), others concealed, and springing out when required (Collin, 
 Mathieu, &c.). 
 
 7. Box of instruments for vesico- vaginal and recto- vaginal fistulse. 
 
 8. Ovariotomy box. 
 
 9. Straight and curved ecraseur, furnished with Emmet's adjuster 
 or Aubry's metallic thread for holding the chain. 
 
 10. Paquelin's thermo- cautery, with Courty's ignipunctor and 
 curved knife. 
 
 II. Galvano-cautery, with wire and electric battery. 
 
CHAPTER III 
 
 GENERAL CHARACTERISTICS OF UTERINE DISEASES — THEIR FREQUENCY 
 PREDISPOSING CAUSES — GENERAL AND LOCAL SYMPTOMS — COM- 
 PLICATIONS — PROGNOSIS — CLASSIFICATION. 
 
 Hitherto I have only considered the characteristics of uterine dis- 
 eases with regard to diagnosis and therapeutic indications. Now I 
 shall endeavour, by considering them in groups, as they sometimes 
 occur naturally, to give, not perhaps a more exact, but a more com- 
 plete view of them, showing their special characteristics, and consider- 
 ing the degree and elements of their curability ; in short, pointing out 
 the various forms they may assume, the natural divisions into which 
 they may be classified, and the relative frequency and importance 
 occupied by each of them. 
 
 1. The first characteristic of uterine diseases is their frequency. I 
 have already refuted the opinion of those who assert that they were 
 less frequent formerly than now. I have shown how it was that they 
 escaped the notice of the ancients. Is it necessary to explain why we, 
 with our means of exploration, encounter them so often? Could it be 
 otherwise with an organ which everything seems to have conspired to 
 make the point towards which all morbid phenomena naturally tend 
 and the starting-point of almost all constitutional disorders. Its 
 position exposes the uterus to constant pressure from the weight 
 of the abdominal viscera, whilst the accomplishment of its functions 
 necessitates not only a hypersemia like that produced in other organs 
 but considerable and repeated sanguineous fluxions, serious nervous 
 disturbance, complete change of tissue and more or less serious trau- 
 matism, in a word, the natural phenomena of menstruation, coitus, 
 pregnancy, delivery ; in short, the uterus reacts constantly on all the 
 organism, and all the organism reacts on it : 2^'^'opter solum uterum^ 
 mulier id est quod est. Now that we know the physiological import- 
 ance of the ovaries and how closely they are connected with the 
 uterus we can apply the same adage to them, admitting an equal 
 frequency in the occurrence of ovarian disease. 
 
 This frequency is so great that it often allows of our presuming the 
 existence of uterine disease, which at the time may be only latent. 
 When the cause of more or less serious general symptoms cannot be 
 discovered, attention should be drawn to the genital economy and inves- 
 tigations should accordingly be made in that direction. By inquiring 
 into the circumstances which have a more or less considerable share in 
 the production of uterine diseases, we shall at the same time account 
 for their frequency and recognise the character assumed by them in 
 their development. 
 
234 UTEEINE DISEASES 
 
 2. Many predisposing cmises are known but very few determming 
 causes. Uterine diseases are generally awakened by the slow and 
 gradual changes produced in the vitality and structure of the organ 
 under the latent and continuous influence of a diathesis ; but we 
 cannot always determine tlie causes which bave originated them. 
 After allj these are of no importance as far as treatment is concerned j 
 whether they are due to a traumatism, to the effects of delivery or 
 abortion, or to a reaction from some injurious impression^ these are 
 often only the accidental causes which may have put the match to the 
 fire, but they have neither prepared it nor kept it up. Therefore, for 
 all practical purposes, it is sufficient to consider the predisposing 
 causes of these diseases, local as well as general. 
 
 The predisposing local causes, which depend on anatomical and 
 physiological conditions peculiar to the uterus, explain not only the 
 frequency of the diseases of this organ, but the relatively greater 
 frequency of some of them, the favorite seat of others, &c. Thus the 
 dependent situation of the uterus accounts for the frequency with 
 which it is congested and engorged, as well as for the difficulty 
 experienced in elfecting a cure. The multiplicity of its means of sus- 
 pension and the change which they undergo in the accomplishment of 
 functions (pregnancy, delivery, &c.) are the natural causes of various 
 displacements of the uterus and often of its engorgement. Its con- 
 nections with the bladder, the rectum and the pelvis with the cellular 
 tissue which fills it and the peritoneal folds lining it, explain the 
 influence which may be exercised by these neighbouring organs on the 
 uterus, and vice versa. 
 
 The various phases of development dispose the uterus to disease in 
 one part more than another. The precocious development of the 
 cervix renders the cervical cavity liable to catarrh even before puberty. 
 The later preponderance of the body explains the frequency of disease 
 of this organ in the adult. Arrested development may suffice to 
 cause a decided flexion, especially anteflexion, which is only the per- 
 sistency of the fcetal condition. 
 
 Even its structure involves a tendency in the organ to certain morbid 
 conditions. The predominance of fibro-muscular tissue disposes the 
 uterus to general or partial hypertrophy, to fibromata, polypi, &c. The 
 richness ot the vascular element and the activity of its circulation dispose 
 it to acute or chronic inflammation, complete or partial, primitive or con- 
 secutive. The absence or rarity of cellular tissue explains the rarity of 
 suppuration, apart from interstitial phlegmons, in the non-puerperal 
 state. The ovary, containing more cellular tissue and an almost infinite 
 number of little vesicles, destined to become Graafian vesicles, is on 
 that account infinitely more hable than the uterus to be affected with 
 suppuration, and to contain purulent, phlegmonous, or cystic cavities. 
 The presence of a mucous membrane, rich in vessels and in glands, 
 disposes the uterus to discharges and catarrhal affections. The 
 mucous membrane of the cervix, and especially that of the os externum, 
 like all other natural orifices, as Tyler Smith, Bernutz and others have 
 pointed out, may be the special seat of various eruptions, herpetic. 
 
GENERAL CHARACTERISTICS 235 
 
 syphilitic^ ulcerous^ &c. The serous peritoneal fold which covers the 
 greater part of the external surface of the womb exposes this organ to 
 serous inflammations and their consequences, gives to peri-uterine in- 
 flammation the special characteristics which often distinguish it, and 
 is the frequent cause of the formation of adhesions and fibro-cellular 
 bands between the different parts of the uterine system, between the 
 ovaries and the Fallopian tubes, and between the Pallopian tubes and 
 the uterus, &c., which suspend temporarily or definitively the accom- 
 plishment of their functions, dispose to phlegmons, or keep up the 
 irritation which favours the persistence of inflammatory centres. 
 
 The continuity of the mucous membrane of the uterus and Fallopian 
 tubes with the peritoneal serous membrane at the ostium uterinum 
 tends to propagate the inflammation of this mucous membrane to the 
 peritoneum, and consequently to increase the evil considerably. This 
 propagation may take place, whether the inflammation be spontaneous 
 or provoked, and this consideration ought to put us on our guard 
 against the consequences which may result from caustic uterine 
 injections, even where they do not penetrate into the peritoneal 
 cavity. 
 
 The vascular activity of the uterine system, with the periodic 
 fluxions which take place in it, expose the whole or various portions 
 of this system to sudden and violent sanguineous fluxions, to consequent 
 congestions, to hsemorrhages internal, external, interstitial or apo- 
 plectic; to hypertrophies, total, partial or histogenetic ; to ovarian 
 products, especially to the most frequent of all, multilocular cysts. 
 
 The periodic repetition of these fluxionary movements at the men- 
 strual period and their return during pregnancy, as well as during 
 uterine diseases, dispose the organ to fluxions, congestions, and to the 
 pains resulting from this plethora of the vascular system, and lastly, to 
 the persistence of these morbid states if critical evacuations do not 
 take place. 
 
 It is at the climacteric especially that this state of uterine hypersemia 
 is developed as the result of persistent congestion unrelieved by any 
 critical evacuations, and this condition not only constitutes a disease 
 in itself, but may produce many kinds of diseases, especially of a 
 diathetic nature. 
 
 Sexual relations have an undoubted influence on the development 
 and perpetuation of uterine diseases. This influence, however, has 
 been exaggerated; it is not responsible for all the diseases attributed 
 to it. West, for example, seems to attribute to coition imperfectly 
 performed an exaggerated influence on the development of certain 
 uterine maladies. It is nevertheless certain that marital intercourse 
 not only may produce disease but keep it up. As to the part which 
 it may have in the production of disease, it is evident that excesses 
 may determine permanent congestion, and may even develop complete 
 or partial metritis, followed later by leucorrhcea, granulations, &c. 
 There is also no doubt that although coition may sometimes be 
 practised at the menstrual period with impunity, such imprudence has 
 often caused congestions, more or less serious inflammations and, what 
 
236 UTERINE DISEASES 
 
 is much, more dangerous, sudden suppression of the sanguineous dis- 
 charge with internal haemorrhage of a formidable nature, such as retro- 
 uterine or peri-uterine hematocele. 
 
 Generally, however, sexual intercourse acts less frequently in pro- 
 ducing than in perpetuating uterine disease. In special circumstances 
 a diathesis may become localised in the uterus from the first sexual ex- 
 citement. As a rulcj however, it is not during the first years of marriage 
 that the greatest number of uterine diseases are developed, but only after 
 disorders of menstruation, pregnancy, abortion and labour. In such 
 cases coitus is neither the orighial nor secondary cause of the disease ; 
 but it keeps it up, prolongs and aggravates it ; I have occasion to 
 observe this every day with regard to uterine congestion. It even 
 causes relapses after a cure has been efl'ected, therefore under certain 
 circumstances we cannot be too particular in forbidding it. 
 
 Pregnancy and labour are beyond all doubt the most frequent causes 
 of the development of uterine disease. They act in two ways : as predis- 
 posing causes by the important modifications imparted to the organic 
 structure, and as exciting causes by the traumatism which they produce. 
 Aran classes two-thirds of all utero-ovarian disease as the results of 
 pregnancy, labour and abortion, one-fourth as occurring in women 
 who have had children, and one-tenth only among virgins and nulli- 
 parEe. Pregnancy congests the uterus, imparting to it a violet hue ; it 
 increases the capacity of its vascular, and especially of its venous 
 system. It hypertrophies its tissue; in short, it determines the in- 
 crease, the fall and the renewal of its mucous membrane, so that when 
 the organ is freed from the product of conception it is in the most 
 favorable circumstances for becoming, or rather for remaining, diseased, 
 for this state of hypertrophy, however shortly prolonged after the ex- 
 pulsion of the foetus, is a real disease. Labour acts as a real traumatism, 
 owing to the mechanical lesions which it produces — the contusion and 
 lacerations of the cervix, the bleeding wound resulting from the detach- 
 ment of the placenta, the local and general reaction which follow, the 
 uterine and peri-uterine inflammation which may be developed, the 
 coincident traumatic fever with the suppuration and gangrene which are 
 sometimes the results of this inflammation and which we may say are 
 only developed in this single case of uterine disease. The results of 
 labour have no less influence on the development of diseases of the 
 womb. The least complicated morbid condition which may result is 
 the persistence of uterine hypertrophy characteristic of pregnancy, 
 owing to defective retrograde evolution of this viscus. It is diflBcult 
 to determine the true causes of this defective involution, but it is pro- 
 bable that they do not difi'er from those which produce other diseases 
 resulting from labour, such as rising too soon, physical fatigue, resuming 
 marital intercourse prematurely, &c. 
 
 After abortion the uterus is even more disposed to become diseased 
 than after delivery at the full period ; not to acute inflammations, 
 suppuration, gangrene, &c., but to congestion, engorgement and 
 hypertrophy, especially to the hypertrophy referred to as due to defec- 
 tive involution. It seems that when the uterus has not passed through 
 
GENERAL OHARACTEEISTICS 237 
 
 the various phases of progressive evolution which ought to be com- 
 pleted between conception and parturition^ the phenomena of natural 
 involution is more difficult than after delivery at full term, and that 
 it is more apt to be arrested. The elements of muscular tissue as 
 well as those of the mucous membrane, when suddenly arrested half 
 way when in full activity of development, have no tendency to pass 
 through the modifications of atrophy, fatty degeneration and retro- 
 gression which characterise involution ; in place of returning rapidly 
 and completely to the normal dimensions of the unimpregnated uterus, 
 they preserve the volume and structure appropriate to gestation, which 
 predispose them to all kinds of morbid alterations. 
 
 If, then, pregnancy, labour and abortion have so much influence on 
 the development of uterine diseases, what must the result be of cases 
 of pregnancy rapidly succeeding one another, which leave the uterus 
 no time to return to its normal condition and hinder the natural work 
 of absorption of the gestative hypertrophy, and which, by keeping the 
 organ in a state of congestion, expose it to the invasion of diatheses ? 
 And yet I must admit that I have known several women in whom the 
 rapid succession of pregnancies (eight or ten in twelve or fifteen 
 years) has not produced the development of any uterine disease, which 
 is one of the most striking proofs of the large share which general 
 affections have in the constitution of diseases of the generative system. 
 In others I have observed a local fatigue produced by the persistence 
 of the tumefaction of this organ, and general consumption due to the 
 impoverishment of blood caused by this continual return of gestation. 
 I have therefore concluded that the development of uterine disease 
 in these women was due rather to the localisation of a diathesis than 
 to the number of pregnancies, which seemed merely to have played 
 the part of exciting cause. 
 
 The neglect of lactation is not without its influence in impeding 
 the process of involution, and consequently in the development of 
 uterine diseases. The considerable and continuous fluxion wOiich 
 lactation keeps up in the breasts probably diverts the fluxionary move- 
 ments from the uterus, and therefore helps to dissipate congestion and 
 engorgement. Lactation is also useful by preventing menstruation, 
 with the fluxion and congestion accompanying it, from coming to add 
 their influence to that of defective involution. It also prevents the 
 premature return of pregnancy and therefore hinders the production 
 of the morbid tendency just pointed out as the consequence of a rapid 
 succession of pregnancies. Investigations made on this subject by 
 Scanzoni show that out of 196 children born at full time of 54 women 
 suffering from uterine affections only 57 had be^n suckled by their 
 mothers, whilst Aran^ tells us that out of 100 women aft'ected with 
 diseases of the womb 70 of them had never suckled. 
 
 Sterility may preserve women from many uterine diseases, but it 
 does not guarantee them from others, especially from those which are 
 dependent on the development and localisation of diathetic affections. 
 Its influence is all the more liable to pass unobserved that when we 
 
 ' Op. cit., p. 93. 
 
238 UTERINE DISEASES 
 
 encounter it accompanied with uterine disease it is not the sterility 
 which has caused the disease^ but the disease which has caused the 
 sterility. With regard to this matter we cannot be too careful to 
 trace the cause of uterine diseases to their first beginning and to the 
 general and local conditions which may keep them up, for in removing 
 them we may be able to cure the disease as well as the sterility. 
 Sterility and celibacy can only be classed together with regard to 
 absence of gestation. They differ entirely in other respects. In 
 sterility the uterus has undergone the excitement of coitus, whilst the 
 absence of this cause in celibacy seems to diminish the chances of the 
 development of uterine diseases. Whether that be so or not, I will 
 sum up my opinion on this point by saying that, with the exception 
 of certain menstrual disturbances and the general disorders dependent 
 on defective function, celibacy does not seem to me to predispose to 
 diseases of the uterus ; but it does not prevent them, I have seen 
 old maiden ladies die of cancer of the womb. As for sterihty, it has 
 seemed to me oftener to be the effect than the cause of disease. In 
 short, in considering the whole of the utero-ovarian system, we see 
 that the diseases of one part of this system may become the causes of 
 disease in the other part, sometimes predisposing, sometimes exciting 
 causes. The community of functions involves a community of morbid 
 susceptibilities. The same Hnks often unite these various organs with 
 regard to pathology as well as physiology. Numerous examples 
 testify to the reciprocal action which diseases of the ovaries and Fal- 
 lopian tubes exercise on the uterus, and vice versa. The covering of 
 all these organs by the same serous membrane is an additional element 
 in favour of this reciprocity of action. Inflammation is propagated by 
 the peritoneum from the uterus to the Fallopian tube and to the ovary, 
 more frequently still in the contrary direction. The adhesions, the 
 membranous bands which form pathological connections between these 
 different organs, are not without their influence ; whether in imposing 
 abnormal conditions in the performance of menstruation, or in favour- 
 ing the escape of the ovum into the peritoneum in place of directing 
 it into the Pallopian tube, they prepare the way for real morbid 
 conditions. 
 
 We know very little with regard to the influence which diseases of 
 the bladder and rectum have on the development of uterine diseases. 
 It is the same respecting the influence exercised by diseases of the 
 mammary glands. Our knowledge is still less advanced with regard to 
 the possible influence suggested by Aran of diseases of the stomach 
 and liver, heart and lungs, in the production of these morbid 
 conditions. 
 
 As for the predisposing general causes, the circumstances which 
 have more or less direct part in uterine pathogeny, are : age, tempera- 
 ment, constitution, and especially diathetic affections and confirmed 
 diseases. 
 
 The age at which the greatest number of diseases of the womb has 
 been observed is certainly that of sexual activity — the age when the 
 generative functions are performed with most activity, when coitus is 
 
GENERAL OHAEAOTEttlSTICS 239 
 
 most frequent, pregnancies most numerous. In 300 cases of metritis 
 Nonat^ observed 155 between twenty and thirty years. Aran/ in 
 100 cases of uterine diseases, had 62 in women between twenty-one 
 and thirty years. That does not mean that uterine disease may not 
 be developed at other ages from childhood to old age. It is, however, 
 exceptional, and even the exception may be remarked by its preference 
 for certain kinds of these diseases and for certain organs of the genital 
 economy. Thus we often see vaginal leucorrhoja in children. I have 
 seen a child before puberty who had the uterine cavity and the external 
 half of the Fallopian tubes filled with a cheesy substance formed of 
 condensed epithelial cells, showing the existence of serious disease. I 
 have seen an ovarian cyst in a little girl of eleven who had never men- 
 struated. Uterine cancer is not rare in the last period of the life of 
 woman, at least after the menopause. 
 
 In short, every age has, so to say, its special predispositions. When 
 we meet with disease of the womb in a child it affects the cervix, which 
 at this age is much more developed than the body. After puberty 
 and before coitus it is the body which is most frequently affected. 
 After pregnancy both segments of the organ may be equally affected. 
 Virginity does not exempt the young girl from uterine diseases. 
 Bennet, Aran and others have made the same observation. They 
 are liable specially to fluxion, congestion, leucorrhoea, uterine catarrh, 
 and even to metritis, but less so than married women, especially women 
 who have had children. The starting-point of these diseases is gene- 
 rally some disorder of menstruation, the predisposing cause being a 
 catarrhal or rheumatic affection, or a scrofulous or herpetic diathesis. 
 Diseases of the body, especially of its mucous membrane, uterine 
 catarrh, and leucorrhoea, are more common than diseases of the cervix 
 amongst virgins. Diseases of the cervix, especially ulcerations and 
 granulations, although sometimes met with in young girls, are much 
 more frequent in married women, and especially in multiparse, in whom 
 the cervix has been exposed to the contusions incidental to excessive 
 intercourse, to the softening of pregnancy, and the lacerations of labour. 
 After the menopause, uterine diseases, besides being rare, may exist for 
 a long time without causing much pain or producing sympathetic 
 disorders ; in fact they may remain latent for an indefinite time. 
 
 We know nothing, at least nothing positive, as to the influence 
 which mode of life, habit, residence in town or country, may exercise 
 on the development of these afiections. Whilst admitting that 
 different modes of life exercise various kinds of influence, I cannot say 
 that one leads more frequently to disease than another. Women of 
 weak constitution and lymphatic temperament are certainly more 
 exposed than others. They are especially exposed to the protraction 
 of the disease owing to their defective reaction and to the predisposi- 
 tion which they have to general debility, and to cachexia? which in them 
 more than in other women are the rapid consequences of the impression 
 produced by the morbid condition on the organism. Heredity may 
 
 ' Op. cit., p. 59. 
 ^ Op. cit., p. 99. 
 
240 UTERINE DISEASES 
 
 have some influence, especially in such diseases as cancer. I have 
 seen a few examples of this kind. I have also observed the same kind 
 of granulations and leucorrhoea in mother and daughter. It must, 
 however, be admitted that direct hereditary influence is not frequent, 
 nor is it clearly proved to exist. 
 
 It is not so, however, with the various diatheses and all general 
 affections, which undoubtedly play a considerable part in the existence 
 of diseases of the womb. Some authors, such as Pidoux, whose ideas 
 seem to have inspired Tillot's^ thesis, exaggerate this influence by 
 invariably attributing to diathetic affections the chief place in the 
 etiology of uterine diseases. It is evident that the uterus, owing to 
 its position, structure and functions, is not only exposed to the localisa- 
 tion of the various diatheses, but has of itself a tendency to originate 
 chronic disease. We cannot, therefore, admit that in the majority of 
 cases uterine lesions are only secondary symptoms occurring under the 
 influence of a general state, nor that the lesion is in the uterus and 
 the disease in the organism. The lesion is evidently the cause of all 
 the suff'erings of the women. Whether, led by experience, we admit 
 the multiplicity and diversity of these lesions, or whether with Lisfranc 
 we give the predominance to engorgement, or with Yelpeau to de- 
 viations and granulations, with Dubois to catarrhal phlegmasia, or with 
 Bennet to metritis, we cannot possibly allow that the serious change 
 which this lesion produces in the vitality of the uterus is not the dis- 
 ease properly so called, and consequently the cause of all the symptoms, 
 general and local ; nor can we admit with Pidoux^ that from a physio- 
 logical point of view the uterus and its annexes are only the centre of 
 the general changes which characterise women from the time of puberty, 
 and not the cause of them. 
 
 Uterine lesions, whether acute or chronic, whether connected with 
 a diathesis or not — whether they be functional, organic, or due to 
 displacement — are really diseases characterised by their own symp- 
 toms requiring direct treatment. Whilst willing to admit that the 
 diatheses have a considerable share in producing them — a much greater 
 share than the local conditions just enumerated — I cannot agree with 
 those who think their influence exclusive. 
 
 There is no chronic uterine disease that is entirely free from the 
 influence of some diathesis. We cannot even make an absolute excep- 
 tion of deviations and displacements, as Bund pointed out in a paper 
 read before the Academy of Medicine in 1849. Thus, supposing that 
 fluxion, congestion, chronic inflammation, hypertrophy may exist 
 independently of a diathetic aft'ection, it is not the less certain that 
 these morbid conditions are in some degree under its influence. As for 
 engorgements, leucorrhoea, granulations, ulcers, cancers, &c., they are 
 almost always dependent on a diathesis or a general condition not less 
 real. 
 
 The knowledge of this diathesis, by enabling the physician to make 
 
 ' De la lesion et de la maladie dans les affections chroniques dii systeme 
 utdrin. These de Paris, 32, 1860. 
 
 ^ Lettre sur la fievre puerperale, 1854 
 
GENERAL CHARACTERISTICS 241 
 
 a general diagnosis, often facilitates the local one. If we have pre- 
 viously discovered or if we recognise the actual existence of a marked 
 diathetic condition, we may suspect it of being the cause of the evil. 
 On the other hand we must beware of the tendency, which was 
 too common with the ancients, of attributing the lesion to a constitu- 
 tional taint of herpes, syphilis, scrofula or tubercle, and of com- 
 mitting Lisfranc's error of mistaking for tubercle some quite different 
 cervical lesion. 
 
 Three orders of facts prove, in my opinion, that the diatheses have 
 a more or less important share in the existence of uterine diseases, and 
 that we ought to take them into account. 
 
 Firstly, the coexistence or simultaneous manifestations of these 
 diathetic conditions in the uterus and in other organs. Thus, we not 
 unfrequently see uterine leucorrhoea associated with vesical or intes- 
 tinal catarrh, sometimes even with bronchial catarrh ; eruptions or 
 ulcerations on the cervix with herpes on the vulva, anus and other parts 
 of the body, especially on the other natural orifices ; a more or less 
 painful but mobile congestion or engorgement of the uterus with rheu- 
 matism or erratic pains in the limbs, even visceral pains having pre- 
 viously manifested themselves in the same patient in other circum- 
 stances ; an engorgement, granulations, ulcers on the cervix, with 
 scrofulous symptoms, glandular swellings, ulcers, impetigo, &c., on 
 other parts of the body. These coincidences are even more frequent 
 in syphilis. They may also be seen in tuberculosis, cancer, &c. 
 Secondly, the alternation between the manifestation and especially 
 the exacerbation of the uterine disease and the localisation of a dia- 
 thesis on another point. This phenomenon is observed especially in 
 affections the seat of which is variable and mobile, like gout, rheuma- 
 tism, catarrh and herpes. Just as in a man I have seen the dartrous 
 diathesis localised successively on the glans, urethra, prostate, bladder, 
 ureter and kidney, so in a woman I have seen the vulva, vagina, 
 cervix, uterus. Fallopian tube, or ovary attacked simultaneously, suc- 
 cessively, or alternately, by the same disease. We know that several 
 cases have been reported lately of ovaritis following on blenorrhagia, 
 vaginitis or metritis, just as orchitis may follow urethral blenorrhagia 
 in man. I have seen some remarkable cases of rheumatism associated 
 with pain and swelling ; of neuralgia depending probably on the same 
 cause, and attacking alternately the uterus, ovary, or some other 
 viscus, such as the bladder, the stomach, or the articulations, the 
 nerves, fibrous tissue, aponeuroses, or lymphatic ganglia. Thirdly, the 
 proof given by treatment, a sure test of the nature of disease. How 
 many diseases there are, apparently simply inflammatory, which have 
 been lessened by the application of leeches, rest, baths and all the 
 other means of antiphlogistic treatment, but which have only been 
 cured by mineral waters, hydropathy and specific treatment appropriate 
 to the character of the evil ! 
 
 The diatheses which have the greatest share in the etiology of 
 chronic diseases of the uterus may be either hereditary or acquired. 
 There is no utility in distinguishing them nor in separating them from 
 
 "]6 
 
242 UTERINE DISEASES 
 
 other general states of tlie organism which may have a similar influence 
 on uterine diseases. We may, therefore, class in this category all 
 spontaneous blood disorders, of which the most frequent type is 
 chlorosis, which plays so important a part in female pathology. 
 Chlorosis may exist already in a woman attacked with a uterine 
 disease. It may even be the cause of this disease. When, however, 
 the latter is developed the chlorosis generally becomes more marked. 
 In some cases it is consecutive to the lesion which was primarily pro- 
 duced by a diathesis. Deglobulisation of the blood, whether it be 
 anterior, concomitant or consecutive to the disease, whether it be 
 cause, effect or simple coincidence, does not the less frequently accom- 
 pany the majority of uterine diseases.-^ 
 
 3, The nature of uterijie diseases. — Most frequently the diatheses 
 have not been the exciting cause of the disease; but after the malady 
 is established they keep it up and really give it its character. The 
 malady would not continue to exist without them ,• and it Avould be 
 impossible to cure it without curing them, or at least without greatly 
 modifying them. 
 
 After the diatheses an important part must be allowed in the pro- 
 duction and chronicity — that is to say, in the nature and character of 
 uterine diseases, to the vitality of the uterus, or rather to its mode of 
 vitality, to the elementary physiological acts which are necessary to 
 the accomplishment of its functions, to the facility with which it under- 
 goes great changes and remarkable alterations in its structure and in 
 its tissues. Undoubtedly the majority of our organs have in the 
 accomplishment of their functions a continuity of action which would 
 seem to make them more liable even than the uterus to the develop- 
 ment of chronic diseases. But they do not undergo such great changes 
 as this viscus does in regard to the innervation, circulation and 
 change of tissue of the organ. It is just because of the extent of the 
 oscillations, the return of these periodical acts, the temporary and 
 exceptional activity of nutrition, that the uterus is more liable to 
 become diseased than any other organ. 
 
 Among the elementary physiological acts which are connected most 
 frequently with the production and aggravation of uterine diseases, we 
 must place in the i5rst rank those which contribute to the accomplish* 
 ment of menstruation, i. e. fluxion, congestion and the critical evacua- 
 tion of blood. These acts occur in almost every uterine disease as 
 cause or complication. The physician can rarely utilise them. He 
 has to frustrate their influence, moderate their manifestation, combat 
 their effects. These three acts, as we shall afterwards see, govern each 
 other mutually : the energy of the fluxion increases the intensity of the 
 congestion, and consequently the amount of the evacuation. When 
 the balance between these three essential elements of the menstrual 
 function is disturbed disease breaks out. 
 
 ' We may include among Llood disorders those produced by general miixsnia- 
 tic poisoning. Paulin Dnpuy, Essai cliniquc sur quelqucs troubles d'origine 
 pahideenne dans les fonctions ffenitales de lafemvie. These de Montpellier, 
 1879. 
 
GENERAL CHARACTERISTICS 243 
 
 Fluxion is not only a powerful cause in the production of uterine 
 diseases, it not only prepares the way for congestion, determines 
 haemorrhage, favours fluxion, aids hypertrophy, keeps up engorgement, 
 furnishes to inflammation its natural element, but it hinders treatment, 
 prolongs the disease by the periodicity of its return, increases it often 
 by its intensity, and, in short, plays the principal part in the relapses 
 which too frequently follow on apparent cure. Aran tells us that 
 congestion ought to he considered under two aspects in uterine patho- 
 logy : sometimes it is connected with an actually existing disease of 
 the uterine system, of which it is a complication, aggravating or pre- 
 cipitating its progress, retarding or hindering its cure ; sometimes it 
 exists alone ; sometimes it facilitates the development of new affections. 
 It constitutes, strictly speaking, an element in uterine disease, and 
 becomes a source of therapeutical indications. The capital indication 
 in fact itself includes two other indications : — 1, to diminish the con- 
 gestive condition at the menstrual period; 2, to subdue the congestive 
 condition which persists after any period till the appearance of the 
 next. The san(/7nneous discharge may be either defective or excessive. 
 If excessive it constitutes a disease (menorrhagia) ; if defective it pre- 
 vents the natural crisis from taking place, and leaves the uterus con- 
 gested, as a result of which we may have all the ills which I have just 
 pointed out in speaking of congestion. 
 
 The physiological acts which take place in the uterus at every 
 menstrual period are produced with much greater intensity at every 
 pregnancy. Only here the fluxion and congestion of the organ are 
 continuous, with the exception of some augmentation at the periods 
 corresponding to the menstrual epochs. The sanguineous discharge, 
 haemorrhage, depletion of the congested organ only occur after delivery. 
 In fact, great changes are effected in the tissue of the womb, and are 
 added as new causes of disease. I do not speak only of the changes 
 of tissue which are produced by gestation, but also of those which arc 
 effected by the return of the organ to the state of vacuity. To the 
 physiological hypertrophy of pregnancy succeeds the physiological 
 atrophy of retrograde evolution. To this we must add the renovation 
 of the mucous membrane, so characteristic of uterine life, that it is 
 produced not only after gestation but sometimes after menstruation 
 alone. 
 
 The structure of the uterus is in accordance with its special func- 
 tions. Its tissue is characterised by the presence of fibro-plastic 
 elements, hence its continual tendency to hypertrophy. This tissue is 
 in constant process of organisation, becoming hypertrophied by preg-* 
 nancy, atrophied after delivery, in order to bring the organ back to its 
 normal dimensions ; in place of the stability characteristic of the other 
 tissues, it has a continual instability, an incessant tendency to increase 
 and decrease. This tendency is indicated by the. presence, especially in 
 the mucous membrane, of the organising element (the flbro-plastic 
 element), and is coincident with analogous physiological tendencies, 
 the habit of fluxionary movement, alternating congestion and deple- 
 tion, &c. 
 
2it UTERINE DISEASES 
 
 Now, fluxlonari/, plastic and hypertrophic tendencies characterise 
 the majority of uterine diseases as they characterise the functions of 
 the organ. Fluxion, plastic exuberance, hypertrophy, may be exhibited 
 in all the elements at once or only in some of them ; hence the fre- 
 quency of engorgements, congestions, fluxes, tumours or homologous 
 productions of all kinds. Localised on the mucous membrane, very 
 limited in extent, spreading to the most superficial part of the papillte 
 of the dermis, to its vessels, and to the epidermis covering it, this 
 hypertrophy gives birth to the granulations so frequently found in the 
 cervix. This same hypertrophy, spreading to the healthy granula- 
 tions of an ulcer, at the moment when the work of cicatrisation brings 
 into play a moye or less energetic increase of plastic action, produces 
 granular fungosities more frequently there than anywhere else. When 
 concentrated in the organs of secretion, it develops tumours, cysts, 
 and follicular polypi. Localised on the tissue proper, on its elements 
 generally, it gives rise to hypertrophy properly so called ; this hyper- 
 trophy may extend to the whole uterus, or be limited to the body or 
 to the neck, or even to one segment of the neck or body, to one of 
 the walls of the latter, or to one of the lips of the former. When 
 limited to certain elements it produces vascular tumours^ fibromata, or 
 polypi. 
 
 Hypertrophy, besides being more common in the uterus than in any 
 other organ, has the tendency to spread exclusively to one or other of 
 the tissues composing the womb, and to a limited region of that organ. 
 In this way the uterus remains increased in size owing to defective in- 
 volution after delivery ; it continues to increase if deviated or flexed, 
 and prolapsus is sufficient to double its volume. On the other hand, 
 its mucous membrane in certain menstrual disorders undergoes an 
 accidental hypertrophy and exfoliation, the cervix becomes the seat of 
 general or polypoid excrescences, the follicles form glandular polypi 
 or cysts, the tissue proper produces fibrous tumours, &c. 
 
 Thus, by its structure, by its functions and the elementary acts 
 which preside over their performance, the uterus differs from all other 
 organs, in being in constant process of organisation, always liable to 
 change of volume and structure. Instability is its special charac- 
 teristic. In its tissue the equilibrium established between the nutri- 
 tive movements of composition and decomposition, assimilation and 
 disassimilation is not stable as in the other tissues ; it is an unstable 
 or momentary equilibrium. At the first impulse, it is disturbed 
 and falls to the one side or to the other. This tendency to adapt 
 itself to the part which it has to play in menstruation, conception, 
 pregnancy and delivery it retains in all circumstances which place it 
 in somewhat analogous conditions. Whether its cavity be filled by 
 mucus, blood, or other fluid, or by a solid body like a polypus; 
 whether a tumour such as a fibroma is developed in the inters! tices of 
 its tissue, or a foreign ibody, external or internal, is introduced within 
 its orifices, fluxion is determined, the uterus becomes congested, hy- 
 pertrophies and contracts in order to expel the tumour or foreign body, 
 then returns to its normal condition, loses its hypertrophic elements. 
 
geK^ebal characteristics 245 
 
 repairs its mucous membrane ; in short, it passes from the state of 
 vacuity to a condition similar to that of gestation, once more returning 
 to that of vacuity. 
 
 These curious, we may say unique properties of the uterine tissue 
 seem to me to place in our hands the key to a mass of physiological, 
 pathological, therapeutical phenomena, which can be utilised for the 
 knowledge and treatment of uterine diseases. These properties evi- 
 dently play a great part in the production of the latter ; and it is 
 also important to consider them again with regard to the form and 
 course which they give to these diseases, and consequently the charac- 
 teristic symptoms which they often communicate, such as hyper- 
 trophy, painful contractions, uterine colics, dilatation of the cervix, 
 &c. &c. 
 
 4. The knoioledge of these properties {and especially the instabilltjf) 
 of the uterine tissue is important in relation to the cure, which they 
 may either hinder or facilitate according to the manner in which 
 they are utilised by the physician in his treatment of the disease. 
 Hence the indication for action. Lornet induced hypertrophy as 
 Simpson did by means of metallic stem pessaries ; sometimes he pro- 
 voked dilatation of the cervix by the introduction of foreign bodies, 
 which develop uterine contractions and so facilitate the expulsion of a 
 polypus, the enucleation of a fibroid ; sometimes he compressed the in- 
 troverted uterus by means of an air pessary, as Tyler Smith did, to 
 provoke simultaneously a dilatation in the neck and a contraction in 
 the body, both alike promoting reduction. Hence also the indication 
 for action in the opposite direction, using means to overcome morbid 
 hypertrophy, by placing the organ under the same conditions as when 
 it spontaneously undergoes retrograde evolution after delivery. Hence 
 the innocuity of intra-uterine cauterisation with the crayon when there 
 is abundant leucorrhoea or considerable granular fungosities ; for the 
 mucous membrane is not affected, or it is easily repaired at the points 
 which may appear to have been too much acted on by the caustic. 
 Hence the innocuity of the actual cautery applied to the cervix or to 
 its tissue ; for its raucous membrane, even if severely affected, which 
 is not often the case, has a manifest tendency towards regeneration. 
 Hence also the resolution induced by these cauterisations in chronic 
 congestion, engorgement and hypertrophy, by promoting absorption 
 and by giving an impetus to nutrition in that direction. 
 
 I shall not dwell longer on the tendency to hypertrophy, the plastic 
 exuberance, the faculty of regeneration, which characterise the uterus 
 anatomically, physiologically and pathologically. I shall have occasion 
 to recur to it throughout this work when speaking of membranous 
 dysmenorrhoea, granulations, fungosities, vegetations, follicular hyper- 
 trophy, follicular tumours and polypi, uterine hsemorrhoidal tumours, 
 partial hypertrophies of the mucous membrane, hypertrophies of the 
 tissue of the body, and of the cervix, fibroma, subperitoneal fibroma, 
 sarcomatous polypi, &c. 
 
 I must, however, remark that this tendency to vegetation is not 
 limited to the uterine tissue. There is the same tendency in the Fal- 
 
2.46 UTEEINE DISEASES 
 
 lopian tubes and in the ovaries, especially under a cystic form in. har- 
 mony with their structure. The same tendency is to be found in the 
 vagina and vulva, with regard to which I shall point out some facts 
 not generally known, showing that the vagina shares the hypertrophic 
 tendencies of the uterus. Por the present I shall only remark that 
 the hypertrophic tendency shown in the highest degree in the mucous 
 membrane, and in the muscular tissue of the uterus and in ovarian 
 cystic formations, may be propagated successively to all the other parts 
 of the generative economy, or separately to the various tissues which 
 enter into their composition, either by simple extension, by participa- 
 tion in a great increase of physiological activity, or by community of 
 morbid influences. 
 
 I think I have given a sufficiently detailed description of the general 
 and local circumstances presiding over the development of uterine 
 diseases to characterise these diseases sufficiently from this point of 
 view. 
 
 Several of the characteristics which remain to be described are simply 
 deduced from these circumstances ; for undoubtedly till we reach 
 them we cannot penetrate to the true nature of the diseases in 
 question. 
 
 5. Uterine diseases intanahly have a double morhid nature, general 
 and local. I cannot share the opinion of Aran,^ who thinks that the 
 differences between the various morbid states are gradually effaced, and 
 that after a certain time, in place of the original disease, we have to 
 contend with a number of local and general symptoms, requiring, 
 according to circumstances, the most varied treatment. Uterine dis- 
 eases always preserve their twofold character ; as diseases of the womb, 
 they often differ from all other organic disease ; as diathetic diseases 
 they have more or less in common with other general affections. They 
 have also a double set of symptoms : local symptoms, dependent 
 on the sensibility and vitality special to the uterus ; and general sym- 
 ptoms, dependent on the diathetic affection or on the sympathetic 
 reaction excited in the organism by the local lesion. 
 
 Uterine diseases may assume different forms according to the manner 
 in which these symptoms present themselves. In this respect^ groups 
 of symptoms, whilst offering infinite varieties in the mode of associa'> 
 tion, nevertheless present themselves under two principal forms, which 
 ought always to be present to the mind of the physician that he may 
 be on his guard against errors of diagnosis : in one, local, in the other, 
 general phenomena predominate. 
 
 The form most easily diagnosed is evidently that in which there is 
 ?L predominance of local Sf/mptoms. These are symptoms always linked 
 together in a somewhat similar way. First, hypogastric pains in- 
 creased by exercise, fatigue, constipation and the approach of the 
 menses, and localised often in the left iliac region. Lumbar, inguinal 
 and femoral pain occur afterwards. Leucorrhcea and menstrual dis- 
 orders sometimes appear very early, at the commencement of the 
 disease with the hypogastric pains, or they may gradually follow these 
 
 1 Op. cit., p. 169. 
 
GENERAL CHARACTERISTICS 247 
 
 first local symptoms. It is evident that uterine disease arising in 
 this way cannot fail to strike the patient and to be diagnosed by the 
 physician, especially if these local symptoms become more and more 
 marked, if the hypogastric pains assume the character of colics, if the 
 persistence or exacerbation of pain in the left iliac region draw the 
 attention to the appendages, and especially if vesical tenesmus and con- 
 stipation are added to the uterine symptoms properly so called. Very 
 often, however, uterine diseases, in place of betraying their presence 
 in away likely to attract attention, remain undiscovered for a longer or 
 shorter time owing to the obscurity, or it may be the complete absence 
 of all local symptoms. In such a case the cry of the suffering organ 
 does not come from the uterus, but from the whole organism. It is 
 the result of the influence invariably exercised by the womb on 
 the whole economy and the sympathetic reaction stirred up by the 
 apparently insignificant disorders of this organ. Every time that a 
 change takes place in the womb, that its functions are modified by 
 puberty, menstruation, conception, pregnancy, the menopause, or that 
 its vitality is impaired or its structure affected by some malady, the 
 harmony of the whole system is disturbed. More than any other 
 organ it is liable to disease, and more than any other organ it reacts 
 on the whole economy. 
 
 The second form, with predominance of general symptoms may be so 
 marked as completely to efface all local phenomena. We can easily 
 understand how the sole existence of general symptoms modifies the 
 symptomatic expression of a local malady, deceiving the patient as to 
 the seat of disease and leading the physician astray in his investiga- 
 tions unless he is on his guard. I have already said that these sym- 
 ptoms in order of frequency are : dyspepsia in every form and degree> 
 with its inevitable result defective nutrition, emaciation, decline, de- 
 globulisation of the blood, discoloration of the skin and mucous mem- 
 brane, palpitations of the heart, feeling of suffocation, cough and 
 nervous symptoms of various kinds. In most cases local symptoms 
 are not entirely wanting, but they are insignificant and intermittent 
 and tolerated by the patient from habit, or from energy of character, 
 or her attention may not be attracted to them owing to their vague 
 character. They must therefore be discovered by the physician. It 
 is surprising what characteristic symptoms pass unnoticed by patients 
 unless we are particular in our inquiries. This is the case with leu- 
 corrhcea; many women think it is almost a normal phenomenon, 
 especially if they have been chlorotic in their youth and the white dis- 
 charge has replaced the sanguineous one, or if the leucorrhcca precedes 
 or follows the menstrual hcemorrhage and is not abundant. Now, it 
 cannot be too distinctly stated that normally there is no white nor 
 transparent discharge, and that when such exists, whatever may be 
 the general or local cause, it ought necessarily to suggest the idea of 
 a genital malady, and that functional disturbance of the digestive organs 
 is not suflficient to cause it ; in fact it is not the dyspepsia which pro- 
 duces the leucorrhcca, but the leucorrhcca which causes the dyspepsia* 
 When the malady presents, itself under this form, with predominance 
 
248 UTERINE DISEASES 
 
 of general symptoms^ it rarely happens that certain characters of these 
 very symptoms do not lead the physician into the right track ; suck 
 are the coexistence of nervous phenomena in the lower limbs, nervous 
 cough, facie,<t uterina and hysterical symptoms, especially a feeling of 
 faintness felt by the patient when standing. 
 
 It is remarkable, as I have already said, that between these two 
 forms there is another in whicli local and general symptoms are con- 
 cealed by a morbid increase of flesh, which gives the patient a fictitious 
 look of health, although there is very real and sometimes very acute 
 general suffering and local pain. I have seen several cases of this 
 kind where the commencement of the malady was mistaken for 
 pregnancy. 
 
 6. The complexity of symptoms more or less vague seems to characterise 
 certain morbid conditions of the womb. Uterine maladies differ in 
 character not only by the predominance of general or local symptoms, 
 but also by the presence or absence of a certain symptom characteristic 
 of a certain morbid condition. 
 
 Sometimes the morbid state is easily determined ; it is accompanied 
 by a certain acuteness ; its characters are well defined, its symptoms 
 have one meaning. Sometimes after a certain period, the acute 
 feature having entirely disappeared, the primitive form gives place to a 
 congestive condition accompanied by several concomitant disturbances, 
 each of which is insufficient to characterise a malady, but which taken 
 together are serious enough, and yet there is no symptom predominant 
 enough to indicate to the physician the dominating element of this 
 morbid condition, the one with which treatment should commence. It 
 is this condition to which Pidoux has given the name of Bysmetria. 
 I know that these complex and half-effaced morbid conditions are not 
 described in uterine pathology, but they exist in practice. In such 
 cases we must attack the various elements of the disease successively, 
 at the risk of being accused of merely treating symptoms ; we often 
 end by simplifying the malady and discovering the true starting point 
 of the chief troubles. I admit that complexity is not special to uterine 
 diseases more than to those of other organs, but it must be taken into 
 account in making the diagnosis. Amongst all these associated morbid 
 elements we must distinguish those which, although blended in one 
 disease in the same organ, yet merit the name of complex diseases, 
 from others which, by remaining always distinct, even when they spread 
 to portions of the same economy, ought to be designated under the 
 name of complications. 
 
 7. The complications of uterine diseases are variable. They are not 
 only the sympathetic phenomena and the general symptoms occasionally 
 developed ; they consist also in the disorders of various organs making 
 part of the uterine system and in the organic disorders of other 
 systems. 
 
 The various organs composing the uterine system are seldom affected 
 singly, or at least they do not remain long without being attacked by 
 some malady which complicates the primitive one. When the ovaries 
 are inflamed or transformed into cysts it is seldom that there is not 
 
GENEEAL CHARAOTEHISTICS 2^0 
 
 fluxion, congestion, engorgement of the uterus. When the uterus is 
 diseased it is perhaps rarer still for the peritoneum, Fallopian tubes 
 and ovaries not to be afPected by the same disease, or at least by the 
 inflammation or congestion accompanying it. Mayer, of Berlin, in a 
 paper entitled ' Quelques mots sur la sterilite,'^ affirms that, out of 
 263 cases of women affected with sterility, and having some uterine 
 ailment, 35 had fluxions or versions with the following complications : 
 13 had endometritis, 8 chronic ovaritis, 7 ovarian tumours, 4 hyper- 
 trophy of the uterus, 2 uterine polypi, 1 a fibroid tumour. Sometimes 
 there are complications which aggravate the evil and increase the 
 difficulties of the case. 
 
 Organs unconnected with the uterine system may also be more or less 
 aff'ected. Thus, in 100 uterine diseases, Aran" has counted the follow- 
 ing as complications : 18 cases of inflammation of the appendages, 31 
 of catarrh, 25 of pulmonary phthisis, 9 of cardiac disease. I think, 
 however, that these complications are not so frequent as these statistics 
 (which probably are hospital statistics) would lead us to suppose. In 
 short, complication like complexity is a certain fact in uterine dis- 
 eases which must be taken into account. The various elements of 
 this morbid association must be attacked simultaneously or successively. 
 Sometimes the complication has not been discovered till the uterus 
 improves. Then the disease of the ovary or peritoneum which had 
 passed unnoticed is distinctly recognised in such a case. This disease 
 claims our attention and supplies the major indications. Such sur- 
 prises can only be avoided by the physician making a very careful and 
 minute examination. 
 
 8. Uterine diseases are essentially chronic. The course which 
 characterises the majority of uterine diseases can be easily deduced 
 from the long details into which I entered when treating of their 
 etiology. With the exception of traumatic and puerperal diseases 
 there is perhaps no uterine malady that is not very slowly developed. 
 A great number even of the diseases of the uterus and appendages 
 which attack women after delivery would not make their appearance 
 if the organ or organism were not predisposed. Therefore, even 
 when we see diseases such as these accompanied by a group of 
 acute symptoms, we may say that all uterine diseases are primarily 
 chronic. 
 
 They owe this character of chronicity to the share which the dia- 
 theses have in their constitution and to the anatomical and physiolo- 
 gical conditions of the uterus on which I have insisted so much. In 
 some circumstances, however, acute symptoms occur at the commence- 
 ment of a uterine disease, at other times later. But these acute 
 symptoms are merely associated with the invasion of the malady or 
 may be exacerbations of it. The disease continues to pursue a chronic 
 course. Its chronicity is kept up by the majority of the causes which 
 induce acute phenomena. The periodical recurrence of fluxion and 
 congestion hinder cure and keep up the evil. If they exceed their 
 
 ' Virchow's Archiv, Sept., 1856. 
 2 Op. cit., p. 155. 
 
250 UTERINE DISEASES 
 
 ordinary proportions or if they are accompanied by some unusual cir- 
 cumstance this is sufficient to revive inflammation or give to other 
 morbid elements renewed nourishment which rekindles the acute 
 symptoms. A¥e may say that the periodical return of subacute 
 symptoms is characteristic, as well as chronicity, of uterine diseases. 
 
 9. The difficulty of cure is not less characteristic of these diseases. 
 Undoubtedly some are incurable. It is also certain that cure may 
 easily be effected when the disease is simple and acute or at least 
 recent ; even then it necessitates a longer treatment than if situated 
 elsewhere. Whilst, however, the majority of uterine diseases are 
 curable, we must admit that they are less so than the majority of dis- 
 eases of other organs. I have already said that spontaneous cures 
 do not occur. I may add that under the influence of the most 
 rational treatment a cure is only effected very slowly. What retards 
 it is the slowness and chronicity of the disease, the part played by the 
 diathesis, the recurrence of menstruation which keeps up the disease, 
 the unfavorable oscillations which this periodical fluxion establishes 
 between the curative and the morbid tendencies, and the fixed exacer- 
 bations and relapses due to menstruation or to other causes. 
 
 The menopause may lead to a return of health, but even this result 
 unfortunately does not always happen. Tluxions, though irregular, 
 are not less common when kept up by an old lesion, and as they are 
 not always accompanied by evacuation, they have all the more tendency 
 to keep up congestion during a certain time, that is till the patient has 
 really entered on old age. 
 
 Therefore, even when under the influence of an appropriate treat- 
 ment the malady has begun to yield, amelioration often remains sta- 
 tionary, and much perseverance and energy are required before the end 
 is reached. A cure cannot be said to have been effected unless it has 
 stood the test of time and the recurrence of several menstrual periods. 
 Subjective symptoms, such as lumbar pain and disorders of innerva- 
 tion, may persist for a long time even after the disappearance of objec- 
 tive symptoms. Treatment must be directed against them uninter- 
 ruptedly, for they too may cause relapses owing to the debilitated state 
 in which they keep the organism. 
 
 Let me add that it is necessary to be on one's guard against the 
 appearance of cure of uterine diseases, in the course of which another 
 malady occurs. When an acute disease is developed concurrelitly 
 with the malady of the womb, the uterine symptoms disappear in 
 some measure in virtue of the law, duohus lahoribus simul obortis non 
 in eodem locO) vehementior ohscurat alterum ; but they return after the 
 cure of the acute disease which had temporarily suspended them. 
 Where a chronic disease occurs the two maladies exist and progress 
 simultaneously, for the uterine disease has weakened the constitution, 
 and this impoverishment only gives a greater hold to the other morbid 
 act. Only a sort of equilibrium is established, in virtue of which 
 sometimes the one sotnetimes the other has the advantage; in such 
 Cases, if the pathological condition endanger life, we must respect the 
 uterine symptoms for fear that an exacerbation of this morbid condi- 
 
GENERAL OHAEACTEEISTICS 251 
 
 tioii should hasten a fatal termination. All practitioners agree as to 
 the necessity of expectant treatment in such cases. 
 
 Two other reasons contribute towards diminishing the chances of 
 cure in the case of uterine diseases which present a marked character- 
 istic of chronicity ; the first is that patients have become so habituated 
 to their sufferings, and have learned to tolerate them so well, that they 
 are unwilling to submit to the exigencies of a treatment the strict 
 observance of which is often the only guarantee of success; for example, 
 in certain diseases it is difficult to prevent marital intercourse, in others 
 to prevent the fatigue entailed by social life. The second is the 
 defective nature of the diagnosis and treatment ; the defective nature 
 of the diagnosis arises from a want of necessary precision, from omit- 
 ting something in an examination, from failing to interpret correctly 
 the symptoms observed, or from the difficulty in unravelling the 
 various phenomena in complex cases ; defective treatment is the result 
 of a defective diagnosis, of the irregularity with which patients carry 
 out their treatment, and in some cases, e.g. deviations, it is the result 
 of the insufficiency of our therapeutical means. 
 
 If we consider the various circumstances I have just enumerated we 
 can easily understand how little chance there is of spontaneous cure in 
 uterine diseases, and how necessary is an intelligent medical inter- 
 ference, which must be both active and persevering if a cure is to be 
 effected. 
 
 10. Before finishing this summary description of uterine diseases, 
 I must refer to ilieir dwersity, and point out that mode of classifica- 
 tion which seems to present them in the most natural order. 
 
 After all that I have said hitherto with regard to the crude sys- 
 tematisations that have been made in uterine pathology, and as to 
 reducing all morbid conditions of the womb to one disease, the reader 
 must have seen that I have throughout this work tried to give proofs 
 of the existence of mani/ morbid conditions differing as to cause, 
 nature, seat, syjnptoms, indications and treatment. I admit that the 
 difference is not always well marked, that the same causes sometimes 
 produce different effects, that these morbid conditions are associated 
 in place of being isolated and distinct ; that, however, does not prevent 
 the existence of a natural diversity. The recognition of this diversity 
 is the best basis of diagnosis and therapeutic indications. 
 
 Only we must remember the meaning of the words uterine disease, 
 and the limits which exist between health and disease in the generative 
 organs. 
 
 Is every abnormal phenomenon, every material change a disease ? Is 
 there any essential and primary affection connecting these lesions?^ 
 Every abnormal phenomenon, every material disorder not involving 
 disturbance of the uterine or other functions is an exceptional fact^ but 
 does not deserve the name of disease. If the uterine functions are 
 disturbed, however, and if this disorder leads to othersj there is disease* 
 As to the diversity of uterine diseases, here as elsewhere we must apply 
 
 ' Boudct, Bedlierchcs sur la nature ct Ics causes dcs afcciions uUrinei: 
 Theses de Paris, 1857. 
 
252 UTERINE DISEASES 
 
 the natural method in order to distinguish the various morbid condi- 
 tions which have a common seat. Now, it is evident that there are 
 physiological disorders of the uterus which may react on the whole 
 organism ; and that there are affections of the whole economy which 
 may be localised in the uterus. There are changes of organic tissue; 
 there are displacements or changes with regard to the relationship of 
 this and neighbouring organs. Lastly, there are diseases depending on 
 one or other, or on both. 
 
 The nature of diseases ought to form the basis of the principal 
 divisions. The variety of form and seat, the diversity of the parts or 
 elements of the organ affected by the disorder, is the basis of the 
 secondary divisions. jNTow in placing ourselves at this double point of 
 view, we at once recognise the existence of uterine diseases that are 
 fundamentally different. Sometimes they are functional disorders, 
 menstrual troubles more or less serious, derangements in the expres- 
 sion and sequence of the physiological phenomena characterising the 
 vitality and destination of the organ. Sometimes they are simply dis- 
 placements, changes of position or direction, resulting from an altera- 
 tion in the statical conditions of the organ, and causing a simple 
 modification in its topographical anatomy and in its relations to the 
 neighbouring organs. At other times the alterations are not limited to 
 simple anatomical or physiological disorders ; they affect the organ in 
 its vitality, in its nutrition, often even in its structure and in the com- 
 ponent elements of its tissue. Sometimes the development of a modi- 
 fication of local vitality or the localisation in the uterus of a general 
 affection communicate to its functions a characteristic disturbance or 
 determine in the organ the manifestation of very characteristic patho- 
 logical acts, and finally the realisation of a fixed morbid condition. 
 Sometimes a real diathesis invades the organ at once, or profits by a 
 simple pathological act to fix itself there, communicating to the 
 morbid condition the anatomical and pathological characters which 
 distinguish it, and lead to its recognition on any other organ. Lastly, 
 persistent alterations of tissue or the formation of new tissue, whether 
 homeomorphous or heteromorphous, produce in the organ functional 
 disturbances and often pathological processes, constituting the chief 
 phenomenal expression of the disease. 
 
 It is plain, therefore, that uterine diseases can be distinguished by 
 the same terms that are used in general and special pathology, viz. as 
 anatomical lesions, vital affections, organic disorders. 
 
 11. The diversity, however, is accompanied ly complexity, through 
 the association of diseases. Eegarded from the same point of view, 
 uterine maladies will be seen to preserve their simplicity less than those 
 of any other organ.' Besides the characteristic complexity, we may 
 remark the tendency in these diseases to be linked to each other ; so 
 that after a certain time it is more or less difficult to discover which is 
 the original malady, and to determine whether the principal indication 
 for treatment lies in the primary or in the subsequent lesions. Some- 
 times in fact displacements cause menstrual disorders and pathological 
 effects, more or less complex ; sometimes menstrual disorders (conges* 
 
GENERAL CHARACTERISTICS 253 
 
 tion and increased weight of the organ) produce displacements. A.fc 
 other times diathetic disorders^ organic lesions, neoplastic tumours 
 determine functional disturbance. On the other hand, functional dis- 
 turbance after a certain time is followed by diathetic disorders and the 
 development of tumours. Displacements tend to produce simple patho- 
 logical processes, as well as the manifestation of the most complex morbid 
 conditions and the development of organic lesions. The worst is, that 
 when these diseases are associated it is difficult to determine which of 
 them causes the most serious symptoms, and, therefore, which ought 
 to be first attacked. For example, it is not often that simple devia' 
 tions cause real pain, but it frequently happens that they are acconi' 
 panied by metritis, pelvic peritonitis, &c., and that consequently they 
 occasion serious accidents. 
 
 We must always try to discover the link which connects pathological 
 processes, and to determine which of the morbid acts takes precedence of 
 the others at a given moment. 
 
 13. In order to classify the various diseases according to their 
 natural order of stcccessioti, we must try to put those foremost which 
 occur most frequently alone, and which are seen more frequently and 
 uncomplicated for a longer time than others, passing afterwards to 
 those which are composite and to those whose composition becomes 
 more and more complex, and at last reaching the most composite of 
 all, in each of which we may say that the whole of uterine pathology 
 may be concentrated. 
 
 I. Classified according to this principle, functional disturbances take 
 the first rank, %. e. diseases in which functional disturbances play the 
 chief part and form the principal element of indication. Whether 
 idiopathic or symptomatic, menstrual disorders are real diseases, for 
 they seriously disturb the health. Menstruation may be considered as 
 a delivery in miniature. Now menstruation and delivery are two 
 functions unlike any others ; in fact they resemble pathological rather 
 than physiological acts : hence their tendency to produce disease. All 
 functional disturbances are connected with menstruation. The cata- 
 menia may be defective, excessive or abnormal, giving rise to amenor^ 
 rhea, including retention and deviation of the menses ; dysmenorrhea^ 
 including uterine neuralgia ; and lastly, menorrhagia and metrorrhagia, 
 in which the sanguineous discharge is not only a critical evacuation 
 but a real haemorrhage (internal haemorrhage is described with pelvic 
 tumours). Not only are disorders of menstruation the most frequent 
 diseases, but they so often complicate uterine maladies and have so 
 large a share in their chronicity or in their exacerbations, that we must 
 always take them into account and discover when they are the cause of 
 these diseases, that we may obtain the clue to an important part of 
 general treatment. For these reasons we ought to commence uterine 
 pathology with the diagnosis and treatment of the disorders of men- 
 struation. 
 
 II. Next to functional disorders, I have placed changes of position 
 the chief characteristic of which is an alteration in the situation 
 direction and form of the uterus. I know that these morbid con- 
 
254 UTEEINE DISEASES 
 
 ditions are seldom as simple as has been supposed, their principal 
 symptoms being as often dependent on their complications as on 
 themselves ; sometimes they may be the result of preceding morbid 
 conditionSj such as congestion, engorgement, and hypertrophy ; whilst 
 in their turn they may produce leucorrhcea, granulations, ulcers. But 
 whatever may be the accompanying complications, whatever may be 
 the displacement, there are cases in which a change in the conditions 
 of the equilibrium of the uterus plays the principal part and may be 
 disengaged from all concomitant phenomena. These changes are of 
 four kinds : 1. Blsj^ilacements, including elevation, descent, and hernia ; 
 
 2. I)eviatio7i8, designated under the names of inclinations, or versions; 
 
 3. Mexions, or changes in the relative position of the two portions of 
 the uterus; 4. Lastly, Liversions, or changes in the'relative position of 
 the external and internal surfaces of the organ. 
 
 III. In proceeding from the simple to the composite, we encounter 
 in the third place morlid states wi'thout neofjlasm. I give this name 
 to affections generated by a simple morbid act, local or general, dia- 
 thetic or not diathetic, but neither accompanied by persistent changes 
 of tissue nor by the formation of new elements. These maladies are 
 often designated by the name of vital affections. The first of all these 
 morbid conditions, those which help to produce or complicate the 
 others, are, in the order of their production : fluxion, characterised by 
 a temporary movement more or less vigorous, single or repeated ; con- 
 gestion, characterised by the persistence of local hyperemia ; engorge- 
 ment, resulting from the repetition or persistence of the preceding 
 states and from effusion of the serous elements of the blood into the 
 affected tissues. Then follows inflammation, which borrows its prin- 
 cipal elements from the preceding morbid conditions, and is character- 
 ised by its tendency to suppuration or hyperplasia, and which occupies 
 a large share in the pathology of the uterus as of that of all other 
 organs. I have classed with, inflammation of the uterus that of its 
 appendages, the surrounding peritoneum and cellular tissue ; i.e. the 
 morbid states known under the names of metritis, endometritis, para- 
 metritis, and perimetritis. I have not even separated ovaritis, inflam- 
 mation of the Pallopian tubes and peri-uterine inflammation from 
 metritis, because these morbid conditions are often associated and 
 influence each other mutually; because when the one exists the 
 development of the other is to be feared; and lastly, because they 
 occasion the same indications and necessitate almost the same treat- 
 ment. The morbid conditions which follow, whilst often connected 
 with inflammation as cause, effect, or complication, are generally 
 dependent on a diathesis. They are : leucorrJuea, liypertrojphy, granu- 
 lations, and fungous growths, ulceration and ^dcers. The importance 
 of hypertrophy, though for long misunderstood can hardly be over- 
 estimated. 
 
 IV. In the fourth rank I have placed organic alterations, i.e. the 
 morbid conditions characterised by a persistent alteration of tissue and 
 differing from each other according as they are produced without the 
 formation of new elements, or with development of anatomical ele- 
 
GENERAL CHAEAOTERISTICS 255 
 
 ments having no analogy with the special elements of the uterine 
 tissue. The first, corresponding to homomorphous productions, 
 inclnde Jil/rot/iata, interstitial fibrous bodies or sub-peritoneal tumours, 
 whether pediculated or not, andpoli/pi, mucous or epithelial, follicular, 
 fibrous or vascular; with which, as far as diagnosis and treatment are 
 concerned, ?/ioles are naturally connected. The second, corresponding 
 to heteromorphous productions, are tubercle and cancer with all their 
 varieties of form and of locality ? 
 
 V. Lastly, I have arranged in a fifth category the organic altera- 
 tions of the appendages and the abdominal or pelvic tumours resulting 
 from their formation. This category, from which ovaritis and peri- 
 metritis have previously been separated, includes only two important 
 morbid conditions: 1. Peri-uterine hematocele, which is as much con- 
 nected with diseases of the appendages as with peri-uterine maladies, 
 since it derives its origin so frequently from haemorrhages of the ovary 
 and Fallopian tubes. 2. Ovarian tumours, among which multilocular 
 cysts take the first place from their importance and the recent progress 
 made in their treatment, and tumotors of the Fallopian tubes, connected 
 as they are with the interesting history of the migration of the ovum 
 and of extra-uterine pregnancy. Sterility, its diagnosis and treatment, 
 form the natural termination to this last chapter and to the knowledge 
 of all the diseases previously studied. 
 
 I have thought it useless to reproduce the statistics of uterine dis- 
 eases given by some gynecologists; for they do not even give an 
 approximate idea of the relative frequence of these various diseases. If 
 it is a question of hospital practice, either a special class of cases is 
 seen, e. g. venereal affections, or only the most serious cases or cases 
 requiring operation : for, as a rule, patients will not go to an hospital 
 while they can move about. Hospital practice, however, never can be 
 a fair sample of the innumerable variety of uterine diseases to be found 
 in any country. A general practitioner having the entire practice of a 
 district in his hands would perhaps be able to furnish more correct 
 statistics. But probably even he would only see the most serious cases ; 
 the majority of the less serious would forego treatment under such cir- 
 cumstances, while others would address themselves to specialists in a 
 neighbouring town. It is almost impossible for any statistics of 
 private practice to give even an approximate idea of the relative fre- 
 quency of different uterine diseases. This difficulty is quite indepen- 
 dent of the diseases themselves ; as for myself, I could not give such 
 statistics. I'ormerly I had a great many cases of metritis, leucorrhcea, 
 polypi, &c. ; now I hardly have one, the reason being that women 
 affected with these diseases are more or less successfully treated by 
 young practitioners. Now, on the contrary, I have great numbers 
 of incurable diseases, cancers, enormous fibromata, and ovarian cysts ; 
 patients coming to me from great distances because the treatment of 
 other doctors has been unsuccessful. Such cases not only occupy 
 much more space in my statistics than they formerly did, but much 
 more than they ought to do from their relative frequency. It is the 
 same with several other diseases, fortunately not incurable like those 
 
256 UTERINE DISEASES 
 
 just named, but more difficult to cure than a number of others, such 
 as flexions, perimetritis, peri-uterine adenitis, phlegmons of the broad 
 ligament, hematoceles, &c., as well as others such as mechanical dys- 
 menorrhoea and the various diseases which result in sterility. These 
 cases, which were almost entirely absent from my first statistics, occupy 
 an important place in my later ones, since my successful treatment 
 of a large number of cases became known to the pubhc, and has been 
 a fact recognised by the profession. 
 
PAET II 
 
 UTEEINE DISEASES IN DETAIL 
 CHAPTER I 
 
 FITNCTIOKAL DISOEDEES. — MEN8TEUATI0N — AMENOEEHffiA — EETENTION OF THE 
 MENSES — DEVIATION OF THE MENSES AND SUPPLEMENTAEY MEN8TEUATI0N 
 — DTSMENOEEHCEA — UTESINE NEUEALGIA — UTEEINE H^MOEEHAOB. 
 
 Strictly speaking, there is only one function with the disorders of 
 which we are concerned, viz. menstruation; and this function can only 
 be deranged in three ways : it may be defective, excessive, or dis- 
 ordered. 
 
 Menstruation is a flow of blood from the uterine cavity, occurring 
 in an intermittent manner, generally at regular intervals, except 
 during pregnancy and lactation, from the age of puberty, i.e. from 12 
 to 15, to that of the climacteric from 45 to 50. Its regular recur- 
 rence shows an aptitude for reproduction besides indicating the most 
 favorable periods for conception. 
 
 The mean duration of the intercalary or intermenstrual period 
 being about a month, these haemorrhages have been designated the 
 monthly periods or menses, or the catamenia ; their regular recurrence 
 at fixed times has led to the term monthly periods ; the dominant fact 
 of the discharge to that of the catamenia ; and the idea of the evacua- 
 tion being favorable to the general health to that o^ jmrgatio menstnia. 
 
 Menstruation is the function. The words monthly period, menses, 
 catamenia, &c., designate the external phenomenon which characterises 
 it. 
 
 Disorders of menstruation 
 
 Menstruation deserves the attention of the physician as a means 
 towards the interpretation of uterine diseases; it is a term of com- 
 parison. If menstruation has rightly been called a pregnancy in 
 miniature, we may say that it offers an epitome of several uterine dis- 
 eases taken as a whole or in some of their elements. Menstruation 
 also deserves attention because it may become a cause of diseases of 
 the womb ; it has a considerable share in uterine etiology as well as 'w\ 
 uterine pathology ; for, although itself a physiological act, it places 
 the organ which is the seat of it in conditions different from the equili- 
 brium which is one of the characteristics of health in all the other 
 organs. Menstruation ought also to excite our interest because, by 
 
 17 
 
258 UTEIIINE DISEASES IN DETA.1L 
 
 its disorders, it always discloses the existence of a uterine disease. 
 Often we have no other means of arriving at a diagnosis. In women 
 suffering from uterine disease, the menses either produce pain, cause 
 its reappearance, or increase it ; they last a longer or shorter time than 
 in the normal condition, and often are so irregular that patients cannot 
 fix the time of their recurrence. Menstruation is also worthy of 
 our serious consideration on account of the aggravation of the 
 local condition which it does not fail to produce in uterine dis- 
 eases, as well as of the interruptions to treatment which it 
 necessitates. Lastly, menstruation itself may be disordered ; in its 
 evolution and recurrence it is subject to more or less serious derange- 
 ments which constitute those uterine diseases which will first occupy 
 our attention. 
 
 In order correctly to appreciate the disorders of menstruation we 
 must follow this function throughout its whole course from beginning 
 to end. It may fail in establishing itself, or great difBculties may 
 present themselves in its establishment, or it may disappear for some 
 time. When established and regulated, circumstances may occur to 
 suspend its course, or if it continue to recuf regularly, it may be accom- 
 panied by more or less serious accidents at every period. The mens- 
 trual discharge may also be deranged with regard to the quantity and 
 quality of the fluid excreted.^ The ordinary division of the disorders 
 of menstruation which, as I have said, may be excessive, defective or 
 deviated, is very practical. The catamenia may not appear at the 
 period of life when we naturally expect them, or they may be sup- 
 pressed after a variable time ; or the discharge may take place with 
 difficulty ; or it may be excessive in quantity, or it may recur too 
 frequently. Hence three great classes of menstrual disorders, respond- 
 ing to which are often three kinds of capital indications. 
 
 1. Amenorrhcea including : retained menstruation and deviated men- 
 struation. 
 
 2. HysmenorrTioRa, to which we may add membranous dj/smenorrhcea 
 and uterine neuralgia. 
 
 3. Uterine hemorrhages, including menorrhagia and metrorrhagia. 
 These menstrual disorders are sometimes symptomatic, sometimes 
 
 idiopathic. It is of great importance to distinguish the one class 
 from the other, and this is what I shall endeavour to do in the 
 description I am about to give of them. 
 
 It is easy to prove that the disorders of menstruation, considered as 
 a whole, are of great practical importance. West^ rightly remarks 
 that the changes oi puberty in the girl, like those of dentition in the 
 child, are not effected suddenly, but are prolonged over a period of 
 some months, during which time diseases frequently occur. 
 
 The tables of mortality show that this period is more fatal to girls 
 than the preceding one, if we compare the numbers of deaths in the 
 two sexes. Quetelet and Smits^ have shown that, whilst in infancy 
 
 ^ Menstruatio aboletur, imminuitur, intenditur, depravatur. (Astriic.) 
 
 2 Diseases of Women, 4th edition. London, 1879, p. 26. 
 
 3 Sur la reproduction et la mortaliU de I'homme. Brussels, 1832. 
 
MENSTEUATION 
 
 259 
 
 mortality is equal in the two sexes or greater amongst boys, it is^ on the 
 contrary, greater amongst girls, in the proportion of 1"28 to 1 from 
 the fourteenth to the eighteenth year, and that it descends in the four 
 following years to 1*05 for girls against 1 for boys. 
 
 The anxiety of parents at the approach of this period is therefore 
 natural. Moreover, it is not without reason that this anxiety increases 
 in proportion to the delay experienced in the first appearance of the 
 menses. Whitehead has proved that the danger of accidents is greater 
 when the menses are delayed than when they are precocious, and the 
 researches made by West confirm this opinion. The following in- 
 teresting statistics are given us by Whitehead •} 
 
 First Menstruation. 
 
 No. of Cases. Unfavorable Cases. 
 
 Proportion. 
 
 From 10 to 14 years . . . 
 „ 15 „ 16 „ ... 
 „ 17 „ 18 „ ... 
 „ 19 and upwards . . 
 
 1141 
 
 1178 
 
 892 
 
 239 
 
 224 
 324 
 
 247 
 97 
 
 19-63 
 18-75 
 27-69 
 
 40-58 
 
 Total ..... 
 
 3450 
 
 1 
 892 22-30 
 
 Whilst delay in the appearance of the catamenia seems to increase 
 the chances of accidents which follow the establishment of this func- 
 tion, its precocity seems to indicate in the uterus an activity favorable 
 h) the development of certain diseases, particularly of organic diseases, 
 or rather of cancer.^ Kussmaul,^ having come across a case of cancer 
 of the ovary in a child of two years with the development of a girl of 
 twelve or fifteen, asked himself if there was any connection between 
 precocious puberty and ovarian disease. After numerous researches 
 he arrived at negative results for serous or dermoid cysts, but positive 
 for sarcomatous or cancerous neoplasms. Out of six cases of this kind 
 which he collected in three there was a history of precocious puberty. 
 EUeaume* made similar researches with regard to the influence of 
 precocious menstruation on the development of uterine cancer, and 
 found that out of twenty-eight cases of this disease menstruation had 
 occurred in nineteen before the age of fourteen years. 
 
 Amenorrhcea. 
 
 Amenorrlma (absence of menstruation), if we consider the etymology 
 of this word, includes the tardy appearance of the menses, their 
 premature cessation, and amenorrhcea properly so called.^ 
 
 ' Treatise an Abortion and Sterility, p. 48. London, 1847. 
 
 - I have often noticed that women affected with organic lesions of the 
 uterus and ovaries had menstruated prematurely and abundantl}'. 
 
 3 W'ilrzbiirger medicinische Zeitschrift, t. iii, 1862 ; Archives gencralcs de 
 tncdecine, fevrier, 1863, t. i, p. 224. 
 
 ■* L' Association mcdicale, 15 fevrier, 1863, p. 55. 
 
 ^ According to Etmiillcr (Castelli Lexicon), the disappearance of the men.scs 
 
260 UTEEINE DISEASES IN DETAIL 
 
 The delay in the appearance of the menses may depend merely on 
 the defective establishment of this function. Sometimes ovulation 
 takes place although there is no uterine haemorrhage. At other times 
 there is delay in the sexual development or a suspension of the repro- 
 ductive functions, either spontaneous or occasional,, by some malady. 
 Lastly, there may be absence of the uterus or imperforation of this 
 organ, causing retention of the menses; therefore I cannot too 
 strongly advise the physician to assure himself of the normal con- 
 formation of the genital organs, in certain critical circumstances in 
 which a girl who has never menstruated may be placed ; for instance, 
 on the eve of marriage. I knew a young woman in this position : 
 the family physician was consulted, and in place of dissuading the 
 parents from marriage he was imprudent enough to advise it, under 
 the pretext that conjugal relationship would not fail to provoke the 
 catamenial flow. Unfortunately, I discovered some years later com- 
 plete absence of the body of the uterus, so that I could give no hope 
 of children to the unfortunate parents who consulted me. I found, 
 however, that the ovaries were present in this young woman ; so, too, 
 were the menstrual molimen and sexual desire. I have had occasion 
 to see other cases of the same kind.^ 
 
 The premature cessation of menstruation may also coincide with the 
 cessation of ovulation or, which is rarer, may precede it. It seldom 
 occurs without some exciting cause, either general or local. When 
 genuine, it is neither accompanied by disorders nor by congestive 
 phenomena in the utero-ovarian economy. 
 
 Amenorrhcea, strictly speaking, is the absence of menstruation after 
 one or more monthly periods. Whether it disappear after some time 
 under the influence of the efforts of nature or of an appropriate treat- 
 ment, or whether it persist to an age when it becomes definitive, being 
 transformed into the menopause, it may constitute an anomaly rather 
 than a morbid condition. Amenorrhoea is normal during pregnancy 
 and lactation. In every other condition it is either an accidental ab- 
 normal condition, or the symptom of a morbid condition, or a real 
 disease. 
 
 Diagnosis. — Symjitomatic amenorrlima depends on various patho- 
 logical conditions of the uterus or of the body generally. As regards 
 the uterus, these are : malformation, either congenital, such as I have 
 described, or acquired, as I shall have occasion to refer to in speaking 
 of retention of the menses ; inflammation, acute or chronic, but espe- 
 cially acute inflammation of the uterus or of its appendages ; rarely 
 organic lesions of the womb ; oftener those of the ovaries. If depen- 
 dent on the general organism, the menses may be suppressed by acute 
 diseases, although this seldom happens when they occur at the com- 
 mencement of a disease ; they are, however, almost always suppressed 
 
 {suppressio lyiensium) should, be distinguished from their delayed appearance 
 (emansio onensmm) . 
 
 ^ Courty, Demande en nullite cle mariage fondce sior le defaut de caracteres 
 sexuels feminins ; consultation medico -14 gcde et considerants du jugement. 
 Montpellier medical, t. xxviii, p. 473. Montpellier, 1872. Annales de Gyne- 
 cologic, t. ii, pp. 325, 410. Paris, 1874. 
 
AMENOERH(EA 261 
 
 towards the decline of tlie disease or during convalescence.^ In chronic 
 diseases the menses diminish, become irregular, and finally are sup- 
 pressed, as the weakness increases and hectic fever makes its appear- 
 ance and the prognosis becomes more grave ; it is what happens every 
 day in tuberculous and cancerous affections, in organic diseases of the 
 heart and in Bright's disease, in cirrhosis of the liver when dropsy 
 commences, in some nervous affections, in anasmia, in chlorosis, in 
 polyuria, diabetes and obstinate diarrhoea.^ In symptomatic amenor- 
 rhoea the cause may disappear whilst the amenorrhoea persists. 
 
 IdiopafMc amenorrhoea is that in which more or less prolonged sus- 
 pension and cessation of menstruation depend on a cause exerting a 
 direct influence on this function.^ Any general disturbance may 
 produce it by arresting the functions of the ovary or uterus, by pre- 
 venting fluxion from taking place, by arresting congestion and haemor- 
 rhage, by turning aside the synergetic movements which establish the 
 molimen and cause the discharge of blood. It is probable that ovula- 
 tion cannot continue to be eff'ected unless uterine hsemorrhage is pro- 
 duced. The impression of cold in any form and on any part of the 
 body — for instance, a cold sitz-bath or foot-bath, a change of linen, a 
 fall or blow, the disturbance caused by a fit of indigestion, by blood- 
 letting, an emetic, pain, or fright — are the most common causes of 
 this derangement. Uterine torpor, congenital or acquired, and pre- 
 mature atrophy of the womb encourage this action. Anxiety, grief, 
 change of habits and residence, as happens for instance with girls 
 who are sent to school, a sedentary life like that in convents, and im- 
 prisonment following an active and free life, often produce a more or 
 less serious and prolonged disturbance in menstruation. The facility 
 with which this function is afi'ected by slight causes is also common to 
 most of the other acts of reproduction ; the impressionability of the 
 generative system seems to be greater than that of the other organic 
 systems, so great that Eaciborski has seen occasion to attribute amenor- 
 rhoea to the simple fear of pregnancy after illicit intercourse, or to the 
 great desire of having children after prolonged steriHty, and this he has 
 designated amenorrhoea from psychical causes. Whether, however, 
 the impression is produced on some part of the body (sudden 
 chill, intestinal parasites) or on the brain (vivid moral impressions), 
 it is by a kind of reflex action on the uterus that amenorrhoea 
 is produced, which has led some writers to call it sympathetic 
 amenorrhoea. 
 
 ' Heravd, Be I'influence des maladies aigues fehriles sur les regies. Raci- 
 borski, Traite de la menstruation. 
 
 ^ Becquerel, op. cit., t. ii, p. 406. 
 
 2 It is evident that cither the ovary or uterus may he affected, hence the 
 division of amenorrhoea, according to Racihorski, into ovarian or radical and 
 uterine. The first may be organic or functional. Functional ovarian amenor- 
 rhoea, caused by a kind of torpor of the ovaiy, is true amenorrhoea ; it may 
 consist either in delays or in complete amenorrhcea. To be still more exact, we 
 must distinguish, from this point of view, three kinds of amenorrha^a : 1, from 
 absence of ovulation ; 2, from absence of uterine congestion ; 3, from absence 
 of sanguineous exhalation. 
 
262 UTERINE DISEASES IN DETAIL 
 
 Differential diagnosis. — It is important to distinguish idiopathic 
 from symptomatic amenorrhoea, from retention of menseSj and from 
 the accidents of various kinds which may result therefrom. 
 
 Idiopathic amenorrhoea is sometimes well tolerated ; but generally it 
 produces more or less serious local or general phenomena. Some- 
 times the local symptoms predominate, especially those of congestion ; 
 fluxion is effected but has not its natural termination; absence of 
 evacuation is not compensated by the natural reaction which tends to 
 dissipate the fluxion after each period, and the congestion continues to 
 increase, sometimes even rising to the degree of a permanent morbid 
 condition. Sometimes fluxion does not take place, but this absence 
 causes a disturbance in the general circulation and in all the other 
 functions. General phenomena are manifested : in a few women it would 
 seem that the habitual absence of sanguineous evacuation produces a 
 plethora (resulting in congestions of the spleen, liver, lungs, or head, 
 causing in the last case headache, drowsiness, congestive amaurosis,^ 
 &c.) ; in others on the contrary, and in the majority the blood 
 becomes impoverished, innervation is disturbed, and symptoms of 
 chloro-ansemia are developed. It is important to distinguish chlorosis 
 produced by amenorrhoea from that of which, on the contrary, amen- 
 orrhoea is symptomatic. 
 
 Symptomatic amenorrhoea is always preceded by the disease of which 
 it is only the symptom,^ till such time as it can continue of itself, by 
 virtue of the morbid habit which the repeated suspension of menstrua- 
 tion has impressed on the economy. Amenorrhoea symptomatic of 
 defective development may have a number of features in common with 
 idiopathic amenorrhoea causing them to be confounded together. 
 Whether there is absence of the uterus or ovaries, or a rudimentary 
 condition of these organs [uterus foetalis or infantilis) they have the 
 common feature of amenorrhoea. When the ovaries are wanting there 
 is only this one negative symptom. In the contrary case, we gene- 
 rally observe all the prodromata of menstruation, lumbar or hypo- 
 gastric pain, a sense of pelvic fulness with pain radiating down the 
 thighs. After lasting for some days this ceases, but is reproduced 
 sooner or later the following month with a certain regularity. In 
 other cases the disturbance is less marked : there is sometimes palpita- 
 tion of the heart and violent headache necessitating bloodletting. 
 Occasionally phenomena of hsemorrhagiparous congestion are devel- 
 oped on various parts of the body, which might lead us to think that 
 the economy was in need of depletion, and tried to effect a vicarious 
 evacuation. The duration of these troubles and hsemorrhagic molimeu 
 is very variable. Sometimes they last for a few years only, not 
 unfrequently, however, they are prolonged for twenty. Then a 
 
 ^ Such is the case related by Samelsohn of complete amaurosis the result of 
 a sudden suppression of the menses, which gradually disappeared when men- 
 struation was again established seven weeks later {Berlin. Klin. Wochenschr., 
 18 Jan., 1875). 
 
 2 We must be on our guard against the tendency that women have o£ attri- 
 buting all their diseases to amenorrha3a in place of regarding it as the effect of 
 various pathological affections from which they may be suffering. 
 
AM£NORRH(EA 263 
 
 gradual amelioration takes place similar to what occurs after tlie 
 menopause in women who have suffered from obstinate dysmenorrhoea. 
 
 Menstrual retention may be diagnosed by the hypogastric tumour of 
 the uterus, disteoded by the accumulation of blood. The symptoms 
 experienced by patients are generally in proportion to the quantity of 
 fluid. Not only are symptoms of molimen manifested every month, 
 but there are signs of repletion of the genital organs often accom- 
 panied by fruitless expulsive eff'orts. These phenomena, differing as 
 they do from those produced in the majority of cases of amenorrhoea, 
 are attended by painful periodical exacerbations, an intolerable and 
 almost continuous nervous erethism, and often still more serious symp- 
 toms. In short, before deciding that there is amenorrhoea, we must 
 ascertain that the genital organs are in normal condition. This 
 examination ought not to be neglected even in women who have had 
 sexual intercourse or children, for the obstacle to the discharge of 
 blood is often internal or may have been produced after labour. The 
 examination should not be confined to the vulva and vagina, but 
 should extend to the uterus and its appendages. Lastly, the possi- 
 bility of pregnancy must not be lost sight of. 
 
 Treatment. — The indications may be various. In the first place 
 amenorrhoea may be compatible with the free exercise of all the func- 
 tions and with perfect health, in which case there is evidently no 
 occasion for treatment. It is the same when it is irremediable and 
 symptomatic of an incurable disease in an advanced stage. 
 
 Treatment ought to be confined to hygienic measures when the 
 amenorrhoea is only a delay in the first appearance of menstruation, or 
 the result of convalescence from acute disease rather than amenorrhoea 
 strictly speaking, and should be directed exclusively to the affection 
 which has suspended ovulation in cases of symptomatic amenorrhoea ; 
 consequently, we must treat nervous asthenia, haemorrhages, im- 
 poverishment of blood, anaemia, chlorosis, or even plethora (when it 
 seems to have a share in producing the disease), without directing our 
 attention to the genital system, and only endeavour to excite the ova- 
 ries or uterus directly by more or less powerful stimulants after having 
 cured the maladies of which the amenorrhoea is only a symptom. 
 
 In idiopathic amenorrhcea the indications vary according to whether 
 the general or local condition predominates. Almost all cases may be 
 included in one or other of these categories; the periodical fluxion 
 may either continue to take place in the uterus, congesting the organ 
 without terminating in a discharge of blood, cases of this category 
 being characterised by the predominance of local symptoms ; or the 
 fluxion may not even take place, being directed instantaneously after 
 suppression to another organ, or it may take this false direction at a 
 later period, or not at all ; cases of this category are characterised 
 by the predominance of general phenomena. The one class or the 
 other, according to the case, becomes the principal source of 
 indication. 
 
 The local phenomena which predominate are chiefly congestive. 
 "When general symptoms predominate they are more varied. For the 
 
264 UTERINE DISEASES IN DETAIL 
 
 habitual suppression of uterine fluxion and evacuation may either de- 
 termine plethora or chloro-ansemia with their various aspects and 
 numerous consequences, or fluxionary movements, so varied in their 
 progress, tendency, aim and termination. Hence two kinds of indi- 
 cations, the one being dependent on the defective normal fluxion which 
 has to be recalled, the other on the intensity and nature of the general 
 disorders which have to be cured ; the one class may predominate, or 
 they may do so alternately at different periods of treatment in the same 
 patient. 
 
 Indicatio7is fiirnisJted hy local troubles or hy phenomena of uterine 
 congestion, — It is not enough to characterise the form of these phe- 
 nomena ; in order to treat them efficiently, we must also determine 
 their essential cause or nature. It is important to be able to refer 
 the local troubles to congestion; but this persistent congestion is 
 only the form of the malady; the basis of the morbid state which 
 keeps up this condition is a disorder aff'ecting the vitality of the 
 uterus. In tracing its origin to this source, we discover that the 
 disorder may affect the vital functions of the organ, its sensibility, 
 contractility, secreting power, &c., or the properties of its tissues, 
 their permeability, elasticity, resistance, &c. It is not, however, 
 always possible to push analysis so far as to determine with certainty 
 which of the two is the source of indication. There may be primarily 
 or secondarily a simultaneous appearance of these various disorders 
 of vitahty, which we regard as the essential cause of hindrance in the 
 evolution of menstruation. We see infinite gradations of this in 
 practice, but in this description we can only touch upon the principal 
 varieties. 
 
 Congestion may be imperfect, or may not be sustained by a sufficient 
 effort, not reaching the highest expression of the physiological act 
 capable of determining evacuation. In this case we must strengthen 
 the fluxion and regulate it, stimulating it by various applications 
 which affect the vascular system of the uterus. Gentle purgatives, 
 e.g. castor oil, or small doses of aloes, or laxative enemata containing 
 manna, molasses^ honey, or a mercurial decoction, or one of lettuce 
 and white beetroot, to which may be added a few spoonfuls of oil, 
 glycerine, or a little soap, produce an intestinal flux^ which is favor- 
 able to the estabhshment of menstruation. On the other hand, mild 
 attractives, such as dry cupping, sinapisms on the upper and inner 
 parts of the thighs as well as on the hypogastrium, or a few leeches 
 appHed to the external surface of the labia, are excellent means of 
 inducing an external discharge of the blood which congests the 
 uterus. 
 
 Uterine congestion may be sufficient, the means of expulsion only being 
 defective. Sometimes irritability of the organ is the principal obstacle. 
 In order to calm this we must have recourse to emollients in various 
 forms : general baths, sitz-baths, liot poultices on the abdomen, fumi- 
 gations, enemata, &c. Sometimes the blood is retained by erethism or 
 by spasm of the uterus. In this case preparations of aconite, henbanej 
 belladonna, or poppy-heads may ^produce the desired result ; they may 
 
AMENOERH(EA 265 
 
 be administered interualljj or externally in the form of enemata, baths, 
 fomentations,, or embrocations. Sometimes inertia of the uterus or 
 suspension of its muscular contractility, are essential conditions of the 
 imperfection of the act. Emmenagogues are then the best uterine 
 evacuants, especially ergot ; electricity, and douches on the cervix may 
 also be tried with the same object. 
 
 In a third class of cases congestion is more than sufficient, exceeding 
 the limits of the physiological menstrual state, and by its excess hin- 
 dering the natural discharge from taking place. The uterus is turgid, 
 its volume greatly increased, its vessels are gorged, its fibres distended, 
 its elasticity and contractility diminished. In this case the indication 
 is to empty the vascular system, either by direct depletion or by revul- 
 sion, with the object of subduing the excessive fluxionary movement 
 which is the primary cause of this congestive tumefaction. The 
 best of all revulsives is bloodletting from the arm ; it ought not to 
 be copious, especially if it has to be repeated ; not more than from 
 three to six ounces of blood should be taken, unless the intensity of 
 the congestion and the attendant symptoms require a more copious 
 evacuation. This is sometimes followed by an immediate appearance 
 of the menses ; or it allows the other means used to produce their 
 effect ; or it may only produce an effect on the following periods, at 
 each of which it ought to be repeated. We shall have occasion to see 
 that the indication for bloodletting occurs in other circumstances, 
 especially in the treatment of amenorrhoea symptomatic of uterine 
 congestion, metritis, peri-uterine inflammations, &c. 
 
 Indications furnished by general trouhles, i.e. by the absence of 
 uterine fluxion and its reaction on the whole economy. — The aim of 
 some is to attract or recall fluxion to the uterus, that of others to cure 
 the general disorders or various affections the starting point of which 
 was the absence or suppression of menstruation, 
 
 I. To attract sanguineous fliixion to the uterus or recall it when it 
 has ceased, is an indication which M'e cannot always fulfil, nor ought 
 we to try to do so in idiopathic amenorrhoea before having fulfilled the 
 second of the two indications just mentioned. _For the general dis- 
 turbances imported by the amenorrhoea into the principal functions of 
 women, especially when they have reached such a height as to have 
 become themselves morbid affections, may ultimately have to be 
 regarded as the essential cause of the suppression of menstruation. 
 Idiopathic amenorrhoea touches so closely upon symptomatic amenor- 
 rhea at this point, that the former may be transformed into the 
 latter ; so that after having been idiopathic and having produced dis- 
 eases of the uterus or of the general economy, amenorrhoea may in its 
 turn become symptomatic of these same diseases. Just as pain is the 
 daughter as well as the mother of inflammation, amenorrhoea is 
 mother and daughter successively of uterine congestion or metritis, of 
 plethora, anaemia, chlorosis, &c. This mutual influence is exerted in 
 various degrees, and the nature of its action in this intervention is as 
 variable. But whatever its mode of action may have been, the 
 amenorrhoea may, in its turn, become so dependent on certain morbid 
 
266 UTERINE DISEASES IN DETAIL 
 
 conditions, that the primary^ sometimes the only indication, is to treat 
 these diseases, the cure of which will bring about at the same time, 
 without the application of any direct means, the cure of the amenor- 
 rhoea. We must therefore take this subordination into account, and, 
 in these complex cases, know how to fix upon the dominant indica- 
 tion, because it is the primary, sometimes the only indication to be 
 fulfilled. 
 
 It would be impossible here to analyse all cases of this kind, or to 
 determine when one of these indications should be fulfilled to the 
 exclusion of the other, when one before, or after the other, or when 
 the two simultaneously. Forced to separate what ought often to be 
 united, and to describe in a certain order of succession what ought 
 often to be practised in an inverse order, we must point out that in 
 describing the treatment of idiopathic amenorrhoea, we have given not 
 the first rank, but the first place to a description of the indications 
 connected with defect of the uterine fluxion, and the second to a 
 description of those connected with the concomitant general disorders. 
 
 To determine the appearance or return of the uterine fluxion is an 
 indication that can be fulfilled by means analogous to those employed 
 to attract fluxion to any part of the economy. It is manifestly easier 
 to attract to the uterus and to establish in this organ a fluxionary 
 movement which is natural to it, than to attract an artificial fluxionary 
 movement to any other part of the body, the latter being essentially 
 a morbid act, whilst the former is a physiological one. This 
 fluxionary movement being intermittent and periodic, the means used 
 to produce it ought to be in harmony with this characteristic, e.g. : 
 when we have not succeeded in re-establishing menstruation during 
 the first days which follow a sudden suppression of the period, we 
 must limit our efforts to the treatment of the symptoms produced, 
 and await the probable return of the following period to try new 
 means. 
 
 All the functions of the uterus having a share in the maintenance 
 of its physiological state will have an equal influence in the cure of 
 amenorrhoea. Menstruation being composed of several successive 
 acts, we shall certainly have more chance of restoring the first of these 
 acts to its normal type if we try to restore the others consecutively, 
 and. to bring into play the faculties and properties of the organ by 
 means of which they are carried out. For instance, evacuation and 
 congestion will encourage the physiological return of fluxion. The 
 realisation of the former processes will exercise a kind of attraction on 
 the latter : whilst on the contrary the more the fluxion falls short of its 
 final result, the less tendency it will have to be reproduced. These 
 principles ought to guide the practitioner as to the nature of the. 
 means he should use, and the order in which he should employ them. 
 Of all these means the most physiological is marriage; we are there- 
 fore justified in advising it, when amenorrhoea does not seem to be 
 dependent on any malformation or defective sexual development, nor 
 to have determined the appearance of any serious disturbance in the 
 uterine system or in the general condition of the patient. Before 
 
AMENOREHCEA 267 
 
 giving such advicCj however, we must ascertain that a uterus is 
 present and that there is no obstacle to the discharge of the menses. 
 If this is the case^ or if amenorrhoea has occurred after repeated men- 
 struation, we must resort to those general and local means which have 
 a tendency to encourage uterine fluxion and hsemorrhage. All medi- 
 caments which attract the blood to the lower part of the body, to the 
 pelvisj rectum and uterus are used to fulfil this indication in the 
 treatment of amenorrhoea. Women themselves know the utility of 
 foot-baths, sitz-baths, sinapisms, fumigations, leeching and purgatives 
 in determining the appearance of the catamenia or recalling them 
 when suppressed. They often employ them without consulting a 
 physician in cases of sudden suppression of the menses under the 
 mfluence of moral emotion, a chill, arrested perspiration, &c. Very 
 hot sitz-baths repeated several times a day, especially when mustard is 
 added (the effect of which is more durable than that of heat) ; fumiga- 
 tions taken by sitting on a high vessel at the bottom of which boiling 
 water has been poured over a handful of aromatic herbs ; vapour 
 douches round the pelvis ; prolonged tepid foot-baths with the addi- 
 tion of half a pound of mustard; sinapisms applied to the lower part 
 of the body, especially to the inner side of the thighs and to the hypo- 
 gastrium ; dry cupping apphed to the same parts ; the application of 
 leeches to the groins, anus, external surface of the labia or even to 
 the cervix (care being taken in the latter case to apply not more than 
 two on each side, and to repeat this application two or three days 
 running); drastic purgatives, such as jalap, gamboge or aloes; enemata 
 of aloes containing from 5ss to 5iiss of aloes suspended in the yolk of 
 an egg and ^iij of water (Schoniein) ; sometimes cold douches to the 
 pelvis and legs ; such are the means usually employed. They often 
 suffice when repeated for several months consecutively. When neces- 
 sary a stimulus may be applied directly to the vagina and cervix by 
 irritating vaginal injections. Ashwell advises 10 to 60 minims of 
 liquid ammonia mixed with ^iss of milk repeated several times a day ; 
 beginning with ten drops and adding five every day till a slight leucor- 
 rhoea is produced. 
 
 There are various ways of encouT&gmg persistence of the congestion 
 which these fluxionary movements determine in the uterus ; for 
 instance by applying very hot emollient cataplasms for a long time 
 to the abdomen, or by enveloping the pelvis and abdomen with hot 
 flannels impregnated with aromatic vapours, and covered with oil-silk 
 or gutta percha, so as to maintain a constant moist heat. For 
 chlorotic patients Pajot recommends that the lower limbs should be 
 bandaged, a powerful and rational means when blood-letting is contra- 
 indicated, and when the digestive organs do not tolerate medicines. 
 
 Other medicaments seem to possess the property not only of con- 
 gesting but also of evacuating the uterus by causing contraction of 
 its muscular wall. Their real or supposed action on the uterus has 
 gained for them the name of emmenagogues. I do not refer to the 
 tincture of iodine and some other medicines which have been tried 
 and too highly vaunted by certain physicians ; probably they answer 
 
2()8 tJTEEINE DISEASES IN DETAIL 
 
 special indications and modify tlie general health rather than exercise 
 any direct local action. But amongst emmenagogues proper if the 
 action of ergot is incontestable, what are we to think of rue, savin, 
 absinthe, saffron, &c., which enjoy a popular reputation ? Ergot 
 evidently causes uterine contractions and facilitates the menstrual dis- 
 charge. It is generally associated with the others in various popular 
 recipes of doubtful efficacy. The following pills combined with the 
 other means just enumerated often prove useful : — Il2ie, Savin, 
 Mrgot. aa gr. |, Aloes gr. \ to gr. |. — Make one pill and take 3 pills 
 the first day, 6 the second, 9 the third, three times a day. As a rule 
 these pills should be preceded by foot-baths, sitz-baths and fumiga- 
 tions, and leeches should be applied to the labia the three days on 
 which the pills are taken. These pills often cause colics and a little 
 diarrhoea. Joret^ and Marotte" give apiol (the active principle of 
 apium petroselimim) for amenorrhcea and dysmenorrhcea in 4-grain 
 doses twice a day at the time of the monthly period. Marotte says 
 that this remedy is sometimes very efficacious, especially in cases of 
 simple amenorrhcea, when apparently the only indication is to act on 
 the uterine circulation, on its vaso-motor system, and so to induce 
 an escape of blood from the vessels. It is the same in dysmenorrhoea 
 not dependent on any mechanical obstacle or organic condition of the 
 uterus. If amenorrhcea and dysmenorrhoea are partly dependent on 
 a general local condition, apiol can only be of use when the comjjlex 
 condition has been brought back to that of simple amenorrhcea or 
 dysmenorrhoea. The use of electricity is quite rational, and has given 
 incontestable proofs of its efficacy. One of the poles should be ap- 
 plied to the loins, the other to the groins, hypogastrium, and 
 perineum. The cervix may be seized with an exciter having two 
 branches isolated, so as to protect the vagina, except at the extremities 
 which embrace the cervix ; or one of the poles may be applied to the 
 cervix, the other to the hypogastrium ; or one of the poles to the 
 uterine cavity, the other to the cervix, hypogastrium, or rectum. It 
 is easy to understand how this repeated excitation may stimulate 
 the fluxionary movement and cause contraction of the uterus. The 
 cold douche applied to the cervix has an analogous action, and may also 
 be useful;^ metritis, however, is to be dreaded. Simpson used other 
 very ingenious means, based on the knowledge of the physiological 
 laws of the uterus, and producing the effect of exciting contractions 
 in that organ. For simple dilatation of the os externum, as in the 
 case of mechanical dysmenorrhoea, Simpson used stems, or rather 
 pessaries {See Tigs. 185 and 186), the stems of which varied in 
 diameter, like the bougies with which the urethral canal is dilated. 
 But besides these pessaries, the mechanical action of which, although 
 limited to the orifices, causes uterine contractions by the contractile 
 reaction of the body from titillation of the cervix, Simpson sometimes 
 introduced into the uterus longer stem pessaries made of two metals^ 
 
 1 Bulletin general de thh'apeuUque, f ev., 1860. 
 
 2 Id., octobre, 1863. 
 
 3 Panas. These de Enguehard. Paris, 1868. 
 
AMENORRHCEA 269 
 
 an instrument which we have already described as the galvanic stem 
 pessary. At other times he applied what he called a dry cupping-glass 
 {See Fig. 207) to the uterine cavity, i. e. a hollow sound pierced with 
 holes at its terminal extremity, the other end being screwed on to a 
 small aspirator. As a vacuum is made in the instrument, a kind of 
 aspiration is effected on the mucous membrane of the uterus, which 
 is thereby sucked against the minute apertures of the sound through 
 which eventually the blood filters after repeated applications 
 have been made several days consecutively, or at several monthly 
 periods. 
 
 II. — General disorders due to amenorrhcea are very numerous and 
 very varied. They may be ranged under two principal divisions, 
 according as they depend on anaemia or plethora. There may be 
 a general 'pl^tliora, or too great a quantity of blood in proportion 
 to the size of the vessels which contain it ; the indication then is 
 clear; we must empty the vascular system by repeated blood-letting, 
 general and local, by purgatives, by regimen, by diminishing the 
 quantity of food, by exercise, &c. The state of plethora may, so to 
 speak, be localised on one point or one organ, which has become con- 
 gested owing to the repeated fluxions of which it has been the 
 seat since the commencement of the amenorrhcea. This congestion 
 is permanent or temporary ; it may be intermittent, recalling the 
 menstrual periodicity, as I shall explain in speaking of deviated or 
 supplementary menstruation. It may even extend to hsemorrhage. 
 Hence different indications varying with the seat of congestion, its 
 character, intensity, duration, its intermittence, its sequences, such 
 as hsemorrhage, &c. If the head, chest, or other important organ is 
 the seat of the evil, the latter must be treated with greater energy 
 without reference to the uterine fluxion which can be recalled after- 
 wards. In short, we must carefully watch the affected organ in the 
 interval or in the absence of the menses, and try to destroy the morbid 
 predisposition which makes it the locus minoris resistentice (E. Fritz). 
 Usually, however, the general disorders of health assume an opposite 
 character from that of plethora, that namely of anamia or chlorosis. 
 These two maladies are often confirmed and greatly increased by 
 amenorrhcea. The nervous disorders which follow suspension of 
 menstruation, even when they do not assume the character of true 
 neurosis, greatly contribute, in concert with digestive troubles and 
 dyspepsia, to derange nutrition, and consequently to throw patients 
 into an anaemic condition or to develop a tendency to chlorosis. This 
 disease is apt to produce derangements in the health very difficult to 
 remedy. Lastly, under these combined influences we may see diathetic 
 affections developed in patients having a predisposition to them, but in 
 whom the outbreak is occasioned by the general debility of the 
 constitution. 
 
 Such are the various sources of indications arising most frequently 
 from general disorders of the health accompanying amenorrhcea. The 
 indications are the same when these diseases have preceded and pro- 
 duced amenorrhcea in place of following it. In both cases we must first 
 
270 UTEEINE DISEASES IN DETAIL 
 
 of all direct our attention to the affection in question, and when it 
 is cured the amenorrhoea will disappear spontaneously. 
 
 In addition to the means to be used in the treatment of a nervous 
 condition, to those which are ef&cacious in cases of dyspepsia, and to 
 the medicaments peculiarly suitable to the diathetic affection that may 
 have been developed, we must employ tonics of all kinds. 
 
 Hygiene must be the basis of our treatment ; a country life, exer- 
 cise, gymnastics, hydropathy, warm clothing, nourishing and easily- 
 digested food, tonics, and iron in one of the forms already indicated, 
 will generally be successful. The use of natural effervescing and chaly- 
 beate waters, taken on the spot, and so involving change of scene and 
 chmate, is often of great service. The waters of Lamalou, Andabre, 
 Sylvanes, Boulou, Vals, (Ardeche), Eoyat, Vichy, may be prescribed 
 in such cases with great hope of success. 
 
 Retention of the Menses. 
 
 This condition is characterised by the apparent absence of the 
 catamenia, which, owing to some cause or other, are retained in the 
 vagina or uterus. It is not, therefore, strictly speaking, a disease ; at 
 the same time it is so marked a symptom and connected so closely 
 with certain anatomical lesions, that it is convenient to describe these 
 various lesions under this common name. Amongst the maladies 
 which may be the causes of this accident the most important are : 
 
 1. Congenital imperforation of the vulvo-uterine canal, including 
 the non-separation of the external genital organs, imperforation of 
 the hymen, absence or obliteration of the vagina, imperforation of the 
 cervix. 
 
 2. The accidental obliteration of the uterus or vagina owing to 
 cicatrix or to gangrene. 
 
 In neither of these two cases can the normal menstrual discharge 
 take place by the efforts of nature. Excretion by abnormal paths 
 {e. g. genito-rectal or tubo-vaginal) can only be effected with great 
 danger. 
 
 Retention of the menses as a morbid condition, therefore, is limited 
 to symptoms pathognomonic of atresia of the genital canals, i. e. to 
 cases in which some obstacle, congenital or acquired, prevents the dis- 
 charge of the catamenia. Characteristic troubles follow, and the indica- 
 tion evidently is to allow the escape of the fluid accumulated in the 
 cavity above the obstacle. 
 
 Puech^ has collected and scientifically explained all cases of this kind 
 in a monograph printed in 1863, in the Transactions of the Academy 
 of Science and Letters of Montpellier, from which I shall make 
 numerous quotations. 
 
 The atresia (literally absence of orifice) or anatomical locaHsation 
 of the obstacle varies in its seat and origin. 
 
 I. With regard to the seat of the atresia, three kinds may be dis- 
 tinguished depending on whether it is in the vulva, vagina, or uterus. 
 
 ^ Be I'atresie des voies genitaJes de lafemme, in-4°, p. 165. Paris, 1864. 
 
RETENTION OF THE MENSES 271 
 
 1. Vulval atresia. — The labia majora as well as the minora may 
 contract adhesions. These are almost always cicatricial; they never 
 cause retention of the menses, but they may interfere with the expul- 
 sion of the urine or lead us to suspect the existence of stone, and they 
 necessitate an operation, insignificant as a rule. With the exception 
 of cicatricial adhesions they yield to simple traction. Imperforation 
 of the hymen is the most common form of vulval atresia.^ Puech has 
 quoted 151 cases. Atresia of the hymen, which is most frequently 
 congenital, may be complicated by an obstacle in the vagina, as 
 Euysch, Schultz, Walther and Burns have observed, or by an obstacle 
 in the cervix, as seen by Butler and Picard. 
 
 2. Vaginal atresia may be congenital or acquired. Congenital 
 vaginal atresia is said to be simple when the obstacle is limited to the 
 vagina, complicated when it involves both vagina and cervix, com- 
 plex when, the vagina being double, one of the canals is obstructed. 
 The first kind is the most common. It may be subdivided according 
 to the extent of the obstacle into three varieties. In the first are in- 
 cluded membranous imperforations ; in the second, cases in which the 
 obstacle extends from 10 to 40 millimetres; whilst the third includes 
 those exceeding the last limit. The second kind is distinguished from 
 the preceding one by imperforation of the cervix ; it presents two 
 varieties, according as the two obstacles are or are not separated by a 
 cavity. The third kind is characterised by duplicity of the vagina and 
 imperforation of one of the canals. This kind, the rarest of all, has 
 been observed by Leroy,^ Deces^ and Eokitansky.* Fifty-three cases 
 are recorded of acquired vaginal atresia. They may be complicated by 
 -multiple adhesions or by a vesico-vaginal fistula, as seen by Meerck 
 and Puech. 
 
 3. Although uterine atresia is rarest of all, fifty-four cases have 
 been collected by Puech. It may be congenital or acquired. In 
 the first case, there is imperforation of the cervix; in the second, 
 obliteration. Imperforations are said to be simple when there is only 
 one cervix ; complex when, the uterus being double, one of the canals 
 is occluded. There are on record thirty-four cases of the first kind 
 and only two of the second. The seat of obliteration is generally the 
 lower part of the cervix, and to this there is but one exception out of 
 twenty-one cases, and that is recorded by Mattei, who observed 
 obliteration of the os internum. 
 
 II. With regard to the origin of atresia, cases may be divided into 
 congenital and acquired. Congenital atresia is an imperforation, 
 acquired atresia an obliteration. 
 
 1. Imperforation, which occurs most frequently, is owing to arrested 
 development. Taking the three zones (vulva, vagina, uterus) into 
 
 ' We find a case of this kind in the Ejihcmcrides d'Alleviagne, Dec. 2, .3rd 
 year, Obs. 151, quoted by Quesnay in his Memoire sur les vices cles humeurs 
 {Memoires de I'Acad. ray. de Chirurgie, t. i). See a case of atresia of the 
 hymen, Fig. 97, p. 90. 
 
 * Journal des connaissances vuklicales, 1S31. 
 ^ Bulletin de la Soch'di anatoviique, 1851. 
 
 * Zeitsclwift der Gesellschaft der A«rzte, 18G(). 
 
272 UTERINE DISEASES IN DETAIL 
 
 which the genital economy may be divided with regard to develop- 
 ment, we find the central zone th.e seat of the abnormality in 197 out 
 of 230 cases; the central zone and the internal zone affected simul- 
 taneously in 7 cases; and in 31 the internal one alone affected. 
 These malformations when cured are not inherited ; at least we have 
 no examples of this kind. 
 
 Fig. 211. Congenital atresia of tlie vagina, from a preparation in St. George's 
 
 ' Musenm (from Barnes) : r, dilated uterus ; v, vagina dilated above the 
 seat of imperforation, through which a sound (b) has been passed. 
 
 2. Olliterations are due to various causes, the most frequent being 
 long and difficult labours, and especially laceration, suppuration, and 
 ganorene ; eleven cases are recorded of their occurrence in the cervix 
 and°thirty-eight in the vagina. Tour times they occurred after the use of 
 caustics which in one case only had been resorted to for a criminal 
 purpose, in the others they had been employed as therapeutic 
 means. ' The cases recorded by "Williams and Eigby, in which caustics 
 had been used to cure cervical ulcers, ought to be a caution to sur- 
 geons. I myself have had to remedy 11 cases of constriction and 9 of 
 complete obliteration either of the os internum or of the upper part 
 of the vagina behind which the cervix was imprisoned, owing to 
 the inopportune or exaggerated application of caustics to the upper 
 part of the vagina or to the cervix. At other times this accident is 
 caused by acute or chronic inflammation of the cervix or vagina; 
 sometimes it is of spontaneous or unknown origin, sometimes it is 
 
EETENTIOX OF THE MENSES 
 
 273 
 
 produced by excessive coitus^ by irritating manipulations, by a tumour 
 or tiexion of the uterus. Syphilis, diphtheria, scarlatina, measles and 
 smallpox are also occasional causes. Lastly, cholera (three cases) and 
 typhoid fever (four cases), by producing mortification of the mucous 
 membrane of the vagina or cervix, have brought about the same result. 
 In short, the morbid adhesions which cause obliteration of the genital 
 canals depend on the formation of cicatricial tissue which unites the 
 two ulcerated surfaces. Happily for the patients these adhesions 
 
 Fig. 212. — Acquired atresia (obliteration) of the cervix, from a preparation 
 given by Barnes to the London Hospital. A woman of forty-three, 
 married and sterile. Obliterating adhesions, caused by endometritis in a 
 and h' ; c, lower part of the cer\ax ; h, middle part dilated ; a, cavity of 
 the body dilated as well as the Fallopian tubes. 
 
 produce contraction and mechanical dysmenorrhcea oftener than 
 obliteration. 
 
 Diagnosis. — Atresia of the genital canals, whatever may be its seat 
 (whether vulva, vagina or uterus), may be simple, complicated or 
 complex. 
 
 The retention of the secretion, which is total and forms a unilocular 
 or bilocular tumour in the two first cases, is only partial in the third, 
 giving rise to the singular phenomenon of the free discharge of the 
 menses, together with all the symptoms of mechanical dysmenorrhcea 
 and of menstrual retention, including the tumour caused by the 
 
 18 
 
274 UTERINE DISEASES IN DETAIL 
 
 retentum, with this difference, that in place of being median this 
 tumour is lateral or unilateral. 
 
 Subjective slffns.—The dominant symptom of atresia therefore is 
 retention of the menses accompanied by phenomena of various kinds ; 
 some local, either uterine (including hsemorrhage) or in neighbouring 
 organs ; others general^ symptomatic or sympathetic. In congenital 
 atresia the commencement is often unnoticed ; it is mistaken for diffi- 
 culties attending the advent of menstruation, the symptoms subside in 
 the interval of the fluxionary movements, and the uterus gradually 
 distends. Acquired atresia, also, may be well tolerated at first ; even 
 from the beginning, however, the symptoms are more serious than in 
 the former. In both cases they take the following course : at the time 
 of the monthly periods the patients experience a sense of discomfort 
 and weight in the pelvis. The back feels as if it were broken, and 
 afterwards becomes the seat of pains which originate in the loins and 
 extend to the hypogastrium and anus. These colics, after having 
 lasted from three to six days, cease of themselves. At the next period 
 the same phenomena take place ; only they gradually increase in 
 intensity, the renal or lumbar pains become more frequent and more 
 acute, their morbid character increases, and sooner or later expulsive 
 pains are developed similar to uterine contractions at labour. At the 
 same time other hypogastric symptoms show themselves; the formation 
 of a tumour of gradually increasing size, due to the dilatation of the 
 uterine cavity from the accumulation of blood, is the inevitable con- 
 sequence of retention of the menses and leads to various complications. 
 These are generally in proportion to the quantity of fluid contained in 
 the womb. If the uterine tumour presses on the sacro-lumbar nerves 
 it causes a tingling and numbness in the legs. If it compresses the 
 rectum it produces constipation or tenesmus ; whilst if it pushes 
 against the bladder it sets up not only vesical tenesmus and dysuria, 
 but also retention or incontinence of urine. 
 
 For some months these are the only disturbances observed. The 
 stomach and nervous system, however, are soon ■ affected sympatheti- 
 cally. There is loss of appetite, nausea and even vomiting. The 
 reaction on the nervous system is quite as serious, a state of erethism 
 is produced by the intolerable pains which continue almost without 
 intermission, as well as a feeling of suffocation and attacks of dyspnoea. 
 Sometimes even delirium occurs, with more or less violent fits of 
 convulsion ; there is often loss of self control verging on insanity ; a 
 propensity to suicide may even manifest itself. The interval of relief 
 between each monthly period gradually becomes shorter. The crises 
 follow almost uninterruptedly, the general health suffers seriously, life 
 being a long series of continued sufferings to the patient mingled with 
 periodical exacerbations. 
 
 Objective signs. — The symptoms revealed by examination of the 
 parts vary according to the seat and existence of the obstacle. 
 
 I. In imperforation of the hymen the touch and sight discover, at 
 the entrance of the vulva, a tumour sometimes deep red sometimes 
 violet, varying in size between a chestnut and a large apple. When 
 
RETENTION OP THE MENSES 275 
 
 the hymen is very much distended the nymphse may be effaced. This 
 tumour, which is generally insensible, becomes distended and painful 
 at the monthly period. Efforts of any kind, cough or pressure on 
 the hypogastrium, by making it more prominent, allow jfluctuation to 
 be perceived. The conical form of the tumour, its projection between 
 the labia, its spontaneous reduction, have led to its being mistaken for 
 prolapsus uteri. Dubois de le Boe, Mauriceau, Amand, have related 
 cases of this mistake. In other cases it has been said to resemble the 
 bag of waters, and this singular error of diagnosis vias once made. 
 
 II. In atresia of the vagina, when the imperforation is membranous, 
 the results arrived at by touch are identical with those just enumerated. 
 When the obstacle is more extensive rectal touch must also be 
 employed. To measure the length of this obstacle the thumb is intro- 
 duced into the lower part of the vagina till the occlusion is reached, whilst 
 the index finger of the same hand is passed into the rectum till the lower 
 border of the tumour is reached. The space between the finger and 
 thumb gives an idea of the extent of the obstacle ; if the thumb is not 
 sufficient the index of the other hand is substituted for it, or a metallic 
 sound : the results of this mode of exploration, though less exact, are 
 valuable. Lastly, to estimate the thickness of the tissues separating 
 the bladder from the rectum, a sound is introduced into the bladder, 
 and is moved about whilst the index finger placed in the rectum follows 
 its course ; we can judge of the space which separates the sound from 
 the finger, and consequently of the thickness of the tumour, by the 
 facility and clearness with which the contact of the instrument is per- 
 ceived. It is curious that, in some cases of obliteration of the vulva 
 and vagina or of partial or total absence of the latter, communications 
 have sometimes existed under the form of a fistula between the uterus 
 and the rectum or the bladder or urethra, these canals serving for 
 coitus to the extent of permitting conception to take place. Oldham, 
 Ilouth,^ Uterhart^ and Spencer Wells ^ have met with cases where the 
 urethra, being either originally large or dilated by use^ has served for 
 coitus, and sometimes even for menstruation. 
 
 III. In atresia of the cervix, vaginal touch reveals the cervix 
 shortened and deformed, projecting very slightly into the vagina and 
 presenting no orifice whatever. The speculum confirms these 
 data and allows the colour of the parts to be seen. The most signi- 
 ficant characteristic, however, is that produced by distension of the 
 uterus, by the tumour so formed, and its projection at the hypo- 
 gastrium. 
 
 Hypogastric tumour. — The hypogastric tumour, more or less volu- 
 minous according to the frequency of menstruation and the quantity 
 of blood exuded, is formed by the distended uterus. Bounded below 
 by the obstacle, on each side by the bones of the pelvis, it can only 
 be developed upwards. Consequently, although at first contained in 
 the pelvis, it soon extends beyond it, and rising into the abdominal 
 
 1 Obstetrical Trans. 1870. 
 
 2 Berlin. Klin. Wochenschrift, 18()9. 
 
 3 Med. Times and Gazette, 1870. 
 
276 
 
 UTERINE DISEASES IN DETAIL 
 
 cavity increases in size till it reaches the dimensions of a pregnancy at 
 full term, sometimes, though rarely, exceeding even that.^ The tumour 
 progresses by degrees, increasing and rising at the menstrual periods, 
 diminishing and falling in the intervals, but each time remaining 
 larger than it was before. Its form is generally globular, at other 
 times it is ovoid and subdivided by strangulation, like a pilgrim^s 
 gourd, when the atresia, being at the base of the vagina, has suc- 
 cessively determined distension of the vagina, cervix, and uterus, the 
 situation of the sphincters of the vaginal orifice and isthmus being 
 indicated by the resistance they offer to dilatation, preventing the 
 
 Fig. 213. — Globular hypogastric tumour, with lateral appendages, produced by 
 dilatation and hypertrophy of the womb M and of the Fallopian tubes 
 T T, owing to retention of the menses from complete absence of the vagina 
 V. Retention of the menses for seven years, puncture by the rectum, 
 followed by purulent peritonitis causing death on the eighth day (after 
 Fiirst, of Leipsic). 
 
 tumour from acquiring at these points the dimensions which it attains 
 in the vagina and in the cervical and uterine cavities. Its position 
 is generally median, but it may be more or less inclined and even 
 lateral. 
 
 As a rule this tumour is single, but in some cases it is double and 
 even triple. These two or three tumours depend either on division 
 of the uterus (Leroy, Deces, Eokitansky, Nelaton) or on dilata- 
 tion of the Pallopian tubes by menstrual blood. In the latter case, 
 which is important in reference to the prognosis, the principal tumour 
 is bounded on one or both sides by an ovoid, cylindrical or vermiform 
 swelling, soft and rolling under the finger. 
 
 This tumour is resistant or doughy to the touch, communicating 
 a sensation of fluctuation ; but the counter-stroke produced by the 
 
 ' Tumours formed by the retention and accumulation of fluids in the imper- 
 forate uterus or vagina may acquire so great a size in the fojtus as to form an 
 obstacle to parturition. (Dr Gervis and Dr Gomer Davies, quoted by Alph. 
 Hergott, Des maladies fcetales qui peuvent /aire obstacle d V accoiichevient, 
 p. 225. These de concours. Paris, 1878.) 
 
RETENTION OF THE MENSES 
 
 277 
 
 displaced fluid is not distinct as in ascites or in a cystic tumour. 
 The fluctuation is all the more obscure because the uterine walls are 
 not only distended but hypertrophied by the repetition of expulsive 
 contractions caused by the retention of the blood (Figs. 213 
 and 214). 
 
 Fig. 214. — Hypogastric tumour in the form of a pilgrim's gourd, caused by 
 retention of the menses owing to imperforation of the vulva ; preparation 
 in the EadclifEe Museum at Oxford ; case described by Tuckwell, | natural 
 size ; v, distended vagina ; ou, os uteri and cavity of uterus above it 
 equally distended ; atresia of the vulva (after Barnes). 
 
 Lateral hamatometra. — The most difficult cases to diagnose are 
 those of complex atresia, i. e. occlusion of one of the vagina or uteri 
 forming part of a duplex sexual system ; because whilst the patient 
 has all the symptoms of dysmenorrhoea, she nevertheless has her 
 periods, and this fact removes from the mind of the physician all 
 idea of retention of the menses. However, after having been apprised 
 of the repeated occurrence of this anatomo-pathological anomaly, 
 and having had the opportunity of seeing a drawing of it as given 
 here, it would be inexcusable to ignore the possibility of its ex- 
 
278 
 
 UTEEINE DISEASES IN DETAIL 
 
 istence. These imperforations of one of the halves of a double 
 genital canal have been met with 11 times in the uterine canal and 
 23 times in the vagina. Out of 28 cases they have been observed 20 
 
 Fig. 215.— Max Jacquet, Ueter Haematometra bei Uterus duplex {Zeitschrift 
 fur Gehurtshi'dfe und Frauenhranhheiten, Bd. i, S. 134. Stuttgart, 1875). 
 Double uterus in a girl of fourteen who had menstraated for some months, 
 and who succumbed to peritonitis caused by retention of the menses in the 
 right uterus which was gi-eatly distended, and in which a thin spot c 
 seemed to coiTespond to the atresia of the cervix of the same size. The 
 left uteras, which is open, shows the arhor vitce ; A B, the longitudinal 
 folds of the vagina, greater behind A than before B ; vestiges of the parti- 
 tion between the piimitive vaginse. 
 
 times on the right and 8 times on the left. They were all cases of 
 uienis hicornis, except two that were bilocular or divided. The most 
 striking symptoms are : manifestation of the pains of menstrual re- 
 tention coinciding with discharge of the catamenia, and the presence 
 of a tumour occupying one side of the hypogastrium and a large 
 part of the pelvic cavity, hindering walking, and causing dysuria or 
 retention of the urine, sometimes fluctuating, easily defined as to its 
 superior limits, sometimes reaching the vulva below and pushing the 
 vao-inal portion of the cervix of the other side upwards, or remaining 
 in the pelvis on one side only, pushing the cervix of the other uterus to 
 one side, or forming, on a level with the urethra (the seat of the 
 atresia) a spherical tumour which projects into one of the vaginal 
 ctils-de-sac, and presses laterally against the open cornu, which it 
 pushes upwards and to one side till it appears to be almost surrounded 
 by it (Eig. 218). Any pressure on the hypogastric tumour is trans- 
 mitted to the vaginal portion and vice-versa.^ 
 
 ' Puech, Annales de Gynecologie, April, June, July, August, 1875. 
 
RETENTION OF THE MENSES 279 
 
 These symptoms and catheterism of the open cornu ought to prevent 
 anv error in diagnosis. Nevertheless, unilateral hsematometra has 
 been taken for congestive dysmenorrhcea, peri-uterine hematocele, and 
 even an ovarian cyst.^ Sometimes it is water instead of blood which 
 fills the imperforate cavity, sometimes it is pus, sometimes the tumour 
 is uterine, but oftener vagino-uterine.- 
 
 These are the most usual symptoms, but sometimes there are others 
 in addition. In the way of coi/iplications we may mention : 1, dis- 
 charges by the genital canals; 2, deviation of the menses; 3, hysteria; 
 4, chlorosis ; 5, vagino- and utero-vesical fistula. 
 
 The modes of termination constitute an element in the diagnosis. 
 They are varied and depend on the disturbances which the presence of 
 an obstacle causes in menstruation. 1. Deviation of the menses may 
 be more than a symptom ; it may also be a mode of termination of the 
 retention. I have had a patient in whom this deviation persisted 
 throughout life. 2. The obstacle may give way, either by bursting (8 
 cases) or by gangrene (4 cases). As a rule, the former mode 
 occurs where the obstacle is thin, and it takes place after violent 
 colics. I have once seen it. 3. The organs containing the menstrual 
 blood are dilated, their walls become thin and in the end give way. 
 When the uterus is the seat of this rupture, death may be the imme- 
 diate consequence ; three cases of the kind have been observed. 
 When it is the vagina or the lower part of the cervix, it is possible for 
 the menstrual blood to be discharged by the bladder ; such cases have 
 been observed by Freteau, Boyer and Desormeaux. 4. Dilatation of 
 the Fallopian tubes by the menstrual blood takes place sooner or later. 
 It is caused by the accumulation of blood and the uterine contractions 
 forcing the orifices of the Fallopian tubes, which then remain open, 
 owing to their loss of contractility. It is in such cases that the sound, 
 when the obstacle has been removed, has been known to enter the uterus 
 and penetrate into the Fallopian tube. The tumour thus formed in 
 the Fallopian tube, especially if in the external half, may attain con- 
 siderable proportions. The blood thus accumulated may be expelled, 
 either by flowing backwards through the ostia uterina (2 casesj or by 
 exuding through the fimbriated extremity into the peritoneum (14 
 cases). Discharge by the uterine orifices necessitates previous eva- 
 cuation of the uterus ; it has only been observed by Barnotte and 
 Amussat. Discharge by the fimbriated extremity is generally fatal. 
 Amussat and Bernutz alone have seen patients recover, thanks to the 
 
 * Carl Staude, " Haematomeira und Haematoholpos bei zweigetheiltem Utero- 
 vaginal Canale. Verwechsehing mit Tmnor Ovarii. Versuch der Ovariotomie, 
 Seilnng." The patient died accidentally six months afterwards, when the 
 uterine tumour, caused by retention of the menses, was discovered. Zeitschrift 
 fiir Geburtsh. und Fraitenlcrank., Bd. i, S. 338. Stuttgart, 1875. 
 
 - W. A. Freund, Haematometra und Haematoholpos lateralis bei Atresia 
 eines rudimentaren Scheidenhanals eines Uterus duplex, in Beitrdge zur 
 Geburtsh. und Gynaehologie, Bd. i, S. 26. Berlin, 1872. Id., id., Beitrdge zur 
 Pathologie des doppelten Genitalhanals, in Zeitschrift fiir Gtburtsh. und 
 Gynaehologie, Bd. i, S. 231. Stuttgart, 1877. — Breisky, Fyometre et pyoholpe 
 lateral, stiite d'atresie d'une inoitie de vagin rudimentaire sur un uterus septus. 
 Archivf. Gynaehologie, Bd. ii, S. 24. Berlin, 1871. 
 
280 UTERINE DISEASES IN DETAIL 
 
 encysting of the blood and to its expulsion through the rectum. As 
 for the other cases recorded^ death occurred so rapidly as to leave no 
 time for the development of peritonitis. Such are the cases of 
 imperforate hymen, related by Brodie, Moore and Paget ; by Boyer, 
 Deces, de Haen, Locatelli, Maisonneuve (2 cases), Munck, of vaginal 
 atresia ; by Hemman and de Pauly of atresia of the cervix. I have 
 seen a woman succumb rapidly to peritonitis caused by atresia of the 
 cervix. 
 
 In lateral hseraatometra the natural terminations are similar to the 
 preceding: spontaneous rupture of the obstacle, perforation of the 
 septum between the two Pallopian tubes (Fig. 216), passage of the 
 
 Fig. 216. — Breisky, Pyometra and Pyokolpos due to atresia of one half of a 
 rudimentary vagina in a uterus septus. Archivfilr Gynaehologie, Bd. ii, S. 
 48. Berlin, 1871. i'fZ,riglrt vagina ; iff?, right uterus filled with pus ; vg,leit 
 vagina ; ug, left uterus ; o, orifice through which the pus retained in-the 
 right utenas was discharged externally throu.gh the left utems and vagina. 
 
 blood from the horn into the Fallopian tube, and from this into the 
 peritoneal cavity, peritonitis caused by repeated crises, or finally, 
 passage of the fluid into the normal uterus and vagina, and subsequent 
 cure. 
 
 In all these cases consumption may supervene and cause death; for 
 dyspepsia, vomiting, continued pain and constant lessening of the 
 interval between the crises, wear out the best constitution and lead to 
 marasmus. Occasionally the menopause, by putting a stop to the 
 discharge, or rather to the sanguineous fluxion, at the same time puts 
 an end to all accidents. 
 
 To sum up, a cure can only take place when the obstacle gives way. 
 Tolerance is established when the menses are deviated, when amenor- 
 rhcea supervenes, or when the menopause is established- Apart from 
 these exceptions, there is always danger of death, and as nothing 
 affords any indication as to which of these terminations will occur, the 
 wisest course is to avoid all by opportune intervention. 
 
 Differential diagnosis. — Without having any pathognomonic signs, 
 strictly speaking, retention of the menses nevertheless causes a number 
 of characteristic symptoms, such as absence of all discharge, the coin- 
 cidence in time between the commencement of the symptoms and the 
 
RETENTION OF THE MENSES 
 
 281 
 
 expected advent of menstruation, the expulsive nature of the pains, 
 their duration from three to eight days, and their recurrence after 
 about a month's interval, their localisation in the loins, hypogastrium 
 and perineum, and lastly, the appearance of a tumour either at the 
 vulva or above the pubis, or in both places simultaneously. 
 
 When all these symptoms have been observed it is easy to diagnose 
 atresia ; but it is different when some are wanting or when they are 
 not well marked. In such cases a number of unjustifiable mistakes 
 are sometimes made : menstrual retention from atresia confounded 
 with prolapsus uteri, sciatica, ascites, cystocele, uterine polypus, 
 amenorrhoea, or even with pregnancy. Sometimes hsematocele, pelvi- 
 peritonitis and purulent tumours of the pelvis, ovarian cysts, hydatid 
 cysts, fibroma, cancer and hydrometra may be mistaken for retention, 
 and vice versa. Amenorrhcea is not attended by periodical exacerba- 
 tions, nor, above all, by a hypogastric tumour. In pregnancy the 
 knowledge of the antecedents, the mode of development of the tumour, 
 the state of the areola of the breasts, especially if the patient has never 
 had children, the results of auscultation (negative in retention, positive 
 in pregnancy) with the physical signs revealed by digital examination, 
 are sufficient to establish the distinction. There is one feature common 
 to hydrometra and hsematometra, viz. occlusion of the cervix; but 
 special and distinctive symptoms also always exist : hydrometra is 
 consecutive to amenorrhoea, and has generally a slow commencement ; 
 
 tct' ' 
 
 Fig. 217. — Freund of Breslau, two cases of lateral ha3inatometra and hfcmato- 
 kolpos from atresia of a rudimentary vaginal canal of double uterus. 
 Beitrdge zur Geburtshulfeund Gynaekologie, Bd. ii, Heft i, S. 26. Berlin, 
 1872. Vertical section : td, i-ight Fallopian tube ; Ird, right round liga- 
 ment ; ovd, right vaginal orifice; av, vaginal atresia; ^r/, left Fallopian 
 tube; Irg, left round ligament; ovg left vaginal os ; li, hymen. 
 
282 
 
 UTERINE DISEASES IN DETAIL 
 
 accidental hsematometra begins suddenly, and is preceded by a disease 
 affecting the cervix. The course of development of the tumour is not 
 identical — in the first it takes place without pain, and almost con- 
 tinuously ; in the second it is painful, and is produced in monthly 
 stages. Lastly, in the one there may be sanguineous discharge, in the 
 other there is none. 
 
 As to the differential diagnosis of various hinds of atresia, a careful 
 examination enables us to discover the special characteristics which I 
 have already pointed out in describing their history. It will be 
 
 ^o 
 
 Fig. 218. — Id. horizontal section : av, vaginal atresia ; vo, left vagina open. 
 
 remembered that lateral tumors (haematometra, hydrometra or pyo- 
 metra), in cases of double genital system usually project into the 
 normal vagina or uterus (Eig. 218), so as to be partly covered by 
 them on one side, and to jut out beyond thera on the other, especially 
 in the upper part corresponding to the cornu and to the Fallopian tube 
 on the side of the seat of obliteration (Eig. 218). 
 
 Treatment. — Out of the great number of cases recorded there are 
 eight only in which the breaking up of the tumour has occurred spon- 
 taneously. The age of the patients thus cured varies from 18 to 22. 
 The time is that of a paroxysm : the necessary prelude, a series of 
 violent colics. The seat of the obstacle was five times at the vulva,^ 
 twice at the vagina,^ once at the cervix.^ In four cases only was this 
 natural perforation produced by gangrene of the obstacle under the 
 influence of continuous pressure of the accumulated blood and of 
 uterine contractions. In that recorded by Allaire d^Hericy* the 
 symptoms had lasted for seventeen months ; the tumour was the size 
 
 ^ Wier, De prestigiis dcemonum, lib. ii, cap. xxxviii. — Schenck, Observa- 
 tiones medicce rariores. Lugduni, 1643, lib. iv, p. 532. — Bartholin, Centur. v., 
 Obs. xliii. — Eschenbach, Obs. vied, chir., p. 8. — Lafitte, Revue therapeutique 
 du Midi, t. X, p. 44. — Scanzoni, op. cit., p. 476 : " A girl of nineteen suffered 
 for two years from severe dysmenorrhoea due to imperforate hymen, when 
 during an attack of pain this membrane suddenly ruptured allowing the escape 
 of about a kilogramme of foetid and decomposed blood. Immediately after this 
 accident we were called and ascertained that the rupture had taken place ; the 
 hymen hung down from the vagina in several irregular shreds." 
 
 2 Delisle, Journal general de medecine, t. Ixvi, p. 94. It may be admitted 
 that the seat of the second obstacle was at the cervix. — Kiwisch, in Scanzoni, 
 op. cit., p. 487. The orifice in this case was irregular and funnel-shaped. 
 
 3 Puech, op. cit., obs. xiv, p. 56. 
 
 * Gazette medicale de Paris, 1832, p. 513. 
 
RETENTION OF THE MENSES 283 
 
 of a small hen's egg, and the hymen presented two blackish points, 
 the one at the centre, the other at the side ; the latter opened first 
 and gave issue to the contents. In that of Demaux^ obliteration of 
 the vagina had been preceded by a difficult labour, and sounds had to 
 be used to dilate the opening which had formed in the centre as the 
 result of sphacelus. In the two last^ gangrene completed the opera- 
 tion which the surgeon had not the courage to finish. We cannot, 
 therefore, count on the eff'orts of nature to bring about a happy termi- 
 nation to a disease the course of which is beset with dangers. We 
 must not, however, conclude that operation is always indicated. We 
 have to consider the real dangers incurred by operation, the still 
 greater perils which may result from the progress of the disease, as well 
 as the abolition of the reproductive functions which always occurs. 
 These three elements of the question are evidently the three principal 
 sources of indication, or contra-indication, to the active intervention 
 of art. The elements furnished by the intensity of the disease, its 
 seat and its nature, must also be taken into account. The more the 
 organs have been distended by the menstrual blood and the more they 
 have lost their power of contraction, the greater likelihood there is of 
 metro-peritonitis and purulent infection finding a favorable field for 
 development. Whatever the size of the tumour may be, if it is 
 bordered by one or two small lateral tumours formed by the distension 
 of the Fallopian tubes, we have reason to fear a fatal result; the 
 operation, perilous as it may be, in this case is the only means of 
 preventing death. With reference to the seat of atresia, imperforation 
 of the hymen and membranous occlusion of the vagina and cervix 
 may be classed together as the least dangerous forms ; after them and 
 in order of increasing gravity come partial absence of the vagina, 
 complete absence of this organ, and lastly absence of the vagina with 
 imperforation of the cervix. Erom another point of view operation 
 as a rule is much more dangerous in acquired than in congenital 
 atresia. 
 
 Whenever an operation is indicated it should be performed as soon 
 as possible, as delay only aggravates the danger owing to the increas- 
 ing dilatation of the uterus at every monthly period. Operation is only 
 absolutely contra-indicated when the uterus is atrophied and there seems 
 no Hkehhood that the menses will be established; before operating 
 therefore we must ascertain that the uterus exists, and that the morbid 
 symptoms are owing to distension of this organ and not to any other 
 cause. Operation is also contra-indicated when the existence of vesical 
 or rectal fistulse allows the escape of the menses by the urethra or anus. 
 In such cases intervention should only be resorted to when the operation 
 is easy and the fistula small and susceptible of cure ; here also, how- 
 ever, there is not strictly speaking retention, and therefore the opera- 
 tion is not urgent. The age of the patient may also be an absolute 
 
 1 Gazette des hopitaux, 1850, p. 567. 
 
 ^ Barth, Gazette medicale de Strasbourg, 1844, p. 221 : Spontaneous cure 
 after four unsuccessful operations. — Blandin, Gazette onedicale de Paris, 1846, 
 p. 57. Operation causing vesical fistula ; spontaneous cure. 
 
284 UTEEINE DISEASES IN DETAIL 
 
 contra-indication ; wliat may be attempted in the case of a young 
 woman of twenty ought not to be thought of in the case of a woman 
 of fifty. Nevertheless though, as a rule, it is wise to abstain when the 
 menopause is established, or when the patient has reached forty and 
 the menstrual periods have diminished in intensity, yet we ought to 
 operate after this age when blood-letting and opium prove ineffectual 
 and the tumour continues to progress ; for women of fifty and upwards 
 have succumbed in such cases to spontaneous rupture of the uterus.^ 
 With the exception of such cases operation is indicated, and the 
 sooner it is had recourse to the better/"- Although Boyer,^ Dupuytren,^ 
 Capuron^ and Cazeaux ^ have condemned it, it seems to me indicated 
 within Ihe limits just stated. The distension of the Fallopian tubes by 
 the menstrual blood, although evidently a source of danger, is not a 
 contra- indication : on the one hand the prospect of imminent death, on 
 the other the success obtained by Amussat, Debrou and Barnotte, 
 authorise active intervention. We should, however, warn the parents of 
 the risk involved. The only real contra-indication is the extent of the 
 obstacle, or rather the extent of the destructions, the length and narrow- 
 ness of the vulvo-uterine cicatrix in cases of accidental obliteration, in 
 short the insurmountable operative difficulties. 
 
 If the atresia has been discovered in childhood the most suitable time 
 for operating is at puberty, just before the appearance of the menses. 
 After menstruation is established the indication is to operate as soon as 
 possible. Whatever the age of the patient may be, this operation, like 
 all others on the uterus, should only be performed in the intercalary 
 period, seven or eight days after menstruation ; at this time the con- 
 gestion is entirely dissipated, and the conditions are therefore the best 
 possible for avoiding inflammation. 
 
 The treatment, essentially surgical, of retention of the menses in- 
 cludes two important indications: — (1) To give free passage to the 
 blood retained above the obstacle ; (2) to maintain the patency of the 
 opening made. 
 
 We may maJce an outlet for the discharge of the blood in two ways, 
 indirectly or directly. The indirect method, which consists in attacking 
 the tumour through the abdomen, the bladder or the rectum, is only 
 admissible in cases of complete absence of the vagina, where it is im- 
 possible to reach the uterus through the recto-vesical space. The best 
 of these three indirect ways is evidently the rectum. I confess, how- 
 ever, that it seems to me more applicable to cases of atresia of the 
 hymen or lower part of the vagina than to those of the uterus, and in 
 this case it is easier to open the tumour directly through the vulva. 
 Although this operation, which was performed for the first time un- 
 successfully by Dubois,^ has been repeated in our days by Oldham, 
 
 ' Duparque, Traite des ruptures de la matrice. 1839, p. 13, 14. 
 
 ^ Traite des malad. chirurg., t. x, p. 447, 4e edit. Paris, 1831. 
 
 ^ Quoted by Pigne, Traite des chirurg., of Chelius, t. ii, p. 62. 
 
 ■* Bulletin de I'Acad. de med., 13th Sept., 1839. 
 
 ° Gazette des hopitaux. 1861, p. 31. 
 
 ^ See Boyer, Traite des malad. chirur,, t. x, p. 447. — Boivin et Duges, op. 
 
EETENTION OF THE MENSES 285 
 
 Baker-Brown, and Hastings-Hamilton, who penetrate from the rectum 
 into the tumour by means of a curved trocar, I cannot refrain from 
 remarking that the operator risks piercing the peritoneum twice, and 
 that, in order to prevent the consequences of the blood remaining in 
 the uterus or vagina, its effusion into the peritoneum is encouraged, 
 whilst, even in case of success, all that is gained is a utero- or vagino- 
 rectal fistula; with which, if it occurs spontaneously, we must be 
 contented, but which is not desirable when gained at the risk of 
 life. 
 
 The direct metliocl consistajP^ attacking the tumour through the 
 vulva and in establishing a lasting communication between the one and 
 the other. This method alone satisfies all indications, for, by pre- 
 venting accidents, it brings the parts back to their natural condition. 
 
 Cauterisation has been tried, but without success, by Felix Plater ^ 
 and Gaspard Bauhin.^ Caustics in fact have inconveniences which are 
 not compensated by any advantage ; it is difficult to use them, and 
 impossible to limit their action, and the orifice is made at the cost of 
 a more or less considerable loss of substance and of the inevitable 
 formation of cicatricial tissue. On the contrary, incision and tearing, 
 either alone or aided by dilatation, are the most suitable means for 
 opening up a vulvo-uterine passage, incisions or puncture sufficing for 
 thin membranous occlusions, incision, dissection and dilatation being 
 necessary for obliterations of considerable depth. As the modes of 
 procedure vary according to the resistance of the obstacles, I will 
 describe the manner of performing each operation successively. 
 
 The bladder having been emptied by means of a catheter, and the 
 rectum by an enema, the patient should lie on her back on the edge of 
 the bed, opposite a window, in the position required for examination 
 by speculum, the pelvis raised, the thighs and legs flexed and apart. 
 An anesthetic should be given, unless especially contra-indicated; 
 and, in most of these operations, the bladder should be raised by 
 means of a sound introduced into its cavity and the rectum should be 
 drawn down by the index finger, 
 
 I, Imperforate hymen. — The plan which seems to me the best is the 
 following, proposed by Puech.^ Having made the hymen bulge out, 
 the centre is seized with forceps, whilst the right hand, with curved 
 scissors or bistoury, removes a circular piece of membrane. The genital 
 organs are then explored with the index finger, a gutta-percha bougie 
 of medium size being afterwards substituted for the finger to close the 
 opening. By this means the blood is prevented from gushing out and 
 the uterine and vaginal cavities are enabled to recover their normal 
 condition, whilst the air, having greater difficulty in penetrating into 
 the uterine cavity, exerts a less injurious influence on it. As a rule, 
 this operation is not followed by any serious consequences ; but we 
 
 cit., t. i, p. 272. Congenital absence of the vagina. Puncture by the rectum. 
 Peritonitis ending in death. 
 
 ' Observationum , lib. iii. Basileaj, 1614, lib. i, p. 241. 
 
 ^ Theatrum anatomicnm. Paris, 1621, lib. i, cap. xxxix, p. 1.S3. 
 
 3 Op. cit., p. 98. 
 
286 UTEEINE DISEASES IN DETAIL 
 
 must not forget that metro-peritonitis may occur and cause deaths as 
 has happened twice out of 135 operations.^ 
 
 II. Atresia of the vagina. — In cases of membranous imperforations, 
 a trocar or straight bistoury is plunged into the obstacle^ and incisions 
 are made in various directions till the finger passes easily. In more 
 extensive atresise there are various modes of procedure, but only two 
 deserve description. 
 
 1. The plan followed by Amussat^ in 1832 consists in more or less 
 violent pressure exercised by the finger or a soft body, with the object 
 of pressing the vulval mucous membrane into the groove corresponding 
 to the entrance of the absent vagina. After a time this yields, and 
 after several attempts, repeated at longer or shorter intervals, the 
 tumour is reached, when the last barrier may be removed by the trocar. 
 This plan is more seductive than perfect. It can neither be employed 
 in accidental atresia, nor in cases where the rectal and vesical walls are 
 separated by a tissue of much resistance. It is very slow. Amussat 
 required six sittings and ten days to reach the uterus ; Parey^ four 
 sittings and thirteen days, besides which, after the second sitting, the 
 sensibility was so great as to make the latter attempts very painful. 
 The patient operated upon by Bernutz* was discouraged after five 
 attempts, in spite of her great desire to be cured. 
 
 3. Dupuytren^s plan ^ consists in the use of the bistoury, combined 
 with separation of the cellular tissue. It is effected in a single sitting. 
 The following is the description of it as modified by Puech,^ By means 
 of a male catheter the bladder is kept raised. The index of the left 
 hand is then passed as far into the intestine as possible to guide the 
 bistoury and to protect the rectum. A transverse incision is then 
 made in the centre of the obstacle, or in the vulval fossa if the vagina 
 is entirely absent ; when the cellular tissue is loose, the operator may, 
 with the finger, catheter,'^ or handle of the bistoury, separate the vesical 
 and rectal walls till the tumour is reached ; when it is thick or very re- 
 sistant it must be carefully dissected, separating the tissues with the 
 handle or the finger rather than cutting them, and when necessary 
 cutting with a probe-pointed bistoury. The operator must proceed 
 slowly and circumspectly, stopping occasionally to examine with the 
 finger to ascertain how far he is from organs that must be avoided. 
 
 1 shall merely mention electricity, as it has been said to possess the 
 property of causing extensile in place of retractile cicatricial tissue; 
 this however has not been proved. When the newly-formed canal 
 
 ^ Quesnay in tis paper 8ur les vices des humeurs, printed in the Memoires 
 de VAcademie de chirurgie (1743, pp. 58, 59), characterises the blood which 
 issues from the vagina after operations for atresia of the hyrnen as being black, 
 thick, often inodorons, but sometimes foetid (De la Motte, Epliemerides d'Al- 
 lemagne, Benivenius, Merch'ren, Aquapendente). 
 
 2 Gazette Medicate de Paris, 1835, p. 785. 
 
 3 Gazette des hopitaux, 1861, p. 69. 
 
 4 Op. cit., t. i, p. 307. 
 
 * Sabatier, Theses de Paris, 1848, no. 68, p. 40. 
 
 6 Op. cit., p. 106. 
 
 7 Fletcher, Medico-surgical Notes and Illustrations. London, 1831, p. 143. 
 — Archiv. gen. de med., 1835, t. vii, p. 549. 
 
RETENTION OF THE MENSES 287 
 
 admits the index iinger easily, and when a clearer perception of fluctua- 
 tion apprises the surgeon of the proximity of the collection of blood, 
 he may plunge the trocar into it, and the issue of a brown syrupy fluid 
 will prove to him that he has succeeded. A small quantity of the 
 fluid is allowed to escape by the canula. This little orifice will only 
 be enlarged after some time to ensure the final result. A few days 
 afterwards a gutta-percha catheter is to be introduced into the uterine 
 cavity, and injections of tepid water with a few drops of carbolic acid 
 are to be made through it. A small syringe should be used, and the 
 injections should be made with great precaution. The dressing 
 finished, the parts are sponged and wiped and the patient placed in 
 bed, care being taken to protect the bedding from being soiled by the 
 black blood and mucous discharge which will be excreted for some 
 days. 
 
 This method is applicable to all cases ; only the use of the finger 
 or soft instruments may be limited according to circumstances, some- 
 times not being required at all. If it is logical to distinguish cases 
 of this kind (the most serious, and those which cause most acci- 
 dents), it is unnecessary, with Verneuil,i to adopt a different plan for 
 them. 
 
 Accidents attending the operation. — Roonhuysen,^ Benevoli,^ Liston,'* 
 the surgeon quoted by DiefFenbach" and Barth^ were obHged to leave 
 the operation unfinished ; Roonhuysen and the surgeon quoted by 
 Dieffeubach because they had involved the rectum and the others 
 from want of courage. On one occasion I was unable to terminate 
 an operation of this kind. The blending of the bladder and rectum 
 was so complete at a certain depth that it would have been imprudent 
 to have continued, for it was impossible to attempt to separate the 
 one from the other. The menstrual retention w^as caused by a 
 cicatricial occlusion of the whole vagina consecutive to gangrenous 
 suppuration after a confinement. The patient was stout, extremely 
 sensitive with regard to the consequences of her infirmity, and 
 threatened by the accidents which often accompany retention. From 
 that time the symptoms were gradually mitigated, and although the 
 menstrual molimen and ovarian activity were more or less felt 
 every month, there was no accumulation of blood in the uterus, no 
 deviation of the menses, nor any other pathological phenomenon, 
 thanks to the palliative treatment prescribed and to the progressive 
 tolerance of the organism. 
 
 The bladder has been injured three times : in one case a cure was 
 effected ; in another a vesico-vaginal fistula was formed which Blandin 
 could not cure; and another time (de Haen), apart from the fistula, 
 
 * Rapport a la Societe de chirurgie sur V operation de M. Patry {Gazette 
 des hupitaux. 1861, p. 69). 
 
 2 Observ. med. rariores Gerardi Blasii. Amstelodami, 1677, p, 30. 
 
 ^ Related by Chainbon and by Colombat. 
 
 ■• Gaz. des hupitaux, 1839, p. 183. 
 
 * Related by Verneuil, Gaz. des. hop., 1861, p. 31. 
 ^ Gazette med. de Strasbourg, 1844, p. 222. 
 
288 UTERINE DISEASES IN DETAIL 
 
 death occurred by the effusion of menstrual blood into the peritoneum 
 through the Fallopian tubes. 
 
 Hsemorrhage is rarely serious ; but it may become troublesome. 
 This has led Camerarius^ Voisin and Guerin to make several short 
 operations. In this case it is necessary in order not to lose the 
 benefit of the first incisions, to insert a foreign body, or even a dilator, 
 in the canal that has been hollowed out. 
 
 The consecutive accidents which may occur are varied : metritis, 
 inflammation of the Pallopian tubes, peritonitis, and even putrid in- 
 fection. Out of 66 operations there were 6 cases of death due to 
 the three last diseases. 
 
 I am convinced that, in accidental obliterations due to puerperal 
 gangrene of the vagina, the tendency of inflammations to assume 
 the gangrenous character may be the cause of fatal symptoms, just as 
 it produced the first accident and the deformity which necessitated 
 the operation. I lost a patient in this way. After great difiiculties, 
 and even a little tearing of the peritoneal cul-de-sac in front of the 
 rectum, I reached the uterus, and things progressed so well for some 
 days that we had hopes of success, when, concurrently with a slight 
 attack of peritonitis easily subdued by treatment, gangrene of the 
 walls of the new canal showed itself, which yielded to no tonic, nor 
 to any injection detersive, antiseptic, stimulating, nor catheretic, and 
 which finally caused death on the fifteenth day. 
 
 Eelapse has been observed four times. It is due to the insufficiency 
 of the operation, to inflammation of the parts, or to neglect of 
 dressing. Contraction of the canal due to the same causes has been 
 observed nine times. 
 
 To sum up, the results are as follows : — Out of 28 operations for 
 congenital atresia 2 were not terminated, and 2 had to be repeated 
 owing to relapses. There were 6 deaths, 4 of which were owing to 
 the reflux of uterine blood j leaving these out of the calculation, 
 there were 2 deaths in 24 cases. Out of 33 cases of accidental 
 atresia, 8 operations were not terminated or had to be repeated ; there 
 were 6 deaths, one of which was owing to a reflux of uterine blood, 
 and another to intercurrent pleurisy ; putting these aside there re- 
 main 4 deaths in 31 cases, a greater mortality than in congenital 
 atresia. 
 
 3. The author's method. I usually prefer rapid operation with 
 the bistoury for accidental atresia ; but for congenital atresia I greatly 
 prefer the slow operation by means of small incisions combined with 
 the use of sponge tents of gradually increasing size, and the pro- 
 longed issue of blood drop by drop.^ 
 
 ^ I have lately had occasion to congratulate myself on the success of this 
 method in a young lady suffering from vaginal atresia. Sponge tents intro- 
 duced into small incisions made every week of increasing depth allowed of my 
 reaching the cervix which, owing to gradual cicatrisation of the wound after 
 every operation, was at last drawn down to a level with the lower part of the 
 vagina, the only part originally existing. Ti-eatment lasted six months. It 
 was followed some months afterwards by pregnancy which terminated in 
 natural delivery. I performed the same operation successfully on a girl last 
 
RETENTION OP THE MENSES 289 
 
 III. Absence of vagina and imperforate cervix. — lu this kind of 
 atresia, the difficulty is to free the cervix; to effect this the circum- 
 ference of this organ should be detached from the surrounding parts 
 with the finger or a soft instrument, after a vagina has been made. 
 In order to prevent the recurrence of the uterine atresia, which 
 Debrou and Patry have observed, Puech^ recommends two operations. 
 In the first, the vagina is to be formed ; in the second, two months 
 afterwards, the uterus is attacked. This, of course, is only possible 
 when the symptoms are not alarming. 
 
 IV. Atresia of the cervix. — Different instruments may be used for 
 attacking this obstacle : the straight or curved trocar, Pleurant's 
 trocar, Priar Comers pointed sound, the pharyngotome, Thomas's 
 lithotome, Plamand^s hysterotome, the ordinary straight and probe- 
 pointed bistouries. 
 
 The first time I had occasion to perform this operation, about thirty 
 years ago, I had a grooved sound made about 30 centimetres long, 
 and fitted on to a wooden handle which was roughened on the side 
 corresponding to the groove. I had also two bistouries made of 
 the same length, one sharp-pointed, the other probe-pointed, both 
 sharp only to the extent of 2 centimetres at the extremity. The 
 cervix having been seized and fixed with the help of the speculum, 
 I punctured it with the pointed bistoury at the spot where a depres- 
 sion was to be seen, and pushed the instrument in the direction of 
 the axis of the cervix to the depth of 15 millimetres ; I then intro- 
 duced the grooved sound, and succeeded in making it penetrate into 
 the uterine cavity, where I felt that it moved freely enough to make 
 sure that it must have penetrated. I next introduced the probe- 
 pointed bistoury into the groove of the sound, and having directed 
 it alternately to both sides, before and behind, I made an incision of 
 some millimetres in length and of about 3 centimetres in depth, 
 around the artificial orifice first made. Except a slight discharge of 
 red blood caused by the incisions, only a few drops of black, thick, 
 viscid blood escaped ; but I was not in the least surprised, for the 
 body of the uterus was not dilated, and the patient suffered from a 
 deviation of the menses, constituting a supplementary menstruation. 
 No accident occurred ; every day I introduced a gutta-percha sound 
 of increasing size, and the patient was soon able to leave. I have 
 since heard that her cure has proved permanent. Since that time a 
 pointed sound has been invented, as well as various concealed hystero- 
 tomes with two blades, analogous to small lithotomes which I have 
 already described as applicable to this operation, as well as to simple 
 incision of the cervix in cases of constriction of the os. I have used 
 them for three operations of the same kind ; one in a virgin, for 
 imperforation ; two others for obliterations occurring after labour, 
 summer. After having reached the uterus with difficulty from the viUva 
 through an imperforate vagina, I made a puncture by whicli all the blood 
 issued from the uterus in fifteen days without any accident, thanks to frequent 
 injections of hot water and carbolic acid. It was only later that I dilated the 
 orifice. 
 
 ^ Op. cit., p. 118. 
 
 19 
 
290 UTERINE DISEASES IN DETAIL 
 
 As to congenital constriction and contraction taking place after con- 
 finements, they occur very frequently, as we shall see when consider- 
 ing mechanical dysmenorrhoea. In such cases, however, simple 
 incision is often insuf&cient, and recourse must be had to one of the 
 operations for autoplasty of the orifice, which I shall describe when 
 we come to the surgical treatment of dysmenorrhcea. Usually the 
 operation ought to be performed in the following way : the cervix is 
 brought into view and fixed by a Pergusson's speculum ; then with a 
 narrow-pointed bistoury a puncture is made at the spot where a de- 
 pression indicates the primitive or probable position of the meatus. 
 We have reason to believe that the uterine cavity is reached when 
 there is a sensation of resistance overcome, and at the same time there 
 oozes out a drop of brown, syrupy fluid. I do not enlarge the orifice 
 by small incisions made in every direction, nor do I allow the accumu- 
 lated fluid to escape till much later. I introduce every day a gutta- 
 percha sound into the uterine cavity, through which I inject small 
 quantities of hot water and carbolic acid. If puncture and incisions 
 are insuflicient recourse must be had to autoplasty. 
 
 The immediate accidents are nil, and the consecutive accidents are 
 identical with those I have described under vaginal atresia ; peritonitis 
 and purulent infection have caused death three times, Eelapse is 
 frequent : seven patients have been cured only after a second opera- 
 tion, and in two a third operation was rendered necessary. It is on 
 that account that autoplasty is often indispensable. 
 
 To sum up, 53 operations have been performed on 41 women, and 
 among these there were 3 deaths and 38 permanent cures; 25 cures of 
 congenital atresia and 2 deaths, 13 cures and 1 death in cases of 
 accidental atresia. 
 
 Dressing. — It is not enough to operate and make an outlet for the 
 menstrual retention; accidents must be prevented, and above all the 
 artificial orifice or newly-made canal must be kept open. 
 
 In order to p-event accidents the discharge of the fluid must be 
 regulated. Left to itself it is sometimes too rapid, giving rise to 
 syncope and other accidents, due to the absence or exaggeration of 
 uterine contraction; sometimes it is too slow, in which case the 
 action of the air may cause putrefaction of the retained fluid. To 
 prevent this antiseptic injections should be made twice a day for a 
 fortnight. If decomposition of the blood, entrance of air, or suppu- 
 ration give rise to a putrid discharge the uterine cavity should be 
 gently washed out with disinfectants. In order to p-eserve the artificial 
 canal or orifice, Puech^ recommends the introduction of india-rubber 
 bougies, the upper third of which should be covered with linen to 
 prevent slipping. In a case of cervical atresia the bougie or sponge 
 tent should be fixed with pledgets of lint, and the whole kept in place 
 with a T bandage. The bougie and dressing should be changed every 
 day or two till the discharge has ceased 'and the injections are 
 unnecessary. In order to fit the vagina for fulfilling its functions> 
 the canal ought to be dilated by applying sponge tents of gradually 
 » Op. cit., p. 126. 
 
DETENTION OP THE MENSES 291 
 
 increasing size, after convalescence has been established. These appli- 
 cations should be suspended during the monthly period ; but when it 
 is over the canal should be examined by speculum, so as to destroy any 
 adhesions that may have been formed. We can only be sure of the 
 result when the walls of this canal are covered by a rose-coloured 
 membrane analogous to the rest of the mucous membrane. As a 
 rule, dilatation need not be continued longer than three or four 
 months. 
 
 In a successful case the ulterior consequences are most favorable. 
 By acting on the local state, making an outlet for the retained fluid, 
 and removing the cause of the crises, the operation exercises a most 
 beneficial influence on the general economy. The patient soon 
 recovers her strength, menstruation is established and recurs regularly 
 without producing either disturbance or pain. Sterility disappears 
 with the cause which occasioned it, women sometimes becoming 
 pregnant soon after the operation ; and Puech has proved by numerous 
 examples, that parturition may occur without laceration. 
 
 Can we count on the restitution of a true vagina ? It is to be feared 
 that the result will be but unsatisfactory when there is little or no 
 vestige of vaginal mucous membrane between the uterus and vulva. 
 Willaume de Metz^ and Amussat obtained a fistula rather than a 
 vagina. Even this result is useful because it allows menstruation to 
 take place and puts a stop to the accidents of retention. But it 
 cannot be hoped that the woman will thereby be fitted for marital 
 intercourse, and still less for childbearing. Although very extra- 
 ordinary cases of this kind have been recorded, we must not forget 
 that serious accidents are to be feared at parturition, as in Debrou^s^ 
 curious case, that the child may be expelled through the perineum, 
 that the recto-vaginal septum may be torn, or that the uterine pains 
 may diminish or cease altogether, &c. These dangers are especially 
 to be feared after operations for accidental atresia, when cicatricial 
 tissue replaces the destroyed vagina. It is said that electricity 
 prevents the formation of this retractile tissue, but hitherto this fact 
 has not been placed beyond doubt. 
 
 If portions of the vagina are left, i.e. of mucous membrane which 
 can be reunited, permitting the re- establishment of a distensible 
 canal between the uterus and vulva, we may hope that in spite of 
 cicatricial tissue and partial contractions following suppuration after 
 the operation, there may be a sufficiency of dilatable material to 
 enable it to fulfil its functions though in an imperfect manner. There 
 are many cases, however, which, though calling for operation, in order 
 
 * Bevue medicate franpaise et etrangere, 182G, t. iii, p. 168. 
 
 ' Fibrous coarctation of the whole vagina ; imperforation oE the cervix. The 
 83'mptoms began at seventeen. At nineteen distension of the uterus and right 
 Fallopian tube. First operation : establishment of the vaginal canal and of 
 the uterine orifice. Eelapse after two months. Second operation followed by 
 complete success. Pregnancy, labour at natural term, eclampsia. Application 
 of forceps ; child stillborn. Fatal peritonitis {Gazette mklicale de Paris, ISolj 
 p. 32). 
 
292 UTERINE DISEASES IN DETAIL 
 
 to prevent the fatal results of retention^ yet demand that we sliould 
 warn the patient of the risk she would run by attempting a renewal of 
 marital intercourse. 
 
 Lastly, in cases where it is not possible to undertake an operation, 
 we must content ourselves with palliative treatment. This exclu- 
 sively medical treatment ought indeed to be prescribed in every case, 
 in order to prevent the accidents of retention till such time as the 
 operation can be performed. It consists in fulfilling two indications 
 which present themselves in the treatment of some other menstrual 
 disorders, especially in uterine fluxion, deviation of the menses, in 
 nervous dysmenorrhoea, in painful and violent uterine contractions, 
 and in imminent peritonitis. These indications are : to revulse, or 
 turn aside the fluxionary movement by bloodletting, purgatives and other 
 revulsives employed methodically, in order to prevent distension of 
 the uterus by a fresh flow of blood every month ; to allay pain and 
 irritability, and to diminish uterine contractions by opiates and nar- 
 cotics, in the form of opiate enemata, chloroform, &c. Secondary 
 indications may arise in different cases, according to the special 
 symptoms which may present themselves. 
 
 Deviation of the Menses and Supplementary Menstruation. 
 
 The various terms, deviation of the memes, supplementary hamor- 
 rJiages, menses per aliena loca,per vias insolitas erumpentes, menorrliagia 
 erronea, menstruatio vicaria, ecfopie or lieierotopie menstruelle, all 
 signify a discharge of blood occurring at periodical times, from other 
 organs than the uterus.^ This abnormal phenomenon sometimes 
 replaces the catamenia, at other times it occurs simultaneously 
 with this discharge which, however, is then greatly diminished. 
 The two varieties ought to be distinguished by different names : the 
 term deviation of the mensesl s used when, in the absence of the 
 catamenia, a more or less abundant hemorrhage occurs almost every 
 month from some other part of the body ; supplementary menstruation 
 may be used in the same circumstances, but rather when an insignifi- 
 cant discharge occurs simultaneously from the uterus. 
 
 Ameuorrhoea is the only disease which can produce this morbid 
 condition. Menstrual retention very seldom does so, only four times 
 in 258 cases. ^ The reason is, that, in amenorrhosa, it is not the 
 defective evacuation, but the cessation of the fluxionary movement 
 towards the uterus and its change of direction which can deviate the 
 menses and produce haemorrhage in some other part of the body 
 after an unwonted fluxion and congestion. There may not even always 
 be haemorrhage; there may only be more or less sudden or durable 
 fluxion towards an organ, congestion of its tissue, a slight sanguineous 
 
 1 A. de Haller, Elementa pliysiologue, t. vii. Lausanne, 1778, lib. xiviii, 
 sect, iii, § 14. Qucc mensmm locuvi tenent. The great physiologist points 
 out in a few lines all parts of the body by which the blood may be discharged 
 when hindered from issuing by the uterus. 
 
 " Puech, Acad, dea sc, seance du 9 dec, 1861. 
 
DEVIATION OF THE MENSES 
 
 293 
 
 interstitial effusion or ecchymosis/ or the production of another 
 discharge. '-^ 
 
 This phenomenon attracted special attention in former ages, when 
 there was a tendency to believe in the marvellous. If in those times 
 people were disposed to be too credulous, in our days there is too 
 great a reaction in the opposite direction. 
 
 Diagnosis. — There is not, strictly speaking, any part of the body 
 from which supplementary menstrual hsemorrhage cannot take place. 
 The tegumentary surfaces, the mucous membranes and the skin, seem 
 to be the points towards which the menses most frequently deviate. 
 The following are the various regions in which this phenomenon has 
 been observed, according to 200 cases collected by Puech from various 
 authors : 
 
 Scalp ...... 
 
 Auditory canal .... 
 
 6 
 6 
 
 Eyes, eyelids, lachrymal caruuculai . 
 
 10 
 
 Nasal epistaxis .... 
 
 18 
 
 Cheeks ..... 
 
 3 
 
 Dental alveoli .... 
 
 10 
 
 Salivary glands, or buccal mucous membrane 
 
 4 
 
 Hsemoptysis ..... 
 
 24 
 
 Hsemateuiesis .... 
 
 32 
 
 Breasts ..... 
 
 25 
 
 Trunk, axillae, back, thoracic parietcs 
 
 10 
 
 Umbilicus ..... 
 
 5 
 
 Hsematuria ..... 
 
 8 
 
 Intestine, haemorrhoids 
 
 10 
 
 Hands and fingers .... 
 
 7 
 
 Lower limbs ...... 
 
 13 
 
 Various seats, wounds, ulcers, exutories 
 
 8 
 
 The above table shows that, whilst these haemorrhages may be pro- 
 duced anywhere, they show a predeliction for certain localities. For 
 instance, the mucous membrane of the stomach, the breasts, the 
 mucous membrane of the bronchi and of the nose. They may even 
 take place from the roots of the nails. At other times they are dis- 
 charged from varicose veins, from recent or old wounds, or from ulcers 
 which resist cicatrisation in spite of all topical applications. I have 
 seen them take place from the vagina and internal surface of the vulva. 
 At other times they are produced from various parts of the body, 
 either simultaneously or separately and alternatively. Pinel has 
 related a case of this kind, and Gendrin another, to which I shall 
 
 ' Torthe (Louis) relates a case he saw at the Hopital Saint-Antoine of 'pur- 
 2)ura hcemorrhagica replacing menstrual hasmorrhage. He has collected nine 
 cases from different authors showing that subcutaneous sanguineous extravasa- 
 tions, ecchymoses, and petechia; resembling pui-pura, sometimes with sometimes 
 without external haemon-hage, constitute a well-marked form of menstrual 
 deviation {D'une forme rare de deviation menstruelle. Theses de Paris, 1877, 
 No. 496). 
 
 - Senator (Berlin Klin. Wochetisch., 16 Dec, 1872, No. 57) mentions four 
 cases of women in whom menstruation was iiTcgular, and who suffered periodi- 
 cally every month from an attack of jaundice, which ceased on the i-eappearance 
 of the catamenia. Fasbender {Id., Ibid., April 20 and -lune 1, 1875) mentions 
 two other cases ; the menses were not suppressed, but only diminished. 
 
294 UTERINE DISEASES IN DETAIL 
 
 afterwards refer. Jacqueraier and Lissner have observed fluctuating 
 sanguineous tumours developed periodically at the surface of the 
 thighs. I have myself observed a case of this kind.^ This^supple- 
 mentary menstrual hsemorrhage occurs always from the mucous mem- 
 brane and the skin, more frequently from the former, because it is 
 more vascular, and because the epithelium offers less resistance than 
 the skin. Although the hsemorrhage is produced periodically, the 
 blood is not always evacuated at every menstruation ; it may accumu- 
 late in a hollow organ, to be discharged at a later period. I knew a 
 maiden lady in whom for a long time supplementary hsemorrhage took 
 place into the stomach; but the blood often remained for several 
 months before being ejected. At every monthly period there occurred 
 very characteristic critical phenomena with serious disorders of the 
 digestion. After some months these disorders acquired greater inten- 
 sity, and it was necessary to have recourse to bleeding to put a stop to 
 the spasm and to provoke vomiting. In the matter vomited there were 
 various layers, evidently superimposed, from the purest blood, to older, 
 denser clots, some decomposed and in a state analogous to putrefac- 
 tion. It was impossible to doubt that these various layers were the 
 result of former successive hsemorrhages produced at epochs corres- 
 ponding to the monthly periods. 
 
 The predisposing causes, general or local, are very obscure. The 
 circumstances under which these hsemorrhages occur vary in each 
 woman, and yet when we examine authenticated cases they have 
 certain symptoms in common. As a rule the women so affected have 
 an extremely sensitive nervous system ; others are hysterical. The age 
 at which these phenomena occur varies : they are generally noticed 
 soon after puberty, or at the approach of the menopause. Tueffard^ 
 relates a very uncommon case, in which the hsemorrhage appeared for 
 the first time at fifty-six, six years after the menopause; it occurred 
 regularly every month by the breasts, the discharge of blood lasting 
 eight days, accompanied by the general phenomena of menstruation, 
 and lasting for a year up to the time when the case was published. 
 
 As a rule the uterus is healthy ; sometimes, however, it is more or 
 less deranged. Puech has met with menstrual deviation eleven times 
 in women in whom the genital canals were closed congenitally or 
 accidentally ; and forty-two times in women having a fcetal uterus or 
 congenital absence of this organ,^ a new proof of the importance of the 
 ovary in producing menstruation. 
 
 The hsemorrhage generally occurs after sudden suppression of the 
 catamenia, produced by a violent moral emotion or by some strong 
 physical impression, such as would be produced, for example, by 
 
 ^ Puech, Memoire sur les Atresies des voies genitales de lafemme. 
 
 2 Union medicale, 30 Nov., 1872. 
 
 ^ Brown has lately published a case of supplementary ejiistaxis in a girl, in 
 whom the vagina was reduced to a cul-de-sac and the uterus to two horns 
 (American Journal of Med. Science, p. 575, 1872). I have also found com- 
 plete absence of the uterus and upper half of the vagina in a girl who had 
 supplementary epistaxis without ever having menstruated ; a painful swelling 
 of one ovaiy was felt every month through the rectum, a little to the right. 
 
DEVIATION OF THE MENSES 295 
 
 sudden immersion in cold water. At other times the menses are only 
 retarded or difficult, when after an insignificant accidental cause, or 
 even without apparent cause, there occurs at the time when the cata- 
 menia ought to appear a sanguineous fluxion towards the region or 
 organ naturally or accidentally predisposed to these haemorrhages. 
 
 Yarious explanations have been given of deviation of the menses. 
 Some have thought, with Bordeu, Vigarous, &c., that this phenomenon 
 is produced by an effort of the womb in virtue of the active influence 
 which this organ exercises on other parts of the body. Others have 
 considered it as independent of the action of the uterus, believing it to 
 be the result of the action of the vis mecUcatrix provoking this pheno- 
 menon in order to replace that which is wanting, and to which the 
 economy is already accustomed. Others again have invoked the theory 
 of metastasis to explain the fact; whilst some deny all connection 
 between menstruation and these haemorrhages, which they believe to be 
 simply congestive. Scanzoni^ has revived an explanation of this 
 phenomenon which we can only partially accept. These haemorrhages, 
 he says, having their seat in organs independent of those of generation, 
 are always occasioned by a predisposition resulting from an anomaly 
 of structure of these organs — an anomaly consisting principally in an 
 unusual thinness and great fragility of the vessels. Under the in- 
 fluence of the general vascular excitement manifested in the majority of 
 women at the monthly period, the blood makes a passage for itself 
 externally by the parts in which the abnormal weakness of the vessels 
 offers least resistance.^ The haemorrhage which results acts on the 
 genital organs in the way of revulsive bloodletting. If it is abundant 
 enough to put a complete stop to uterine congestion there will be no 
 discharge from the womb ; if, on the contrary, it is scanty the supple- 
 mentary haemorrhage may be accompanied by a shght oozing of blood 
 from the genital organs. 
 
 The connection of these haemorrhages wdth menstruation cannot be 
 denied; but we cannot be satisfied with the explanation of a so-called 
 metastasis of blood to another organ, in the way the ancients under- 
 stood it, and which the figurative expression of deviated menstnmtion 
 would imply if taken literally. Is it not merely a phenome- 
 non of reflex action, in consequence of which the fluxionary movement, 
 finding an obstacle in the uterus, terminates in another organ and 
 produces an abnormal haemorrhage ? The predisposition of the organ, 
 its relatively inferior power of resistance to morbid attacks, would 
 determine the question of locality.'^ 
 
 The influence exercised ^ by supplementary menstruation on uterine 
 menstruation varies according to the date of the amenorrhcea, andaccord- 
 
 » Op. cit., p. 319. 
 
 ^ There is something true, as regards the seat of deviated menstruation, in 
 the clioicc of the phace oJTcring least resistance ; only wc must not ho content 
 with the admission that these hacmorrhagiparous organs are places offering least 
 vascular resistance, they must rather he regarded as tissues or organs oJVering 
 least resistance to any morbid influence in general. 
 
 ' Lorey adopts this pathogeny (Des vomisscments de sanr/ supplementaire, 
 &c. Theses de Paris, 1875). 
 
296 UTERINE DISEASES IN DETAIL 
 
 ing to the existence or absence of fluxion towards the uterus. If the 
 amenorrhoea is recent and is produced by a sudden suppression, 
 Scanzoni^s explanation is undoubtedly correct ; I have lately seen a 
 girl who has had hemoptysis under such circumstances; in such a 
 case the catamenia may return the following month; the fluxion 
 towards the lungs is not of sufficiently long standing to have taken 
 root there, nor has the uterine fluxion been so completely mobilised 
 as to be irremediably deviated. If, however, the amenorrhcea has 
 lasted long, the conditions are reversed ; the uterus is not only not 
 congested, the fluxion is not even directed towards it ; the abundance 
 or scantiness of the supplementary hsemorrhage will have very little 
 influence on the absence or presence of uterine hsemorrhage. On the 
 other hand, of however old a date the amenorrhcea may be, if there is 
 periodical fluxion towards the uterus and congestion of that organ, 
 and especially if the functional disorder depends on defective evacua- 
 tion, or derangement in the physiological manifestation of the third 
 element of this function, the menstrual haemorrhage may reappear in 
 spite of the supplementary haemorrhage. 
 
 It seems as if other excretions may be supplementary to menstrual 
 haemorrhage, e.g. hypersecretion of saliva, sweat, urine, intestinal 
 mucus, diarrhoea, pus from ulcers, bile causing jaundice, &c. This 
 appears less incredible to us than to Nonat^ when we remember that 
 diarrhoea often precedes menstruation, whilst leucorrhoea replaces it in 
 chlorotic patients suffering from amenorrhoea. 
 
 Apart from these theories, we must find out whether there is the 
 same connection between ovulation or spontaneous dehiscence and the 
 supplementary haemorrhage known as deviated menstruation that there 
 is between periodical dehiscence and the concomitant uterine haemor- 
 rhage, especially if the hseraorrhage, whatever may be its seat, occurs 
 simultaneously with ovulation. Light has been thrown on this 
 question by the interesting researches of Puech.^ A very interesting 
 autopsy showed that the formation of the corpora lutea, and especi- 
 ally the recent rupture of a Graafian vesicle may coincide with each 
 supplementary haemorrhage. It has also been proved that pregnancy 
 may occur in patients affected with deviation of the menses. 
 
 The medical journal of Montpelher^ relates the case of a woman 
 who had deviation of the menses, the discharge taking place through 
 a fistula at the right side of the chest : pregnancy occurred putting a 
 stop to this discharge, and after delivery menstruation took place 
 normally. 
 
 Pauli * knew a girl of seventeen in whom menstruation was replaced 
 for eighteen months by bleeding of the nose. After her confinement 
 menstruation reappeared regularly. 
 
 A woman of thirty, of delicate constitution, married for five years 
 ■without having children, menstruated regularly to the age of twenty- 
 
 » Op. cit., p. 587. 
 
 * Academie des sciences. Seance du 13, avril, 186.3. 
 ^ Journ. de med. de Montpellier, 2' serie, t. v, p. 212. 
 ■* Gazette viedicale, 1839, p. 636. 
 
DEVIATION OF THE MENSES 297 
 
 six. At that time menstruation ceased^ and the woman believed her- 
 self to be pregnant. A few weeks afterwards a tumour was formed 
 in the left hypochondriac region, which suppurated, burst, and was 
 converted into a large ulcer fifteen centimetres square, from which a 
 certain quantity of blood was discharged regularly every three or four 
 weeks. The internal administration of emmenagogues, and the appli- 
 cation of leeches were continued for some years without success. The 
 woman at last became pregnant ; the discharge of blood from the 
 ulcer ceased, the wound cicatrised, and all passed off well. Two 
 months after delivery normal menstruation recommenced and has 
 continued regularly for five years.^ 
 
 In other cases which we have to relate pregnancy occurred in iden- 
 tical conditions, but was not followed by similar good results. Preg- 
 nancy and lactation, it is true, suspended the deviation, but only tem- 
 porarily, the supplementary hsemorrhage reappearing after delivery or 
 after lactation. — Catherine Vincent, who menstruated at nine years, had 
 her monthly periods regularly during eight days of every month. She 
 was hysterical, and when annoyed the catamenia were accompanied by 
 the oozing of a sero-sanguineous discharge from the left breast and axilla. 
 She became pregnant and was delivered at the seventh month. When 
 menstruation was re-established the deviation also reappeared, and 
 besides taking place from the parts above-mentioned, it occurred also 
 from the skin of the left loin, from the back, the epigastrium, the left 
 thigh, &c.^ — A woman of weak constitution had after her first confine- 
 ment a suppression for five months, then the catamenia were scanty 
 for five or six months. At that time she had a considerable vomiting 
 of blood, which was repeated at her monthly periods. Under these 
 conditions she became pregnant; after delivery epistaxis occurred 
 periodically, then hematemesis.^ — A woman who had never menstruated 
 except by hematemesis became pregnant; she had a good confinement, 
 and suckled her child for some months. On being obliged to give up 
 nursing the hematemesis returned. Afterwards she became dropsical, 
 and died at the end of six months.* — A woman of thirty-one had a 
 sudden suppression owing to a great fright she had experienced at her 
 monthly period. The following month the catamenia hardly appeared, 
 but there was expectoration of blood, which stopped spontaneously at 
 the end of four days. From that time a more or less abundant dis- 
 charge of blood occurred every month by the lungs. During her 
 pregnancies menstruation and hemoptysis both ceased. After delivery, 
 and even during lactation, the hemoptysis returned. Her health, how- 
 ever, was in no way affected.^ — Brierre de Boismont tells of a woman 
 who had deviation of the menses during her whole life in spite of a 
 good confinement. — Molinetti knew a woman of great beauty who, till 
 the age of fifty, had vomiting of blood every month in place of mcn- 
 
 ' Gazette medicale, 1843, p. 532. — Obs. o£ Dr. Scliwabo of Weimar. 
 ^ Bulletin de la Societe royale de mcdecine. — Obs. of Dr. Bonfils. 
 ^ Gendrin, Traitr. i^thilosophique de mcdecine i^Tutique, t. ii, p. (55. 
 ■• Journal de medecine, 1757, t. vii, p. 384. — Obs. by Henry, Surgeon at 
 Auxerre. 
 
 • Hoft'mann, t. ii, p. 207. 
 
298 UTEPJNE DISEASES IN DETAIL 
 
 struation. This did not prevent her from having several children.^ — 
 A woman of twenty-four, who had never menstruated, was subject from 
 the age of fifteen to monthly epistaxis. She became pregnant, when 
 the epistaxis disappeared, to return, however, with its previous regu- 
 larity six weeks after her confinement.^ 
 
 We see, therefore, that, except in cases of atresia or serious disorder 
 of the uterus, deviation of the menses does not imply sterility ; unless 
 there be serious derangement of the economy ovulation continues to 
 take place, and ruptitre of the Graafian vesicle coincides loitTi the 
 period of the deviation. Pregnancy is therefore possible and has been 
 observed : it suspends the deviation, which, however, reappears after 
 delivery or lactation. Deviation of the menses depends on the san- 
 guineous fluxion being turned from the uterus by some cause to 
 another organ predisposed, anatomically, physiologically or pathologi- 
 cally to become ^'d pars recipiens of this fluxion. The recurrence and 
 the periodicity of the phenomenon depend on the same causes of vital 
 habit which kept up the periodicity of the uterine fluxion in its normal 
 type. 
 
 Treatment. — Although compatible with health, and sometimes lasting 
 from puberty to the menopause, deviation of the menses is nevertheless 
 a pathological process ; it is even a serious condition, as it has fre- 
 quently caused death. It is more than a functional disorder, it is an 
 essentially morbid state. It is useless to say that it is a beneficent 
 effort of the vis medicatrix ; it is not the less true that the hgemorrhage 
 takes place by organs whose structure is not physiologically suited for 
 its production, and that it is provoked and kept up by a special morbid 
 condition. It is true that the economy becomes habituated to such a 
 state, and tolerance may be established, nevertheless the health is not 
 perfect till the supplementary hsemorrhage is replaced by normal men- 
 struation. The prognosis varies according to several circumstances 
 connected with the production of the hsemorrhages, their seat, &c. It 
 is only serious when women who are already debiHtated become more 
 so by the prolongation and abundance of this loss. Death, as I have 
 said, may result, and one of the most curious examples of this termi- 
 nation is that published by "Fricker de Horb,^ in which a third attack 
 of supplementary nasal epistaxis was followed by death. It is unneces- 
 sary to say that when hsemorrhage occurs in important organs the 
 danger is increased. 
 
 Lastly, considered in themselves, and independently of the organs 
 in which they are locahsed, supplementary hasmorrhages are always a 
 troublesome accident. Except in cases of atresia, when they really 
 prove beneficial by obviating uterine distension, they produce great 
 inconvenience to the patient ; they always indicate debility ; they are 
 extremely difficult to cure; they recur with extreme facility, and as 
 
 1 Eelated by Berger, Physioloyie, chap, xx, p. 252. 
 
 2 Otto Obersaeur, Virchow's Archiv, 1872, vol. xlv, part 3. 
 
 3 Medecin. Correspondenz-JBlatt, 1844, p. 510. — Dunlap {New YorJc Journ. 
 of Medicine, May, 1856), bajmorrbage from the gums ; after cupping with the 
 scarificator htemorrhage ensued and carried off the patient, 
 
DEVIATION OF THE MENSES 299 
 
 they may change their seat or threaten an important organ, they 
 ought to have the serious consideration of the physician. Cases are 
 on record which have lasted during the whole of menstrual life, in 
 spite of the most suitable treatment. De Mynck and Kluyskens^ 
 have related a case in which supplementary haemorrhage from the 
 breast, established at forty, terminated at fifty-eight in a cancer. 
 
 Treatment should be directed : 1st, to the amenorrhcea, by means 
 previously described; 2nd, to the supplementary haemorrhage, the 
 abundance and seat of which may indicate various means in addition to 
 haemostatics, according to the speciality of the case. Nothing seems 
 simpler than these indications, and yet the result is very uncertain. 
 
 The treatment of amenorrhcea in these cases consists principally in 
 strengthening the constitution and in drawing to the uterus the 
 liaemorrhagic molimen produced in other organs. 
 
 In order to fulfil the first indication, besides having recourse to 
 therapeutical means, great attention should be paid to hygiene. In 
 addition to a generous diet, exercise ought to be prescribed ; if the 
 patient is too weak to walk she ought to drive. Tonics should be 
 given, and the best of these are quinine and iron. 
 
 To fulfil the second indication, to determine a fluxionary movement 
 towards the uterus sufficiently strong to turn aside the abnormal 
 fluxion, we may employ irritating topical applications, mustard, sitz 
 baths, dry cupping, or with the scarificator, leeches to the inner and 
 upper parts of the thighs, or one or two leeches to the cervix, or 
 better still dry cupping which does not cause loss of blood, or, 
 if necessary, intra-uterine dry cupping as advised by Simpson. The 
 time chosen for beginning this treatment should be one or two days 
 before the monthly period, and it should be continued the whole time 
 it lasts, till the phenomena of abnormal fluxion have completely 
 disappeared. 
 
 The treatment of supplementary hcemorrhages is less important, 
 except when these discharges endanger life by their intensity. In 
 such cases we must have recourse to the most powerful haemostatics, 
 and to the various means employed in the general treatment of 
 haemorrhages. We must, however, beware of trying to subdue these 
 abnormal haemorrhages energetically before having re-established 
 normal menstruation : we should run the risk of producing them on 
 another and more important organ. Forestus" and Chauflfe^ relate 
 cases of mental derangement and fatal cerebral apoplexy occurring as 
 the result of such inopportune treatment. 
 
 ' Gazette ined. de Paris, 1844, p. 595. 
 ^ De cerebri morho, obs. 24. 
 
 ■^ Des accidents et des maladies qui survlenncnt a la cessation de la mens- 
 truation. Theses do Paris, an x. 
 
300 UTEIMNE DISEASES IN DETAIL 
 
 Dysmenorrhcea 
 
 Dysmenorrhoea^ according to its etymology, is difficult menstruation. 
 This disease includes sluggishness and difficulty attending the cata- 
 menial discharge ; irregular menstruation ; pains, often very violent, 
 usually preceding the sanguineous flow, sometimes accompanying it ; 
 menstrual evacuation in certain cases nil, in others insufficient, some- 
 times putting a stop to the pain on its first appearance, but some- 
 times occurring without any cessation of the pain, and occasionally 
 acquiring an intensity which amounts to metrorrhagia. 
 
 Diagnosis. — Aran ^ has given a very exact description of dys- 
 menorrhoea and of the distinctive features of this pathological 
 condition. "The menses may be delayed in many women without 
 affording cause for anxiety. Nothing but disorder of the general 
 health or abnormal phenomena manifested in the genital economy need 
 direct the attention to what otherwise is merely an anomaly of 
 menstruation. In women suffering from chlorosis or from any serious 
 disease of a debilitating nature, the menses are delayed more and 
 more, till at last they cease altogether or only recur at long and 
 irregular intervals; unless an effort is made by the organism to 
 re-establish them, the physician ought to confine his attention to the 
 chlorosis and to the debilitating pathological condition ; delay in the 
 appearance of the menses is only a cry of alarm, a signal of distress 
 from the economy. They may, however, be delayed amid symptoms 
 which betray an energetic effort for their re-establishment. Very often 
 these symptoms do not differ much from those which coincide with the 
 sudden or prolonged suppression of the catamenia ; but, limited to the 
 genital economy, or at least affecting it principally, they have with 
 reason received the name of dysmenorrhcea. The symptoms of 
 dysmenorrhcea, without being completely similar in all cases, yet have 
 a common basis, viz. sluggishness, the difficulty with which the dis- 
 charge is established each time, its irregularity ; the presence of pain 
 in the uterine system, and often in other of the organic systems for 
 some hours or days before its appearance, pain which increases till the 
 catamenia appear." 
 
 It is easy to understand that dysmenorrhcea is principally met with 
 in girls, or in women who have never been pregnant. It is not 
 enough to recognise its existence in the preceding symptoms ; it is 
 important further to distinguish between symptomatic and idiopathic 
 dysmenorrhcea. In one sense all dysmenorrhcea is symptomatic of a 
 morbid condition; but when this condition is not produced by any 
 persistent organic derangement, and may disappear under the influence 
 of a modification of the functions of innervation or of the vascular 
 system, the dysmenorrhcea is called idiopathic; when, on the contrary, 
 it is caused by contraction of the orifices or by a disorder of the 
 mucous membrane requiring the intervention of the surgeon, it is called 
 spnptomatic. 
 
 1 Op. cit., p. 300. 
 
DYSMENORRHCEA 30l 
 
 Djsmenorrlioea may be s?/mptomaiic of simple neuralgia, especially 
 of lumbo-sacral neuralgia. It may also be symptomatic of an organic 
 lesion depending on a nutritive alteration of local life, a fibrous 
 tumour, polypus, hypertrophy, or the localisation of a diathetic affec- 
 tion such as cancer ; but these lesions are complicated with menor- 
 rhagia and metrorrhagia more frequently than with dysmenorrhoea. 
 
 It may also be symptomatic of the formation of a clot in the uterine 
 cavity ; but this formation infers other lesions, such as coarctation of 
 the cervical orifice or dilatation of the body of the womb. It is fre- 
 quently symptomatic of uterine congestion, of acute or chronic uterine 
 inflammation, of inflammation of the appendages, &c. Oftener still, 
 it is symptomatic of anteflexion or retroflexion, and especially of torsion 
 and contraction of the cervico -uterine canal, with partial retention of 
 the menses, and of the monthly exfoliation followed by the periodical 
 expulsion of the mucous membrane with the menstrual blood ; hence 
 the name of mechanical dysmenorrhcea and of membranous dysmenor- 
 rhoea to distinguish them from symptomatic dysmenorrhoea. 
 
 Idiopathic dysmenorrhoea is not connected with any cause foreign 
 to menstruation itself. It is a functional irregularity affecting one or 
 more of the three elements (fluxion, congestion, evacuation) of the 
 catamenial act, and produced by a deterioration in the health and 
 oftener in the local life of the organ, the nature of which may vary, 
 allowing of the existence of differences in the essential cause of dys- 
 menorrhoea, and consequently in the indications for treatment. With 
 regard to this nature, all physicians recognise a nervous, spasmodic, 
 hysteriform dysmenorrhoea, and a sanguineous, vascular, congestive 
 form. The first depends on a state of pain, spasm, or neuralgia, which 
 has led to its being called catamenial hysteralgia ; the second depends 
 principally on hypersemia of the organ. The first consists specially in 
 a derangement of the mode in which the fluxion takes place towards 
 the organ, or of the mode in which the uterus is accessory to the 
 evacuation of the fluid, under the influence of a derangement of in- 
 nervation ; the second, in an excess of congestion or an alteration in 
 the manner in which it is produced, either that it is limited to the 
 uterus or that it is extended to the Pallopian tubes and to the ovaries 
 under the influence of a derangement of the circulation, and is vitiated 
 in its mode of termination, even to the extent of producing hseraor- 
 rhagic centres in the Fallopian tube or in the ovary, and even 
 hsematocele. 
 
 1. Idiopathic Bt/smenorrhoea 
 
 Differential diagnosis. — Nervous dysmenorrhcBa is characterised by 
 general and local disorders of innervation. Pain, spasm, neuralgia, 
 developed in the uterus, in the uterine system, in the neighbouring 
 organs, or even in the whole economy during menstruation, may equally 
 play the part of essential cause of the disease, either separately, suc- 
 cessively or simultaneously. These morbid conditions may be them- 
 selves under the dependence of various general or diathetic affections. 
 However that may be, one of these elements, pain, spasm or neu- 
 
/ 
 
 302 UTERINE DISEASES IN DETAIL 
 
 ralgia may characterise this kind of dysmenorrhcea in an especial 
 way. 
 
 As a rule the symptoms (discomfort, dyspepsia, cephalalgia, more or 
 less violent lumbar and hypogastric pain) cease as soon as the menses 
 appear, especially when the discharge is abundant ; if, however, it only 
 comes by drops (stillicidium uteri of Aetius, tUerine strangury, as con- 
 trasted with vesical strangury) they may persist for a longer or shorter 
 time, and be the indication of a contraction of the cervix or of the os 
 internum in which the nervous state seems specially to be localised ; 
 they may continue till the expulsion of a clot, which follows the incom- 
 plete sanguinolent or sero-sanguinolent discharge permitted by the im- 
 perfect permeability of the orifice, or which is accompanied by real 
 menorrhagia, and announces the imminent cessation of the trouble and 
 soon of menstruation itself. These symptoms may attain an extreme 
 degree of intensity ; I have seen girls shed tears, scream with pain, 
 writhe in bed, roll on the ground. The violence of the pains may even 
 react on the whole economy, causing nausea, vomiting, hysterical or 
 epileptiform symptoms, &c. 
 
 Congestive dysmenorrhcea is characterised by the symptoms of con- 
 gestion itself ; discomfort, sense of pelvic fulness and weight, frequent 
 micturition, heat and smarting in passing water, tenesmus, diarrhoea, 
 swelling of the breasts. The symptoms may increase during the first 
 few hours following the commencement of evacuation. The pain may 
 increase so as to assume the character of the expulsive pains of labour, 
 shooting down the groins and thighs, increasing at intervals and being 
 accompanied by swelling of the hypogastrium, which cannot tolerate 
 the touch of the hand or the contact of the clothes. At this period 
 the pains may attain the violence and assume the form of those of 
 nervous dysmenorrhcea, both in their local manifestation and in their 
 reaction on the whole economy. Usually all these phenomena, the pain 
 especially, disappear in proportion as the flow increases, unless the 
 dysmenorrhcea has caused congestion of the uterus. At other times 
 patients sufi'er from dull pelvic pain, not only all the time of the men- 
 strual flow but also for some days after it has stopped. 
 
 It is the congestive form that is related to what Simpson^ called 
 ovarian dysjnenorrhma, which depends on the excess of congestion 
 which causes the pain affecting the ovary rather than the uterus. 
 The tension and sensitiveness of the ovaries are especially evident 
 when these organs are displaced, either into the recto-vaginal cul-de-sac 
 of the peritoneum, or into a hernial sac.~ It is often met with in 
 aneemic women as the result of defective equilibrium, of unequal 
 distribution of blood. It is also frequently observed in prostitutes, in 
 i whom it is produced b)? venereal excesses, and it is sometimes met with 
 in old maids and in young widows as a consequence of unsatisfied 
 sexual instinct. 
 
 * Simpson, op. cit., p. 411. 
 
 ' In a case related by Oldham {Philosophical Transactions), in which the 
 6vaiy descended by the inguinal canal into the labium, this organ swelled some! 
 days before the appearance of the menses, and the patient suffered greatly. 
 
DTSMENOREHGEA 303 
 
 Treatment. — The indications differ according to the nature of the 
 dysmenorrhcea. 
 
 In nervous dysmenorrlma the two elements of pain and spasm are 
 the two principal sources of indications. The element of neuralgia and 
 the neuralgic form assumed by the pain may give rise to a third order 
 of indications, to the special indications of neuralgia ; these may exist 
 apart from the menstrual period, they may vary according to the locali- 
 sation of the neuralgia and the essential cause of the affection which 
 keeps it up ; frequently, however, the same medication is employed with 
 equally good results in cases of neuralgia, properly so called, and of 
 pain. 
 
 Fain is subdued by narcotics, and, if necessary, by anesthetics, such 
 as the various preparations of opium, morphia, laudanum, henbane, 
 belladonna, Indian hemp,^ ether, chloroform, &c. 
 
 To prevent dysmenorrhcea, general baths for an hour or more should 
 be [prescribed, made with a decoction of bran or gelatine, and re- 
 peated daily for some days before the menses are expected ; or sitz- 
 baths with vaginal injections of a decoction of poppy-heads, or 
 henbane and belladonna leaves; sedative embrocations of camphorated 
 chamomile oil, laudanum, morphia, &c., should be applied to the 
 hypogastrium, the groins, and the inner surface of the thighs, and 
 care should be taken to keep the bowels open by means of emollient 
 or laxative enemata. The moment that the catamenia appear, if there 
 is dysmenorrhoeic pain, opium or morphia should be given ; perhaps 
 the best method is to give a small enema of decoction of marshmallow 
 or poppy-heads with from 10 to 20 drops of laudanum, which may 
 be repeated. Bromide of potassium in doses of from 8 grains to 5j 
 in the day, given before, during, and after menstruation sometimes 
 produces beneficial effects. Hot linen, antispasmodic infusions, baths 
 of bran or lime-tree flowers (Jx in a bath) taken during menstruation 
 may produce a sedative effect. Lastly, if the pain instead of yielding 
 becomes excessive, inhalations of ether or chloroform may be tried, 
 as advised by Bennet and Aran. 
 
 Spasm is more effectually subdued by the administration of anti- 
 spasmodics given alone or associated with the sedatives just men- 
 tioned. Orange-flower water, ether, valerian, castoreum, musk, 
 camphor, assafoetida, ammonia, hydropathy, have often put a stop 
 to the most violent attacks of dysmenorrhcea. After having used baths 
 and narcotics as preventive measures in the various forms above named, 
 spasm may often be relieved by 25 to 30 drops of the following anti- 
 spasmodic mixture : Sulphuric Ether, Tinct. Valerian., Tinct. Castor., 
 Tinct. Op., aa 5J, with a tablespoonful of distilled orange-flower 
 water in half a glass of eau svcree, to be taken in spoonfuls every five 
 minutes ; a second dose may be given in an hour if required. I 
 
 ' ^. Lupulin, gr. 3 ; 
 
 Ext. Cannabis Ind., gr. \. 
 
 M. ft. pilula. 
 Sig. Take two pills In the morning and tlirce in the evening as soon as thd 
 first 3ymptoms appear (Deljout, Aran). 
 
304 UTERINE DISEASES IN DETAIL 
 
 have little confidence in musk and camphor^ but if the above-named 
 antispasmodics do not succeed, assafoetida may do good (1^ gr. in a 
 pill given every hour, or 30 gr. suspended in yolk of egg in 3^ oz. 
 of decoction of poppy-heads as an enema); or 15 gr. of sesquicar- 
 bonate of ammonia, or a few drops of ammonia in a glass of water. 
 Lastly, cold compresses on the hypogastrium, and other hydropathic 
 applications often do great good when administered with caution. 
 
 When spasm especially affects the cervix, and it has been ascer- 
 tained, by the pain which the sound causes, and by the difficulty of 
 passing it through the internal os, that this orifice is probably con- 
 tracted, we may try the effect of applying belladonna to the cervix, 
 or we may inject a few drops of a solution of neutral sulphate of 
 atropine (1 in 100) into the tissue; or douche this organ with 
 carbolic acid or chloroform spray ; or subdue the spasm by using 
 the sound every day or every other day shortly bsfore the monthly 
 period, or even by introducing a gutta-percha sound or one of 
 Simpson^s solid pessaries of ivory or metal, and leaving it for a few 
 hours. This, however, ought not to be employed unless we are 
 sure of the absence of any inflammatory element, and only after 
 having tested the susceptibility of the uterus by touch. 
 
 In congestive di/smenorrlicea there are two different sources of indi- 
 cation : an excess or defect of strength, hypersthenia, or asthenia, 
 which, although opposite in character, may equally cause hypersemia. 
 
 Hypersthenia, by increasing the intensity, energy, and persistency 
 of fluxion, gives to congestion an importance which exceeds all 
 physiological bounds, and brings about all the conditions of acute 
 uterine congestion. The treatment of this morbid condition does not 
 differ from that of congestion. Asthenia, implying defective fluxion or 
 inertia of the uterus in excreting the menses, indicates the use of 
 various stimulants of the uterine system, the value of which has 
 already been discussed in the treatment of amenorrhoea : attractions, 
 emmenagogues, cold douches, electricity, kc, or even the momentary 
 or prolonged introduction of the sound or of solid stem pessaries into 
 the uterine cavity. 
 
 In the interval between the monthly periods baths of bran or starch 
 should be recommended, and especially exercise, living in the country, 
 travelling, &c. West^ and Simpson,^ believing that dysmenorrhcea is 
 caused by a rheumatic or gouty diathesis, recommend the use of 
 tincture of colchicum associated with small doses of laudanum and 
 antimonial wine. The colchicum is to be continued during the 
 whole intercalary period, or the iodide of potassium may be substi- 
 tuted for it. A^ichy water, the baths of Carlsbad or Wiesbaden, and 
 other means indicated by the nature of the affection complete the 
 treatment. 
 
 Lastly, the indications vary according to whether we are consulted 
 during the crisis or in the intervals. In the first case, as Simpson^ 
 
 1 Op. cit , p. 87. 
 - Op. cit., p. 242. 
 ■' Op. cit., p. 234. 
 
DYSMENOERH(EA 305 
 
 wisely remarks, the treatment is simply palliative, our aim being to 
 mitigate the paroxysm ; in the second, it is curative, radical or pre- 
 ventive, the indication being to destroy the obstacle to the free 
 evacuation of blood, or to prevent the return of the symptoms by 
 various means, according as the dysmenorrhoea is nervous or conges- 
 tive; not only by therapeutical means, but by hygiene, hydropathy, 
 exercise on horseback and on foot, in short, by every means that 
 can subdue the nervous irritability, or diminish the tendt-ncy to con- 
 gestion by re-establishing equilibrium in the general circulation. 
 
 2. Mechanical djjsnienorrhcea 
 
 This malady, which Simpson^ describes under the name of obstruc- 
 tive dysraenorrhma, and which some German authors designate as 
 stenosis of the cervix, is nothing more than the series of symptoms 
 developed by the energetic and painful contractions of the uterus in its 
 endeavour to expel the product of menstruation through too narrow an 
 orifice. It is in miniature the morbid state produced by complete 
 retention. 
 
 Diagnosis. — The seat of contraction may be at the external os, 
 throughout the cervico uterine canal, or at the internal os; but usually 
 it is at the external os. Mackintosh^ called attention to this subject 
 in 1823, and in 1826 proposed dilatation by bougies. The cause, 
 which is always organic, is a congenital malformation, or a cicatrix 
 following upon inflammation and ulceration of the cervix, laceration, 
 or inopportune or unskilful cauterisations. When the deformity is 
 congenital it is designated by the name of narrow os; when accidental 
 it is called contracted os. The malady is characterised not only by the 
 violence of the expulsive pain, uterine tenesmus and muscular contrac- 
 tions of the womb, but by the difficulty of evacuation, the blood 
 escaping only in small quantities at intervals, sometimes under the 
 form of narrow elongated clots mixed with fibrinous concretions. The 
 tumefaction of the uterus by the blood, which has a difticulty in 
 escaping, causes excessive congestion and irritation in the organ, 
 which, according to Eigby,^ is sometimes transraitttd to the ovary, 
 producing pains in the groin and even causing menorrhagia. The 
 examination of the uterus by speculum, and the introduction of a very 
 fine sound, enables us to ascertain the reality of the impediment. 
 AYhen the contraction is at the internal os it is sometimes necessary to 
 dilate the external orifice and cervical cavity previously with sponge 
 tents in order to make sure of the fact. It seldom happens that the 
 internal os is narrow when the external one is so, unless the narrow- 
 ness of the former is more marked than that of the latter ; for the im- 
 pediment caused by the latter to the escape of the blood produces an 
 accumulation of this fluid in the uterine cavity situated above, and so 
 necessarily leads to the dilatation of the internal orifice. The narrow- 
 ness of the OS is the most common obstacle to menstrual excretion. It 
 
 1 Op. cit., p. 215. 
 
 ^ Practice of Physic, 4tli edit., t. ii, pp. 436, 481. London, 1836. 
 
 ^ Med. Times, 25th October, 1851. 
 
 20 
 
806 
 
 UTERINE DISEASES IN DETAIL 
 
 is always indicated by the circular form of this orifice (a point instead 
 of a line) , so much so, that circular form and narrowness of the orifice 
 are almost synonymous, whilst narrowness of the os and dysmenorrhoea 
 are almost invariably associated. If menstruation is scanty this 
 narrowness may not have any troublesome consequences, and may 
 even, to a certain point, pass unnoticed. This is what often occurs at 
 the commencement of sexual life. If, however, the fluxionary move- 
 ment and the quantity of menstrual blood are increased by the develop- 
 ment of puberty or by marriage, the blood has difficulty in escaping, 
 and clots are formed, which increase the difficulty. Expulsive pains 
 are developed ; sometimes uterine cramps are associated with these 
 pains. DysmenorrhcEa is accompanied by retention, and assumes the 
 form of spasmodic nervous dysmenorrhoea. By dint of contracting in 
 order to expel the retained blood, by constant dilatation from this 
 menstrual retention, the uterus is in a continual state of hypersemia, 
 and remains congested. The dysmenorrhcea takes the character of 
 congestive dysmenorrhcea. This character is added or even substituted 
 for those of retention or spasm. The congestion cannot long remain 
 in the parenchyma with pain, contractions, &c., without producing 
 inflammation in the tissue proper. On its side contact with the retained 
 blood irritates the mucous membrane, and soon metritis (parenchy- 
 matous, congestive, sometimes hsemorrhagic) and endometritis (leucor- 
 rhceic, granular, &c.) are added to or substituted for the simple 
 mechanical dysmenorrhcea which was present at the outset. 
 
 Fig. 219. 
 
 Fig. 220. 
 
 Fig. 221. 
 
 Fig. 219. — Narrow round os on a cervix of normal conformation already con- 
 gested. 
 
 Fig. 220. — Narrow os, round and excentric, on a cervix of normal conformation 
 more strongly congested. 
 
 Fig. 221. — Narrow os, round and excentric, on a cervix of normal conformation, 
 still more congested than the others and inflamed. 
 
 Such is the course which the malady takes in married women. 
 Thenceforwards symptoms of inflammation are added to those of 
 mechanical dysmenorrhoea caused by narrowness of the os. These 
 symptoms become aggravated, and are multiplied and complicated day 
 by day. Sterility, which is equally a consequence of narrow os, is 
 associated with the other symptoms, and helps to complete the 
 diagnosis. 
 
DYSMENORRHCEA 
 
 307 
 
 In virgins this mechanical dysmenorrhoea may cause the gradual 
 diminution of the menstrual haemorrhage till it ceases almost entirely, 
 sometimes completely, when atrophy may be produced ; but this is rare. 
 
 Fig. 222. Fig. 223. Fig. 224. 
 
 Fig. 222. — Congenitally narrow os on projecting cervix (after Sims). 
 
 Fig. 223. — Narrow os on a congested projecting cervix. 
 
 Fig. 224. — Narrow os on an inflamed and congested projecting cervix. 
 
 In married women, on the contrary, the phenomena previously 
 described occur invariably ; whether the cervix is normal, slightly 
 conical, or very conical and long, it gradually increases in volume, as 
 seen in the accompanying figures. Besides increasing in size it becomes 
 
 Fig. 225. Fig. 226. Fig. 227. 
 
 Fig. 225. — Narrow os on a long and conical cervix. 
 Fig. 226. — Narrow os on a long, conical and congested cervix. 
 Fig. 227. — Narrow os on a long, conical, congested and inflamed cervix. 
 
 dark red in colour, very sensitive and painful to the touch; the 
 orifice becomes slightly enlarged, sometimes assuming a cup form, but 
 still remains insufficient for excretion. Therefore, in order to put a 
 stop to these troubles it must be enlarged. The preceding figures 
 show the changes which mechanical dysmenorrhoea produces in the 
 cervix, whilst the figures which follow, taken from plaster casts, show 
 the changes produced in the form of the uterine cavities. When the 
 narrowness of the os is sufficient to cause retention of the menses or 
 of mucus, the capacity of the uterine cavity may be increased; and even 
 
308 
 
 UTERINE DISEASES IN DETAIL 
 
 the orifices of the Fallopian tubes may become sufficiently dilated to 
 allow of the entrance of the sound. 
 
 Fig. 228. Fig. 229. 
 
 Fig 228. — Cast of the cavities of a normal uterus in a virgin of seventeen. 
 Fig. 229. — Cast of the uterine cavities in a nullipara of twenty-five or thirty ; 
 
 marked constriction and elongation of the isthmus ; enlargement of the 
 
 cervical cavity ; constriction of the external orifice. 
 
 Fig. 230. Fig. 231. 
 
 Fig. 230. — Cast of the uterine cavities in a nullipara of forty-two ; marked 
 constriction of the os externum. Its form is the same as that of the 
 virgin uterus, hut the horns are larger, the isthmus is dilated, and owing 
 to the constriction d, the upper segment of the hody and the cervical 
 cavity are more developed. 
 
 Fig. 231. — Cast of the uterine cavities in a multipara of thirty-five ; constric- 
 tion and torsion of the isthmus ; permanent lateral deviation of the body 
 on the cervix ; c, well-marked enlargement of the body. 
 
DYSMENORRHCEA 309 
 
 Torsion of the isthmus (Fig. 231) which, Kke other flexions, may 
 either be primitive or occur after childbirth, is also a cause of mechan- 
 ical dysmenorrhoea, to which I shall have occasion to refer when 
 speaking of flexions. 
 
 Treatment. — It is important to treat mechanical dysmenorrhoea 
 because the pains that it produces are intense and have no tendency 
 to disappear naturally, because sterility is the invariable consequence, 
 and the secondary effects disorder the health seriously. The treatment 
 is mechanical, like the cause of the disease, and at the same time that 
 it cures the dysmenorrhoea it also removes the inflammation and con- 
 gestion which result, as well as the leucorrhoea and other disorders of 
 the mucous membrane which owe their existence to the same cause, 
 and very often it is followed by pregnancy. It is analogous to that em- 
 ployed in constrictions of other organs, consisting in dilatation (rapid 
 or gradual), incision, or autoplasty of a new orifice. 
 
 1. Dilatation. — Rapid dilatation by means of intra-uterine forceps 
 or speculum, the branches of which are introduced closed into the 
 cervix and then opened quickly, has the disadvantage of causing 
 lacerations. It is only admissible in cases of constriction caused by 
 muscular contraction of the sphincter, with more than a sufficiency of 
 mucous membrane externally as well as internally, that is, in spite of 
 EUinger^s ^ assertion, in the minority of cases. Gradual dilatation is 
 preferable. Of course, before using a dilator we must be sure that 
 the dysmenorrhoea, and the constriction which causes it, are not con- 
 nected with some other morbid condition. Among complications 
 which contra-indicate the use of dilatation I may mention inflamma- 
 tion especially. If there be any uterine, peri-uterine, or ovarian 
 phlegmasia it should be subdued by leeching and the use of anti- 
 phle^istics ; for in siich cases there would be as great a danger in 
 dilating as in cauterising the cervix. Mackintosh^ used flexible 
 bougies or metallic rods of gradually increasing "volume ; Rigby a 
 dilator with steel blades, which were opened and left for some time in 
 the cervix; Eaynaud, of Montauban,^ conical wax bougies, by means 
 of which he obtained pregnancy in two very interesting cases of 
 dysmenorrhoea and sterility ; Simpson metalHc stems of gradually 
 increasing size, supported by an oval bulb, which rests on the poste- 
 rior wall of the vagina and keeps the instrument in place without 
 causing fatigue. These stems are left a longer or shorter time, 
 according to the irritability of the uterus and the sensitiveness of the 
 patient. As a rule, she ought to remain in bed ; if she is sensitive 
 the instrument is only left for one or two hours. It is applied again 
 the next day or the following one; the stem is changed for a larger 
 one as soon as the canal is sufficiently dilated to allow of its entrance. 
 If the patient tolerates the dilatation well, the first stem may be left 
 
 ' Arcliivfilr Chjnaelcol., Bd. v, Heft. 2. Berlin. 
 
 ^ Out of twenty-seven women he cured twenty-four, and eleven of the 
 twenty-four had children. 
 
 ' Jobert de Laniballe's " Report to the Academy of Medicine on llaynaud's 
 Paper," Bulletin de V Academic, 25 June, 1850. 
 
310 
 
 UTERINE DISEASES IN DETAIL 
 
 Fig. 232. 
 
 Simpson's intra- 
 uterine stem. 
 
 longer, and when it is withdrawn it may be replaced by a second, and 
 that by a third, and so on. Simpson regularly em- 
 ployed this means of dilatation. Bennet^ prefers 
 bougies of wax or gutta percha to metallic sounds. 
 He says that, when used cautiously, good results 
 can be obtained without suffering, and in cases of 
 slight constriction no further treatment is required. 
 Wax bougies may be used every second day till the 
 canal is sufficiently dilated ; each bougie should be 
 kept in place for some hours. When using Simpson's 
 metallic sounds Bennet gives them a slight curve, 
 with the concavity on the anterior surface, that they 
 may be better adapted to the form of the cervico- 
 uterine canal. Sims has wisely substituted the use 
 of aluminum for other metals in the manufacture of 
 these dilators. Aluminum is light, not easily de- 
 composed, and more readily borne than any other 
 metal. Nevertheless, instead of making use of 
 bougies or catheters it is better to have recourse to 
 dilating bodies, and to the most inoffensive of all, 
 viz. prepared sponge. 
 
 The naturally dilating bodies are especially useful when we cannot 
 at once succeed in passing the internal orifice, either on account of its 
 excessive narrowness, or on account of deviation, inflexion or torsion 
 of the cervico-uterine canal. If they do not effect the complete dila- 
 tation of this canal including the internal orifice, they at least prepare 
 the way for the penetration of instruments through this orifice. The 
 treatment may be completed afterwards by incision or by the introduc- 
 tion of bougies or metallic stems into the cavity of the womb. The 
 dilating body most commonly employed is prepared sponge, which 
 should be applied according to the rules previously laid down (p. 149). 
 Each sponge-tent should penetrate a little further than the preceding 
 one, and as this application should be discontinued during menstrua- 
 tion, one or two months are often required to produce complete dila- 
 tation. Laminaria may be substituted for sponge-tents in dilating the 
 external orifice, but it should never be used for the os internum, the 
 swelling of the laminaria above the constriction rendering extraction of 
 the stem impossible without lacerations, which may endanger the life 
 of the patient. Prepared sponge alone ought to be employed in 
 dilating the cervico-uterine orifice, and as I do not see any advantage 
 that laminaria has over sponge, I use the latter exclusively for 
 the dilatation of the vaginal orifice, as well as for the os internum. 
 Unfortunately dilatation is often insufficient, especially for the os 
 externum. 
 
 II. Incision. — When dilatation appears insufficient, incision of the 
 cervix should be resorted to. This little operation, to which the 
 imposing name of uterotomy or hysterotomy has been given, is not un- 
 accompanied by accidents when performed inopportunely or too deeply. 
 1 Op. cit., p. 338. 
 
DYSMENORRHCEA 311 
 
 The incision may be single or multiple, superficial or deep ; it may be 
 limited to one, or extended to both orifices of the cervix. Some 
 gynecologists proscribe division of the os internum in all circumstances.^ 
 As for myself, I have often remarked that obstruction of the internal 
 orifice is caused by a curve or flexion of the uterus, a tumour on a level 
 with the orifice, or simple hypertrophy of the upper part of the anterior 
 cervical wall ; but some constrictions are produced by congenital mal- 
 formation, others by retraction of the circular or oblique fibres of this 
 orifice, and others again by true contraction of the sort of sphincter 
 which surrounds this orifice, the existence of which seems to me as 
 clearly proved by my anatomical investigations as by the physiological 
 phenomena I have observed. I acknowledge that incision of this orifice 
 is much more dangerous than that of the external one ; fortunately 
 it is less frequently necessary. Nevertheless I think that dilatation by 
 sponge-tents, and even by superficial incision, may be performed 
 without danger, provided that suitable precautions be taken to arrest 
 haemorrhage if it threaten to be serious, and especially by avoiding 
 operation at the menstrual period. 
 
 It is only accidentally and quite exceptionally that division of the 
 external orifice can lead to any accidents. It is so often indicated 
 that we must give up all hope of curing a large number of uterine 
 maladies caused by a narrow vaginal orifice if its enlargement is to be 
 proscribed. 
 
 Different metJiods of incision. — The utility of hysterotomy being 
 admitted, all that remains is to procure the best instruments and dis- 
 cover the best way of performing the operation. I began by using 
 the simplest instruments : a pair of long-handled scissors ; a director 
 with a long stem fitted on to a handle ; a bistoury with a short blade 
 like that of a tenotome, pointed or probe-pointed according to cir- 
 cumstances, with a long stem mounted on a handle which could be 
 introduced into the uterus along the groove of the director. 
 
 I will describe the way in which I now perform the operation with 
 the same instruments, with the addition of a pair of diverging tena- 
 culum hook forceps ; before doing so, however, I shall mention the 
 instruments invented for the same purpose by other gynecologists, and 
 which in some cases may be preferable by simplifying the operation 
 and rendering it more rapid. The first of these instruments, Simp- 
 son's^ hysterotome (Fig. 208, p. 227), is a kind of concealed bistoury, 
 resembling in its mechanism the lithotome of Friar Come, and which 
 requires no description. Simpson, after incision, always applied the 
 tincture of perchloride of iron or the glycerole of it to the cervix by 
 means of a brush, and he plugged if necessary. The second, the 
 double hysterotome, several varieties of which have been invented in 
 France and England (Fig. 209, p. 227), allows of the incision of both 
 sides of the cervix simultaneously. If Greenhalgh's instrument were 
 less complicated and less costly there is no doubt it would be prefer- 
 
 ^ Discussion at the Obstetrical Society of London, June 7, ISGo. Lancet, 
 July 15th, 1865, and Obstetrical Transactions, 1866. 
 ^ Op. cit., p. 254. 
 
312 UTEEINE DISEASES IN DETAIL 
 
 able to others^ for by an ingenious contrivance the blades, in springing 
 out, cut the tissues of the cervix from within outwards to an extent 
 which increases in proportion as they advance from the cervico-uterine 
 orifice to the utero-vaginal one ; besides, the divergence of the two 
 blunt blades, on a level with the vaginal orifice, separates the walls of 
 the vagina from the sharp blades, and stretches the tissue of the cervix 
 so as to facilitate incision. The analogous but simpler instrument 
 made by Mathieu^ although far from presenting the regularity and 
 perfection of Greenhalgh^s, is often useful. Many operators prefer 
 scissors of various kinds to these concealed bistouries. Kiichen- 
 meister has invented a pair of scissors, the external blade of which is 
 armed with a point which penetrates the tissue of the cervix and fixes 
 the instrument at the desired height. Others have used scissors 
 with toothed blades, to make the section a kind of tearing, so as to 
 prevent hsemorrhage. 
 
 I have abandoned scissors as well as simple and double metrotomes, 
 and have adopted a method by which the extent of the incision can be 
 better controlled. Incision in some cases, however, being insufficient, 
 recourse must be had to autoplasty. I shall, therefore, before de- 
 scribing these operations (incision and autoplasty) explain in which 
 cases the one operation ought to be preferred to the other. 
 
 Indications for incision and autoplasty afforded hy the condition of 
 the vaginal orifice. — In cases of congenital narrowness there is gene- 
 rally a want of depth in the contraction of the os externum (Pig. 233). 
 This may depend on two causes: — 1. On the contraction of the 
 sphincter (the mucous membrane is puckered, as is often the case 
 with the orifice of the prepuce). This contraction will certainly 
 yield to slow dilatation by sponge tents or to rapid dilatation with 
 simple forceps, the blades being quickly opened after their intro- 
 duction. 2. On the scantiness of the mucous membrane itself (in 
 these cases it is not puckered) . Slow dilatation may be tried ; but 
 incision is generally necessary ; it succeeds because the two folds of 
 mucous membrane (the vaginal and cervical) are close together and 
 easily adhere to one another (this may be aided by the application of 
 fine sutures). Lastly, the widening of the opening caused by the two 
 lateral incisions persists almost completely, because the tissue of the 
 uterine wall is thin and the cervical cavity which it limits is very large 
 (Pig. 223). 
 
 In cases of accidental constriction, and in some even of congenital 
 narrowness, the constriction is of some depth. In place of an 
 orifice (o) there is a real canal (o %') (Fig. 234), varying in length and 
 breadth. If the external mucous membrane of the vaginal portion of 
 the cervix is sufficiently extensive, the same cannot be said of the 
 limited internal mucous membrane, separated from the other by a more 
 or less considerable thickness of tissue proper, and unable to come 
 into contact with it, both on account of its insufficiency (there is want 
 of material) and in consequence of the interposition of a foreign tissue 
 in the regular conformation of the uterine orifice. If this canal be 
 divided by a simple incision we enter an insignificantly small cervical 
 
DYSMENOERHCEA 
 
 313 
 
 cavity. The internal mucous membrane can never be brought into 
 contact, and still less made to adhere to the external one, and the 
 
 Fig. 233. — Congenital pin-point os ex- 
 ternum. The orifice o has no depth. 
 The uteiine cavities which are behind 
 are dilated by the accumulation of 
 retained blood. 
 
 Fig. 234. — Congenital pin-point os, 
 having the depth of a true 
 canal o i ; the fibro-muscular tis- 
 sue of the uteiTis helps to make 
 the orifice. The uterine cavities 
 are also greatly dilated. 
 
 divided tissues will unite again, either directly by immediate reunion, 
 or by cicatrisation and the gradual retraction of each commissure, from 
 the angles of the bilateral incision to the primitive orifice. In such a 
 case we must ensure the persistence of the commissures by an auto- 
 plastic operation. 
 
 1. Division of the orifice by bilateral incisio?i. — The method I have 
 adopted for a number of years is the following:— In order to fix the 
 uterus and at the same time to give to the tissues the tension 
 requisite for clean and exact incisions, I introduce into the orifice 
 my long diverging tenaculum hook forceps (see Fig. 235), one hook of 
 which penetrates into the centre of the anterior lip, the other into the 
 posterior. By opening them as wide as possible 1 fix the cervix and 
 draw it a little towards the vulva whilst stretching each side right and 
 left, so as to be able to perform the section slowly, regularly, and to 
 the extent which seems to me necessary .^ Two fine stitches may be 
 applied afterwards, or a metaUic suture to each side. As a rule this 
 is not necessary. If I think congestion of the organ renders a little 
 bleeding advisable I let a sufficient quantity of blood flow after the 
 
 ' Olshausen {Sammhuuj Klinlscher Vortraege von Volhnann, No. (j7,^ Leip- 
 zig, 1874) has often recourse to what he calls bleeding dilatation ; but in per- 
 forming it, like me, he prefers using a simple probc-iwinted bistoury. 
 
314 
 
 UTERINE DISEASES IN DETAIL 
 
 Fig. 235. — Division of the os 
 externwm by bilateral inci- 
 sion. 
 
 Fig. 236. — Instniment for 
 perforating the cervix and 
 passing a vegetable or 
 metallic thread through 
 it ; this is often indispen- 
 sable on account of the 
 resistance and hardness 
 of the uterine tissue : s, 
 sound penetrating into the 
 cervix ; a, needle pushed 
 by a piston, v, through 
 one side of the cervix and 
 retained by the double 
 hook e. 
 
 operation and then plug to prevent hsemorrhage. The patient removes 
 the plugging by degrees, beginning the second or third day, taking 
 baths or at least injections, which greatly facilitates the extraction of 
 
DYSMENORRHCEA 
 
 315 
 
 the cotton wool. Great patience and care are required to prevent the 
 occurrence of haemorrhage or inflammation. Rest in bed should be 
 enjoined for a few days, and sometimes the additional precautions of 
 cataplasms, laxatives, enemata of laudanum, emollient vaginal injec- 
 tions, &c., should be resorted to. If necessary, the enlargement of the 
 orifice may be completed by the application of sponge tents, but not 
 before the following month. 
 
 2. Bilateral division by means of elastic ligatiire. — In order to 
 ensure the permanence of this dilatation I have tried to perforate each 
 side of the vaginal portion of the cervix at a certain distance from the 
 orifice by means of a special instrument (Fig. 236) made for passing 
 iron or silver wire, which I draw tightly after the following monthly 
 period, tightening it gradually till the tissue has been completely 
 divided. Latterly I have substituted elastic ligature for metallic 
 
 Fig. 237. — Cervix, through which an elastic ligature has heen passed right and 
 left from the natural to the artificial orifice. 
 
 wire, performing in fact an operation similar to that for anal fistula. 
 Making on both sides of the natural orifice, at a distance df 1 or 2 
 centimetres, a new orifice, I pass through this opening an elastic 
 thread, which comes out at the os. I stretch it tightly, and after 
 having tied it firmly with a wax thread leave it. The bilateral section 
 is effected slowly, and I have often the satisfaction of seeing the large 
 opening that has been made remain permanent. 
 
 Fig. 238. — Autoplasty by the formation of ai-tificial commissures. Dissection 
 of two lateral pieces of triangular mucous membrane cc' o', hh' o" ; circu- 
 lar orifice o. 
 
316 
 
 UTERINE DISEASES IN DETAIL 
 
 HI. Aiitoplasty} — lu cases where tissue is wanting, an artificial 
 uterine orifice must be made. 
 
 Fig. 239. — Id., deep lateral incision extending from the narrow circular orifice 
 to the centre of the base of the triangular flaps c(^ o', bV o". 
 
 1. Autoplastj/ hij the formation of artificial commissures. — If the 
 orifice is narrow but the cervix not conical, I dissect lateral triangular 
 or quadrangular flaps; when these are turned back (Pig. 238) I 
 
 r^ 
 
 Fig. 24:0.— Id. 
 
 0' 
 
 Fig. 241.— Id. 
 
 stretch the orifice well with my diverging tenaculum hook forceps, 
 and divide it right and left (Fig. 239), and between these two lips 
 which are held apart,~I insinuate into each bleeding commissure thus 
 made the bleeding surface of each lateral flap, keeping it in position 
 by means of one or two simple or button sutures on each side (Figs. 
 240, 241). The threads are removed sooner or later as in vesico- 
 vaginal fistulaj. 
 
 The results of these autoplastics are most interesting (Pig. 242). I 
 have seen some several years after operation in which the enlargement 
 of the orifice with solid commissures had remained intact. In the 
 patients who had undergone this operation dysmenorrhoea was cured, 
 and in several pregnancy had occurred. 
 
 2. Autoplasty by excision of vjeiJge- shaped pieces of fibrous tissue 
 and turning dozvn the fiaps of vaginal or external vmcovs viembrane on 
 
 ^ Societede chirurgie, 1872. — Montpellier mediccd, t. xxx, pp. 515, 522, an. 
 1873. 
 
DYSMENORRHCEA 
 
 317 
 
 to the cervical or internal mucous membrane. — When the cervix is 
 conical, and when, consequently, there is an excess of fibrous tissue as 
 
 Fig. 242. — JcZ., appearance of the orifice and its comniis.sures after the removal 
 of the sutures. Later on, the points of the dissected pieces are drawn into 
 the commissures by the retraction of the cicatrix, and the oi'ifice becomes 
 more regular (figure drawn from nature). 
 
 well as an alteration in the shape of the organ, autoplasty is facilitated 
 by the excision of two prismatic portions of this tissue before and 
 behind, and by the suture to the cervical mucous membrane of quad- 
 rangular flaps of the vaginal mucous membrane, both before and behind. 
 (See Pigs. 243 — 246, and their explanations.) 
 
 Fig. 21i. 
 
 Fig. 243. — Quadrangular flaps of external mucous membrane of the cervix, 
 meant to be turned down towards the internal mucous membrane after 
 excision of a prismatic portion of the tissue proper. 
 
 Fig. 244. — Plan of operation : v v, vagina ; m to, quadrangular vaginal flaps, 
 designated by the same letters as in Fig. 243 ; c, cervical cavity ; a a, 
 dotted lines showing the limits of the excision of a prismatic portion of 
 the tissue proper ; m' in', points of the cervical mucous membrane which 
 are to be united to points mm of the vaginal mucous membrane. 
 
 3. Autoplasty hy excision of conical pieces of the vaginal portion of 
 the cervix. — The method by dissecting quadrangular flaps which I 
 
318 
 
 UTERINE DISEASES IN DETAIL 
 
 have just described has been imitated by Simon, of Heidelberg, and 
 described bj Max Marckwald^ under the new name of autoplasty by 
 
 Fig. 245. — Four metallic sutures ap- Fig. 246. — Plan of the result of the 
 
 plied so as to keep the anterior operation : v v, vagina ; c, cervical 
 
 and posterior dissected pieces of cavity ; mira, points of union of 
 
 external mucous membrane in con- the dissected pieces of external 
 
 tact with the lining cervical mem- membrane with the internal, 
 brane. 
 
 conical flaps. The former has performed it sixteen times, the latter 
 four. This method of autoplasty is especially suitable to hyper- 
 trophied elongation of the cervix; the operation fulfils the double 
 
 Fig. 247. — Max Marckwald's method Fig. 248. — Id., juxtaposition of the 
 
 of autoplasty by excision of conical mucous membranes. The sutures 
 
 pieces. Dissection of the mucous drawn together, 
 membrane. Excision of the pieces. 
 Insertion of the sutures. 
 
 indication of diminishing the volume of the cervix and making as large 
 an orifice as possible, there being no fear of subsequent contraction, 
 such as occurs after simple division of the cervix or after excision of 
 the whole thickness of the cervix including the mucous membranes. 
 This last method, however, being much more complicated than mine, 
 
 ' Archivfilr Gynaecologie, Bd. viii, S. 48, Berlin, 1875. 
 
DYSMENOEEHa]A 319 
 
 ought to be reserved for cases in which it is indispensable to excise a 
 large portion of the cervix. 
 
 3. 'Memhranous BysmenorrTio&a. 
 
 One of the most curious maladies, and somewhat similar to con- 
 gestive djsmenorrhoea, is that described by Oldham in 1 846 under the 
 name qI pseudo-membranous dysmenorrliKa, which Simpson studied at 
 the same time under that of pathological exfoliation of the uterine 
 mucous memhrane, and which would be more correctly designated 
 membranous dysmenorrhma?- Although this disease is far from 
 common, the singularity of this sort of mould of the uterine mucous 
 membrane and its connection with the decidua have attracted the atten- 
 tion of many writers. Besides being one of the most interesting 
 forms of dysmenorrhoea, it is one of which the very existence has been 
 the subject of lively debate. Whilst some, with Bernutz/ considered 
 its existence as established beyond question, Robin^ and others* denied 
 it, founding their arguments on the similarity of its morbid products 
 with those expelled a month or six weeks after conception. This can- 
 not be gainsaid; I mjself have often recognised products of abortion 
 in them. 
 
 The arguments in favour of membranous dysmenorrhoea are drawn 
 on the one hand from the fact that the phenomenon may be repeated 
 regularly every month till cure takes place, notwithstanding the dis- 
 continuance of marital intercourse, and on the other, that it has been 
 observed in virgins. 
 
 I. Many cases have been published of persistent membranous dys- 
 menorrhoea in married women, about which there can be no doubt. 
 The first case of this kind which is carefully recorded is Morgagni's.^ 
 It is a case of membranous dysmenorrhoea in a multipara which gradually 
 disappeared at the approach of the menopause. The entire eocfoUated 
 mucous membrane was expelled in the form of a bag. 
 
 The hollow polypiform tumour due to dysmenorrhoea, described by 
 
 ' Oldham, London Med. Gazette, 1846, vol. ii, p. 970. — Simpson, Monthly 
 Journal of Med. Science, Sept., 1846, p. 161. 
 
 ^ Bernutz, op. cit., p. 128. 
 
 ' Gazette medicale de Paris, 1857, p. 761. 
 
 ■* Raciborsl<i, quoted by Aran, p. 308. Since then, however, Eaeiborski has 
 admitted the fact of the pathological exfoliation of the uterine mucous mem- 
 brane (See Traite de la menstruation, p. 559. Paris, 1868). 
 
 '" Morgagni, De sedibus et causis niorboruvi. Letter xlviii. " Of false 
 pregnancy, abortion, and unhappy delivery," § 12. In 1814, Moreaii also, in his 
 inaugural thesis, describes the existence of this disease. He says, "Evrat has 
 frequently observed that sterile women, some days after intercourse, passed 
 portions of membrane analogous to the decidua, but the expulsion of these 
 membranous fragments did not generally take place till the monthly period, 
 and was invariably accompanied by tension, weight, and sometimes by dull 
 hypogastric pain ; may we not reasonably infer," he adds, " that the excitement 
 produced by coitus is sometimes sufficient to determine the formation of the 
 decidx;a without fecundation having taken place." Althoiigb our ideas on the 
 nature of the decidua are quite different from those of Moreavi, it is not the 
 less true that these exfoliated and expelled mucous membranes are, after all, a 
 species of decidua. 
 
320 UTEETNE DISEASES IX DETAIL 
 
 Boivin and Dnges/ may be connected with this same disease, as also 
 the exfoliated products recognised as belonging to the uterine mucous 
 membrane by Coste, Lebert, Eollin, Dutard and Laboulbene, whose 
 ■works have been judiciously revised by Semelaigne.^ One of the cases 
 published by Tyler Smith/ another published by Hegar,* a third ob- 
 served by Tilt/5 ^^^ others to which I shall afterwards refer are examples 
 which seem indisputable. Troque,^ who has recently published an in- 
 teresting monograph on membranous dysmenorrhoea, relates thirteen 
 doubtful and fourteen authentic cases, without counting those of 
 Lehnert and Eggel which I shall presently quote, that of BourgareP 
 and those which have come under my own observation during the last 
 few years. There is no doubt that the product expelled at every men- 
 struation was not always examined with all the detail of which a micro- 
 scopic examination admits ; the monthly repetition of the phenomenon, 
 however, was established, and the existence of membranous dysmenor- 
 rhoea cannot be doubted when patients observe the most absolute 
 abstinence from sexual intercourse as mine have done.^ In this way 
 I have lately observed two new cases of undoubted monthly uterine 
 exfoliation. The first relates to a patient who began to menstruate 
 regularly and abundantly at sixteen ; at twenty-one she had a natural 
 labour followed by chronic metritis cured in a few months, at least to 
 all appearance ; at thirty tardy and insufficient menses, with phenomena' 
 of abortion. Since then membranous dysmenorrhoea, and the same 
 whether sexual intercourse was discontinued or not. The expulsion 
 became more painful after four years. Cauterisation of the uterine 
 cavity with nitrate of silver ; result almost nil. 
 
 The other case is that of a young woman presenting traces of rachitis 
 and some scrofulous symptoms; married for two years; nullipara. 
 Membranous dysmenorrhcea occurring at every menstruation and 
 several times taken for abortion. Leeches applied to the vaginal 
 portion of the cervix, division of the os. Eetro-uterine inflammation, 
 probably diathetic ; formation and spontaneous opening of an abscess. 
 Death from consumption. 
 
 1 have noticed that a large proportion of the patients affected with 
 membranous dysmenorrhoea have, like the above named, a bad con- 
 stitution, are weak, lymphatic, scrofulous, or disposed to tubercle. 
 The malady, although local, seems to depend upon a general condition 
 which makes the probability of cure very uncertain. On the other 
 hand, we sometimes find a tendency to the same disease in several 
 
 ^ Maladies de I'uterus, t. ii, p. 419. 
 
 2 De la Dijsmenorrliee onembraneuse et de la mevihrane dysmenorrheale. 
 These de Paris, Xo. 232, annee 1851. 
 
 3 The Lancet, 18 June, 1855, p. 608. 
 
 4 Monatsschrift filr Geburtsh, 1863, Bd. xxii, S. 176. 
 
 ^ Arch, of Med., 1861, yoI. iii, p. 96. — On iiterine and ovarian inflamma- 
 tion (exfoliative internal metritis), p. 267. London, 1862. 
 
 ® Ktvde critique sur la dysmenorrhee mcmhraneuse. Paris, 1869. 
 
 " Union viedicale de la Provence, 1864. 
 
 ® Couriy, Nouvelles observations de dysmenorrliee membraneuse, in Mont- 
 pellier medical, t. sxiii, p. 215, 1869. 
 
DYSMENOEEHCEA 321 
 
 women of the same family, a fact to be taken into account with regard 
 to etiology. Brouardel has communicated to Siredey (Nouv. diet, de 
 med. et de chirurgie pratiques, art. " Dysmenorrhee"j Duplan's case of 
 a girl who had five sisters, all of whom suffered from membranous 
 dysmenorrhcea ever since their first menstruation. One of Siredey^s 
 patients has a sister who, like herself, has suffered from membranous 
 dysmenorrhcea. 
 
 II. The montlily exfoliation of the mucous membrane has not been 
 observed as frequently in virgins as in married women, for the simple 
 reason that membranous dysmenorrhcea, like all other uterine diseases, 
 is rarer in the former than in the latter, and that the physician is taken 
 less into the confidence of the former with regard to what occurs in 
 the course of a menstrual malady, were it for no other reason than the 
 ignorance and want of observation of the patient. No one, however, 
 engaged in scientific research, or who makes minute inquiries into 
 all doubtful cases of menstrual disorders occurring in a large gynae- 
 cological practice_, can fail. to meet with authentic cases of the malady 
 in question in virgins, and consequently to acquire a new scientific 
 proof of its existence independently of conception and abortion. In 
 this way I have collected four cases of membranous dysmenorrhcea in 
 virgins, which are not without interest. The first was observed by 
 Dubois of Neufchatel,^ and is a case of expulsion of membrane from 
 the uterus at the monthly period in a girl of eighteen. The second 
 case is that of a girl of sixteen expelHng dysmenorrhoeic membrane.^ 
 The third case is one of membranous dysmenorrhcea existing throughout 
 the virginity of the patient as well as after marriage. The case is 
 related by Eggel,-^ who read it before the Gynaecological Society of 
 Berlin, when several members admitted the existence of this disease in 
 virgins. Lastly, I have myself seen a case of membranous dysmenor- 
 rhcea in a virgin, the cause of which was obscure, and which was only 
 ameliorated by partial treatment. 
 
 The latter series of cases proves that the exfoliation of the uterine 
 mucous membrane may take place independently of any abortion. 
 The membrane which is expelled periodically presents, it will be seen, 
 the special characters of the uterine mucous membrane. It often has 
 the triangular form of the cavity of the body of the uterus (Fig. 249). 
 Sometimes it is divided into two triangular portions ; sometimes it is 
 expelled in small fragments (Fig. 250). When it is passed entire it 
 
 ' Dubois of Neufcliatel, Gazette med. de Paris, 1847, p. 729 and 909. 
 
 ^ Monatsschrift fur GeburtsJcunde, 1868, Bd. xxxi, S. 5. 
 
 ' Eggel, Monatsschrift filr GeburtsJcunde, 1869, lid. xxxiii, S. 11.— Solowief 
 A\ex2indre {Decidua menstrualis, Archiv. filr Gynaekolocfie, 13d. ii, S. 66. Berlin, 
 1S71) describes the case of a girl of twenty-one wbose hymen was intact and 
 who had frequently passed fragments of exfoliated mucous membrane after 
 dysmenorrhcea. Einkel relates another case of expulsion of tlie uterine 
 mucous membrane in a virgin in whom the hymen was intact, and two others 
 in women who had abstained from sexual intercourse for two or three months 
 {Archiv filr pathol.Anat.und Physiol., Bd. Ixiii, 1875). Beigel admits also tliat 
 it is not rare to meet with it in virgins (Archiv fiir Gynaekologie, Band ix;, 
 Heft 1). 
 
 21 
 
322 
 
 UTERINE DISEASES IN DETAIL 
 
 generally presents several orifices ; the lower one, irregular, with the 
 border more or less torn, corresponds with the os internum ; the two 
 
 Fig. 249. — Uterine mucous 
 membrane expelled en- 
 tire, opened, sho'n'ing the 
 smooth internal cavity 
 perforated with glandular 
 orifices, and the external 
 surface covered with vil- 
 losities, the extremities 
 of blind tubular glands. 
 Preparation in St. 
 Thomas's Museum, na- 
 tural size (after Barnes). 
 
 Fig. 250. — Portion of the uterine mucous 
 membrane expelled in dysmenon-hoea 
 (after Oldham). It is the first figure 
 ever given of the exfoliated mucous 
 membrane. There are two others in 
 Tilt's work {On Uterine and Ovarian 
 Inflammation, p. 266 etseq. London, 
 1862), and another in Henning's 
 Memoiv{MonatsscJiriftfurGeburts'k., 
 1864). The monthly expulsion of 
 the mucous membrane generally 
 takes place in this way, in fragments. 
 
 others, which are very small and situated at the two upper angles of 
 the expelled product, correspond with the ostia uterina. The colour 
 is usually deep red ; the external surface is villous, sometimes infil- 
 trated with small clots of blood, whilst the internal surface is perforated 
 with holes corresponding with the glandular orifices, and is smooth to 
 the touch. Vannoni has observed that when the sac is inverted 
 during its expulsion from the uterus the villous surface may be found 
 within. 
 
 As a rule the external surface is very slightly villous ; the villosities 
 may, however, acquire a considerable size, as Henning, of Leipsig, has 
 seen.^ In this case, described under the name of villous dysmenor- 
 rJicea, it is difficult to admit that the villosities belong to a chorion, 
 and that the expelled membrane is a product of abortion, as the phe- 
 nomenon was repeated six times, and each time at an interval of exactly 
 a month. Although this case is very different from the preceding ones, 
 it seems to be an additional example of exfoliative dysmenorrhcea. 
 Examined by the microscope, the product presented the structure of 
 the uterine mucous membrane, only differing from the decidua by the 
 slighter development of its capillary vessels, by the small amount of 
 
 1 Monatsschriftfiir GeburtsTc., 1864, Bd. xxiv, S. 130. 
 
DYSMENOEEHCEA 323 
 
 its special cells and of its epithelium, which is of the prismatic instead of 
 the pavement variety, like that of the decidua at the second month. This 
 product contained a great quantity of debris of utricular or blind glands. 
 The causes of this pathological exfoliation are very obscure. Oldham 
 explains nothing in attributing it to ovarian influence ; this influence 
 has neither been proved nor defined. Tilt/ in a communication to the 
 London Medical Society, connects it with an inflammatory condition ; 
 in a later pubhcation, however, he justly remarks that the latter is not 
 only the cause but the consequence of the passage of the sac or of this 
 kind of delivery which occurs monthly. Scanzoni says he has only seen 
 one case in which there was not an appreciable alteration of the womb ; 
 in all others, the uterine walls were the seat of a chronic engorgement, 
 or there were flexions, fibroids or polypi. As for myself, I do not know 
 of a single case in which the disease was not preceded by more or less 
 disturbance of the economy or of the uterus, shown by painful and 
 irregular menstruation. It seems to me to be the result of a san- 
 guineous congestion, a kind of apoplexy of the mucous membrane -^ in 
 support of this opinion we may refer to the small clots found infiltrated 
 in the expelled product, adding that, like apoplexy, it may be produced 
 
 ' The Lancet, 1853. — Several authors, commencing with Andral {Anat. 
 pathol., t, ii, p. 681. Paris, 1829), and including Huchardand Labadie-Lagrave, 
 attribute the exfoliation of the uterine mucous membrane to inflammation or 
 irritation. They call it menstrual metritis (Archiv. gen. de med., 1870) ; 
 Kaschewai'owa {ZJeher die Endometritis decidualis chronica, mMonatssch.filr 
 Geburtsk., Bd. xxxii, Heft 5). In some cases the inflammatory nature of the 
 disease cannot be denied, as in Labadie-Lagrave 's cases {vaginitis, endometritis, 
 membranous dijsinenorrhoza for nineteen years, antiphlogistic treatment and 
 cure) and in Huchard's (membranous dysmenorrhcea connected with tnenstrual 
 metritis for thirty -tioo years, contrast between the amelioration of the sym- 
 ftoms in the intercalary period and their aggravation at each monthly period, 
 improvement from the use of emollients. Huchard and Labadie-Lagrave, 
 Contributions a I'etude de la dysmenorrhee membraneuse {Arch. gen. de med. 
 de Paris, 1870-72). We do not, however, consider that this form of dys- 
 menorrhoea is necessarily the consequence of inflammation, nor that it should 
 be designated exfoliative endometritis as Beigel suggests {Arch.filr GynaeJcol., 
 Bd. ix, Heft 1. Berlin, 1876). Gaillard Thomas is also of our opinion (op. cit., 
 p. 595). — Besides, we know that membranes analogous to those referred to are 
 found in the uterus at other times than the monthly period, and there is no 
 reason why inflammation should have more share in the formation of the one 
 than of the oihev {Chronit Slawjansky, Endometritis decidualis hemorrhagica 
 hei Cholerahranhen, in Archiv fur Gynaecol. ,Bd. iv, S. 285. Berlin, 1872). — 
 Other authors, e. g. Mandl {Zur Pathologic und Therapie der Dysmencn-rhcea 
 membranacea, Wiener medical Presse, 1869, No. 1 to 16. Monatssch. filr 
 Geburtsk., Bd. xxxiv, Heft 5. Berlin, 1869), regard it as special {morbus sui 
 generis), whilst following Robin and Haussmann some consider it early abortion 
 (avortement ovulaire) ; but if so, it should be possible to recognise it by its 
 form, structure, &c. 
 
 - For which reason Hegar and Eigenbrodt have given it the name of apo- 
 plectic dysmenorrhcea. Besides, the thrombic accumulations, the real sub- 
 mucous apoplectic centres prove the existence of sanguineous efEusions, which 
 associated with uterine contractions would be the chief secondary causes of the 
 exfoliation of the uterine mucous membrane. The membrane is separated 
 from the subjacent surface by a fibrinous layer containing free round cells 
 (Beigel) or by real apoplectic centres, the results of sub-epithelial or sub- 
 mucous sanguineous extravasations (Huchard and Labadie-Lagrave). 
 
324 UTEEINE DISEASES TN DETAIL 
 
 in the absence of any organic alteration of the womb ; the mucous 
 membrane must also have a special tendency to exfoliation. As to 
 dysmenorrhcea, strictly so called, although it usually accompanies ex- 
 foliation, it may be wanting without the malady losing its distinctive 
 character, which is the expulsion of the mucous membrane. Exfolia- 
 tion and expulsion of the mucous membrane are the anatomo-patho- 
 logical elements of the disease in question. Mayer,^ of Berlin, relates 
 the case of a married lady, twenty-seven years of age, who was sterile, 
 and who suffered from the monthly exfoliation of a thick and consistent 
 membrane without dysmenorrhoea. The dysmenorrhoeic pain depends 
 solely on the relation between the size of the expelled membrane and 
 the orifice through which it has to pass. 
 
 A little reflection on the special nature of uterine diseases will con- 
 vince us that there is nothing so very extraordinary in membranous 
 dysmenorrhcea. The same properties characterise the organs and tissues 
 in the evolution of their pathological processes as in the accomplish- 
 ment of their physiological processes. Many pathological phenomena 
 are only an impairment or an exaggeration of physiological ones. With 
 various degrees of reaction to pathogenic causes, the tissues respond 
 to the action of these causes in the same way that they respond to the 
 causes which normally elicit the display of their activity. Now the 
 uterine mucous membrane becomes hypertrophied and is exfoliated by 
 the physiological act of parturition, and by the pathological act of 
 abortion (intermediate between the exfoliation of parturition and 
 that of dysmenorrhoea). Is it surprising that, under the influence 
 of a uterine disease which places the tissues in a condition 
 analogous to that of the beginning of pregnancy and abortion, this 
 mucous membrane should be exfoliated in the same way, although it 
 does not contain any product of conception ? In this case an abnormal 
 process takes place analogous to what occurs normally under the in- 
 fluence of conception. This process commences at the ripening of 
 every ovum in the ovary, at the dehiscence of every Graafian vesicle, at 
 every menstrual period. The mucous membrane swells and commences 
 to hypertrophy, as if in preparation for a possible conception. It is 
 this periodical hypertrophy of the mucous membrane which has been 
 described by Aveling under the name of nidation, and in place of hyper- 
 trophy Aveling,2 WilliamSjS and others admit a monthly development, 
 a new formation after every menstruation. This new uterine mucous 
 membrane formed during each intercalary period, is supposed to be 
 entirely detached and expelled every month, owing to fatty degeneration 
 and disintegration with subjacent haemorrhage, and to disappear with 
 the menstrual discharge in fragments which escape observation. There- 
 fore Avehng calls it the nidal decidua to distinguish it from the decidua 
 of gestation. Membranous dysmenorrhoea is, according to this theory, 
 only an exaggeration of this phenomenon. 
 
 1 Beitrdge zur Geburtskwnd. und GynaeJcol., Bd. iv, Heft 1, S. 33. Berlin, 
 1875. 
 
 ^ London Obstetrical Journal, July, 1874. 
 3 Id., Februaiy and March, 1875. 
 
DYSMENORRHGEA 325 
 
 The formation of a new mucous membrane every month is not proved, 
 and I think the exfoliation of this membrane is only an exceptional fact. 
 The only thing really proved is the enormous hypertrophy of the uterine 
 mucous membrane at every menstrual period. An excess of this hyper- 
 trophy is sufiicient to constitute an obstacle to the discharge of the 
 menstrual blood and a local cause of the detachment of the mucous 
 membrane by subjacent sanguineous effusion. It is not even necessary 
 to suggest this hypothesis. In fact when fecundation does not take 
 place, the uterine mucous membrane resumes its normal condition, and all 
 congestion and erection ceases in the utero-ovarian system. If, 
 however, this regressive atrophy (the analogue in miniature of the 
 retrograde evolution following delivery) is absent owing to a local 
 malady or a general condition reacting on the uterus, there will be a 
 great risk of exfoliation of the mucous membrane taking place. 
 Now, I have observed that the majority of women affected with 
 membranous dysmenorrhoea are thin, delicate, chlorotic, rachitic or 
 scrofulous. 
 
 All writers have made the same remark ; and some physicians 
 consider this malady merely as the localisation of a variable diathetic 
 affection, the nature of which is not yet clear, but the existence of 
 which is probable, since it is sometimes seen in several women of the 
 same family (p. 321). If some refuse to see in membranous dys- 
 menorrhoea the localisation of a general affection, they cannot deny 
 that the reaction of the disease is sometimes propagated to more or 
 less distant organs ; for instance, a propagation of this kind may 
 produce real exfoliative enteritis;^ it is perhaps a propagation of the 
 same kind which causes buccal ichthyosis, and which has led Gautier, 
 of Geneva,^ to suppose that the disease in question is only uterine 
 ichthyosis, detached in patches. To sum up, there is a connection 
 between membranous dysmenorrhoea and morbid conditions of 
 other organs till now imperfectly determined, but which deserves 
 attention. 
 
 Diagnosis. — The symptoms of this affection are those of congestive 
 dysraenorrho3a, frequently aggravated by complications. When un- 
 complicated, the disorders only exist at the monthly period. 
 Scaiizoni^ observed in one of his patients an acute pain in the renal 
 and umbilical regions, occurring eight or even fifteen days before the 
 menses appeared ; this, however, is exceptional, usually pain appears 
 only the evening before menstruation. It seems to cease all at 
 once with the appearance of the discharge, but recommences shortly 
 afterwards with renewed intensity. It is at first congestive or in- 
 flammatory, with a feeling of fulness in the pelvis, heat, tension at the 
 hypogastrium, in the loins, and in all the pelvic cavity. It afterwards 
 becomes expulsive and intermittent, assuming the character of labour 
 pains, of real uterine contractions which may be transformed into 
 
 ' Huchard and Labadie-Lagrave {Archiv. gen. de medecine, 1870). 
 * Congrhs international des sciences medicales, 5* session, p. 4G0. Geneva, 
 1878. 
 
 ^ Op. cit., p. 335. 
 
326 UTEEINE DISEASES IN DETAIL 
 
 cramp, which requires to be calmed in order to regulate contraction 
 and facilitate the expulsion of the caducous membrane. At last, after 
 repeated alternations of exacerbation and comparative relief, lasting 
 from four to six hours, a more or less extensive membrane is expelled 
 either at once or at different times in fragments, and from this 
 moment there is a diminution of the violence of the pains. After 
 expulsion there is a pale red discharge soon replaced by one altogether 
 mucous in character. At the next monthly period the same scene may 
 be repeated with more or less violence ; only the membrane may be less 
 extensive, and may no longer represent the mould of the uterine 
 cavity exactly. This indicates an improvement which may either 
 be due to treatment or to natural causes, giving us reason to hope 
 that cure is not far off. 
 
 It is not uncommon for exfoliation and expulsion of the uterine 
 mucous membrane to coincide with other serious pathological states. 
 These concomitant phenomena are : general deterioration of health, 
 ansemia, chlorosis, scrofula, tuberculosis, leucorrhoea, chronic endo- 
 metritis, repeated formation of false membranes, of coagulation of 
 mucus, of epithelial desquamation of other organs, such as the tubuli 
 uriniferi in catarrhal nephritis, the trunks of the bronchi and the 
 trachea, the larynx, the pharynx as the seat of pultaceous angina, &c. 
 Glairy enteritis (not including dysentery, diphtheria and thrush) and 
 exfoliative enteritis (Heyfelder, Siredey, Huchard, &c.) have been 
 observed simultaneously with exfoliative metritis, as have also analogous 
 alterations of the mucous membrane of the bladder (Luschka, Vir- 
 chow's Archiv ; Deneffe, Bulletin de la Soc. anat. de Paris, 1 862 ; 
 Spencer Wells, Obstetric. Transact, vol. iv) and of the vaginal mucous 
 membrane (Tyler Smith, Farre, Vannoni, Tilt, Delore). 
 
 Differential diagnosis. — Membranous dysmenorrhoea must be dis- 
 tinguished from abortion. There are differences, as Raciborski^ says, 
 which enable us to distinguish them ; the dysmenorrhoeic expulsive 
 pains precede the monthly hsemorrhage, whilst heemorrhage precedes 
 the pains of abortion ; in the former the cervix is closed, in the 
 latter it is open ; the dysmenorrhoeic membrane is generally in frag- 
 ments, that of abortion more or less entire; if entire, the former is 
 rather triangular (moulded on the uterine cavity), the latter ovoid ;2 
 the former is often an incomplete decidua, in which a great number 
 of elements, glandular and vascular especially, are wanting, the 
 latter, like every gravid decidua, is thicker, richer in vascular 
 arborisations, and even showing a trace of the spot where the ovum^ 
 w^as lodged; the former is only expelled at the menstrual period which 
 is not delayed,^ the latter at other times, independently of menstru- 
 
 ^ Traite de la menstruation, p. 559. Paris, 1868, 
 
 * See the form of this decidua of aboi-tion, compared with that of the dys- 
 menorrhoeic membrane (fig. 249) in a drawing added to my paj^er entitled, 
 Mecanisme habituel de I'avortement dans les premiers mois de la grossesse, 
 &c., Montpellier medical, t. v, pp. 215, 428, &c., 1860. 
 
 ^ Gillet de Grandmont, De la muqueuse iiterine et de son evolution pendant 
 la menstruation et la grossesse. Inaugural thesis. Paris, 1864. 
 
 ^ This expulsion occuriing always at the menstrual period may be repeated 
 
DYSMENOREHIEA 327 
 
 ation, usually after some delay^ that is to say, its expulsion is pre- 
 ceded by a gestatory amenorrhcea (however short) ; the former has a 
 cylindrical, the latter a pavement epithelium ; the former is often 
 accompanied by symptoms of metritis and inflammatory exudations, the 
 latter by neither. It is important to notice these diff'erences in 
 forming a prognosis and to confirm them by enjoining strict discon- 
 tinuance of marital intercourse ; for if it is a question of mem- 
 branous dysmenorrhcea an unfavorable prognosis as to a future preg- 
 nancy will be given ; if it is a question of abortion the prognosis 
 will be relatively favorable to another pregnancy, at least propor- 
 tionately to the gravity of the causes which have produced the 
 abortion. 
 
 The expulsion of the exfoliated mucous membrane has often been 
 confounded with that of other products of the womb. Apart from 
 clots of blood, we know that a certain number of products, appa- 
 rently membranous, may come from the uterus. But an attentive, 
 minute histological examination, aided by the microscope, will not 
 fail to detect profound differences under apparent analogies. The 
 apparently similar membranous products which may be expelled 
 from the uterus may be classed under three heads : 1, coagulations of 
 mucus presenting the characters of inflammatory exudations, moulded 
 on the uterine cavity, and preserving sufiicient consistency to be 
 expelled under the form of entire pseudo- membranes, being sometimes 
 formed of several homogeneous layers or plastic concretions which 
 increase their thickness and tenacity, and may give rise to an exudative 
 djjsmenorrlicea ;^ the desquamation there efl'ected is sometimes only 
 the first stage of the malady followed by exfohation which will take 
 place later on; 'i,, false memhranes strictly so-called, analogous to those 
 M'hich are formed on other mucous membranes from slight epidermic 
 exfoliations lined with coagulations of mucus, analogous to those of 
 thrush and to more serious exfoliations lined with fibrinous products, 
 separating from the dermis of the mucous membrane only by ulceration 
 or laceration, which are of the same nature as croupous membranes and 
 equally serious, hence the name of diphtheritic metritis. We may there- 
 fore give the name oi pseudo-membranous or diphtheritic dysmenorrhea^ 
 to this disease ; 3, lastly, the uteririe mucous membrane itseU , which is 
 separated from the underlying tissue as at delivery or at miscarriage 
 or at a simple abortion, and which is expelled sometimes entire in the 
 form of a sac, with external or internal villosities according as it 
 
 consecutively for eight years (Case of Veit, Christot), ten years (Hucliard), 
 fifteen years (Mandl), in fact indefinitely. 
 
 ' No one doubts the reality and nature of these exudations and of these 
 coagulations of mucus. 
 
 ^ This name has been adopted by Huchard and Labadie-Lagrave {Contribu- 
 tion a I'etude de la dysmenorrhee memhraneuse, Paris, 1873, and Arch, de 
 med., loc. cit.). Boggs (Notes et reflexions chirurgicales sur les phlegmasies de 
 la matrice. Theses de Paris, 18(36) ; Hervieux (Traite clinique et pratique des 
 maladies puerperales, t. i, p. 240. Paris, 1870) ; Krieger {Die menstruation^ 
 eine gynaehologisclie Studie, S. 196. Berlin, 1869) ; Scanzoni (op. cit., p. 335) ; 
 Churchill (op. cit., p. 218). 
 
328 
 
 UTERINE DISEASES IN DETAIL 
 
 passes directly or inverted^ sometimes in more or less considerable 
 fragments, sometimes in small shreds, but always with its characteristic 
 elements, its glands, epithelium, &c. It is for the disease characterised 
 by the exfoliation and expulsion of the uterine mucous membrane 
 itself that we must reserve the name of membranous or exfoliative 
 dysmenorrhcea} 
 
 Lastly, besides products of the womb, there are also membranous 
 debris from the vagina (epithelial vaginitis of Tyler Smith and Tarre, 
 Archives of Med. 1856-59, vol. i, p. 71), sometimes even real 
 moulds of the vagina, expelled by patients, as described by A. Parre 
 [Beale's Archives) and Barnes (op. cit., p. 217), which must not be 
 confounded with membranes produced by dysraenorrhceic uterine 
 exfoliation, and which differ in every respect. Besides the difference 
 in the macroscopic and microscopic characters of the expelled pro- 
 
 FiG. 251. — Exfoliated vaginal mucous membrane, forming a mould of the 
 vagina, in St. Thomas's Museum (Barnes). 
 
 ducts, it is sufficient to add, to complete the diagnosis, that the 
 vaginal products are always expelled without dysmenorrJmic pains. 
 
 Treatment. — Although this disease does not involve risk of life, it 
 is serious, not only because of the monthly suffering, but also on 
 account of the reproductive functions. It is all the more important to 
 treat it, as Beigel justly remarks, because it is a cause of sterility and 
 abortion. I have collected several cases in which abortion was 
 
 ' Savietti {Contribution a l' etude cle la caduque menstrnelle. Turin, 1869) ; 
 Bolowiei {Deciduamenstrualis, Archiv f. Gynaek., Bd. ii, S. 68, 1870) ; Hegar 
 and Mayer {Beitrdge zur Pathologie des Eies, Virchow's Archiv, Bd. ii, S. 161 
 1871). 
 
DTSMENORRHCEA 329 
 
 undoubtedly connected with this morbid state, and a number of 
 others, in which this disease was so evidently a cause of sterility that 
 in several conception followed the cure of the malady. The patient 
 whose history is related by Henning is a striking example of this : 
 after having expelled these membranous products six times during 
 the first six months of her marriage, she was cured so completely 
 that three months afterwards she became pregnant and had a good 
 delivery. 
 
 I may here quote two other equally authentic cases of cure of 
 membranous dysmenorrhoea. I could mention several others, but do 
 not wish to put before the reader any cases as to which there could be 
 the slightest doubt. 
 
 The first case is an example of membranous dysmenorrhoea in a 
 virgin with aggravation of symptoms after marriage. — Sterility, — 
 Amelioration. — Widowhood, cure, — Second marriage. — Two preg- 
 nancies followed by delivery at term. It is probable that the con- 
 solidation of the cure by widowhood was the indirect cause of the 
 cessation of sterility at the commencement of the second marriage. 
 
 The second case is an example of membranous dysmenorrhcea occur- 
 ring after marriage and an abortion. — Slight retroflexion, leucorrhoea, 
 menorrhagia. — Long duration of the disease. — Cure after a long con- 
 tinued, general treatment, tonic and anti-diathetic, and slight cauterisa- 
 tions followed by tonic apphcations to the uterine mucous membrane. 
 It is evident that in these two cases the disease was of an inflammatory 
 nature. That does not imply that an analogous treatment would not 
 succeed even when symptoms of metritis were less accentuated. We 
 must, however, remember that, membranous dysmenorrhoea being 
 frequently connected with a serious disturbance of the constitution, we 
 must try to modify the constitution by general treatment, more fre- 
 quently tonic, alterative and anti-diathetic than anti-phlogistic. The 
 local treatment is less difficult to institute. 
 
 The treatment varies, not only according to the patients and their 
 constitution, but also according to the stage at which the physician is 
 consulted and the complications which may co-exist. Eeferring 
 the reader for these latter to the chapters devoted to them. I 
 will confine myself now to mentioning what should be done in the 
 simplest cases, those in which the inflammatory element is the only 
 complication to be feared. Whatever the case may be, the primary 
 indication at the time of suffering is to alleviate and diminish the 
 pain; preparations of opium given internally should be associated 
 with belladonna or chloroform liniments applied to the abdomen. In 
 the intercalary period, however, it will be well to apply some leeches 
 to the cervix and to cauterise the uterine cavity with nitrate of silver. 
 Although these means have often succeeded, especially in the hands 
 of Tilt, they have also failed ; Scanzoni has cauterised for whole 
 months without obtaining the slightest alleviation. These failures 
 chiefly depend on the nature of the compHcations : when they cannot 
 be combated successfully the dysmenorrhoea resists all therapeutic 
 efforts. 
 
330 UTERINE DISEASES IN DETAIL , 
 
 To prevent the formation of membranes, especiallj in exudative or 
 pseudo-membranous and even in diphtheritic dysmenorrhcea, we may- 
 resort to the injection of a saturated solution of chlorate of potash or 
 to crayons of chlorate of potash introduced every two days into the 
 uterine cavity ; they are sometimes completely dissolved, at other times 
 reduced to small fragments in twelve hours. Injections of a strongly- 
 alkaline solution of bicarbonate of soda may act favorably on the 
 mucous membrane. Solowief^ has proposed electricity for the same 
 purpose. 
 
 When the dysmenorrhoeic symptoms seem to be produced by want of 
 proportion between the uterine orifice and the membrane which has 
 to be expelled we may follow the example of Tyler Smith,^ who relieved 
 a patient by introducing a metal stem into the cervix in order to dilate 
 mechanically. This question requires more investigation. It seems 
 to me, that in the majority of cases, the local indications are limited as 
 follows : — 1, by dilatation or incision to render the uterine orifice easy 
 to pass ; sufficient attention is not paid to this matter : prepared 
 sponge is in such cases an excellent means of dilatation and of render- 
 ing the tissues supple ; 2, to modify the internal surface of the organ 
 by catheretics or slight caustics, such as fine injections of saturated 
 solution of chlorate of potash (the action of which on the mucous 
 membranes is so efficacious), or of nitrate of silver, tannin, perchloride 
 of iron, iodine, or of very weak solutions of arsenic or mercury, or 
 even chloride of zinc greatly diluted. It is only by modifying the 
 tissue of the mucous membrane and its vitality more or less ener- 
 getically that we can hope to arrest this continued tendency to 
 exfoliation. 
 
 The treatment which I have found most successful consists in 
 dilating the cervix with sponge-tents, the dilating and resolvent action 
 of which is assisted by the use of belladonna ointment, the application 
 of mercurial ointment to the hypogastrium, by small rectal injections 
 of iodide of potassium, by emollient and alkaline baths, and by a tonic 
 and antiphlogistic general treatment, in which hydropathy should not 
 be forgotten ; the surface of the uterine mucous membrane should be 
 modified simultaneously by the direct application of chlorate of potas- 
 sium, nitrate of silver, tannin, iodine, perchloride of iron, ointment of 
 red precipitate of mercury, &c., according to the predominance of the 
 local indication. During the whole time of treatment the general 
 health should be particularly attended to, tonics, alteratives, a good 
 regimen, exercise, hydropathy, mineral waters being prescribed as may 
 be specially indicated; in this way we must try favorably to modify 
 the constitution, which in its turn will exercise a beneficial influence 
 on the uterus. 
 
 Uteeine Neuralgia 
 
 Uterine neuralgia or hyderalgia is hke the neuralgia of all other 
 organs, a serious disorder of sensibihty, characterised by acute pain, 
 
 ' Archivf. Gynaecolog., Bd. viii, S. 3. Berlin, 1875. 
 2 The Lancet, 16 June, 1875. 
 
UTERINE NEURALGIA 331 
 
 independent of any other morbid state such as congestion, inflamma- 
 tion, &c., which, however, may co-exist with it. Whilst believing 
 that neuralgia is usually the localisation of diathetic affections, such as 
 catarrh, rheumatism, arthritis, gout, herpetism, &c., I admit that it 
 may be developed temporarily in an organ as a simple morbid act, 
 resulting from the existence of a local or general pathological condition. 
 Hysteralgia is what the ancients called a disease without matter, a 
 transition point between simple local uterine diseases without neoplasm, 
 and those maladies depending on a general affection, characterised by 
 an organic alteration. 
 
 J)ia(/7wsis.—l>i onaV- distinguishes primitive hysteralgia, occurring 
 suddenly, in which the nervous pain commences in the uterus and is 
 propagated into various regions of the body, from secondare/ hys- 
 teralgia manifested subsequently to a neuralgia developed on some 
 other point of the organism. He also distinguishes idiopathic from 
 symptomatic hysteralgia. The latter, which may depend on metritis, 
 pen-uterine phlegmon, &c., does not seem to me to be as important as 
 the former ; for it is accompanied by symptoms foreign to the neuralgia 
 itself, and yields to the treatment of the dominating malady. As for 
 idiopathic neuralgia, although it is a disease without matter, it is not 
 only nervous and essential, but also diathetic like sciatica and all other 
 neuralgias. 
 
 Uterine neuralgia usually coexists with lumbo-abdominal, lumbo- 
 sacral or intercostal neuralgia. Valleix ^ considers uterine neuralgia 
 as nothing more than the mode in which these morbid states are 
 manifested, i.e. as a lumbo-abdominal neuralgia, of which the most 
 painful spot is situated in the uterus. The majority of practitioners 
 look upon uterine neuralgia as primitive, and the pain produced in the 
 various nerves of the lumbar plexus as only sympathetic or sympto- 
 matic irradiations. Struck by the coincidence of uterine neuralgia 
 with cervico-brachial, facial, supra-orbital and especially with inter- 
 costal neuralgia, Bassereau ^ admits that the painful condition of the 
 uterus reacts through the branches of the great sympathetic on the 
 intercostal nerves determining neuralgia. There may assuredly be 
 irradiation, or reflex action, or coexistence of two neuralgias under the 
 influence of a common morbid affection. 
 
 It is probably this malady which Gooch "* designated by the name 
 of irritable uterus. Although several writers have attributed his 
 description to metritis or to the painful contractions which any kind 
 of disorder may excite in the organ, I think that the name of perma- 
 nent dysmenorrhoea, which he also gave it, leaves no doubt as to the 
 nature of the pain and its continuity during the intercalary periods as 
 
 ' Op. cit., p. 393. 
 
 ^ Traite des nevralgies et Bullet, gen. de tlier., Jan., 1847. — Guide du viede- 
 cin praticien, t. v, p. 195. Paris, 18G1. 
 
 3 Essai sur la n^vralgie intercostale consideree comme symptomatique de 
 quelques affections viscerales. Tiieses de Paris, 1840. 
 
 ^ On the more important diseases pecidiar to women, p. 332. London, 1831. 
 — See also Genest, Gazette medicale, 1830, pp. 323, 385 ; St-ott, Gazette medic. 
 1834, p. 809 ; Balling, Neue Zeit.f. Geburtsk., Bd. i, S. 21, 2nd case. 
 
332 UTERINE DISEASES IN DETAIL 
 
 well as during menstruation. It is this character of spontaneous and 
 continued pain, hardly interrupted for an hour^ often seated in the 
 lower part of the uterus, quite different from uterine colics or expul- 
 sive pain, sometimes causing intolerable suffering at the slightest 
 movement or touch, radiating into the lumbar plexus, which allows of 
 our diagnosing hysteralgia and distinguishing it from other painful 
 states of the womb. This is all the more striking, as usually it is 
 only the isthmus and the mucous membrane of the body of the uterus 
 that are sensitive. The sensibility of other parts is very dull ; the 
 cervix apparently having none. 
 
 The pain varies in nature from the sensation of itching, irritation, 
 intolerable heat to that of intense shooting pain in the uterus and in 
 the course of the nerves just referred to. It is often confined to one 
 side of the pelvis. It may be aggravated by heat as well as by move- 
 ment. It prevents sleep or interrupts it suddenly by a fit of pain. 
 It is greatly increased by the cervix being touched, and I have seen it 
 accompanied by contraction of the vulvo-vaginal sphincter. 
 
 It is generally worse a few days before the menses, without, however, 
 interfering with the regularity of menstruation, it does not necessarily 
 hinder the free exit of blood, and consequently, while liable to be 
 confounded with nervous dysmenorrhoea on account of the develop- 
 ment of pain and the dysmenorrhoeic symptoms which may complicate 
 it, it may be distinguished by the freedom with which the catamenial 
 discharge takes place, and by the absence of the expulsive "pains cha- 
 racteristic of uterine colic. 
 
 The differential diagnosis is certainly difficult when there are com- 
 plications. Por example, nervous, congestive or even mechanical 
 dysmenorrhoea, congestion, inflammation, hypertrophy of the uterus, 
 peri-uterine inflammations, prolapse of the uterus and vagina, with the 
 very painful draggings thereby caused, organic lesions such as cancer, 
 hysteria and the local phenomena accompanying it, are all morbid 
 states which may be mistaken for neuralgia owing to the pain which 
 they cause. Therefore great care should be taken to discover if any 
 of these lesions exist; for hysteralgia is so rare that, however violent 
 and persistent the pain may be, we should always presume that it is 
 symptomatic of some one of these morbid states rather than of hyster- 
 algia. Graily Hewitt regards it as being only a symptom of retro- 
 flexion ; in a supposed case of uterine neuralgia related by Allison,^ 
 the autopsy disclosed a serious peri-uterine inflammatory lesion. 
 Even the effects of uterine neuralgia help to conceal its true nature ; 
 leucorrhoea in fact may accompany it as a symptom, just as salivation 
 and tears accompany neuralgia of the trifacial, and whilst in the 
 majority of cases we are liable to be misled in attributing to a sup- 
 posed hysteralgia the pains produced by another disease, so on the 
 other hand we may overlook hysteralgia when it really exists, attribut- 
 ing the suffering to leucorrhoea which is only one of its symptoms. 
 
 ^ Paiuful affection of the cervix, excision, cure ; deatli the following year. 
 The post-mortem examination showed adhesions uniting the uterus to the 
 hladder and rectum [Gazette mkl. de Paris, 1843,, p. 301). 
 
UTEEINE NEURALGIA 333 
 
 The characteristics of neuralgia, however, are sufficiently well marked 
 by the pains just described which are accompanied by great sensibility 
 of the neighbouring tissues, sharp attacks of pain with slight inter- 
 mittence, shooting pains, &c. The seat of hysteralgia may also 
 require to be diagnosed ; it is sometimes in the body but more fre- 
 quently in the cervix, according to Malgaigne 3^ it may even be con- 
 fined to the right or left. 
 
 Treatment. — Hysteralgia, although not a fatal illness, is very serious, 
 owing to its duration and the extreme difficulty of curing it. Of three 
 patients Scanzoni^ only saw one cured, and even this cure was effected 
 spontaneously as the result of marriage, the disease having resisted all 
 treatment. The two other patients were treated in vain by several 
 physicians. We must therefore attack the evil early and by general and 
 local means powerful enough to give some hope of a good result. The 
 treatment must necessarily vary with the nature of the neuralgia. 
 Judging from my own practice^ I think half of all the cases of 
 neuralgia are connected with rheumatism or an analogous diathesis. 
 Therefore we ought to prescribe a treatment appropriate to this malady, 
 sulphur or alkaline mineral waters, vapour baths and hydropathy 
 which is the best sedative as well as an excellent means of treating 
 rheumatism in young women. In addition, we must prescribe the 
 general or local treatment suitable for the special nervous form charac- 
 terising the neuralgia, which is neither simple pain nor spasm. 
 
 The most efficient internal remedies are narcotics and antispasmodics, 
 associated with tonics and even with iron according to the indication. 
 Sulphate of quinine with digitalis or aconite has produced very good 
 results in many cases, especially when the neuralgia, as is often the 
 case, assumes an intermittent or periodic type. When necessary, the 
 attacks may be alleviated by inhalations of chloroform, and local 
 sedatives should be applied to the hypogastrium, uterus and rectum. 
 The transcurrent cauterisation recommended by Nonat may also be 
 tried on the lower part of the abdomen, or better still hypodermic 
 injections of morphia may be given. Suppositories or small injec- 
 tions containing laudanum or belladonna may be introduced into the 
 rectum till narcotism is produced ; or vaginal irrigations may be 
 made with decoctions of hemlock, poppy heads, or belladonna in sitz- 
 baths of the same composition. Carbonic acid or chloroform spray 
 may be applied to the cervix. Aran advises the local application of 
 ice, or better still of laudanum. Malgaigne who, with the majority of 
 Trench writers, thinks hysteralgia much more common than it is, 
 recommends division of one or both lips of the cervix. 
 
 The best of all local applications is the hypodermic injection of 
 morjjhia or atropine. It has been suggested that these injections 
 should be made into the uterine tissue itself, but the latter is so 
 vascular that it bleeds at once on being punctured, and so the injec- 
 tion is apt to be lost ; besides, patients atlected with uterine neuralgia 
 
 1 Sur la nevralgie du col de I'uterus, &c. Revue medico-chirurgicale, avril, 
 1848. 
 
 2 Scanzoni, op. cit., p. 339. 
 
334 UTEEINE DISEASES IN DETAIL 
 
 suffer terribly when the cervix is touched. Therefore it is better to 
 make these punctures in the hypogastrium at some painful point corre- 
 sponding to the ramifications of the lumbo-abdominal branches.^ The 
 puncture is made into a fold of the skin, and as soon as the injection 
 is made the finger should be applied to the skin as the canula is with- 
 drawn so as to prevent the return of the fluid ; the puncture is then 
 covered by a drop of collodion, when a local and general narcotism is 
 rapidly obtained. The injection should be repeated sufficiently often 
 to prevent the return of pain, and the points of puncture should be 
 varied according to necessity. 
 
 In addition to these injections chloral may be given to procure 
 sleep, and bromide of potassium for the hysterical symptoms. It is 
 very seldom that these three principal means, aided by some of the 
 accessory measures mentioned, such as belladonna, henbane, supposito- 
 ries, fomentations, &c., do not temporarily alleviate the sufi'ering, whilst 
 we must trust to mineral waters, alteratives, specifics, &c., for attacking 
 the source of the evil, i. e. the diathetic affection (rheumatism, herpes, 
 &c.) which is generally the hidden cause of uterine neuralgia. 
 
 I have obtained such satisfactory results from these means that I 
 am convinced that, when associated with hydropathy, they constitute 
 the most efficacious, if not the only efficacious treatment of hysteralgia. 
 
 Uterine Hemorrhage 
 
 Uterine hcemorrhage may occur under three different circumstances : 
 — I, in the unimpregnated uterus ; 2, during pregnancy;^ 3, 
 after delivery or abortion. These latter forms depend generally on 
 special causes which have to be studied in connection with pregnancy 
 and delivery — that is to say, with the conditions which produce them. 
 I shall, therefore, confine myself to the first kind. 
 
 Uterine haemorrhage occurring in the unimpregnated state is called 
 menorrhagia when it is apparently only an exaggeration of the monthly 
 period, and metrorrhagia when it is independent of the menses. It 
 may assume various forms : the quantity of blood discharged in the 
 same time may be greater than usual (a phenomenon which often 
 depends on a disorder of the mucous membrane) ; or the periods may 
 last longer, the result being the same, though due to a different cause 
 (generally to the persistence of congestion); or they may recur more 
 frequently, thus giving a different character to the malady (connecting 
 it with more frequent ovulation). Lastly, there may be an intermenstrual 
 discharge of blood independent of menstruation, and constituting a 
 symptom of an organic disorder or morbid state similar to that which 
 
 ^ De l'effi,cacite des injections narcotiques sous-cutances dans le traitement 
 des nevralgies. Montpellier medical, Courty, October and November, 1859. 
 
 ' Coui'ty, Memoire sur le mecanisme hahituel de Vavortement dans les <pre- 
 Tniers mois de la grossesse, &c., Montpellier medical, 1860. Barnes, Lectures 
 on Obstetrical Operations, 2nd edition. London, 1871, p. 387. 
 
UTEEINE H^MOERHACxE 335 
 
 obtains in other organs under the name of hsemorrhage, and which 
 alone therefore has a right to the name of metrorrhagia. 
 
 Uterine haemorrhage is also an important symptom, and occurs so 
 frequently that it deserves the serious attention of the physician. It 
 may be idiopathic or symptomatic. 
 
 1. The possibility of idiopathic metrorrhagia has been wrongly denied. 
 It is not uncommon for the menses to be occasionally more abundant 
 than usual without the existence of any abnormal condition. In some 
 women they may be less abundant one month, and increased in 
 quantity the following month ; or having been retarded or suppressed 
 they may return abundantly, as if to compensate for the temporary 
 suspension. Frequent cases of this kind occur at the menopause. 
 They often alternate or coincide with congestions or hseraorrhoids, and 
 like these may disappear. No anatomical alteration is to be seen in 
 the uterus beyond a temporary distension of the capillaries. There are 
 some cases on record of metrorrhagia terminating in death which 
 could not be explained by the existence of any lesion. 
 
 Case 1. — West' has related a case of deatt from metrorrhagia in which no 
 other lesion could be found than a small clot in the cavity of the womb, with- 
 out any alteration in the mucous membrane. In another case the autopsy is 
 not given. 
 
 Case 2. — Obre'^ has seen the same occur in a virgin of fourteen years, in 
 whom the first menstrual discharge could not be arrested. Everything was 
 normal except the uterine mucous membrane, which was softened and ecchy- 
 mosed and detached fi-om the muscular layer in several places. 
 
 Case 3. — Whitehead-'' has seen a similar case; only here menstruation had 
 been regularly established for four years. When the girl was seventeen she fell 
 on the ice in the street, and sustained a severe shock. Ten days after the 
 menses appeared, and were followed by profuse haemorrhage, which lasted five 
 or six days, from the effects of which she only recovered in ten or twelve days. 
 The catamenia returned the following month, and lasted for sixteen days. The 
 next menstrual period they returned, but a few days afterwards they were 
 rejjlaced by a metrorrhagia, which it was impossible to control, and which ter- 
 minated fatally in thirteen days. At the autopsy no organic lesion was 
 discovered. The uterus was nuUiparous, rather larger than usual ; its walls, 
 although less firm than usual, were of normal thickness. It contained a clot of 
 blood, which filled the cavity ; the appendages were normal. 
 
 Menorrhagia is more frequently idiopathic than metrorrhagia : e. g. 
 premature and tardy menstruation, uterine epistaxis, hsemorrhages from 
 excessive ovarian pain, from prolonged uterine erection, from inertia 
 and disturbance of vaso-motor innervation. 
 
 2. Symptomatic metrorrhagia occurs very often, more so than 
 dysmenorrhcea or symptomatic amenorrhoea. It happens more frequently 
 in the intercalary period than during menstruation ; it often continues 
 almost uninterruptedly from one period to another with exacerbations 
 corresponding sometimes with the menses, sometimes not. 
 
 Metrorrhagia may be symptomatic of local diseases or of general 
 affections not localised on the uterus. Amongst local diseases may be 
 reckoned hemorrhagiparous congestion, defective involution, rarely 
 
 ' West, op. cit., p. 65. 
 
 ^ British Medical Journal, 1857 ; Gazette mid. de Paris, 1856, p. 596. 
 
 ' London Medical Gazette, 1846 ; Archives de medccine, 1846, t. xii, p. 483. 
 
336 UTEEINE DISEASES IN DETAIL • 
 
 metritis, sometimes softening of the uterine tissue or alterations in the 
 mucous membrane (granulations, fungosities, exfoliations, ulcerations),^ 
 very often polypi, hydatidiform or fleshy moles, fibroma, cancer ; less 
 frequently hematoceles, peri-uterine inflammation, ovaritis, organic 
 lesions, cystic or otherwise, of the ovary, especially in their first stages, 
 deviations, flexions, &c. As for ovarian neuralgia, the influence which 
 it is said to have in producing hsemorrhage has been greatly exagge- 
 rated. Amongst general affections we may mention : the acute exan- 
 themata, smallpox, measles, scarlatina, typhoid fever (in the course of 
 which uterine epistaxis may occur)," and above all the hgemorrhagic 
 diathesis,^ the influence of which is felt upon the uterus as well as upon 
 all other organs; sometimes plethora, but more frequently impoverish- 
 ment of blood from Bright's disease/ chloro- anaemia, scorbutus, &c. : 
 lastly, blood stasis in the system of the vena cava inferior from incom- 
 petence of the mitral valve, mitral constriction, hypertrophy of the 
 heart, development of abdominal tumours or other chronic maladies. 
 In fact it is much more common than idiopathic hsemorrhage. It is 
 characterised by frequent recurrence and persistency. 
 
 Diagnosis. — It is a differential diagnosis that is required. It is not 
 difficult to assure ourselves that the blood comes from the uterine 
 cavity, but it is not so easy to decide whether we have to do with 
 monorrhagia or metrorrhagia; whether the hsemorrhage is symptomatic 
 or idiopathic, active or passive, &c. The knowledge of the causes and 
 analysis of the symptoms facilitate this diagnosis. Amongst the pre- 
 disposing causes age should be taken into consideration. Middle age 
 is the period when haemorrhages, like all other uterine diseases, are 
 most common. Metrorrhagia is also very common at the menopause, 
 constituting one of its most remarkable phenomena. Brierre de 
 Boismont^ has observed fifty-seven cases out of 141 women arrived at 
 the climacteric. It is difficult to believe that metrorrhagia can be idio- 
 pathic after the menopause. We know very little as to the influence 
 of constitution, temperament, general health, &c. The influence of 
 hygienic agents seems to be undoubted. According to Saucerotte,^ 
 women who inhabit the highest points of the Yosges are subject to 
 haemorrhages. The influence of hot climates or change of chmate, 
 and the abuse of hot baths, as in the East, is certain. What are we 
 to think of that of alcohol, of the abuse of hot-water bottles, and of so 
 many other real or imaginary causes to which great importance has 
 been attached ? 
 
 Probably a more real predisposing cause is to be found in the 
 structure of the uterus itself, its mucous membrane, its muscular 
 
 ^ Occasionally more serious alterations produce metrorrhagia ; e.g. the case 
 related by Grailly Hewitt of fatal ha3morrhage after delivery, diie to a trau- 
 matic aneurism of the uterine artery {Obstet. Transact., v. ix, p. 246. London, 
 1867). 
 
 ^ Upon utei-ine epistaxis, so called by Giibler. V. supra, p. 410. 
 
 ■'' Gendrin, Traite de med. philos., t. ii. 
 
 "* West, op. cit., p. 54. 
 
 5 Op. cif., p. 223. 
 
 ^ Melanges de chiriirgie, p. 25. 
 
UTERINE H^MOEEHAGE 337 
 
 tissue, its vascular system, the activity of its circulation, the inertia of 
 its muscular tissue, &c. 
 
 Among determining causes simple physical acts (a blow, a fall, the 
 application of leeches to the cervix) may give rise to metrorrhagia, 
 which may assume the character of active hsemorrhage if it is the result 
 of the violence of the reaction rather than of the traumatism itself; but 
 sexual excitement, violence of menstrual moliraen, excessive inter- 
 course, especially in the case of prostitutes,^ as well as influences of 
 the same kind on neighbouring organs, e. g. repeated drastic pur- 
 gatives, are all causes which rather increase the activity of the haemor- 
 rhage than originate it. Although moral impressions more frequently 
 suspend menstruation, they may exceptionally produce an excessive 
 flow of the menses, or even metrorrhagia. 
 
 The symptoms of metrorrhagia are those of haemorrhages in general : 
 progressive debility, pallor, chilliness, especially of the extremities, 
 small pulse, tingling in the ears, giddiness, &c. Those of essential 
 or idiopathic metrorrhagia are variable. Sometimes the discharge of 
 blood and even uterine fluxion are intermittent, the blood flows to 
 the uterus in jerks, the loss seems to cease or at least diminish in con- 
 siderable proportions, but it soon returns with violence ; at other 
 times the discharge of blood is continuous, without pain or colics, but 
 with increasing loss of strength. Sometimes the discharge is pure 
 blood, red or black, but liquid ; at other times, after an apparent in- 
 terruption or after the excretion of a certain quantity of sanguinolent 
 serum, more or less voluminous clots are passed accompanied by uterine 
 colics indicating alternations of distension and contraction of the 
 organ. 
 
 Those of symptomatic metrorrhagia are symptoms peculiar to each 
 of the morbid states of which the haemorrhage may be symptomatic. 
 We must beware of confounding metrorrhagia or menorrhagia with 
 the consequences of an abortion at the commencement of a pregnancy. 
 Women are apt to mislead the physician by attributing the unforeseen 
 and abundant recurrence of menstruation to a delay of the monthly 
 period. Generally this delay is due to pregnancy and the recurrence 
 is an abortion, as shown by the nature of the pains, which are real 
 uterine colics, and by the expulsion of an embryo, a villous placenta, 
 or a decidua, on which a circular groove may be seen, indicating the 
 point where the ovum was lodged. The likelihood of this should 
 always, therefore, be present to our mind, and a careful examination 
 should be made. Active and passive haemorrhage should also be dis- 
 tinguished ; for symptomatic metrorrhagia itself may be either active 
 or passive, the result of a simple stasis of blood, or of an energetic 
 uterine reaction. 
 
 Active or sthenic metrorrhagia, by general or local fluxion, or by 
 vascular expansion, is accompanied by all the signs which characterise 
 fluxionary movements, and by all the symptoms of local congestion 
 and excitement or of general reaction which are peculiar to this patho- 
 
 ^ Parent-Duchatelet, de la Prostitution dans la ville de Paris, t. i, p. 232, 
 3« edit., 1857. 
 
 22 
 
338 UTEEINE DISEASES IN DETAIL 
 
 logical act : pain^ tension, sense of weight in the uterus, pain and 
 dragging in the loins and groins, pruritus at the vulva, painful tume- 
 faction of the breasts ; shooting neuralgic pains in the kidneys and 
 legs ; hardness, swelling, extreme sensibility of the hypogastrium ; 
 tumefaction, heat, sensitiveness, dark red colour of the vulva, vagina 
 and cervix ; a general excitement, a strong and rather quick pulse, 
 followed by weariness, cramp, giddiness, feverishness, and sometimes 
 by various nervous or hysterical symptoms ; in short, an exaggeration 
 of the ordinary symptoms of uterine fluxion as they occur at the com- 
 mencement of menstruation. Passive metrorrhagia is asthenic. It is 
 favoured by general conditions not only of debility, atony and asthenia, 
 but still more by those characterised by adynamia, such as scorbutus 
 and other serious constitutional disorders. It is never preceded by 
 premonitory symptoms, nor accompanied by the local phenomena 
 which characterise the hsemorrhagic molimen. There are no signs 
 of local plethora in the genital organs; of the heat, tension 
 and arterial pulsation which characterise fluxionary movements. 
 The pulse is quick, but small and compressible, and there is 
 a general chilliness and want of reaction. The haemorrhage, 
 which generally occurs suddenly and with a certain moderation, 
 continues uninterruptedly, sometimes without clots when the blood 
 is serous. The clots and colics are to be met with in both kinds 
 of hsemorrhage, but with shades of difference which suffice to 
 distinguish them ; for instance, the expulsive pains are less acute 
 and less frequent in passive hsemorrhage, whilst active hsemorrhage 
 is characterised by extreme sensibility or hysteralgia and by repeated 
 uterine colics. 
 
 Treatment. — The first question is : Should the hsemorrhage in metror- 
 rhagia, or even in menorrhagia be arrested ? In the immense majority 
 of cases this may be answered in the affirmative. The hsemorrhage 
 becomes injurious whenever it passes the limits of menstrual evacua- 
 tion ', for it is insufficient to effect depletion of the organ, it continues 
 or recurs indefinitely, one hsemorrhage is followed by another, the 
 morbid habit is established, the constitution deteriorates, the blood is 
 impoverished, the patient becomes anaemic, and these conditions, in 
 place of being favorable to the cessation of the hsemorrhage, only 
 facilitate it and induce its return, so that from being active it becomes 
 passive. Therefore every means should be taken to prevent and arrest 
 metrorrhagia. 
 
 The means to be employed vary acccording to the nature of the 
 hsemorrhage. The indications are principally drawn from the active or 
 passive character of the metrorrhagia. In the former case we have to 
 contend with the fluxionary movement, the fluxion and even congestion 
 of the organ. In the latter, with exhalation and exudation, as well as 
 with the general debility of the constitution and impoverishment of the 
 blood. The indications vary also according as the hsemorrhage is 
 symptomatic or idiopathic. In the former case, arresting the flow 
 of blood is only a palliative treatment which, though useful, is insuffi- 
 cient as it does not attack the malady which causes the hsemorrhage ; 
 
UTERINE HiEMORRHAGE 339 
 
 in the latter case^ it is from the hsemorrhage itself and its nature that 
 the indications are taken. 
 
 I cannot now enumerate the means of treatment of the various 
 maladies which determine symptomatic hsemorrhage. They will be 
 described in connection with each disease. I cannot even review all 
 the means of treatment of the various pathological elements which 
 participate in the production of idiopathic haemorrhages, for these 
 various elements require to be treated independently of the flow of 
 blood which they may produce^ but which they do not necessarily 
 cause. I shall therefore only consider them from the point of view of 
 the share which they take in the production of haemorrhage. 
 
 Metrorrhagia, strictly so-called, being separated from the maladies 
 which produce it, and from the elements which co-operate in its mani- 
 festation, it only remains for us to state the indications special to it ; 
 these are : — 1, to prevent the fluxionary movement from taking place; 
 2, to divert it when it has taken place ; 3, to subdue the congestion 
 and erethism ; 4, to employ haemostatics ; 5, to destroy haemorrhagi- 
 parous organic alterations of the mucous membrane ; 6, to prevent 
 haemorrhage by mechanical obstacles ; 7, to treat the impoverishment 
 of the blood and its want of plasticity. 
 
 1. To prevent the occurrence of the fluxionary movement, — This can 
 be attained by the use of three means : rest, local refrigeration, 
 general heat. There should be absolute rest, the patient lying on her 
 back with the thighs and legs flexed, and supported by pillows, and 
 the head or at least the shoulders low. She should be kept in this 
 position, not rising even to pass water. Local refrigeration is obtained 
 by means of compresses soaked in cold water of the temperature of the 
 room in winter, in spring water or ice in summer; these compresses 
 should be applied to the abdomen and upper part of the thighs and 
 renewed as they become warm. 
 
 It is often better in order not to wet the patient, to substitute for 
 the compresses a bladder or gutta-percha bag filled with pieces of ice 
 which can be renewed as they melt, or fragments of ice may be intro- 
 duced into the vagina every quarter of an hour. General heat should 
 be maintained by blankets, or eider-down quilts, and hot- water bottles 
 to the feet and arms. If necessary sinapisms may be applied to the 
 wrists, arms and even upper part of the chest, the knees, calves and 
 insteps. Ventilation should also be attended to. In all haemorrhages 
 great care should be taken to renew the air of the room frequently. 
 By these means, not only is a bracing effect produced on the whole 
 body, but a kind of general revulsion is effected on the whole system 
 which has a tendency to divert the fluxionary movement from the 
 uterus ; hematosis is facilitated, and by the rapid renewal of air in the 
 lungs an activity is given to the general circulation favorable to peri- 
 pheric circulation and tending to subdue the disposition of fluxionary 
 movements to select one point in preference to all others, 
 
 2. To divert the fluxion hy revulsives. — The most powerful revulsive 
 is bloodletting. It should be from the arm rather than the foot, for 
 the blood should be diverted from the lower to the upper part of the 
 
340 UTEEIlfE DISEASES TN DETAIL 
 
 body, and not merely deviated from the pelvis to the feet. Blood- 
 letting is not always limited to a revulsive bleeding. If the patient is 
 strong, plethoric, and experiencing a movement of general expansion 
 or fluxion, copious depletion should be resorted to. If she has not 
 too much blood, or if there is a tendency to debility, if the bleeding 
 has to be repeated every month as a preventive measure against a 
 menorrhagia which threatens to become habitual, it will sufBce to take 
 from 1^ to 4^ ounces from the vein according to Lisfranc's method. 
 "When the fluxion, in place of being imminent or recent, is fixed on 
 the organ, derivative applications of leeches or cupping to the hypo- 
 gastrium, to the iliac regions and loins, will mobilise the congestion 
 and advantageously precede the use of revulsives proper. A powerful 
 revulsive action may be effected in ansemic women without loss of 
 blood by dry cupping of the loins, back, thorax, arms or breasts 
 according to the precept of Hippocrates. i In such cases there is no 
 need to fear the use of large cupping glasses acting on the whole of a 
 limb according to Junod/s method. The application of ligatures to 
 the root of the four limbs, according to Galen's precept, so as to 
 congest them by retaining in them the venous blood, is a very good 
 substitute for large cupping glasses, which are not always at hand. 
 All that is required are four handkerchiefs folded like scarfs and tied 
 tightly round each limb, and tightened at will by means of small 
 sticks passed through the knot of the handkerchief. I have never 
 had recourse to this means in uterine haemorrhages, but it has been of 
 such great use in very serious cases of haemoptysis, that I have the 
 greatest confidence in it. Lastly, sinapisms on the arms are also 
 excellent revulsives which should not be neglected. 
 
 If the fluxion is persistent or of long standing, and if it has a ten- 
 dency to be renewed periodically or to become chronic, more continuous 
 revulsives ought to be employed : — blisters, even exutories, or, if the 
 patient is young, hydropathy in the intervals between the attacks. 
 Lastly, ipecacuanha and antimony as used by Stoll and Linke in 
 metrorrhagia when sympathetic of bilious affections, and emetics gene- 
 rally, may be useful as revulsives as well as means of perturbation. 
 Ipecacuanha in small doses frequently repeated has proved very efiica- 
 cious, probably by the movement of expansion which it determines 
 towards the periphery. 
 
 3. To subdue the congestion which foUovjs tlie fluxion or the erethism 
 which accompanies it. — I have seen patients in whom haemorrhage 
 was arrested by the application of leeches to the cervix, after the 
 failure of the majority of means usually employed. In these cases 
 the haemorrhage seemed to be kept up by a painful and persistent 
 congestion of the uterus. The indication is clear; it must not be 
 misunderstood, for no other means than direct depletion of the organ 
 will avail. When general or local nervous and vascular erethism is 
 associated with congestion, sedatives, antispasmodics and narcotics 
 may be indicated. Aran recommends veratrine in large doses, 
 Dickinson digitalis, Behier opium by the mouth or laudanum in rectal 
 ' Ti-anslation by Littre, Aphorism 50, Section v, t. iv, p. 551. 
 
UTERINE HiEMOREHAGE 341 
 
 injections. The progress of the haemorrhage must however be 
 watchedj care being taken that time is not lost in the use of remedies 
 which produce no effect. It is difficult to know whether the warm 
 bath acts as a sedative or as a general revulsive in the treatment of 
 metrorrhagia ; but there is no doubt that in some cases it is sufficient 
 to arrest the haemorrhage. Unfortunately we have not yet been able 
 to determine when this treatment is indicated. Heat applied to the 
 loins often does great good, and can never do harm. To sum up 
 what we know with regard to this subject, we must be content to say 
 that the application of heat to the lumbar region according to Chap- 
 man's plan (the application of an india-rubber bag filled with water as 
 hot as the patient can bear), in order to stimulate the vaso-motor 
 action of the sympathetic ganglia, has succeeded with de Mussy,^ 
 Cusco and myself. So, too, has the application of heat to the uterus 
 and vagina. A vaginal injection of water as hot as can be borne (as 
 a rule, 45° centigrade) is often the best way of preventing or stopping 
 uterine haemorrhage. Like Emmet I have tried these injections 
 repeatedly and found them to have an excellent haemostatic effect 
 {Annates de Gynecologie de Paris, mai, 1880). Experience has 
 proved the use of digitalis as an additional sedative of the vascular 
 system ; by lessening the frequency of the pulse, it diminishes the 
 impulse by which the blood is incessantly accumulated in the con- 
 gested organ. 
 
 4. The use of hamostatics, strictly/ so called, astringents, styptics^ 
 and coagulants. — These means are especially indicated in the treat- 
 ment of passive metrorrhagia when there is exudation as well as im- 
 poverishment of blood and general debility ; they are also very often 
 indicated in the palliative treatment of symptomatic metrorrhagia. 
 The local application of cold to the hypogastrium by a bladder filled 
 with ice, cold compresses, enemata, sitz-baths, vaginal plugging 
 with ice, should be made continuously. The most convenient plan is 
 for the patient herself to introduce ice frequently into the vagina, the 
 water discharged being received by a sponge placed under the four- 
 chette in a piece of waterproof. Acids and astringents should be 
 taken internally. Those most employed are : vinegar and water, or a 
 few drops of dilute sulphuric acid in a glass of lemonade, a spoonful 
 of which may be taken every quarter of an hour. This simple means 
 is often very successful. Tincture of cinnamon, as advised by Van 
 Swieten, the Germans, Recamier, Gosselin and Aran (from 1| to 5 
 drachms in four ounces of water, of which one tablespoonful every 
 hour), alum, acetate of lead, catechu, tannic acid, and especially 
 rhatany, are recommended, as in all haemorrhages. The extract of 
 rhatany, given in an enema (15 gv. to one quart), or in mixture 
 (H. Ext. Ehat. 3j, Syr. Aurant. 3j, Aq. ^iv. Sig. ^ss every two 
 hours), is one of the most efficacious and the least dangerous of 
 astringents.2 I have often tried perchloride of iron, but do not trust 
 
 ' Annales de Gynecologie de Paris, July, 1875. 
 
 ^ I often give the following prescription : — Infuse 4^ gr. of digitalis leaves 
 in 4 oz. of water. Add 1 oz. of syrup of comfrey, 5 drachms of syrup of 
 
342 UTERINE DISEASES IN DETAIL 
 
 to it. If indicated by impoverishment of blood, ansemia, or a scor- 
 butic condition, it should be prescribed in the dose of from 15 minims 
 to 5J in a glass of water, of which one tablespoonful should be taken 
 every two hours, followed by cold milk to remove the disagreeable 
 sensation left in the throat. In chronic metrorrhagia with chloro- 
 angemia I give from 5 to 15 drops morning and evening in water 
 followed by a glass of milk. It may also be applied directly to the 
 uterine mucous membrane. Weber, of St. Petersburg, injects a 
 solution into the uterine cavity. I have done the same, commencing 
 with small quantities, and trying to avoid the formation of clots, 
 the expulsion of which would be painful and might cause additional 
 hgemorrhage. I prefer the use of the tincture of iodine. Uterine 
 specifics, i. e. drugs which have the property of exciting uterine con- 
 traction as well as of favouring hemastasis, are employed along with 
 the preceding in the treatment of metrorrhagia, e.ff. savin and ergot, 
 the latter especially. I generally prescribe 4 grains every six hours, 
 or if necessary every three hours, in a little coffee or brandy or sugar 
 and water. When the action has to be kept up for some time I use 
 ergotine instead.^ The application of electricity to the uterus, by 
 inducing contractions of the tissue, is a valuable adjuvant of ergot, 
 especially when the latter is not tolerated ; the interrnpted current 
 should be used. 
 
 5, To destroy the organic alterations hy which the discharge of Mood 
 is produced, and to modify the state of the mucous membrane in which 
 these alterations are developed. — Eecamier^s curette renders great 
 services in such cases. I have had a broader one made, and also two 
 others of a different pattern {see p. 225), and with these instruments 
 can remove fungosities however large they may be, and even small 
 polypiform excrescences. There are hsemorrhages that can be arrested 
 in no other way. It is sometimes necessary to dilate the uterine 
 orifice by sponge tents before introducing the curette. After such 
 operations, local hemastatics or caustics ought almost always to be 
 applied to the uterine mucous membrane and cavity by means of in- 
 jections.^ I often use a cameFs-hair brush saturated with tincture of 
 iodine or perchloride of iron, or rolled in the powder of nitrate of 
 silver, in place of injections ; sometimes I inject a piece of solid 
 caustic by means of a canula with piston {see p. 222). The medica- 
 ments most commonly used as injections to modify the mucous mem- 
 ether, and 5 draclims of tincture of cinnamon, 1 drachm of extract of rhatany, 
 15 gr. of Bonjean's ergotine, and 14 gr. of extract of opium. Shake the 
 bottle and take one dessert spoonful every six, or if necessary every four 
 hours. 
 
 1 The hypodermic injection of ergotine is very convenient ; the usual formula 
 is 15 gr. of ergotine (Bonjean) dissolved in 100 minims of pure glycerine and 
 5ij of distilled water. Two Pravaz syringes are filled and injected : \ gr. to 
 \\ gr. of ergotine will arrest h£emorrhage in a few minutes. Doubtless the 
 haemorrhage often occurs again ; the ■ hemastasis is only temporary, but even 
 that is a great gain. 
 
 2 Real, Theses de Paris, 1852 ; Dupierris, Gazette des hopitaux, 1869 ; 
 Guyot, Theses de Paris, 1868. 
 
CHANGES OP POSITION 343 
 
 membrane are : alum, tannin, perchloride of iron, tincture of iodine, 
 or a concentrated solution of nitrate of silver. 
 
 6. To prevent the discharge of blood by a mechanical obstacle is the 
 last and often the first means to which the continuance or violence of 
 the hsemorrhage obliges us to resort ; a heroic means the use of which 
 must not be neglected whilst there is yet time. This means is plug- 
 ging. It must be preceded by an iced injection of solution of alum, 
 and by the application to the uterus of a pledget of lint saturated with 
 tincture of perchloride of iron or charged with a hemastatic powder ; 
 the vagina is then filled with cotton wool, the last tampon being kept 
 in place by a T bandage. There is nothing further to do than to 
 watch lest the hsemorrhage which has been arrested in the vagina 
 should take place internally, distending the uterus and passing along 
 the Fallopian tubes. Should this occur, which rarely happens, the 
 plugging must be renewed, and the other means previously described 
 must be once more employed with increased energy. 
 
 In cases of hsemorrhage kept up by uterine inertia, in thin women 
 in whom the abdominal parietes are easily depressed, I should be in- 
 clined to try compression of the aorta before plugging. I do not 
 understand the objections which have been made to this method. I 
 have seen two women saved by it after delivery : the aorta was com- 
 pressed by the midwife or myself for three hours, during which time, 
 by emptying the uterus of clots, by irritating the cervix, by grasping 
 the fundus and administering ergot I succeeded in getting the womb 
 to contract, and was rewarded by the formation above the pubis of 
 the hard reassuring uterine globe. 
 
 7. To treat the dehility and impoverishment of blood ivhich dispose 
 to hemorrhage by the defective plasticity of this fluid and by the 
 
 facility given to the production offluxionary movements or passive con- 
 gestions by defective equilibrium. Whatever the nature of the hsemor- 
 rhage may be, care must be taken to prevent its return by using means 
 to prevent fluxion, to increase the plasticity of the blood, to give tone 
 to the vessels, to strengthen the constitution by a good regimen, 
 tonics, bark, iron, &c. We must prevent relapses as in all uterine 
 diseases, remembering that we can only be sure that a cure has been 
 effected after the recurrence of several normal and regular monthly 
 periods. 
 
 CHAPTER II 
 
 CHANGES OF POSITION — DISPLACEMENTS — DEVIATIONS — FLEXIONS — INVERSION 
 
 With the exception of cases of hernia, prolapsus^ retroflexion, 
 complete retroversion and inversion, simple changes of position very 
 seldom determine the development of serious morbid symptoms. They 
 deserve attention, however, owing to the complications which precede, 
 accompany or follow them, and which are sometimes the chief cause 
 of the pains felt. These maladies are not only mechanical lesions. 
 
344 UTEEINE DISEASES IN DETAIL 
 
 they may be designated : diseases in which an alteration of the 
 mechanical conditions of the uterus plays the principal part, causing 
 a disturbance in the relationship of this organ with neighbouring 
 organs. This disturbance may occur in three ways according as it 
 may affect : 1, the means of suspension (utero-sacral ligaments) which 
 form a suspensory ring for the organ^ ensuring its fixity of position 
 in the pelvis at a certain height ; 2^ the supports direct or indirect 
 (broad and round ligaments, vaginal attachments, pelvic connective 
 tissue), which keep the longitudinal axis of the uterus in the normal 
 median inclination, whilst allowing divergences which its natural in- 
 difference for a fixed position renders compatible with health ; 3, the 
 consistency of the uterine tissue, the relative dimensions of the walls 
 and borders, the reciprocal relations of the two segments (body and 
 neck) which determine the preservation of the normal form of the 
 organ, and the natural relations of the various parts with each other. 
 According to these three modes of origin the primitive alteration leads 
 to a secondary one: 1, in the position of the organ; 2, in its abso- 
 lute direction and its relations with neighbouring organs ; 3, in the 
 relative direction or the reciprocal relations of its two segments. In 
 the first case this secondary alteration takes the name of displacement, 
 in the second that of deviation, in the third that q{ flexion. 
 
 1. Displacements of the uterus are, therefore, changes in the 
 positio7i of this organ. The womb, not being properly retained in 
 place by its suspensory ring, or yielding to the pressure or traction 
 exercised by a neighbouring organ, abandons its proper place. It 
 escapes partially or entirely from the pelvic cavity by a subcutaneous 
 opening, and forms a hernia under the skin {hysterocele) , or it remains 
 in this cavity, but at a difi'erent spot from its natural position, giving 
 rise to displacements properly so called, horizontal or vertical, the 
 most important of which is descent {prolapsus'). Hernise of the 
 ovary and Pallopian tubes are analogous displacements, and will be 
 described at the same time as those of the uterus. 
 
 2. Deviations are changes of direction of the uterus as a whole, or 
 displacements of the vertical axis of the organ, independent of those 
 of its suspensory ring, the latter either preserving its normal position 
 or not. They vary in degree, from the slightest inchnation to the 
 most complete version. 
 
 3. Flexions are alterations in the form of the organ owing to a 
 change of direction of one portion with regard to the other. The 
 organ as a whole may or may not preserve its normal position and 
 direction. It follows that flexions may either exist alone or coincide 
 with displacements and deviations. They sometimes coincide with 
 another change of direction, which it is interesting to take into 
 account, viz. deviation of tTie transverse axis. This axis turns slightly 
 sometimes to one side sometimes to the other, so that the anterior 
 surface of the uterus, instead of looking straight forwards, looks 
 forwards and to the right or forwards and to the left. This deviation 
 is of little consequence when both segments of the womb are equally 
 affected, but if the deviation affects them unequally there is torsion, 
 
CHANGES OF POSITION 345 
 
 which may cause other symptoms^ and be the source of special indica- 
 tions. 
 
 4. Lastly, inversion is another mode in which the statical conditions 
 of the uterus may be altered. Cruveilhier compared it to prolapsus, in 
 common with which it has the anatomical characteristic of invagina- 
 tion, whilst, in common with flexions, it has a change in the mutual 
 position of the various parts of the uterus with regard to each other. 
 It is characterised also by a change in the reciprocal relations of its 
 two surfaces, the internal surface gradually becoming external and 
 convex, whilst the external becomes internal and concave. It follows 
 that the organ is in a sense turned inside out, like the finger of a 
 glove. 
 
 With the exception of inversion, which is essentially a morbid con- 
 dition, and prolapsus, which involves destruction of the suspensory 
 attachments of the womb, all the different changes of position (dis- 
 placement, deviation, torsion, flexion) may occur in foetal life which, 
 representing a certain period in the development of the genital organs, 
 or rather a stage in the progressive changes in their position in the 
 pelvis, can only be explained by the influence exercised on them by 
 the normal or abnormal evolution of the neighbouring organs. 
 
 Ereund,^ in a recent work on the development and changes in 
 position of the rectum, bladder and genital canal from the sixth week 
 of foetal life up till birth, shows that the changes in position brought 
 about by organic evolution simultaneously in the rectum and bladder, 
 cause inverse changes in the uterus; that the distension of the rectum 
 by the meconium and that of the bladder by the urine exercise an 
 important influence upon the elevation of this organ. Lastly, that the 
 descent of the intestinal convolutions into the pelvis, the daily evacua- 
 tions of rectum and bladder, and the increased size of the pelvic 
 cavity, notify a period of restitution or return, during which the 
 uterus is liberated from the temporary changes in position which the 
 development of the pelvic organs had imposed upon it. These 
 changes, however, may become permanent ; normal at one period, 
 they sometimes persist as anomahes. The pelvic organs themselves 
 may be developed abnormally, new alterations in the natural position 
 of the uterus may be produced, and may persist and constitute so 
 many pathological elements new in the history of the changes in 
 position of the uterus. These changes are met with in about one 
 third of the patients affected with uterine disease, either constituting 
 a disease in themselves or complicating some other malady or organic 
 disorder. They occur, I think, less frequently in the south of France 
 than in the north, especially prolapsus. As to relative frequency, 
 anteflexions and anteversions^ are much the most numerous; then 
 come retroflexions and retroversions ; then prolapsus, and lastly, 
 lateroversions and lateroflexions, double incurvations, torsions, dis- 
 placements of the organ as a whole, either forwards, backwards or 
 
 ^ Max Bernhard Freund, Die Lageentwlckelung der Beclcenorgane xmsbeson- 
 dere des loeiblichen Genitalcaaals und ihre Ahivege. Breslau, 186'1. 
 ^ See pi^. 17, 23. 
 
346 UTERINE DISEASES IN DETAIL 
 
 laterally. Inversions are rarest of all, with the exception of hernia of 
 the uterus and ovaries. 
 
 Displacements 
 
 The importance of displacements of the uterus, from a practical 
 point of view, depends on whether they are simple or compHcated. 
 Ascent, descent and horizontal displacements, such as lateral position 
 or lateral migration and even antero-posterior migration may generally 
 be ranked as simple displacements. Whilst, on the contrary, cases 
 of hernia and prolapsus must be considered as complicated dis- 
 placements. 
 
 1. Hernia of the Ovaries and Fallopian Tubes 
 
 This is sometimes produced by an alteration affecting the organs 
 themselves, sometimes by displacements of the uterus or changes in it. 
 
 I. Hernia of the ovary is not the only displacement of this organ. 
 Congestion or inflammation may increase the size and weight of the 
 ovary and cause its displacement into the pelvis, especially descent 
 either laterally or behind the uterus.^ This displacement is easily dis- 
 covered by rectal and even by vaginal touch, as well as by the increased 
 size and sensibility of the ovary. Its pathological sensibility is de- 
 veloped to such an extent, that the least pressure produces intense 
 pain. — On the other hand, when the ovaries are merely dragged by 
 a deviated or flexed uterus, it is seldom that this displacement is not 
 at last complicated by congestion of these organs. Lastly, when the 
 displacement coincides with ovarian inflammation the phlegmasia 
 often extends to the peritoneum, especially if the ovary, Fallopian 
 tube and uterus are affected simultaneously. Peritonitis generally 
 leaves vicious adhesions between the ovaries and neighbouring organs. 
 These adhesions, by rendering displacements of the ovaries permanent, 
 form, according to Madame Boivin, one of the most frequent and 
 least known causes of abortion. They attach the ovary sometimes to 
 the Fallopian tube or to the uterus (which causes sterility), sometimes 
 to the csecum, to the colon, to the sigmoid flexure, to the rectum or 
 to the walls of the pelvis.^ 
 
 Hernise of the ovary are displacements outside the pelvis, which 
 occur less frequently than the preceding, but yet oftener than is 
 generally believed. The first detailed case was published in the 
 seventeenth century by Bessiere, a surgeon in Paris. Deneux^ wrote 
 an interesting paper on this subject in the beginning of this century. 
 Velpeau* described this disease under the name of ovarioncie. Several 
 
 ^ Braun lias described some of these displacements under the name of 
 ovario-vaginal hernia {Monatsschrift fur Gehtirts'k., Bd. xiv, S. 472). 
 
 ^ Barnes gives a very practical resume of the principal causes of displace- 
 ments of the ovary, op. cit., p. 297. 
 
 ^ Becherches sur la hemic de I'ovaire. Paris, 1813. 
 
 ^ Dictionn. en 30 vol., t. xxii, p. 558. Paris, 1840. 
 
DISPLACEMENTS 347 
 
 new cases have been recently published.^ I have myself seen five 
 cases of ovarian hernia : a right inguinal hernia, reducible, in a child 
 of ten (probably congenital) ; a right crural hernia, irreducible, in a 
 virgin of forty, which sometimes swelled and became painful at the 
 monthly period, and was at one time attacked by inflammation, when 
 it developed symptoms of stricture, which yielded to antiphlogistics 
 and purgatives ; a right crural hernia in a woman of forty-two, who 
 assured me that the tumour, which had existed for fifteen years, 
 became painful and larger at every monthly period ; she succumbed 
 to symptoms of stricture and peritonitis, the slow progress of which 
 (about fifteen days) would have allowed of her being saved, had she 
 not obstinately refused any kind of operation ; a left crural hernia in 
 a nullipara of fifty, who had ceased menstruating for four years, and 
 who remembered having sometimes experienced pains in the tumour 
 during menstruation ; she had worn an elastic bandage for twenty- 
 five y.ears to contain the hernia, the nature of which had probably 
 been misunderstood j a left inguinal hernia, probably congenital, in a 
 virgin of twenty-six, forming in the groin a tumour very sensitive to 
 the touch, very painful and larger at every monthly period, and which 
 coincided with a marked obhquity of the uterus, the cervix of which 
 looked backwards and to the right ; the puffiness of the tumour led 
 to the supposition that the Eallopian tube shared in the displacement ; 
 a bandage tried for some months had to be abandoned, on account of 
 the pain that it caused. 
 
 Inguinal ovarian hernia is more frequent than crural in newly-born 
 children, and indeed at every age, contrary to what we might expect, 
 the reverse generally being the case with intestinal hernise in women. — 
 According to Deneux crural is to inguinal in the proportion of one 
 to nine, according to Murat two to nine. — The iscJiiaiic or dorsal has 
 been described by Papeu,^ who discovered in a hernia the presence 
 simultaneously of the intestine and right ovary; Camper, in 1759, 
 found one, in the sac of which the left ovary alone was contained. — 
 Umbilical ovarioncia may occur in cases of pregnancy or of any uterine 
 disorders sufiicient to cause displacement of the ovaries towards the 
 umbilicus. 
 
 Ovarian hernia may be simple or double. In the latter case it 
 may occur on both sides at once, through the corresponding openings, 
 as in Pottos case,^ where both ovaries were removed ; or tlirough 
 different openings, such as the umbilical and ischiatic, as in Camper's 
 case. According to the statistics of Puech, completed since the pub- 
 lication of his paper,^ there are on record 8£ cases of inguinal hernia, 
 12 of crural, £ of ischiatic, 3 of abdominal (the results of abscess or 
 of Caesarian operation), and 1 through the foramen ovale (Kiwisch) ; 
 but of the 8;'- inguinal 50 are undoubtedly congenital, IG doubtful, 
 16 really accidental. Congenital hernia has been found twenty-six 
 
 1 Loumaigne, De la hernie cle I'ovaire. Paris, 1869. 
 ^ Haller, Disputationes cldrur., 1750. 
 3 Pott's Works, vol. iii, p. 329. London, 1783. 
 ^ Des ovaires, cle leurs anomalies. Paris, 1873. 
 
348 UTEEINE DISEASES IN DETAIL 
 
 times unilateral, twenty-four times bilateral or double. — They are 
 often complicated by malformations of the genital organs, e. g. accom- 
 panied four times with uterus unicornis or bicornis, fourteen times 
 with hermaphrodism, sixteen times with apparent or real absence of 
 the uterus. 
 
 Erom an analysis of the cases just mentioned we may conclude that 
 ovarian hernia belong to two quite distinct classes : 1, congenital 
 hernise, always inguinal, often double, and when single generally left, 
 caused by an abnormal descent of the ovaries analogous to the normal 
 descent of the testicles, constituting anomalies rather than diseases, 
 and coinciding usually with anomalies of the genital organs, such as 
 embryonic uterus, uterus unicornis, hermaphrodism, &c. ; 2, hernise 
 properly so called, accidental and morbid, right or left indifferently, 
 inguinal or crural, oftener crural, frequently following an intestinal 
 hernia, in which case the ovary may occupy the sac either alone or 
 simultaneously with the intestine, epiploon, &c., occurring in well- 
 formed adult women. ^ 
 
 If congenital hernia is inguinal it is because the persistence of 
 Nuck's canal favours its production. Lassus^ gives an example. If 
 accidental hernia, on the contrary, seems to be more often crural, it 
 is because, like intestinal hernia, it takes place through the abdo- 
 minal opening which is the widest in women. 
 
 Ovarian hernia when congenital and observed in early life generally 
 contains only the ovary ; it may be the same in the adult ; but in old 
 hernise the ovary has sometimes dragged down with it the Fallopian 
 tubes, the uterus, the vagina, and the intestine. When a hernia of 
 long standing is complex, it seems to be because the ovary has carried 
 with it the Fallopian tube and even the uterus ; for by the fact of its 
 displacement the ovary drags the womb to the side of the herniary 
 tumour; the uterus then executes two distinct movements, a swinging 
 one, by which its fundus is inclined forwards, and another of rotation, 
 which directs its posterior surface towards the side of the displace- 
 ment ; one of its angles is then turned towards the ring through which 
 the ovary has passed ; the intestine presses and increases the uterine 
 deviation, tending to complicate the ovarian hernia with that of the 
 Fallopian tube and even with the uterus. Ovarioncia is very seldom 
 complicated with enterocele. Lastly, ovarian hernia may be reducible 
 or irreducible. Its irreducibility may depend on increased size, 
 adhesions or strangulation. 
 
 II. Hernia of the Fallopian tube may be produced, according to 
 Nelaton,'^ by ovarian hernia. The oviduct very rarely escapes through 
 one of the abdominal orifices by itself. Such a case, however, has 
 been described by Scholler : a little girl, who died three weeks after 
 
 ^ Puech, who has collected the greatest number of cases of ovarian hernia, 
 thinks that a radical distinction should be made between these two kinds ; he 
 therefore proposes that congenital ovarian hernia should be called inguinal 
 ectopia. 
 
 ^ Med. oper., t. i, p. 211. Paris, an iii. 
 
 3 Patholog. externe, t. iv, p. 440. Paris, 1857. 
 
DISPLACEMENTS 349 
 
 birth, had a tumour in the right inguinal region, which reached as far 
 as the labium, and contained the Eallopian tube, red and swollen, but 
 without adhesions. The round ligament of the same side was shorter 
 than the other. The uterus was slightly displaced, its axis not being 
 parallel with that of the body. 
 
 Diagnosis. — This is drawn from the following data : at the groin, 
 in the direction of the principal axis, or in the labium, or even below 
 the crural arch, there is a small ovoid tumour, circumscribed, painful, 
 dull on percussion, reduced with difficulty and rarely spontaneously, 
 always without gurgling although slightly indented, of a dense homo- 
 geneous consistency, not easily detached from the soft parts; if we 
 pull it, so as to increase the displacement, we perceive behind it a 
 flattened fibrous cord passing through the ring. The pain is increased 
 by pressure, by dorsal decubitus or by lateral decubitus on the oppo- 
 site side from the hernia (Seller), by the movements of the legs, by 
 stooping and rising again, so much so as to cause limping (Guersant) 
 and to make all work impossible (Imbert, Percival-Pott, &c.) ; it is 
 also aggravated by pressure on the hypogastrium, by pushing the 
 fundus of the uterus from the seat of the hernia, or drawing the 
 cervix near it with the finger (Lassus) ; it is propagated into the 
 pelvis and loins by a very painful sensation of dragging ; it extends 
 from the seat of the hernia to the uterus and if, with the end of the 
 finger introduced into the vagina or rectum a considerable movement is 
 conveyed to the womb from the side opposite to that of the tumour, 
 this movement is transmitted to the contents of the hernia (Lassus). 
 This movement should be made suddenly, and is aided by pressure on 
 the hypogastrium from the other hand, or better still by means of the 
 uterine sound,^ which acts simultaneously on the whole of the uterus 
 and at the same time reveals the inclination of the fundus of the organ 
 towards the hernia ; it is well for an assistant to place his fingers on 
 the tumour in order to judge of the amount of movement communi- 
 cated ; similar movements cannot be transmitted to an enterocele 
 (Loumaigne^s case).^ Pain which is absent in some patients and in a 
 state of rest or in the intercalary period, is developed on the contrary 
 by exertion, the advent of menstruation, coitus, &c. ;^ it increases also 
 with the size of the organ at puberty, at every menstrual period, during 
 ge^tation and by taxis; it may increase to such an extent as to be 
 symptomatic of strangulation. 
 
 Although these symptoms would seem sufficient for distinguishing 
 between an ovarioncia and an intestinal or epiploic hernia, an abscess of 
 the groin, a lymphatic tumour, &c., many mistakes have been made. 
 Inflammation, atrophy, cystic, cancerous or tubercular degeneration 
 of the ovaries, are sometimes met with simultaneously and increase 
 the difficulties of diagnosis. We must also remember that, even 
 
 ' Huguier, Traitc de VhystdroTnetrie, p. 202. Paris, 18G5. 
 
 ^ When digital touch cannot be practlsecl, owing to absence of the uterus or 
 in the case oi: children, examination must be made througli the bladder and by- 
 rectal touch. 
 
 ^ In ovarian hernia, coitus becomes sometimes so painful tliat marital inter- 
 course is impossible. Beigel gives instances of this (op. cit., t. i, p. \'M)). 
 
350 UTEEINE DISEASES IN DETAIL 
 
 when inguinal hernia is double, it is no obstacle to menstruation, and 
 that while it may cause sterility (when the ovary is not accompanied 
 by the Fallopian tube in the common hernial sac), it does not abso- 
 lutely prevent uterine pregnancy, and that it frequently predisposes to 
 extra-uterine pregnancy.^ 
 
 Treatment. — This consists in reducing the ovarian tumour and in 
 keeping it reduced. It is easily done when the hernia is recent and 
 when the ovary is not adherent to the sac. As a rule, however, after 
 a short time the tumour ceases to be reducible. In such cases it must 
 be protected from blows and from friction by a suitable bandage, e.g. 
 a truss with a concave cushion. 
 
 When symptoms of strangulation are developed the patient should 
 be kept in a position of semi-flexion, and leeches, poultices and emol- 
 lient or narcotic fomentations should be applied over the tumour. 
 If the strangulation persists an operation is indicated,^ i. e. the ring 
 which produces it must be incised ; for it is enough to cause death. I 
 have seen a woman affected with crural hernia of the right ovary suc- 
 cumb to peritonitis as a consequence of strangulation of the hernia. 
 The ovary can seldom be reduced after incision ; it will be found too 
 adherent to the internal surface of the sac. The adhesions must first 
 be destroyed and reduction made afterwards, or else we must imitate 
 Lassus, and after having incised the ring apply emollient applications 
 to the ovary, dress it simply, and when the inflammation has passed 
 exercise moderate and methodic pressure. 
 
 If the ovary is degenerated, cancerous or transformed into a mul- 
 tilocular cyst, it should be removed. In some cases, as in that of 
 Pott, the operation has not been followed by any accident. In Pott's^ 
 case there was double inguinal ovarian hernia in a woman of twenty - 
 three -, the removal of both ovaries was followed by cure, but men- 
 struation ceased. Meadows* published a very interesting case of 
 inguinal hernia of the right ovary, which was successfully removed. 
 In other cases extirpation is not necessary, the hernia being found 
 reducible after incision of the ring. Loper^ obtained a cure in this 
 way. The case was one of inguinal hernia of the right ovary occur- 
 ring after delivery in the sac of an old enterocele. Kelotomy neces- 
 sitated the destruction of some adhesions and also incision in order 
 to allow of the reduction of the ovary. The operation was followed 
 by cure. By adding these three cases to those already recorded we 
 find that out of sixteen cases of reduction or extirpation of ruptured 
 ovaries there have been nine definite cures and seven deaths, five of 
 which followed extirpation. Although these statistics are not en- 
 
 ' Balin, Art de guerir les hernies, p. 150. Paris, 1768. — Widerstein, Gazette 
 hebdomadaire de medecine, 1853, p. 79. — B^ekiovzik, Monatssch. fiii' Geburtsk., 
 Bd. xvi, S. 475, 1860. 
 
 ^ Owen, British Med. Journal, 13 Dec, 1873. — Wibaich, Theses de Paris, 
 1874, no. 469. 
 
 ^ Pott's Works, vol. iii, p. 329. London, 1783. — MacClmr, American Journal 
 of Obstetrics, vol. vi, p. 613. 
 
 ■• Trans, of the Obstet. Soc. London, 1861, p. 438. 
 
 * Monatssch. fiir Oeburtsh., 1866, S. 453. 
 
DISPLACEMENTS 351 
 
 couraging we cannot avoid the necessity of operation when life is in 
 danger, but it should only be resorted to in such cases. 
 
 We may therefore lay down the following rules : 1, to incise and 
 reduce, in children and young women, congenital and recent herniaj 
 which have neither been inflamed nor as yet present any extensive 
 adhesions ; 2, to protect, in women who are mothers, by means of a 
 truss with a concave pad, hernise which are not very painful, but which 
 have become irreducible owing to adhesions; 3, only extirpate the 
 ovaries when the hernia is irreducible, adherent, painful, and has de- 
 veloped symptoms of strangulation and inflammation which have 
 resisted antiphlogistic treatment and endanger life. 
 
 2. Hernia of til e Uterus {EysteroceleY 
 
 It is not uncommon to see the uterus, when distended by preg- 
 nancy, protrude between the recti muscles (separated by several pre- 
 ceding pregnancies), and hang down like a kind of wallet, even as low 
 as the thighs when the excessively distended linea alba is incapable of 
 supporting it ; it is rare, however, to see this organ undergo the 
 displacement for which the name of hernia is reserved. A certain 
 number of authentic facts, however, prove that the uterus may be 
 dragged a certain distance from its normal position and, with other 
 abdominal viscera, become surrounded by a hernial sac, in which it 
 may become developed, contain the product of conception, and reach 
 the natural term of gestation. 
 
 I. Hernise of the uterus during pregnancy ought not to be confounded,^ 
 as they have been by Desormeaux and Dubois,^ with those pro- 
 jections of the gravid womb which take place owing to a stretching 
 of the linea alba or of some other part of the musculo-aponeurotic 
 walls of the abdomen. There is a great difference between this 
 accident commonly known as pendulous belly, and real uterine hernia, 
 whether produced by an artificial opening caused by stretching or 
 effected through the natural openings or through the abdominal rings 
 which usually give passage to other ruptured viscera. 
 
 Hernia of the linea alba may occur during gestation and even at 
 the moment of delivery.^ Inguinal hernia may also take place during 
 gestation, in spite of the great development of the uterus in advanced 
 pregnancy, its production being favoured by the anterior existence of 
 a large enterocele. The circumstances which favour and those which 
 determine the formation of these herniae are very variable, as the fol- 
 lowing facts seem to show. 
 
 Sennert ^ relates that a cooper's wife received a blow from a stick 
 in the groin at the beginning of pregnancy ; a few days later a hernia 
 
 ' Doering, Tie liernicB uterina atque hancjusto tempore sifhsequentis partus 
 Ccesarei historid. Vitemb., 1612. — One ides, Dissert, de hernia uteri. Leyde, 
 1780. 
 
 - liepertoire general des sciences medicales, t. xxx, p. 331. Paris, 1846. 
 
 ^ J. L. Petit, quoted by Boivin and Duges. — Paccini, Hernia of tlie linea 
 alba ; operation, cure. Gazette medicale de Paris, 1834, p. 409.— John Bell, two 
 cases, Id., ibid., 1849, p. 308. 
 
 ■* Medic, practica, lib. iv, sect. 2, chap, xvii, p. 654, quoted by Verdier, 
 Memoires de V Academic royale de chirurgie, t. ii, p. 2. 
 
352 UTERINE DISEASES IN DETAIL 
 
 was seen at this point; it was formed by the uterus. The pregnancy- 
 reached term ; the Caesarian operation w'as performed ; the chUd lived 
 nine years, the woman died suddenly on the twentieth day, the 
 autopsy failing to reveal the cause of death. 
 
 DcEring ^ in a letter to Fabrice of Hilden, gives the history of a 
 woman who at her last pregnancy had a hernia of the uterus, probably 
 inguinal, and who had also to undergo the Csesarian operation ; the child 
 although robust died in a few months, the mother succumbed in three 
 days ; Cruveilhier thinks that the hernia existed before pregnancy and 
 that it was wrong to perform the Csesarian section ; the following fact 
 seems to justify this opinion. Saxtorph " relates that a woman had a 
 tumour in the inguinal region for some years ; she became pregnant 
 for the fifth time; during pregnancy the tumour gradually increased, 
 the uterus evidently being contained in it ; delivery took place natur- 
 ally and the uterus remained projecting under the integument. In 
 other cases, however, the hernia has really been produced during ges- 
 tation, and when it has been impossible for delivery to be effected 
 naturally, Csesarian section has occasionally been successful. Eousset^ 
 tells of a woman whose uterus had escaped through the centre of the 
 abdomen and who yet had a natural delivery ; after another pregnancy 
 the result was equally favorable, although the hernia was irreducible. 
 Euysch ^ relates the case of a uterine hernia produced after an abscess, 
 which was reduced at the time of delivery by the midwife and parturi- 
 tion was normal. Ledesma ^ has seen a right inguinal hernia of the 
 uterus produced in the third month of a seventh pregnancy, in a 
 woman previously affected, and even before marriage, with inguinal 
 enterocele. Attempts at reduction having failed he performed the 
 Csesarian operation, which was successful as regards both mother and 
 child; the uterus continued irreducible. Fischer ^ met with a woman 
 of forty-four who had had seven children, and who suffered greatly at 
 every pregnancy from a large right inguinal hernia, which she had ten 
 years before her marriage. Towards the end of her eighth pregnancy 
 the uterus escaped through the inguinal ring and was held fixed by 
 the neck of the sac; labour having commenced with rupture of the 
 bag of waters without being able to terminate naturally, Csesarian 
 section was performed. The patient died the fifth day, the child lived. 
 
 II. Hernise of the unimj^regnated uterus are more difficult to explain 
 on account of the deep position of this organ ; they probably often 
 depend on a congenital tendency or on the appendages of one side, 
 which have been previously displaced, dragging on the uterus. They 
 have been found m several autopsies.' Cruveilhier thinks that hernia 
 
 1 CEuvres de Fahrice de Eilden, p. 833, edit, of 1646. 
 
 " Bibliotheque medic, t. Ixvii, p. 59. 
 
 •'' Boyer, Traite des mal. chirurg., t. ix, p. 386. 
 
 "' Advers. anat. medic, deca., ii, p. 23. 
 
 * Journal de la Soc. de vied. prat, de Montpellier, t. i, p. 441. Montpellier, 
 1840. 
 
 ^ Annales de la chirurgie frangaise et etrangere, t. v, p. 249. Paris, 1842. 
 
 ^ Chopart et Desault, Traite des vial, chirurg. et des oper. qui lew con- 
 viennent,t.u, -p. SOo.—lLaWement, Mem. de la Soc. vied, d'emul.., 3* annee, 
 
DISPLACEMENTS 353 
 
 of the uterus is usually consecutive to that of the ovary and Pallopian 
 tube, and that the womb is gradually displaced by a kind of attraction. 
 Deneux explains how uterine hernia follows that of the ovary by 
 means of a double movement of rotation from below upwards and 
 from one side to the other ; the fundus looks forwards, the posterior 
 surface becomes lateral, the angle corresponding to the affected ap- 
 pendages is naturally drawn towards the ring, and finally passes 
 through it ; the enlarged size of the hernial sac is made partly at 
 the expense of the broad ligament which is also displaced. Hernia of 
 the ovary would in this case be the first stage of a displacement, of 
 which the last stage would be hernia of the uterus ;^ hence the utility 
 of describing these displacements together. However, in the Atlas of 
 Boivin and Duges (PI. xi, fig. 3) there is a drawing after Cloquet, of 
 a right crural hernia of the uterus, ovaries and Fallopian tubes, in 
 a newly-born child, where the fundus of the uterus seems to have 
 been first displaced. The persistence of the canal of Nuck after 
 birth explains the possibility of hernia of the uterus ; the position of 
 the uterus and its annexes above the pelvic cavity at birth accounts 
 for its comparative frequency in children. To sum up, there are 
 several varieties of uterine as of intestinal hernia, according to the 
 position and anatomical relations of the sac : 1 Inguinal liyderocele. 
 Sometimes the whole uterus, sometimes the fundus only, enters the 
 external inguinal ring or only the internal. These cases, quoted by 
 Chopart, Lallement and Cruveilhier are very rare, especially those in 
 which the displacement affected the gravid uterus. Several of the 
 cases published are doubtful, or may be considered as extra-uterine 
 pregnancies occurring beyond the inguinal canal ; Skrivan and 
 Lumpe^s^ cases may be interpreted in this way. A real hernia of a 
 gravid uterus can only take place through the inguinal canal when it 
 has been preceded by a very large intestinal hernia. — 2. Crural 
 hjsterocele. The fundus enters the crural ring. Sennert, Doering, 
 Saxtorph^ have seen it occur in pregnancy, and Lallement in the uu- 
 impregnated state. — 3. Umbilical hysterocele has never been seen 
 hitherto except in the gravid uterus. The cases mentioned by 
 Leotaud* and Murray^ may be added to those already cited : in 
 Murray^s case reduction was effected ; in Leotaud's reduction was 
 very easy, but the tumour could not be kept reduced without em- 
 barrassing the respiration excessively. Delivery took place at term 
 without any accident. — 4. Ventral hysierocele is the most frequent ; 
 it is sometimes produced after rupture of the aponeuroses, especially 
 at the linea alba, sometimes after laceration of the abdominal muscles, 
 especially of the recti. I have seen three cases — two on the linea 
 
 p. 323, and Bulletin de la Faculte de med. de Paris, t. i, p. 1. — Cruveilhier, 
 Anat. pttthol., xxxiv** liv., pi. 6. 
 
 ' Beitrdye zur Gehurtsh. und GynaeTc., Bd. vii, 1870. 
 
 2 Zeitschrift der Ges. der Aertze. Vienna, 1851, No. 9, and 1853, No. 6. 
 
 3 Colled. Soc. Hafn., 1775, t. ii, p. 323. 
 "• Gazette des Iwjpitaux, 1859, p. 419. 
 
 ^ Lancet, April, 1859. — Journal des connaissances medico-cliirurgicales,^ 
 1859, p. 654. 
 
 23 
 
354 UTERINE DISEASES IN DETAIL 
 
 alba and one on the right side of the hypogastrium. Puech had 
 a case of this kind as the result of several deliveries in quick suc- 
 cession. 
 
 The diagnosis of uterine hernia is not difficult, even in the unim- 
 pregnated organ; palpation associated with vaginal touch will help 
 the practitioner to distinguish the nature of the tumour and the 
 kind of displacement. It is not indispensable to feel the point 
 of a sound introduced into the uterine cavity through the sac, as 
 Kiwisch^ says. 
 
 Treatment is less easy. In the rare cases in which the hernia is 
 reducible, reduction should be made and maintained by a bandage, as 
 in the treatment of enterocele. In the more frequent cases in which 
 the existence of adhesions or the development of pregnancy renders 
 reduction impossible, we must content ourselves with supporting the 
 uterus by means of a well-made and very elastic abdominal belt, or 
 by means of a truss, to which if necessary an elevated point d'appui 
 can be given by making it pass over the shoulders. When pregnancy 
 exists and the hernia takes place through a natural opening like the 
 inguinal ring, which is not susceptible of much dilatation, instead of 
 through the stretched linea alba, which one may hope still further to 
 enlarge, several suggestions occur : Should attempts at reduction be 
 made involving incision of the ring as in cases of strangulated hernia ? 
 Should abortion be induced in order to prevent the dangers which 
 delivery at term would cause to the mother ? To these questions I 
 can give no positive answer. Lastly, when the ruptured uterus. has 
 reached the term of gestation there is no room for hesitation. 
 Cfesarian section must be performed at the very commencement of 
 labour; experience having shown that it has sometimes saved the 
 mother as well as the child. 
 
 3. Horizontal Displacements 
 
 Horizontal displacements {antero-, retro-, or latero-positions) can 
 hardly be produced except by the development of a tumour in some 
 part of the uterus (sub-peritoneal fibro-myoma) or in the pelvic cavity, 
 either a retro-uterine hematocele, a phlegmon, pelvi-peritonitis, a 
 multilocular cyst or some other malady of the ovary, disease of the 
 bladder or rectum, or a tumour of the bones of the pelvis, &c. It is 
 seldom that they are not complicated with deviation. The diagnosis is 
 easy. As for treatment, since they do not constitute a disease but 
 only a symptom, we must discover the malady which has caused them 
 and treat it. 
 
 The uterus may be "^w^h-Q^ forwards against the pubis by a fibroma^ 
 
 ^ Scanzoni, op. cit., p. 121. 
 
 ^ I have lately seen a patient die from the effects of the compression exer- 
 cised by a fibro-myoma of the posterior segment of the uterus upon the neck 
 of the bladder and the rectum, the functions of which had been totally sus- 
 pended by the development of the tumour within the pelvic cavity and the 
 consequent flattening of the large intestine, which had become quite im- 
 permeable to the faeces. Unfortunately the patient, to whom I proposed 
 
DISPLACEMENTS 355 
 
 or a retro-uterine or a retro- vaginal cyst, by a hematocele, by inflam- 
 mation, retro-uterine pelvi-peritonitis, an abscess in the same region, 
 a rectal tumour, or sometimes even a stercoraceous one, so as to pre- 
 vent micturition, and may only be perceptible to the finger at the bottom 
 of a narrow groove. Less frequently it is pushed bachvards, usually by 
 a fibro-myoma of the anterior wall, or an anterior sub- peritoneal 
 tumour. Lastly, it may be pushed to one side by a tumour, a cyst of 
 the ovary or broad ligament, or an inflammatory swelling of the same 
 ligament. To sum up, this displacement, though of little consequence 
 as regards the uterus itself, becomes a valuable sign of the development 
 of one or other of the diseases just referred to. 
 
 Slight lateral displacements may sometimes be observed, depending 
 on a congenital tendency, like those of which Cruveilhier^ speaks, and 
 which Freund^ has shown by his researches must be attributed to the 
 central, left lateral, or exceptionally to the right lateral position of the 
 rectum, differences of situation which may cause lateral displacements 
 of the uterus in an opposite direction. 
 
 I have also seen the uterus occupy a position anterior or posterior 
 to its normal position in the pelvis, and which did not seem to depend 
 on any peri-uterine malady, but on a congenital anomaly, especially on 
 a relative shortness of one of the vaginal walls (for I have observed 
 that this shortness coincided almost always with one or other of these 
 antero-posterior displacements) . 
 
 4. Ascent of the Uterus 
 
 The ascent of the uterus, which is more frequently met with in 
 pregnancy than in a state of vacuity, may, according to Colombat,^ be 
 determined by a number of causes, among others by a defect in the 
 length and width of the uterine ligaments, by inflammation, engorge- 
 ment and dropsy of the Fallopian tubes and ovaries, extra-uterine 
 pregnancy, the first stage of ante version and retroversion, and lastly, 
 by the dilatation of the uterine cavity by hydatids and other foreign 
 bodies. 
 
 Sometimes, as Goupil observes,* there is in very rare cases con- 
 genital elevation of the uterus, depending probably on the shortness of 
 the utero-lumbar ligaments, the abnormal length of the vagina, the 
 height of the patient, or sometimes even on her embonpoint. In most 
 cases, however, ascent of the uterus, like its horizontal displacements, 
 is symptomatic of a disease in this organ or outside it. It may be 
 caused by a hematocele, pelvic tumour, or some disease outside the 
 organ. Contrary, however, to horizontal displacements, it is generally 
 caused by the development of the uterus itself, or at least of its appen- 
 
 hystei'otomy, refused to be operated on. The neck was firrnlj pressed against 
 the pubis. 
 
 ' Anat. descript., Splanclmologie, p. 471. Paris, 1865. 
 
 ^ Die Lageentwichelung der Beckenorgane, &c. Breslau, 1864. 
 
 * Traits complet des maladies des femmes, t. i, p. 339. Paris, 1843. 
 
 ■* Bernutz et Goupil, CUnique medicale sur les maladies des femmes, t. ii, 
 p. 614. Paris, 1862. 
 
356 UTEEINE DISEASES IN DETAIL 
 
 dages. This ascent is sometimes the symptom of a purely physio- 
 logical state, such as pregnancy. At other times it depends on the 
 increased size of the uterus, due to various pathological conditions, 
 such as a polypus, hypertrophy, a mole, and especially a fibrous body. 
 In all these cases it is owing to its increased size that the uterus can 
 no longer be contained in the pelvic cavity, and gradually rises above 
 the brim. A large ovarian cyst, especially if there are adhesions 
 between the ovary and the uterus, may drag the uterus up with it. 
 Peritoneal adhesions occurring after delivery between the fundus of the 
 uterus and the abdominal or pelvic walls may produce the same effect. 
 Ascent of the uterus is often accompanied by elongation or dragging 
 of the vagina, the effacement of its folds and disappearance of its cul- 
 de-sac, with elongation, atrophic wasting, and finally, laceration of the 
 cervix} 
 
 Ascent of the uterus as a symptom should also attract the attention 
 of the physician, leading him to search for the cause of the displace- 
 ment. It is evident that ascent of the womb causes, in its turn, dis- 
 tension and elongation of the vagina, sometimes disappearance of the 
 vaginal portion of the cervix, increased size of the uterine cavities, or 
 other symptoms varying with the cause which has determined the 
 ascent. 
 
 Treatment can only be applied to the cause on which the displace- 
 ment depends. 
 
 5. Descent of the Uterus 
 
 There are three degrees of prolapsus or descent of the uterus, the 
 last of which goes by the name of procidentia. The first degree of 
 prolapsus may extend to contact of the vaginal portion of the neck 
 with the perineeal floor. The second degree is characterised by the pre- 
 sence of the cervix at the vulva. The third degree qx procidentia sup- 
 poses the uterus outside the vagina and vulva hanging down between 
 the thighs.^ This malady evidently offers great varieties as to degree, 
 form and complications, several of which have lately been brought to 
 light. Amongst the works which have contributed most to show the 
 way in which uterine prolapsus is produced, and to distinguish it from 
 the diseases which may simulate or complicate it, we may mention 
 those of Boivin and Duges,^ on the part which relaxation of the utero- 
 sacral ligaments play, Huguier's* paper on the hypertrophic elonga- 
 tion of the cervix, and Legendre's^ experiments on the phenomena 
 which take place when traction is made on the uterus of a dead body 
 so as to drag it downwards. 
 
 ' Nunn, Pathol. Transact., vol. x. — Barnes, op. cit., p. 678. 
 
 ^ Gosselin, CUniq. chirurg., t. ii, p. 534. Paris, 1873. — Barnes considers 
 prolapsus as invagination of the uterus by the vagina ; procidentia as com- 
 plete inversion of the vagina or uterine hernia through the vagina. 
 
 3 Op. cit., i, 84. 
 
 * Op. cit. Paris, 1859. ^ 
 
 ^ De la chute de Vuterus. Competition thesis, p. 104. Paris, 1860. See 
 also Savage's work, The Female Pelvic Organs, Tab. xi, and Transact, of the 
 Obstet. Sac. of London, vol. x, p. 235. 
 
DISPLACEMENTS 357 
 
 The observation of pathological facts shows that prolapsus may 
 either afifect the wliole uterus or the cervix only^ owing to the hyper- 
 trophic elongation of this segment of the uterus ; prolapsus of the 
 cervix (which is then the symptom of a disease quite different from 
 real prolapsus of the womb) is incomplete when the hypertrophy only 
 affects the vaginal portion, complete when both parts are affected.^ 
 On the other hand, prolapsus may be simple or complex : simple when 
 the cervix occupies the summit of the vaginal invagination, when the 
 uterus is in a normal state, and unaccompanied by any other organ in 
 its displacement ; complex when the neighbouring organs are diseased 
 or displaced, or when the uterus itself presents an important physiolo- 
 gical or pathological alteration. The chief complications depending 
 on the neighbouring organs are : cystocele, stone in the bladder, recto- 
 cele, hsemorrlioidal tumours, even intestinal hernise in more or less 
 distant parts. The chief complications on the side of the uterus are : 
 pregnancy, hypertrophy and elongation, engorgement, congestion, 
 softening, inflammation, excoriations, ulcers, leucorrhcea, polypi, devia- 
 tions, flexions and inversion. 
 
 Such are the elements which ought to serve as a basis for the 
 various indications when it is a question of treatment. It is an 
 important element in the success of this treatment, and in the diag- 
 nosis of the malady, to determine the anatomo -pathological alterations 
 which prolapsus produces in the uterus and in the neighbouring 
 parts. 
 
 In prolapsus the uterus is still contained in the pelvis, and the 
 disease may be difficult to distinguish from simple hypertrophic elon- 
 gation of the cervix or body ; all the more so as there may be longi- 
 tudinal hypertrophy of this organ without prolapsus. 
 
 In procidentia, the uterus being outside the pelvis, a vacuum is 
 necessarily produced in the region which it occupied, and consequently 
 a cul-de-sac presents itself above the displaced uterus containing the 
 Fallopian tubes, ovaries and one or more knuckles of intestine; before 
 and behind this organ are prolongations of the vesico-uterine and 
 recto-uterine peritoneal culs-de-sac ; the fundus of the bladder adher- 
 ing to the cervix of the uterus is necessarily involved in its descent 
 and forms, in the anterior part of the tumour, in front of the womb, 
 below the urethral canal, a diverticulum or cavity accessory to the 
 vesical cavity^ which thus in many cases becomes bilobed, owing to 
 the uterine fundus being on a level with the inferior outlet of the 
 pelvis; the rectum may accompany the displacement of the womb 
 behind, as the bladder does in front. 
 
 The surface of the tumour is nothing but the vaginal mucous mem- 
 brane inverted by a kind of displacement similar to that which the 
 intestinal mucous membrane sometimes undergoes, especially in the 
 rectum, and which is designated invagination ; this invagination offers 
 degrees corresponding to those of the descent of the womb : it may 
 begin at the upper part, and this usually happens when the uterine 
 
 ' See Ascent of the Utertis, p. 355. Tins elongation may even occur without 
 hypertrophy : see Sims, op. cit., p. 353. 
 
358 
 
 UTERINE DISEASES IX DETAIL 
 
 displacement is primarily owing to defective resistance of the suspen- 
 sory ligaments ; it may, however, also commence at the lower portion 
 of the vagina, in which case it is produced independently of the uterine 
 
 Fig. 252. — Procidentia vrith cystocele, two peritoneal cuh-de-sac, an anterior 
 and posterior, half natural size ; preparation in St. George's Mnseum 
 (after Barnes). This preparation is similar to that represented in Cniveil- 
 hier's Anatomie pathologique, 26« liAa-aison, pi. 4, fig. 2. m, womb ; 
 o, ovary ; E, rectum ; a, anus ; p, pubis ; T, bladder ; V, urethra ; G, 
 cystocele ; T, vesical trigone at the base of the bladder fonning the cysto- 
 cele ; P A, anterior peritoneal cul-de-sac ; p p, posterior peritoneal cul-de-sac. 
 
 prolapsus or concurrently with it, by the relaxation of the vaginal 
 mucous membrane, the loosening of its adhesions to the neighbouring 
 parts, and by defective resistance of the perinseal floor, &c. 
 
 "When procidentia is complete invagination of the vaginal mucous 
 membrane is so also, and this membrane becomes external, convex, 
 distended by the organs, which are pushed down with it, and to which 
 it forms a common envelope. The phenomena which occur in the 
 accomplishment of this morbid act are therefore in some respects 
 similar to those produced in cases of invagination or prolapse of the 
 rectum. 
 
 Prolapsus of the vagina may take place without displacement of the 
 uterus and other pelvic organs. It may be dependent, as West rightly 
 remarks, on a kind of hypertrophy of this canal, which prevents it 
 
DISPLACEMENTS 
 
 359 
 
 from remaining within its own limits, pushing one of its folds out of 
 the vulva. This hypertrophy occurs usually during pregnancy. The 
 vagina, like the uterus, increases in length (which allows the uterus to 
 rise above the pelvis) and in breadth (which allows the head of the 
 foetus to escape), without speaking of its thickness. After delivery, if 
 the retrograde evolution of the vagina is arrested in its progress, as 
 sometimes happens with the uterus, and especially if the perinseum has 
 been injured, whenever the patient attempts to walk or make any other 
 exertion, the vagina will descend and project beyond the vulva. 
 
 ^^ - ^^^. / 
 
 Fig. 253. — Cystocele of the first degree of procidentia, complicated by haemor- 
 rhoids (Sims). 
 
 Cystocele and rectocele, like vaginal invagination, not only often 
 comphcate prolapsus, but frequently precede it. The tumour acquires 
 thereby greater size ; the defective resistance of the perinseal floor, 
 indicated by the premature appearance of these complications, is a 
 condition unfavorable for treatment. The presence of peritoneal ciils 
 de-sac before and behind the uterus is still more so, and ought to be 
 seriously taken into consideration in cases where excision of a part 
 of the tumour or cauterisation of the vagina would seem to be 
 indicated. 
 
 The cervix uteri, normal or altered by disease, is to be found in the 
 centre of the tumour; sometimes contracted, at other times affected 
 with a kind of eversion or ectropion, which exposes a portion of the 
 cervical ca\aty externally, as if the invagination which had begun upon 
 
360 UTERINE DISEASES IN DETAIL 
 
 the vaginal mucous membrane was gradually continued on the uterine 
 walls, effecting eversion. In any case this ectropion is the end and 
 not the commencement of prolapsus.^ 
 
 Usually the uterus becomes congested and hypertrophied, owing to 
 its descent. This hypertrophy may either affect the whole organ or a 
 portion of it only, most frequently the cervix, either in its infra- 
 vaginal or supra-vaginal part. In this case the hypertrophy is the 
 consequence of the prolapsus, whilst at other times it is the cause 
 of it. 
 
 The suspensory ligaments are, perhaps, of all the organs of the 
 uterine system those which undergo the most serious alterations. 
 These utero-sacral and utero-lumbar ligaments, covered by the folds 
 of Douglas, are sometimes torn, more frequently completely relaxed, 
 the only vestiges of them remaining being a few folds stretched out in 
 the form of a fan in the sacro-iliac cavity, which go into folds when 
 the uterus is brought back into its normal position. The broad liga- 
 ments may become puckered, held back by bands of adhesion, suffering 
 from the effects of displacement without having contributed to produce 
 it. The round ligaments have still less share in displacement, neither 
 undergoing any modification nor losing their ordinary flexuosity. The 
 vulva is very much distended, the posterior commissure effaced, the 
 perinseum very much thinned, and its rupture is the final act in pro- 
 ducing prolapsus.^ The descent of the uterus, therefore, does not 
 depend on this organ itself, but on alterations in the organs which 
 support it and maintain it in its position. 
 
 We may say of this, as of all displacements, that it is less a disease 
 than a symptom — a symptom of disease or traumatism of the suspen- 
 sory ligaments, a symptom of a pathological condition of the neigh- 
 bouring organs, of the perinseum, vulval opening, &c. Therefore it 
 usually only occurs in flabby women after numerous deliveries, or after 
 laceration of the perinseum or accidental rupture of the utero-lumbar 
 ligaments from a fall or violent effort. It is not uncommon to find in 
 patients affected with hernia displacements of the same kind, attribu- 
 table to the same troublesome tendency of the organism. I know a 
 lady who suffers simultaneously from two inguinal hernise, an umbilical 
 hernia and a prolapsus uteri. Prolapsus, however, may occur in 
 young girls,^ either from a congenital tendency, an original laxity of 
 the ligaments, or from the effects of a sudden rupture of the utero- 
 lumbar ligaments or the perinseum by a fall or a violent effort. De 
 Graaf, Saviard, Mauriceau, Chopart and other writers have related 
 cases of the kind. 
 
 Among the predisposing causes of prolapsus may be placed those 
 general diseases which make their influence felt on the pelvic organs. 
 Tuberculous women are subject to it. Beigel (op. cit., t. ii, p. 291) 
 
 ^ Scanzoni, op. cit., p. 128. — Jobert, Union med., 1858. — Le Grendre, op. cit., 
 p. 64. — Boivin and Duges, Atlas, pi. ix, fig. 8. 
 
 ^ Matthews Duncan, On the Function of the Perinceum in Procidentia 
 Uteri— Edin. Med. Journal, 1871, p. 673. 
 
 ' Churchill, Diseases of Women, p. 431. Dublin, 1864. — Monro, Edin. Med. 
 Essays, iii, 282. — Nonat, op. cit., p. 444. 
 
DISPLACEMENTS 361 
 
 found sixty-four cases of it out of 140 tuberculous women, among 
 others a lady, who having lost 20 lbs. in weight in a very short time 
 by practising Banting, found herself one day without any cause a 
 sufferer from prolapsus. It occurs also in women whose occupations 
 oblige them to stand, make violent efforts, &c., e.g. washerwomen, 
 workwomen and charwomen, singers, and, according to Klinge,^ nuns 
 suffer more frequently than others from prolapsus from prolonged 
 standing and kneeling and from singing. A wide pelvis with ampli- 
 tude and relaxation of the vagina dispose to prolapsus uteri, as also do 
 tumours and increased weight of the uterus. These pliysiological or 
 pathological conditions, however, are not sufficient- to produce it. 
 There must be rupture or relaxation of the suspensory ligaments. The 
 resistance of these ligaments is what really prevents prolapsus, the 
 resistance of the perinseum and the neighbouring parts is only a 
 secondary obstacle to the final accomplishment of its descent. Eelaxa- 
 tion of the utero-sacral ligaments being also the indispensable condition 
 of retroversion, as we shall afterwards see, it follows that retroversion 
 usually precedes prolapsus and is, so to say, the first stage of it. This 
 has been remarked by several practitioners. West says that every 
 prolapsed uterus is also more or less retroverted. According to Sims,^ 
 there must be retroversion before procidentia can take place, retrover- 
 sion involving relaxation of all the ligaments ; the existence of ante- 
 version makes prolapsus impossible. According to Barnes also, the 
 uterus cannot descend when auteverted. As soon as there is retrover- 
 sion the relaxation of the suspensory ligaments and the weight of the 
 intestines upon the anterior surface of the uterus tend to lower it and 
 to increase the displacement. This fact cannot be too much insisted 
 on. As another consequence, owing to the impossibility of restoring 
 the resistance of the lumbar ligaments, it follows that it is impossible 
 to effect a radical cure in a woman affected with procidentia, and from 
 the possibility of restoring vaginal, vulval and perinseal resistance, or of 
 supplying it artificially, the possibility of a palliative cure may be 
 deduced. 
 
 We cannot hope to reach the causes which have produced the dis- 
 placement ; they have either ceased long ago, or their persistent 
 nature defies almost all our means of action. They divide themselves 
 into two classes, according to whether the disease has been produced 
 suddenly or slowly. In the first case a fall, a violent effort, the act 
 of raising a heavy weight, &c., has ruptured the utero-sacral ligaments, 
 either from excess of the tension which the heavy uterus has exercised 
 on them, or from the energy of the muscular contraction displayed, 
 and has pushed the uterus outside the external organs of generation, 
 as it may push the intestine outside the rings and produce a hernia. 
 In the second case, the continued weight of the womb, the repetition 
 of efforts produced by constipation or by any other action necessitating 
 the bent position, continuous pressure exercised on the abdominal 
 
 1 Dissertatio de procidenti uteri ususque pessariorwin in hoc morho. Got- 
 tingen, 1867. 
 
 2 Op. cit., p. 295. 
 
362 TJTEEINB DISEASES IN DETAIL 
 
 organs and tending to make the uterus descend (any action apparently 
 slight, the slow and continuous persistence of which, however, greatly 
 increases its importance), gradually relax the lumbar ligaments, deprive 
 them of all elasticity, increase their length, and act in the same way 
 on the perinseal resistance, producing irremediable displacement of the 
 organ. The first mode is the cause of prolapsus in young women ; 
 the second is more frequently met with in old women. 
 
 The importance of the part which pregnancy plays may lead us to 
 presume that the age when prolapsus occurs is most frequently that 
 of sexual activity. Verdier^ out of 156 cases counted 7 as occurring 
 between the ages of sixteen and twenty, 21 between twenty-one and 
 twenty-five, 38 between twenty-six and thirty, 33 between thirty-one 
 and thirty-five, 25 between thirty-six and forty, 16 between forty-one 
 and forty-five, 9 between forty-six and fifty, 9 between fifty-one and 
 sixty-three. BeigeP met with 1 in a woman of ninety-two, which 
 was produced at thirty ; Monro^ observed 1 in a child of three ; and 
 Wiilaume'* 1 in a newly-born infant. 
 
 The experiments of Le Gendre^ and Bastien allow of our measuring 
 approximately the amount of force necessary to produce procidentia 
 and to destroy the resistance of the uterine ligaments. A force of 
 from 45 lbs. to 50 lbs. is sufficient to force the cervix to the vulva. 
 Experience proves that this result may be obtained by distension of 
 the suspensory ligaments, without causing any permanent elongation 
 and still less a rupture of these organs, as we see that the uterus 
 when left to itself resumes its normal position and preserves it inde- 
 finitely after operations for vaginal fistula, excision of polypi and abla- 
 tion of fibrous bodies, all of which necessitate drawing down of the 
 uterus. By applying a force of 111 lbs. to traction exercised on the 
 uterus, this organ is drawn through the vulva and prolapsus is pro- 
 duced. By slow traction the same result is obtained with less force. 
 In this way moderate but continuous pressure produces the same 
 result. Tumours, which sometimes raise the uterus out of the pelvis, 
 pull it down, on the contrary, when the circumstances are reversed. 
 Beigel observed a case of prolapsus caused by an increase in the size of 
 the liver, another by the spleen. Dilatation of the bladder or rectum, 
 or a stercoraceous tumour may do the same. — Tumours of the vulva 
 may influence the vagina, causing invagination and subsequent 
 prolapsus. 
 
 The relative frequency of prolapsus, which greatly exceeds that of 
 all other displacements, is easily explained, for so many circumstances 
 conspire to drag the uterus down : this organ is suspended in a 
 large cavity by means of ligaments susceptible of extension; its 
 weight and size may considerably increase under the influence of con- 
 
 ^ Traits pratique cles hernies, deplacements et maladies de la onatrice. 
 Paris, 1840. 
 
 2 Op. cit., t. ii, p. 291. 
 
 ^ Edin. Medic. Essay, vol. iii, p. 282. 
 
 ■* Beigel, op. cit., t. ii, p. 291. 
 
 5 Op. cit., p. 104. 
 
DISPLACEMENTS 363 
 
 ditions which also diminish the resistance of the ligaments; one of 
 these conditions occurs very frequently, viz. pregnancy ; lastly, it is 
 naturally pushed downwards by the weight of the viscera and by the 
 contractions of the abdominal muscles. With such predispositions a 
 relatively insignificant cause suffices to produce prolapsus. 
 
 Diagnosis — suhjective signs. — When prolapsus is not produced 
 suddenly, patients experience symptoms which attract their attention 
 before the appearance of a tumour at the vulva : discomfort, weight, 
 dragging in the loins, abdominal pains radiating sometimes into the 
 groins, downward pressure on the perinseum, weight in the pelvic 
 cavity, as if the contents were drawn outwards, occasionally vaginal 
 tenesmus, frequent desire to micturate and go to stool, vesical and 
 rectal tenesmus, pain at the points where the pelvic nerves are com- 
 pressed, painful pressure of the uterus on the hymen in virgins, in- 
 crease of all these symptoms at the menstrual period, nervous erethism, 
 digestive troubles : such are the phenomena which strike the attention 
 at first. When the tumour appears at the vulva the preceding sym- 
 ptoms persist, but are diminished when the patients are at rest, and 
 especially when lying, and increased when they stand long, when they 
 have to make violent eff'orts or lift weights. Patients experience a 
 sensation which makes them fear that the womb or other organs con- 
 tained in the pelvis are on the point of falling ; it seems as if a part 
 of themselves is drawn downwards. Cazalis and Le Gendre have drawn 
 attention to a phenomenon that is very persistent, that is, vaginal 
 tenesmus or that inclination to strain, to expel the tumour, which is 
 caused by chronic congestion and by the vague dull pains felt in the 
 bottom of the cavity, and which is also occasioned by hsemorrhoidal 
 tumours; this tenesmus is probably not without influence on the 
 descent of the vaginal mucous membrane. The tumour itself is not 
 generally painful, and when it has lasted for some time the action of 
 the air often renders it insensible ; for the membrane covering it has 
 exchanged the characteristics of a mucous membrane for those of skin, 
 its epithelium has become an epidermis, which tolerates the contact of 
 neighbouring parts. 
 
 Two general remarks may be made about these various symptoms. 
 The first is that they are more marked when the prolapsus is not con- 
 secutive to a delivery or miscarriage, and especially when it has occurred 
 suddenly. The second is that they are not always in proportion to 
 the gravity of the displacement, but rather to the complications of the 
 prolapsus and the nervous sensibility of the patient. In some women 
 menstruation may be arrested or be irregular, whilst in others it may 
 be increased, though this seldom happens ; the tumour which is re- 
 ducible in the intercalary period may become irreducible and undergo 
 strangulation at the menstrual period, as in a case seen by Linas.^ 
 The congestion which is kept up in the uterus by its descent does not 
 only determine pain in the organ, it also increases its weight and size, 
 causing hypertrophy which tends to perpetuate the displacement ; 
 sometimes it even produces passive haemorrhage and uterine leucor- 
 ' Xonat, op. cit., \). 448. 
 
364 UTERINE DISEASES IN DETAIL 
 
 rhoea, without counting possible disorders of the appendages.^ Unless 
 the tumour is irreducible, marital intercourse is quite possible, for the 
 dorsal decubitus enables the patient to replace the uterus ; there are 
 cases in which intromission has taken place into the uterine orifice.^ 
 Therefore it is not rare to see women suffering from prolapsus become 
 pregnant. In such cases the prolapsus should be reduced as soon as 
 possible ; sometimes reduction takes place spontaneously, and owing to 
 the ascent of the uterus above the pelvic cavity after the third month, 
 the patients are temporarily delivered from this infirmity.^ It is not 
 indeed impossible for gestation to take place in complete procidentia, 
 the patient being obliged to support the uterus between her thighs 
 during pregnancy, till the time comes when the contractions of this 
 organ are sufficient to accomplish delivery. Examples of this are given 
 by Wagner, Chopart, Nonat,^ &c. 
 
 In a few cases pregnancy follows its normal course. When the 
 uterus has not remained entirely outside the pelvis, prolapsus of the 
 cervix and part of the body is likely to be reproduced at the moment 
 of delivery and obliges the accoucheur to resort to version.^ 
 
 A peculiar sensation of dragging at the umbilicus, vesical tenesmus 
 and difficulty in micturition depend on repletion of the prolapsed 
 bladder with the anterior vaginal wall, on the formation of the diver- 
 ticulum of this organ as it is dragged into the cystocele, and on the 
 deviation of the urethral canal, which in place of being directed 
 towards the pubis, is directed downwards towards the bottom of the 
 bladder, being dragged by the uterus ; it follows that patients in order 
 to empty the bladder have to strain in the bent position, which is so 
 favorable to prolapsus, making violent efforts alike prejudicial to their 
 condition and useless in securing micturition ; and are often obliged to 
 bend forwards and to compress the cystocele, in order to raise the 
 vesical diverticulum and empty the bladder. ^ The urine which, for 
 reasons just indicated, cannot be expelled to any distance, runs over 
 the tumour, irritating and ulcerating the vaginal mucous membrane 
 so much as sometimes to produce gangrene and cause vesico-vaginal 
 fistula.'' Sometimes there is retention necessitating the use of the 
 catheter which is often attended with difficulty, and this is followed by 
 
 ' Otto von Franque, Der Vorfall der Gebdrmutter in anatomischer und 
 Jclinischer Beziehung. Wiirzburg, 1860, S. 13. 
 
 ^ Hervey and Franque, op. cit., p. 14. 
 
 ^ Kiwisch, Klinische Vortrdge, Bd. i, S. 159. Prague, 1854. 
 
 ■* Op. cit., p. 451. 
 
 * See d'Erchia, II filiatre sebezio, 1867. — Amussat, Gazette med. de Paris, 
 1832, p. 588.— Husty, Monatssch., Bd. xx, S. 248.— Gussecow, Id., Bd. xxi, S. 99. 
 — Needon, Id., Bd. xxiii, S. 222'. — Aubinais, Gaz. des hopitaux, 1866, p. 378. — 
 Frage, Gaz. med. de Paris, 2 Dec, 1866. — Sattler, Zeitschrift filr Wunddrzte 
 und Geburtshillfe, 1872, No. 3. — Rubicki, Virchow's Jahresbericht, 1873, S. 
 660. — Burns, Principles of Midwifery. London, 1824, p. 130. 
 
 ^ This mechanical irritation of the urethra, according to several surgeons, 
 accounts for the presence, in these patients more frequently than in others, of 
 fungous excrescences of the urethra, and small polypi in the meatus, which 
 form an obstacle to micturition and add to the discomfort of the patient. 
 
 ^ Scanzoni, op. cit., p. 129. 
 
DISPLACEMENTS 
 
 365 
 
 incontinence of urine. One consequence of this accident is the decom- 
 position of the urine^ which becomes thick and viscous, and charged 
 with phosphates. Another troublesome consequence is degeneration 
 of the kidneys ; the ureters, being stretched and compressed/ become 
 dilated as well as the pelvis of the kidney, and in course of time the 
 secreting substance of the kidneys atrophies (Kiwisch and Yirchow) . 
 Another consequence of the retention of the urine in this diverticulum 
 is the formation of vesical calculi, or their increase in cases where they 
 existed before the cystocele (Ruysch, Ferra, Cruveilhier, Gosselin, 
 Goupil, &c.). Lastly, the vesical mucous membrane may itself 
 become the seat of a muco-purulent secretion and of a concretion of 
 urinary deposits which produce, especially in its vaginal diverticulum, 
 an accumulation of a more or less considerable number of vesical 
 calculi." Eoper ^ has met with several together which could be moved 
 under the fingers. 
 
 Pig. 254. — Incomplete procidentia uteri, witli liypertropliy of the vaginal 
 poi-tion of the cervix (after Sims). 
 
 With regard to the rectum, we find pains, tenesmus, difficult defe- 
 cation, obstinate constipation, inflammation and ulceration of the 
 mucous membrane owing to the contact with fsecal matter,* and in the 
 case of rectocele, an accumulation in the intestinal diverticulum of 
 
 ' Philippe {British Med. Journal, p. 128, 1870) describes two cases in which 
 the ureters, compressed directly by the tumour, dilated and gave rise to uraemia, 
 followed by fatal results. 
 
 2 Blandin, quoted by Le Gendre, op. cit., p. 76. 
 
 ^ Barnes, op. cit., p. 632. 
 
 * Huguier, Allomjements Injpertrojyhiques du col. 
 
366 
 
 UTEEINE DISEASES IN DETAIL 
 
 fseces which the patients are obh'ged to force back with the tumour in 
 order that they may escape by the anus. 
 
 Objective symptoms. — Direct examination by touch and sight suffice 
 to make diagnosis easy. The first symptom is the presence of a 
 tumour at or outside the vulva. This tumour, which is pear shaped, 
 directed downwards and surrounded by folds of vaginal mucous mem- 
 brane, keeps the labia apart ; the surface is red or pink, dry, smooth, 
 sometimes excoriated ; the top, conical or slightly swollen, presents a 
 transverse fissure, the os uteri, from which there is an exudation of 
 mucus ; the base seems sometimes pediculated by constriction of the 
 vulval ring ; in front of it may be seen the meatus ; and behind it the 
 perinseum forced back, projecting and diminished in its antero-pos- 
 terior diameter ; the anus itself may project, giving passage to a 
 hernia of its mucous membrane. 
 
 This soft depressible tumour, mobile in every direction, and easily 
 pushed back, gives a sensation of great resistance. It can be reduced 
 completely, and is reproduced with great facility. In this double 
 movement the reduction and invagination of the mucous membrane 
 can be easily ascertained. When inversion of the vagina is not com- 
 plete, a circular groove may be felt more or less marked above the 
 tumour; this is the portion of the vaginal mucous membrane which 
 has not been inverted, under which the characteristic hardness of the 
 uterus may be perceived. Rectal touch allows the diagnosis to be 
 completed by determining the position occupied by the uterine fundus 
 
 Fia. 255. — Complete procidentia uteri of twenty years' standing, in a woman 
 
 of seventy years. 
 
DISPLACEMENTS 
 
 367 
 
 below the pelvic cavity ; whilst catheterism discloses the cystocele, and 
 by associating it with rectal touch the information given by the latter 
 as to the descent of the fundus ideri and its absence from the cavity 
 is confirmed. The form of the tumour^ resembling at first that of the 
 neck, afterwards becomes conical, surrounded by folds at its base, 
 and finally gets more and more globular and smooth in proportion as 
 its size increases. Its volume may become very considerable, when 
 in addition to prolapsus of the uterus there is also prolapsus of the 
 vagina, bladder, rectum and small intestine, the latter known by its 
 gurgling and filling the posterior peritoneal cul-de-sac ; an extreme 
 case which is very rare, but which is possible, for I have seen a case 
 of the kind : it may reach the size of the head of a foetus and even 
 of an adult. Defecation and micturition are considerably impeded, 
 especially if the tumour is irreducible. 
 
 The colour of the vaginal mucous membrane with which the 
 tumour is covered is also gradually altered by the congestion which 
 makes it darker by exposure to the air, and by friction which imparts 
 to it a greyish tint, and by irritation and inflammation which produce 
 
 Fig. 256. — Complete •procidentia uteri with cystocele and rectocele, hyper- 
 trophy and ulceration of the cervix and eversion of the cervical mucous 
 membrane (after Sims). 
 
 ulceration in the neighbourhood of the urethra and the most depend- 
 ent portion of the tumour. Continued contact with the external air 
 renders this membrane dry and discoloured, imparting to it the charac- 
 teristics of skin^ without, however, preventing it from regaining its pro- 
 
 ^ This is so true, that in an old negress affected for fifty years with complete 
 procidentia this membrane became as black as the skin, and was even covered 
 with down. 
 
368 UTEEINE DISEASES IN DETAIL 
 
 perties of mucous membrane should the tumour be retained for a time 
 in the pelvic cavity ; but if the tumour increases in size and remains ex- 
 ternalj its mucous membrane and the adjacent tissues become congested, 
 thickened, hypertrophied, whilst those parts exposed to friction pre- 
 sent irregular ulcers in patches, from which a little pus is excreted 
 and which sometimes beconie affected Mdth gangrene. The uterine 
 orifice, as well as the isthmus and cavity of the body, which are ob- 
 literated in aged women, are, on the contrary, sometimes dilated in 
 young women ; I have already spoken of this peculiar dilatation and 
 eversion which may extend to five centimetres in diameter,^ and conse- 
 quently be sufficient to admit the penis, examples of which eminent 
 writers have given us. Palpation and percussion of the tumour may 
 give the sensation of fluctuation in front. Pressure on the same point 
 makes the urine escape from the meatus. Compression of the whole 
 of the tumoui-, which is not painful in chronic prolapsus, diminishes 
 the volume and communicates a sensation of internal resistance pro- 
 duced by a cylindrical organ larger above than below, terminating on 
 a level with the upper and strangulated part of the tumour, and 
 possessing all the characteristics of the uterus. It is not always easy 
 to reach above the body ; but the neck is more easily perceived through 
 the inverted vagina, because of its being harder, longer, more cylin- 
 drical than in a normal condition, especially in the numerous cases in 
 which the displacement of the cervix depends on the elongation of the 
 neck more than on the descent of the uterus. The presence of the 
 intestines in the posterior peritoneal cul-de-sac is recognised by the 
 peculiar gurgling sound heard when reduction is being made. 
 Catheterisation shows the direction of the urethra towards the lowest 
 part of the tumour, the existence and extent of the diverticulum of 
 the bladder, and consequently the lowest limits of the cystocele, and 
 lastly, the upper limit of the uterus in the centre of the tumour. By 
 rectal touch we discover the rectocele, the position, deviations or 
 curves of the uterus, and the elongation of the suspensory ligaments. 
 Lastly, the use of the uterine sound allows us to determine in a still 
 more precise manner the upper border of the uterus, the length of its 
 vertical diameter, and consequently the absence or development of the 
 longitudinal hypertrophy of the neck, and lastly, the various altera- 
 tions in the direction of this organ. I do not understand the danger 
 that Le Gendre apprehends from its use.^ 
 
 Differential diagnosis. — The characteristics just enumerated hardly 
 allow of our failing to recognise an infirmity so marked as uterine pro- 
 lapsus ; it is not, however, so easy to distinguish simple from compli- 
 cated cases, nor to determine the nature of the complications. 
 Tumours arising from the cervix or even from the cavity of the body 
 often project at the vulva, or outside, gradually dragging the uterus with 
 them especially when they are large, and causing vaginal invagination 
 to some extent, which is another cause of error. These fibrous, 
 mucous, follicular polypi are difficult to distinguish from prolapsus by 
 
 1 Huguier, Allong. hypertropliiqiie. 
 » Op. cit., p. 68. 
 
DISPLACEMENTS 
 
 369 
 
 their external aspect, on account of the alterations affecting the 
 vaginal mucous membrane when the prolapsus is of long standing. 
 It might be thought that the existence of the os uteri allowing the 
 sound to penetrate into the uterine cavity would be a sufficiently dis- 
 tinctive mark ; it is not so, however, for the orifice may be obliterated 
 or hidden, e.g. pushed forward by uterine retroversion (co-incident 
 with prolapsus), which places the fundus of the uterus in the posterior 
 peritoneal cul-de-sac, and its cervix in front against the pubis. In 
 such cases catheterisation and rectal touch will help to show the 
 absence of the uterus from the cavity, and to determine the ex- 
 istence of retroversion in the tumour. As for vulval or extra-vulval 
 tumours, in the formation of which the uterus does not participate, 
 such as cystocele, rectocele, cysts of the labia and vagina, catheterisa- 
 tion, rectal and vaginal touch suffice to determine which organ is dis- 
 placed and whether the uterus occupies its normal position. There 
 is, however, one malady which it is especially important to distinguish 
 from prolapsus nteri, viz. uterine inversion. It must be remembered 
 that uterine inversion does not necessarily involve propulsion of a 
 tumour outside the vaginal cavity, and that when this is produced it is 
 because prolapsus is added to inversion owing to the elongation or 
 rupture of the utero-sacral ligaments. Now, inversion is almost 
 
 -Complete procidentia uteri 
 
 Fig. 258. — Complete inversion of the 
 uterus complicated by vaginal in- 
 vagination or uterine prolapsus. 
 
 always produced suddenly, from traction exercised on the adherent 
 placenta, or from violent eS'orts accompanying the expulsion of the 
 foetus, from a fibrous tumour or a polypus. The surface of the 
 tumour has the spotted aspect of the congested uterine mucous mem- 
 brane in place of the wrinkles of the vaginal mucous membrane ; it 
 often causes dangerous haemorrhages ; it is globular, broader below 
 than at the vulva, where there is a strangulated pedicle ; on a level 
 with this pedicle the vaginal culs-de-sac and uterine lips may be seen, 
 
 24 
 
370 UTEEINE DISEASES IN DETAIL 
 
 the outline of which may be followed by the finger, whether the inver- 
 sion has affected them and the neighbouring part of the vagina, or 
 whether they have kept their normal position, surrounding the portion 
 of the inverted neck with a kind of ring. This tumour shows no 
 trace of an os uteri. Lastly, neither rectal nor vaginal touch, nor yet 
 catheterisation, discloses the presence of the body of the uterus, 
 supposing it has remained large enough and soft enough to be pene- 
 trable. Pregnancy is said to be a complication not unfrequently 
 met with, especially when prolapsus is incomplete and the largest part 
 of the organ is still contained in the cavity. The presumptive signs 
 of pregnancy, especially the rapid development of the uterine tumour 
 in a woman whose youth and health exclude the idea of any disease, 
 and later on the signs of certainty, can leave no doubt as to the 
 existence of this complication. It is evident that prolapsus even in 
 the first degree is an obstacle to the regular progress of gestation. 
 If the uterus cannot be reduced grave symptoms may arise, followed 
 frequently by abortion or miscarriage. The dead foetus has been seen 
 to remain for some time in the prolapsed uterus before being expelled ; 
 in a few cases, to which I have already referred, pregnancy has termi- 
 nated normally, delivery having been eflTected solely by the contrac- 
 tion of the organ. Catheterisation reveals the existence of vesical 
 calculi. 
 
 Lastly, the hypertrophic elongation of the neck is beyond doubt the 
 most frequent complication. Huguier regarded the majority of cases 
 of prolapsus as simple inversion of the vagina gradually pushed 
 towards the vulva, on a level with, or outside this orifice, by the pro- 
 gressive elongation of the hypertrophied neck of the uterus. I can, 
 however, afiirm that there are cases of simple longitudinal hypertrophy 
 as well as of simple prolapsus and even procidentia without hyper- 
 trophy, besides a great number of cases of prolapsus complicated with 
 more or less marked hypertrophy. It is easy to see that constant 
 congestion of the prolapsed uterus at last causes hypertrophy, especially 
 of the supra-vaginal portion of the cervix. This elongation of the 
 neck was first observed by Morgagni •} afterwards described by Levret,^ 
 was called by Nivchow prolapsus of the uterus without procidentia of 
 theftmdus,^ and was exhaustively studied by Huguier under the name 
 of hypertrophic elongations.* We may add that prolapsus must also 
 be distinguished from hermaphroditism; in the 17th century a 
 woman was taken for a hermaphrodite till Saviard ^ announced that he 
 had treated her for prolapsus uteri, which he had reduced. Valentin 
 saw a similar case :^ a woman was taken for a hermaphrodite and 
 accused of impotence ; an examination showed the mistake, the uterus 
 was reduced and capacity for conjugal intercourse admitted. 
 
 Treatment, — Uterine prolapsus hinders women from moving about 
 
 1 Be Sedibus, Sec, Epist., 45, art. 11. 
 
 ^ Journal de med. et de chir. de Roux, vol. xl, p. 352. 
 
 ^ Verhandlungen der Gesellschaft fiir GebiirtsJc. Berlin, Bd. il, S.j205. 
 
 •* Memoires de V Academie, 1859. 
 
 * Nouveau reciieil d' observations chirurgicales. 
 
 ^ Franqiie, op. cit., p. 27. 
 
DISPLACEMENTS 371 
 
 freely, the least effort, especially that of lifting weights, bringing on 
 lumbar and pelvic pain, which is all the more annoying from often 
 being incurable. When I say incurable, I mean in an absolute 
 manner; for there is no reason to despair of ameliorating the evil, or 
 at least of palliating it. It is, however, alike impossible for art and 
 nature to bring about a complete and lasting cure, especially when the 
 prolapsus is chronic and has passed into the state of complete proci- 
 dentia. Acute prolapsus is more easily cured : the ligaments which 
 are relaxed are elastic like the tissue of the organ itself; we may 
 therefore hope to see the supports of the womb recover a certain 
 degree of their retractility, sufficiently so to retain the organ in a 
 position somewhat similar to its normal one if we lose no time in 
 applying suitable treatment. 
 
 The patient should observe the abdominal rather than the dorsal 
 decubitus in order to help the uterus to ascend, and to shorten the 
 distance between the neck and the promontory; when walking the 
 uterus should if necessary be supported by a Hodge or some other 
 kind of pessary, the bladder should be kept empty, and astringent 
 applications (powdered tannin in a small pledget of cotton wool) 
 should be made to the cervix. On the other hand, prolapsus when 
 left to nature has a tendency to increase : the intestines fill the vacuum 
 left by the uterus in the pelvis, preventing this organ from resuming 
 its own place and continuing to push it down by the pressure which 
 they exercise on it, whilst the prolapsus of the vagina is daily increased 
 by the efforts of defecation. The presence of the uterus provokes 
 expulsive efforts which increase the evil. I know that the possibility 
 of spontaneous cure has been admitted by some. Scanzoni^ thinks 
 that peritonitis, w^hich is sometimes developed after traumatism or 
 delivery in a woman affected with prolapsus, may, by determining 
 adhesions between the fundus of the uterus and some other portion of 
 the visceral or parietal peritoneum, become the means of retaining the 
 uterus in the pelvic cavity. In the same way cicatricial coarctations 
 following suppurative vaginitis, by supporting the uterus from below 
 and preventing its falling towards the vulva so as to invert the vagina, 
 may bring about natural cures. These modes of cure, however, are 
 very rare and not suitable for imitation by art. We must therefore 
 content ourselves with a palliative cure which renders the infirmity 
 supportable and prevents the displacement from being produced to its 
 full extent, without hoping to modify the malady itself, the relaxation, 
 rupture of the attachments, &c., which are the cause of the displace- 
 ment. The measure of curability is furnished by the relation between 
 the indications to which this lesion may give rise, and the imperfect 
 means which we are able to employ in order to fulfil them. 
 
 The sources of therapeutic indications here as everywhere lie in the 
 pathological elements the association of which constitutes prolapsus. 
 The treatment necessarily varies with the case. In prolapsus two 
 distinct pathological states must be admitted : simple prolapsus of a 
 normal uterus, and descent of the vagina from a hypertrophied uterus. 
 
 1 Op. cit., p. 130. 
 
372 UTEEINE DISEASES IN DETAIL 
 
 Sometimes weakening of the suspensory ligaments is the primary 
 cause of the prolapsus; sometimes it is the weight of the womb 
 increased by defective involution, congestion or hypertrophy. These 
 two states are often combined, the one which has occurred first soon 
 producing the other. 
 
 1. Let us first take simple descent of the uterus, without hyper- 
 trophy. The cause of the displacement is not in the womb : it exists 
 in the abdomen above or below the uterus ; above, tumours, dropsy, 
 pressure, efforts, elongation or rupture of the suspensory ligaments, 
 may push the womb downwards or let it fall; below, hypertrophy, 
 tumours, prolapsus and relaxation of the vagina, laceration of the 
 perinseum, may draw it in the same direction or withdraw from it all 
 support. The indications are two : one easy, reduction ; one difficult, 
 retention. Eeduction may take place simply, if there is no other 
 obstacle than vaginal prolapsus, by taxis similar to what is employed 
 in the reduction of hernise. It may necessitate the destruction of 
 obstacles opposed to its accomplishment, e.g. puncture in ascites and 
 in ovarian cysts, the application of belts to support the abdomen, the 
 ablation of vaginal tumours, &c. In order to maintain reduction the 
 suspensory ligaments must be acted on, the distended ligaments 
 shortened, the torn ligaments reunited, contractility restored to the 
 paralysed muscular fibres, the last-named being only possible in the 
 beginning. The impossibility of acting efiicaciously by these means 
 on the morbid elements to which they are addressed has led to the 
 idea of maintaining reduction by giving tone to the vagina and sup- 
 porting the perinseal wall by bandages or pads ; by supplying the de- 
 fective resistance of the vulval ring and vagina by intravaginal 
 supports, pessaries, hysterophores ; by contracting the vaginal or 
 vulval ring by excision, either circular, longitudinal or in folds 
 (followed by adhesive or inodular cicatrisation), by cauterisation, by 
 constriction and gangrene, by ligature, suture, or by any other means 
 causing loss of substance. Lastly, by closing the vaginal orifice in- 
 completely by inSbulation, or completely by suture. 
 
 2. In cases of prolapsi uteri with elongation the hypertrophy may 
 afPect either the body, neck or isthmus, and be produced by the 
 development of tumours, polypi, fibromata, or by various alterations of 
 the cervix, by a hypertrophic inflammation, or oftener by mere hyper- 
 trophy. There are two indications : one or other may be fulfilled 
 according to the case. The cause of the prolapsus may be removed by 
 bringing the uterus back to its normal dimensions, i. e. by favouring 
 absorption or by removing tumours developed on the surface or in the 
 tissue itself by excision, crushing, cauterisation, ligature, &c., or the 
 uterus may be reduced and maintained by efficient support without 
 removing the cause of the descent. This palliative cure is often suffi- 
 cient, the compression of the organ being tolerated by the habit which 
 the pelvis has contracted of containing large bodies, especially if they 
 are flexible. 
 
 3. In the association of these two principal varieties of prolapsus 
 the one always plays the part of complication with regard to the other. 
 
DISPLACEMENTS 873 
 
 It is important to distinguish which of the two is the primary malady 
 and which the secondary, even when the latter has acquired a major 
 importance. The primitive element should be attacked first, and then 
 the secondary, which has become permanent. These general indications 
 being laid down, let us see how treatment should be practically carried 
 out. 
 
 I. Reduction. — This is easy, and often spontaneous. In most 
 patients the horizontal decubitus on the abdomen is sufficient to cause 
 the entrance of the tumour, as is proved by the facility with which 
 conception takes place in such cases. In a few patients the favorable 
 tendency of the horizontal position is increased by the natural action 
 of the vaginal walls (and probably also of the ligaments), which, in 
 contracting from below upwards, raise the uterus so as to replace it in 
 the pelvis. Scanzoni has proved this by projecting cold water on a 
 prolapsus the size of the fist, which then entered the pelvis sponta- 
 neously. If reduction does not take place spontaneously owing to the 
 increase of volume which constriction of the vulva determines in the 
 recent or congested tumour, or if it is desirable to use some means of 
 retention in cases where the uterus does not easily rise, artificial reduc- 
 tion must be made by performing a kmd of taxis on the tumour similar 
 to that used in reducing hernise. 1. The patient lying on her hack 
 with the head and limbs flexed so as to prevent all abdominal pressure 
 and the pelvis slightly raised, the tumour is grasped with both hands 
 and compressed in such a manner that the various parts composing it 
 rise successively irito the cavity. The uterus may either be first 
 pushed back, the reduction of the vaginal inversion taking place after- 
 wards, or the vaginal wall near the vulva, as well as the rectocele and 
 cystocele (when these complications exist), may be first replaced and 
 the womb afterwards. 2. If difiiculty is experienced in effecting re- 
 duction when the patient is in the dorsal decubitus, we take advantage 
 of the fact that, as the essential causes of prolapsus are relaxation of the 
 suspensory ligaments and retroversion, reduction will be facihtated by 
 placing the uterus in anteversion, and by bringing the neck near to the 
 sacro-lumbar ligaments. In fact, by placing the patient in ventral 
 pronation on elbows and knees we are able to replace the uterus much 
 more easily than in any other way, and to reduce the rectocele and 
 cystocele at the same time. The weight of the abdominal viscera 
 descending towards the umbiKcus, the traction which they exercise on 
 the womb, and the entrance of air into the vagina, are all favorable 
 conditions for facilitating reduction. 
 
 Whether it be the neck or vagina which has escaped first in the 
 commencement of prolapsus, there is no doubt it is the vagina which 
 escapes first in long-standing procidentia. If after having replaced the 
 parts in their normal position the patient is asked to make an effort to 
 expel them anew, the anterior vaginal wall will be seen to descend 
 against the perinseum in the form of a cystocele. A slight effort will 
 push it beyond the vulva, and the neck will follow immediately, drag- 
 ging with it the posterior wall of the vagina. In reducing procidentia 
 we must therefore reverse this order : begin by replacing the posterior 
 
374 UTERINE DISEASES IN DETAIL 
 
 cul-de-sac, then the neck; the anterior wall of the vagina and the 
 bladder will follow naturally. The swelling which has occurred in the 
 tumour owing to congestion, the development of inflammatory pheno- 
 mena or constriction of the vulval ring, is not the only reason why 
 reduction should be undertaken at once. A more important one still 
 is pregnancy. Although in this latter case the irreducible uterus may 
 be sufficiently supported by a suitable bandage to reach the term of 
 gestation without accidents, and to expel a living fcetus from its cavity, 
 yet it is prudent to attempt reduction before the size of the foetus 
 prevents the passage of the womb through the vulva and outlet. 
 Mauriceau^ once effected reduction at the fifth month. 
 
 The prognosis is not more unfavorable when reduction is difficult. 
 Provided that it be possible, there is all the more chance that it will 
 be maintained owing to the resistance of the vulva and perinseum. If, 
 however, it be possible, the nature of the obstacles which hinder or 
 retard it must be determined, in order to apply an appropriate treat- 
 ment. In a few cases reduction is impossible. Tor example, a number 
 of small fibroid tumours filling the pelvic cavity may prevent it (Sims). 
 The adhesions of intestinal circumvolutions to the internal wall of the 
 sac may be another cause. If there is merely congestion or oedema, 
 the horizontal position of the patient, elevation of the tumour, applica- 
 tions of cold, astringents, styptics in various forms, sufiice to facilitate 
 reduction. If there is chronic inflammation, rest, the application of 
 leeches to the cervix, emollient fomentations and the use of other 
 antiphlogistic means, are usually successful in diminishing inflamma- 
 tory tumefaction sufficiently to allow of reduction of the prolapsus. 
 It is the same with the remarkable and frequent hypertrophic thicken- 
 ing of the vaginal walls : rest, the horizontal position, applications of 
 glycerine, resolvent fomentations, may effect modifications favorable to 
 reduction. Lastly, the parts must be gradually accustomed to resume 
 a position which has become|abnormal to them. 
 
 It must not be thought that ulcers and other alterations mentioned 
 as being frequently developed on the vaginal mucous membrane in 
 long-standing cases of prolapsus are contra-indications to reduction, 
 and necessitate preliminary treatment as Scanzoni advises. As a rule, 
 the mucous membrane is cured spontaneously when no longer exposed 
 to the contact of air, of urine and to friction. Therefore it may be said 
 that reduction is usually easy, whatever may be the obstacles ; all that 
 is wanted is a great deal of patience. Unfortunately, however, it is 
 difficult to maintain the tumour reduced. 
 
 II. Retention. — Some means of retention are only used as pallia- 
 tives, others aim at producing a radical cure. The former are all the 
 more satisfactory because, without pretending to efi'ect a radical cure, 
 they sometimes contribute powerfully to it by enabling the ligaments 
 to recover their elasticity and the uterine supports their resistance ; 
 whilst every day^s experience proves that, in addition to the danger 
 which accompanies the latter, they are quite insufficient to realise the 
 
 ^ Observations sur la grossesse et l' accouchement, Obs. 95, p. 78. Paris, 
 1728. 
 
DISPLACEMENTS 375 
 
 aim to which they pretend. Both, but especially the artificial means 
 of retention, may be helped in their action by medical treatment. 
 Sometimes this is the only treatment that can be used and we should 
 always begin with it. 
 
 A. General or medical treatment. — This should be directed against 
 chronic congestion, engorgement and all causes of increased weight of 
 the uterus, as well as against debility, laxity of the ligaments, defective 
 tone of the soft parts which support the uterus, and of the whole 
 organism. Resolvents associated with restoratives, tonics, hydropathy, 
 &c., constitute the principal agents of this treatment. 
 
 If the evil is due to a labour or miscarriage, to fatigue during a 
 menstrual period followed by neglect at the following periods, then 
 absolute rest, the horizontal position, laxatives, cold sitz-baths, astrin- 
 gent injections, vaginal applications of tannin or alum, local depletion 
 if necessary, will often suffice to diminish the volume of the congested 
 or hypertrophied uterus and gradually to dispose it to resume its 
 normal position. 
 
 These means must be used for several months and be resorted to 
 again and again. If the prolapsus depends on a sudden distension of 
 the ligaments, and has been produced suddenly in a young woman, in 
 fact, if it be recent and acute, the same means may suffice, especially if 
 the genu-pectoral attitude is assumed. 
 
 Electricity and the cold douche exercise on the suspensory ligaments 
 a local action, the association of which with general hydropathy and 
 tonics produces excellent effects. If electricity is tried one of the 
 poles should be applied to the cervix and the other to the groins and 
 sacral region at the point of attachment of the utero-lumbar ligaments. 
 If hydropathy is prescribed, general hydropathy should always be 
 combined with the douche or spray on the loins, sides and groins and 
 the treatment should be continued for a long time. When nothing 
 better can be had cold sitz-baths may be prescribed for one minute at 
 a time and repeated five or six times in the day. Although there is 
 no certainty of a cure being obtained from this kind of treatment, it 
 will be well to give it a fair trial and for a long time if there is no 
 contra-indication. I have seen it produce excellent results. I am in 
 the habit of seeing a lady for whom I prescribed this treatment more 
 than twenty years ago for a prolapsus which made walking impossible 
 and produced terrible attacks of hysteria ; she continued the treatment 
 for six months, and since that time she has had no serious hysterical 
 symptoms, and she can walk as far and almost as easily as before she 
 was ill. I ought to add that she could never bear a pessary. 
 
 These are really the only means that can produce in the tissues a 
 natural modification capable of overcoming the cause of the descent. 
 They ought always to be used, and sometimes exclusively, especially in 
 cases of slight prolapsus that are recent and due to a uterine malady 
 which is still curable. 
 
 B. Palliative mechanical treatment is indicated in cases of long- 
 standing prolapsus, with rupture of the suspensory ligaments, lacera- 
 tion of the perinseum, cystocele, rectocele, &c. The mechanical means 
 
376 UTEEINE DISEASES II<« DETAIL 
 
 of retention are very numerous, but in this apparent wealth we have 
 only an additional proof of real poverty. I do not mean to say that 
 any one of these means does not answer some special indication. But 
 the contact of these foreign bodies with the mucous membrane, the 
 embarrassment which their size causes in the cavity, the irritation, the 
 pathological secretions and the other alterations of tissue to which 
 their presence gives rise, the trouble which their introduction causes to 
 patients, owing to the difficulty which they have in introducing them, 
 the shocks felt by the neighbouring organs, the painful pressure which 
 they necessitate on other parts, all go to prove a state of imperfection 
 in these means which makes them intolerable to many patients. There- 
 fore, as a rule, they should frequently be withdrawn from the vagina, 
 not only for the sake of cleanliness but to rest the organ, and, when a 
 tendency towards cure shows itself, which may occur when there is 
 only relaxation without laceration, instruments of gradually decreasing 
 size should be used till they can be dispensed with altogether. The 
 pessary, by maintaining the organ in its natural place, allows the 
 tissues in virtue of their natural elasticity to resume their normal 
 size and resistance, in fact gradually to effect a cure. Therefore it is 
 a mistake to say : A prolapsus is a hernia, and a pessary is a bandage 
 which retains it. A pessary by maintaining the reduction places the 
 uterus in a condition to recover, if that be possible, a contractility 
 temporarily suspended. 
 
 The choice of the pessary ought to depend on whether the vulva 
 and perinseura are intact and resistant or not. 
 
 a. When the v^ilva and perinaum are intact, when the contractility 
 of the fibrous and muscular tissue of the vagina has not disappeared, 
 the smallest foreign body with a surface sufficiently soft not to irritate 
 the mucous membrane, and large enough to fill the space which sepa- 
 rates the cervix in its normal position from the perinseum suffices to 
 sustain the uterus in its normal position. 
 
 1. The simplest and often the best of all these pessaries is a fine 
 sponge {see Tig. 154, p. 198), or if that cannot be had, a tampon 
 saturated in an astringent or styptic solution -} the sponge should be 
 carefully washed every day, and taken out for the night when the 
 patient is in the horizontal position. Spherical pessaries are in their 
 action somewhat like sponge ; they press equally on all sides, but by 
 dilating the vagina in every direction have the disadvantage of changing 
 its form and of compressing important organs, especially the bladder 
 and rectum. 
 
 By making spherical pessaries elastic, as Gariel has done {see 
 Pig. 155, p. 193), they can more easily mould themselves to the 
 vaginal cavity and multiply their points d'appui without provoking 
 pain. They have been covered by a layer of amadou to make contact 
 with the vagina less trying, and when resistance of the perinseum is 
 defective, they may be kept in the vagina by means of a perinseal pad 
 kept in place by a T bandage. With the view of avoiding painful 
 
 ^ In 1853, Tordjce Barlcer wrote a paper on the treatment of procidentia by 
 the use of tampons soaked in a solution of tannin, which is quoted by Sims. 
 
DISPLACEMENTS 377 
 
 pressure, bung-shaped pessaries have beea invented which preserve the 
 form of the vagina, and others like a sandglass, which, from the hol- 
 lowing out of their central part, have no oihev point cVappui than the 
 cervix on one side and the perinseum on the other ; unfortunately the 
 size of these instruments makes them intolerable. 
 
 2. The difficulty of maintaining these pessaries in the vagina even 
 when the vulva offers a certain amount of resistance, and the import- 
 ance of avoiding compression of the rectum and bladder have led to 
 spherical pessaries being transformed into discs and ovals pierced in 
 the centre to preserve the uterus from contact with them and to facili- 
 tate the evacuation of mucus ; they have also been hollowed out in 
 front and behind to avoid pressure on the rectum and bladder. Such 
 has been the origin of the biscuit-shaped or figure-of-8 pessaries, which 
 are introduced longitudinally and afterwards turned round in the 
 vagina, so that their greatest diameter is transversal. Lastly, to 
 avoid distension of the vagina as well as painful pressure on bladder 
 and rectum in cases where the resistance of the perinseum is consider- 
 able, cup-shaped pessaries with a short stem have been invented, like 
 those of Hervez de Chegoin, Simpson, &c., which support the cervix 
 in their cavity, whilst their other extremity rests on the perinseum. 
 Besides, however, necessitating the resistant perinseum, these retentive 
 means are insufficient for a displacement like prolapsus. 
 
 3. The disadvantages of distension of the whole vagina when pushed 
 beyond certain limits have led German gynecologists to try to support 
 the uterus by distending the upper part of the vagina. This is the 
 origin of the new pessaries incorrectly called liysterophores ; these 
 hysterophores, like pessaries, may be free or retained, may either have 
 their two points d'appui on the vagina which they distend, or they 
 may support the vagina by means of an external point d'apptii. 
 Kilian's elytromoclilion was the first one invented. To make the in- 
 troduction of the instrument easier, its position more fixed and the 
 divergence of its extremities more constant, Zwank (of Hamburg) 
 invented his hysterophore, composed of two wings with stems and 
 furnished with a hinge in the centre, which allows of closing the wings 
 in introducing the instrument, and when once it is in place of sepa- 
 rating them to distend the vagina, keeping them in position by a screw. 
 Schilling made the use of the instrument inconvenient by trying to 
 regulate the divergence of the wings by means of a vice ; but Eulen- 
 bourg and Savage have improved it, the former by substituting an 
 india-rubber ring, the latter, a tube of the same material for Zwank's 
 screw (Figs. 170, 171, pp. 196, 197). 
 
 4. We cannot advise the use of any of these means excepting 
 always a sponge, a tampon, and Gariel's pessary, which are useful 
 in some cases, especially when associated with astringent applications ; 
 they all have the disadvantage of irritating the vaginal and uterine 
 mucous membranes, and of taking up too much space or exercising 
 painful pressure which is not compensated by the advantages they 
 offer. This cannot be said of Hodge's lever pessary, vvhich has been 
 still further improved during the last few years. This is the best 
 
378 
 
 OTEEINE DISEASES IX DETAIL 
 
 pessary, both wlien the prolapsus is recent and the vagina has pre- 
 served its contractility (which is apt to be lost by the use of the 
 
 Fig. 259. — Hodge's aluminium pes- 
 sary : a, antei'ior transverse 
 branch, indented on a level with 
 the urethra ; h, transverse pos- 
 tero-superior rounded branch. 
 
 Fig. 260. — Hodge's pessaiy in place ; its 
 form is less sigmoid than in Fig. 
 259. Evei-y time the inferior branch 
 descends, at every inspiration, the 
 upper one rises and raises the womb 
 along -with the posterior vaginal 
 cid-de-sac. 
 
 previously named instruments owing to their excessive distension 
 of the vagina), and when the vagina has lost this contractility, when 
 the perinseum is weakened, and when we must try, by keeping the 
 uterus in its place, to restore the contractility and resistance of these 
 organs as well as of the suspensory hgaments. In the first place 
 instead of distending the vagina and of being fixed in it^ the instru- 
 ment is mobile, rising and falling at every inspiration. It has the 
 sigmoid form, and its size may be determined approximately by a 
 measurement made with the finger. The length ought to be such 
 that when the postero-superior limb is at the further end of the pos- 
 terior vaginal cul-de-sac, without touching the uterus, the antero- 
 inferior one is behind the symphysis, above the meatus. It is intro- 
 duced by pushing the posterior limb fi.rst upwards then backwards, so 
 that, guided by the finger, it reaches the posterior vaginal cul-de-sac, 
 when the anterior limb should be raised and brought behind the 
 pubis. When in place its action is as follows : during inspiration, 
 when the intestines are pushed against the uterus and bladder and 
 cause the anterior vaginal wall to descend, the antero-inferior limb of 
 the pessary which rests on this wall, follows it in this movement and 
 descends a little ; the postero-superior limb necessarily rises in an 
 opposite direction, raising the roof of the vagina and with it the 
 uterus, the cervix being raised and directed backwards whilst the 
 fundus is inclined forwards (if care has been taken to reduce it pre- 
 viously) ; now when the fundus is anteverted, it is impossible that it 
 can fall. The action of the pessary is helped by the posterior wall of 
 the vagina and the perinseum constituting a firm, thick, elastic tissue 
 which, partly owing to its contractility, partly under the influence of 
 
DISPLACEMENTS 379 
 
 atmospheric pressure, is maintained in immediate contact with the 
 anterior wall and prevents prolapsus. This pressure is exercised 
 naturally on the upper limb of the pessary embraced by the vagina. 
 The vulval sphincter by its contraction also assists in supporting the 
 instrument. The patient ought to wear her pessary continuously; 
 it is unnecessary to withdraw it at night, it does not prevent coitus, 
 nor even conception and pregnancy, which occur frequently, although 
 it is better to avoid marital intercourse while wearing it. Its light- 
 ness and its cleanliness, which is easily maintained by warm vaginal 
 injections made twice a day with a weak solution of carbolic acid, 
 exempt its use from all inconvenience. It only requires to be 
 removed occasionally, to prevent accidents and allow of local exami- 
 nation. Therefore it is the first pessary that should be tried, especi- 
 ally when the prolapsus is recent, and when it is not accompanied by 
 any lesion of the vagina or perinseum. When it fails we may have 
 recourse to other kinds of pessaries which we are about to describe ; 
 but we must not expect more than a palliative cure from them, no 
 more than from a truss. 
 
 h. When the vulva is enlarged, the perinceum thin or destitute of 
 elasticity/, and even the four chette lacerated, the defective resistance 
 of the perinseum must necessarily be supplied by a pad which replaces 
 it, or by means which keep the uterus raised by supporting it either 
 directly or indirectly. 
 
 1. A simple perinceal pad (Fig. 152, p. 192) furnished with straps 
 fastened to a strong belt or pelvic corset may suffice to maintain the 
 uterus in the pelvic cavity, thus converting the painful prolapsus into 
 a descent that can be tolerated. The pad ought to be of wood, ivory, 
 gutta percha or horsehair, and sufficiently thick ; the straps of strong 
 leather and cylindrical, kept in place behind and before by buckles 
 placed as near the centre as possible ; the belt, a piece of ticking lined 
 with chamois leather with a padded metallic plate, resting above the 
 pubis (Hull), or rather on the upper part of the sacrum (Ashburner), 
 the firm and mild compression of which considerably relieves lumbar 
 pain. I have seen these means succeed even in cases of hypertrophy 
 of the cervix, the replacing of which could be eff'ected without pain. 
 By not distending the vagina it has the advantage of enabling it to 
 recover its elasticity. 
 
 2. The inadequacy, however, of this means has suggested the idea 
 of seeking externally for the points d'apptci which are refused by the 
 vulva and perinseum to c^ip- shaped pessaries, which seem the best fitted, 
 especially when elastic, to support the uterus directly, without distend- 
 ing or pressing painfully on the parts situated in the neighbourhood 
 or below it. This is the origin of all the cup-and-hall pessaries on 
 which the cervix rests, including those of Bauhin,^ Suret, Desormeaux 
 and Amussat^ {see Fig. 180, p. 199J, as well as those of Bourjeaurd, 
 
 1 Bauhin, A'^'pendix ad partum ccesareum Bosseti, quoted by Sabatiev, 
 Memoires de I' Acad, de chir., t. iii, j). .374. 
 
 ^ Bourgeiy and Jacob, Medecine operatoire, t. ii, p. 319 and pi. 72. Paris 
 1840. 
 
380 UTERINE DISEASES IN DETAIL 
 
 Gabriel, Coxeter, &c., all of which are pierced with an opening 
 in the centre for the discharge of fluids {see Fig. 181, p. 199), and 
 attached to a belt by flexible supports, like those of Bourjeaurd, or by 
 rigid stems made mobile by the ductility of the metal or by the play of 
 certain articulations of the stem which bears the cup destined to sup- 
 port the uterus, like those of Lazarewitch^ and other makers. 
 
 3. Lastly, the difficulty of supporting the uterus directly and the 
 drawback of the cervix resting (especially when it is diseased) upon a 
 hard body which irritates it, ulcerates it, or makes it bleed, has sug- 
 gested the idea of using indirect points d^appui which, by raising the 
 vagina, maintain the uterus also m its place. 
 
 One of the simplest and most convenient instruments of this kind is 
 Scanzoni^s pessary on a movable pivot, the stem of which supports a 
 polished sphere and has its point d''app%i below on a T bandage by 
 means of a ball-and-socket joint {see Y\g. 183, p. 199). The instru- 
 ments called retained hysterophores are also of this kind. These are 
 bent stems taking their point d'appui on the plate of a hypogastric 
 belt, and terminating in a sphere, a ring or a plate sufficiently elastic 
 and resistent to keep the anterior vaginal cul-de-sac raised without 
 hurting it. Saviard^s pessary and the hysterophores of Roser, Scauzoiii, 
 Charriere and Becquerel are of this kind {see Fig. 182, p. 199). 
 
 c. Surgical treatment or radical cure. — This consists in modifica- 
 tions efi'ected on the perinseum, vulva and vagina by various operations, 
 with the object of exercising on the reduced uterus natural and per- 
 manent retention. These operations aim at closing or contracting 
 the passages which allow the escape of the prolapsed uterus. 
 
 a. Closing the vulval ring completely may be tried in cases where the 
 patient is aged, the uterus obliterated, &c. It may be eft'ected by one 
 of the means about to be described as used simply to contract it, or by 
 the operation of Vidal de Cassis for obliteration of the vagina in cases 
 of vesico-vaginal fistula. The vulva may be incompletely closed by the 
 union of the labia, i. e. by infibulation. This operation was success- 
 fully performed by Schietfer in 1856 by means of a trocar and leaden 
 thread. Klein ^ repeated it, passing two threads of lead and failed ; 
 the uterus escaping near the commissure, was hurt and strangulated by 
 the thread. In 1859 Aran^ performed it four times; one case relapsed, 
 another was followed by strangulation; the result of the two others is 
 unknown. 
 
 h. Contraction of the passages which afford escape to the prolapsus 
 may be effected : 1, on the vulva or on the vagina in the neighbourhood 
 of the vulva ; 2, on the vulva and perinseum ; 3, on the vagina only. 
 
 1. Contraction of the vulva {episiorap/iy) is obtained by the dissec- 
 tion and suture of the three inferior quarters of the labia, an operation 
 suggested by Mende and executed by Fricke, of Hamburg,^ in 1833. 
 
 1 Coup d'oeil sur les changements de forme et de position de V uterus et sur 
 iy.ur traitement. Paris, 1862. 
 - Deutsche Klinik, 1856. 
 3'„0p. cit., p. 1047. 
 
 •* jtinnalen der chirurgischen Ahtheilungen des allgemein. KranJccnhauses in 
 Hamb-arg, Bd. 2, S. 142. Gottingen, 1833. 
 
DISPLACEMENTS 381 
 
 Adhesion is not always complete ; disunion of the fragments below has 
 been observed^ and consequently the persistence of an opening against 
 the fourchette. This accident is not exactly unfavorable, for it pre- 
 vents the surfaces which have been brought together from being sepa- 
 rated by hsemorrhage or suppuration, as has happened in other cases ; 
 besides, the perinseal opening, though narrow enough to prevent the 
 escape of the uterus, is sufficient for the menstrual discharge, and has 
 been dilated enough to allow of the passage of the foetus in labour, as 
 in the case described by Platt.^ Unfortunately the success of this 
 operation is far from being certain. If it has succeeded once with 
 Loscher and once with Knorre, it has failed once with Velpeau and 
 Paget and four times with Scanzoni, once with Koux, and several times 
 with Stoltz, the labia distending without rupturing till they allowed 
 the tumour to escape anew. Therefore, although recommended by 
 DiefPenbach, episioraphy was definitely condemned by Kilian. Perhaps 
 it would have been successful if performed as Kuschler advised, deep 
 suture associated with superficial suture, as in perineoraphy. — Con- 
 traction of the vulval portion of the vagina, inferior elytroraphy , per- 
 formed by Malgaigne in 1837, did not succeed. Simon also failed in 
 performing elytro-episiorapliy, i. e. juxtaposition and suture after 
 dissection of the vulva and lower portion of the vagina. 
 
 %. Contraction of the vulva and perinaeum, episio-perineoraphy , 
 consists in the greatest extent of juxtaposition by extending the incisions 
 from the vulva to the perinseum, and in the increase of the depth and 
 resistance of the cicatrix which contracts the vulva behind. The resto- 
 ration of the perineeum, far superior to partial obliteration of the vulva, 
 restores to the pelvic organs the support of which they had been 
 deprived by an accident, and seems to constitute an essentially cura- 
 tive measure. The operation consists in removing a portion of tissue 
 in the shape of a horse- shoe and uniting the two sides by a double set 
 of sutures, consisting of three deep and three superficial stitches. 
 Cases of relapse seem to have been exceptional and to have de- 
 pended on the extreme smallness of the uterus ; there was no death. 
 Breslau does not excise the dissected fragments, but turns them 
 inside out, placing them in juxtaposition, like a spur or beak, in 
 front of the perinseum, a method which gives more height to the plane 
 of reunion. Hilton^ and Oldham^ have added section of the anal 
 sphincter to facilitate the autoplasty and to extend the perinseum. 
 This operation, although inaugurated in France by Stoltz, of Strasburg, 
 has been performed most frequently in Germany and England, and 
 principally by Baker Brown,* who performs similar operations for 
 cystocele, rectocele, and rupture of the perinseum. In 1861 this surgeon 
 had operated on forty-one patients by this method : the result was thirty- 
 eight cures, improvement in two cases, one relapse. Unfortunately 
 
 ' Gazette viedicale, 1836, p. 16. 
 - Guy's Hospital Reports, 2nd series, vol. viil, 1854. 
 ^ Med. Times artd Gazette, 1857. 
 
 '' On Surgical Diseases of Women, 2nd edit., p. 96. London, 18(51. — See 
 also Savage, Lancet, vol. i, p. 164, 1858. 
 
382 UTEEINE DISEASES IN DETAIL 
 
 he does not say how long it is since his patients were operated on; 
 and as firmcess of the perinseum and existence of the hymen do not 
 prevent uterine prolapsus, we may be certain that restoration of the 
 perinseum does not suffice to cure it. Kuckler, of Darmstadt, and Anger 
 pursue a much surer method ; the latter proceeds by dissecting off the 
 mucous membrane of the labia and the neighbouring part of the vagina, 
 and both carry the dissection and suture close to the urethral orifice. 
 Anger has ascertained that cure was persistent eighteen months after- 
 wards ; this operation is therefore successful, but the escape of vaginal 
 mucous is difficult and coitus impossible. 
 
 3. Stricture of the vagina has been produced by suppuration and 
 by the formation of retractile cicatricial tisme (Hamilton)^, in imi- 
 tation of the traumatic cicatrices which obliterate or contract the 
 vagina. This suppuration and consequent cicatrisation are brought 
 about by the simple excision of a zone of vaginal mucous membrane 
 all round the tumour, as proposed by Eomain Gerardin -^ or by the 
 excision of a piece of the vagina and uterus at the top of the tumour, 
 as performed by Mayer, an excision which may necessitate the applica- 
 tion of the actual cautery to arrest the hsemorrhage; or by the 
 excision of several fragments round the neck (Cruveilhier), in imitation 
 of Dupuytren^s quadrangular excision of portions of tissue, to cure 
 anal prolapsus. The formation of a cicatrix may also be procured by 
 cauterisation with nitrate of silver (Cruveilhier), or acid nitrate of 
 mercury (Laugier), the actual cautery (Velpeau), or sulphuric acid 
 (Selnow) ; in all cases, however, cauterisation is either insufficient or 
 dangerous. Therefore this means has never been tried for complete ob- 
 literation of the vagina as proposed by Gerardin. The ligature applied 
 to one or several portions of the raised vaginal mucous membrane, as 
 to the pedicle of a polypus, as proposed by Blasius,^ or the wrinkled 
 suture proposed by Bellini under the name of colpodesmorajphy , are 
 equivalent to suture after excision. Lastly, joincement, simple or by 
 caustics, intended to provoke gangrene in several folds of the vaginal 
 mucous membrane, which are retained between the teeth of strong 
 serre-fines, has been proposed and practised by Desgranges, of Lyons. 
 This surgeon has pubhshed several successes due to the application 
 of this method. Nelaton has also had successful cases. The means 
 is ingenious, but the operation frequently requires to be repeated, and 
 is not without danger. This is the drawback of almost all the opera- 
 tions just described ; they are liable to cause serious dangers in 
 trying to cure an infirmity which is usually unattended with any, 
 and to substitute a deformity admissible in old women, but which in 
 the young may be the cause of pains and fresh dangers, from the 
 
 ^ Cooper's Dictionary of Surgery. 
 
 ' Arch. gen. de med., viii, 132. Paris, 1824. 
 
 3 Neue Operationsmethode heim GehdrmuUervorfall mittels hreisformiger 
 Ligaturen. In a woman of twenty- four years Blasius applied four along the 
 vagina, the first in the neighbourhood of the uterus, the second near the vulval 
 orifice, the two others in the interval. It is needless to say that the result 
 cannot be counted upon. Frenssisclie Vereinszeitung, 1844, n. 41. Schmidt's 
 Jahrbiicher. Bd. 45, S. 52. 
 
DISPLACEMENTS 383 
 
 obstacle which it puts in the way of the accomplishment of the 
 functions of the vulvo-uterine canal, especially that of delivery. 
 These operations I think are only indicated when extreme relaxation 
 of the vulva and vagina, cystocele or rectocele, occur not only as con- 
 secutive elements and secondary complications, but as principal 
 elements and serious complications of prolapsus. If narrowing of 
 the vagina is decidedly indicated, as alone able to prevent prolapsus, 
 suture of this membranous canal on one or both of its walls is pre- 
 ferable to all these operations. This suture is known by the name of 
 elytrorapliy or colporaphy . 
 
 Elytrorapliy or colporaphy is an operation which consists in dissect- 
 ing off a band of mucous membrane from the anterior or posterior 
 vaginal wall between two longitudinal incisions, and bringing together 
 the edges of the wound with points of suture. Marshall Ball^ invented 
 this operation. Heming, quoted by Boivin and Duges,^ performed it 
 successfully in 1831, Ireland^ modified it by making the incisions on 
 the side of the tumour to avoid wounding the bladder. A. Berard, 
 who gave it its name, performed it several times unsuccessfully. 
 Velpeau fixed the threads before finishing the incision and repeated 
 the operation before and behind without more success. Scanzoni 
 performed it thirteen times without success. Therefore, although 
 Dieffenbach has modified the proceeding by removing two bands in 
 place of only one oval one as formerly, and by repeating the operation 
 several times in a different spot, if the tumour is reproduced, the 
 majority of surgeons regard this method of treatment as useless, 
 besides being attended with danger. Colporaphy, however, has been 
 revived after undergoing several modifications ensuring for it more 
 success in the future than it has had in the past. 
 
 a. Anterior elytroraphy. — Marion Sims* in place of making the 
 suture after having denuded a large oval surface of the anterior vaginal 
 wall (as in his first attempts), has improved the operation by dissect- 
 ing off the anterior wall a portion of mucous membrane in the form of 
 a trowel (Fig. 261), so as to form a real fold, the upper ends of which 
 (e d) are brought into contact and so directly support the neck of the 
 uterus. In a case where the rest of the suture had failed, Emmet ^ 
 ascertained that the union of the surfaces (c d, Eig. 261) and the con- 
 sequent narrowing of the vagina in the anterior cul-de-sac sufficed to 
 maintain the uterus in place. 
 
 The performance of elytrorapliy by this method is a delicate opera- 
 tion. The patient lies on her back or on the left side. Denudation 
 and suture being usually performed on the anterior vaginal wall, 
 the posterior wall and the perinseum are depressed by a Sims' 
 
 ' He removed a band of mucous membrane the length of the vagina and 
 12 mm. in breadth, and united the edges of the wound by sutures ; two years 
 afterwards, in 1833, Vincent found the uterus and vagina in position. 
 
 ^ Translation of Heming's paper, 1834, p. 53. 
 
 ^ Gazette med., 1832. 
 
 * Op. cit , p. 310. 
 
 * A Radical Operation for Procidentia Uteri, New York Medical Journal, 
 April, lS(i5. 
 
384 TJTEEINE DISEASES IN DETAIL 
 
 speculum. I then fix in the anterior lip of the cervix the two 
 terminal ends of a catheter, the convexity of which depresses the ante- 
 rior vaginal wall towards the bladder ; the curve of the catheter is 
 
 Fig. 261. — Elytroraphy as performed by Sims, a, h, c, d, bleeding surface in the 
 form of a trowel ; /, central part of the anterior vaginal wall, which will 
 be enclosed by bringing the sides of the wound a c, b d, together ; e, com- 
 munication of the farther cavity/ with the anterior utero-vaginal groove 
 insufficient to allow the passage of the cervix. It will be seen that the 
 meatus is below, the patient being in the genu-pectoral position. 
 
 buried under the lateral folds formed by the mucous membrane, and 
 these folds indicate very exactly, where they meet in the median line, 
 the spot where the mucous membrane ought to be dissected, so that 
 these folds may be afterwards brought into contact. I then pass a 
 solution of nitrate of silver over these folds and afterwards one of salt, 
 which whitens them and allows me to mark out beforehand and very 
 exactly the surface which has to be denuded ; in order to trace the 
 transverse line of denudation (e d) the cervix is drawn downwards. 
 In tracing the branches of the V care must be taken to make them 
 neither too divergent nor too close together. I then reproduce the 
 cystocele, which makes denudation easier ; a few points of suture may 
 even be made before reducing anew. These sutures should be placed 
 transversely, commencing from below, and the uterus should be pushed 
 backwards with the sound till those nearest the cervix are passed. 
 The sutures must embrace the whole of the denuded tissue (c d) to the 
 exclusion of the undenuded portion (e), where it is important to leave 
 a canal for the discharge of the mucous or purulent secretions which 
 may accumulate in the bag (/). The cervix should be supported 
 by the catheter till all the sutures have beoi closed and tightly 
 fastened. The patient should be in the dorsal position and remain in 
 
DISPLACEMENTS 
 
 385 
 
 bed for several days or even weeks ; it is well to use the catheter for 
 some days and produce constipation by opiates. The lower sutures 
 may be withdrawn at the end of eight or ten days, the upper ones in 
 a fortnight. 
 
 b. Posterior colporaphij . — xiccording to American surgeons, ely- 
 troraphy should most frequently be practised on the anterior vaginal 
 wall, because cystocele usually complicates procidentia uteri. As, 
 however, the artificial support to the uterus is of more consequence 
 than the complications of cystocele or rectocele, we are not surprised 
 that Siuion, of Heidelberg (thinking it better to strengthen the poste- 
 rior wall of the vagina in order to make it a support for the uterus and 
 the anterior wall), should have substituted posterior elytrorapliy or, to 
 use his own expression, posterior colporaphy^ for Sims's operation. By 
 means of a broad fenestrated speculum which dilates the vagina he 
 removes, with scissors or bistoury, a portion of the mucous membrane 
 and subjacent tissue to within about an inch of the vaginal insertion of 
 the neck. The upper extremity of the denuded surface ought not to 
 be pointed, but almost square, so that after cicatrisation has taken 
 
 Fia. 262. — Colpo-perineorapliy of Simon and Hegar : c p E, juxtaposition 
 of the right and left bleeding surfaces of the vagina and perinseum kept 
 in contact by alternate long and short sutures, at the upper part a pro- 
 jecting fold of the vagina makes a supporting surface for the cervix ; 
 E, vagina ; c u, vaginal portion of the cervix ; v, bladder ; e, rectum. 
 
 place there is a kind of bag above the cicatrix which receives and 
 retains tbe cervix ; a very practical precaution without which the 
 cervix would penetrate into the narrowed canal, would insinuate itself 
 into it like a wedge, and by gradually dilating it would eventually 
 make its way through it and reproduce the prolapsus. Below, the 
 posterior portion of the labia must be denuded, so that by uniting 
 
 ' Hegar and Kaltcnbach, Die operative Gijnaekolocjie mil Einschluss dev 
 gynaehologischen Untersuchungslehre, S. 399, 401. Erlangen, 1874. 
 
 25 
 
386 
 
 UTERINE DISEASES IN DETAIL 
 
 them there may be an elongated perinseum, prolonged forwards, forming 
 a curve terminated by a spur which forms an extended point d'appui. 
 The opposite borders of the wound are brought together by suture, 
 and by the union of the two surfaces a firm and dense cicatricial band 
 is obtained, which occupies almost the whole length of the posterior 
 vaginal wall. The vagina is not only narrowed, it is also rigid and 
 sufficiently thick to support its own weight and that of the uterus.^ 
 
 I may just mention lateral and bilateral elytroraphy , which may be 
 suitable exceptionally to a specially broad vagina, and which have been 
 tried by some operators. I should, however, always prefer colpoperi- 
 neoraphy or Lefort^s operation, or, as a last resource, occlusion of the 
 
 vaojma. 
 
 c. Median colporapTiy of the vagina has recently been performed by 
 Leon Lefort.^ The uterus being outside the vulva, a portion of mucous 
 membrane is dissected off each of the vaginal walls from their middle 
 part, about six centimetres long and two wide. The uterus is reduced 
 sufBciently to bring into contact the uterine extremities of these two 
 denuded surfaces, and three sutures are applied to this transverse 
 border, uniting the anterior and posterior vaginal walls in a linear 
 direction. The union of the lateral borders is effected afterwards by 
 passing a metallic thread on each side, first through the border of the 
 anterior denuded surface, and then through the corresponding border 
 of the posterior surface ; a thread being placed in the same way on 
 
 ' The Kolpoperineoplasty of Bischoff, of Bale, described by Banga (Bale, 
 1875), is very similar to this. It has the advantage not only of narrowing the 
 vagina behind, but of curving it, changing its direction by bringing the axis 
 forwards. Hegar's Colpoperineoraphy (op. cit., p. 407, et seq.) is a modifi- 
 cation of Simon's. 
 
 ^ Bulletin general de therapeutique, t. xcii, p. 337, 1877. 
 
DISPLACEMENTS 387 
 
 the opposite border and at the same height, it suffices to fasten these 
 two sutures, in order to increase the reduction of the uterus bj bring- 
 ing the opposite vaginal walls together. This reduction is finished in 
 proportion as the sutures are fixed, and when the two borders of the 
 denuded surfaces have been united in their whole length reduction is 
 complete. The threads that have served for suture of the transverse 
 border nearest the uterus being hidden in the upper part of the 
 vagina, are not easily accessible when union is effected some days 
 afterwards ; therefore they should be left long, so that they can be 
 easily seized when they have become free. In his first case Lefort 
 completed his operation hj perineorapki/, which seemed to him necessi- 
 tated by the relaxation of the vulva. Median colporaphy has the ad- 
 vantage of not preventing coitus, while placing in the vagina an 
 obstacle which, from its position, ought to prevent a return of the pro- 
 lapsus better than any other operation. 
 
 d. Obliteration of the vagiyia, — Obliteration of the upper part of 
 the vagina is the only means of preventing the recurrence of prolapsus 
 in an old woman. We must not, however, ignore the accompanying 
 evils : that marital intercourse is absolutely prevented, and that the 
 cervix is enclosed behind a transverse partition of the vagina, where it 
 is soon surrounded by an accumulation of mucus and pus, which 
 macerates the epithelium and causes ulceration and degeneration. 
 
 e. As for amputation of the cervix, by which Huguier has proposed 
 to treat prolapsus in cases of hypertrophic elongation of the neck, I 
 shall refer to it when we come to hypertrophy of the uterus. 
 
 I have performed all these operations with a relative success, which 
 enables me to recommend them. I speak of colporaphy and peri- 
 neoraphy. In eight patients I have tried to narrow the vagina by 
 suture ; this narrowing in three cases was effected on the anterior 
 vaginal wall, in five others on the posterior wall and the perinseum. 
 All these patients were able to resume the exercise and occupations 
 which they had been forced to abandon. JFour of them did not 
 require to use any instruments; the four others, including those 
 operated on by anterior elytroraphy, had to continue the use of 
 a belt with perinseal pad to support the uterus; this organ did 
 not seem to have any tendency to escape, but the belt and pad 
 greatly facilitated exercise. I have not yet had occasion to try 
 Lefort's method, but I should not hesitate to do so, adding perineo- 
 raphy to his median colporaphy, if the gravity of the evil involved 
 the necessity of giving more strength and resistance, by an increase of 
 thickness, to the support of the uterus. Posterior colporaphy seems 
 to me theoretically preferable, and my practice has justified this theory ; 
 I should therefore advise it when there is reason for attempting a 
 radical cure of these maladies. If the cystocele has not yielded to this 
 operation, anterior colporaphy may be added. If hypertrophic elonga- 
 tion of the cervix complicates prolapsus, amputation of the cervix must 
 be performed. But even when justified in performing these three 
 operations on the same patient, as Tracy of Melbourne did, we must 
 beware of doing so at one sitting as he did ; a considerable interval 
 
388 UTEEIXE DISEASES IN DETAIL 
 
 should^ on the contrary^ be placed between them. I do not speak of 
 perineoraphy, which is evidently included in posterior colporaphy in 
 Simon's operation. 
 
 Before undertaking any of these operations the patient should for 
 some time previously assume the decubitus which is most favorable to 
 reduction ; it is wonderful what amelioration is obtained by this simple 
 means^ which greatly lessens the gravity of the operations that have 
 to be performed, 
 
 Deviations 
 
 Deviations are changes in the direction of the uterus^ or in the 
 relations of its locgitudinal axis vrith the brim, the pelvic cavity, and 
 the viscera contained in it. When this change is slight it takes the 
 name of inclination, and of obliquity when lateral; when more marked 
 that of deviation, and when still more marked that of version. 
 
 These three expressions designate the various phases through which 
 the uterus passes before reachiug the last degree of deviation. At first 
 slightly inclined in one direction the axis of the uterus deviates more 
 and more from its normal direction, till the organ is completely turned 
 upon one of its surfaces or sides, afl'ecting a horizontal direction, and 
 with its fundus looking forwards or backwards, to the right or to the 
 left, sometimes even looking downwards as well as backwards, whence 
 the name of version {veriere). 
 
 The deviations receive their special names from the side of the 
 cavity towards which the fundus is directed, the cervix always taking 
 the opposite direction. If the fundus inclines forwards and down- 
 wards the cervix looks backwards and upwards; if it inclines back- 
 wards the cervix looks forwards. That is because in deviations the 
 change of the uterus does not affect the absolute position of the organ, 
 not being a real displacement ; the suspensory ring is not displaced. 
 "VTe must, however, admit that it is frequently otherwise, in which 
 case descent or ascent are combined with deviation. TVhen the uterus 
 is retroverted it is almost always at the same time prolapsed; when 
 anteverted it is often elevated. Sometimes also the tissue of the uterus 
 is altered as well as the ligaments, and retroversion is accompanied by 
 retroflexion and prolapsus, and in the same way anteversion is accom- 
 panied by anteflexion and elevation. Flexions of the uterus may, 
 therefore, coincide with deviations, but Marion Sims goes too far iu 
 regarding them as different degrees of the same condition. The 
 pathological alteration of the ligaments is the real cause of persis- 
 tent deviations ; the pathological alteration of the tissue of the uterus 
 is the sole cause of flexions. With regard to the latter, I will 
 try to explain why in certain circumstances they should occur simulta- 
 neously. 
 
 There are four principal deviations : anteversion, retroversion, and 
 lateral versions, right and left. It is evident' that between these 
 cardinal directions there may be intermediate deviations, designated by 
 
DEVIATIONS 
 
 389 
 
 the names of ante-later oversion or retro-lateroversion. They are^ how- 
 ever, of secondary importance. Anteversion and retroversion are much 
 
 
 P'iG. 264. — Right unicorn uterus, with absence of the horn and the left appen- 
 dages, simulating a dexti'oversion or dextroflexion. u, uterus ; c u, cervix 
 uteri ; o, ovary ; t. Fallopian tube. 
 
 the most common and the most marked. Lateroversions are limited 
 by the broad ligament, in which the organ is too deeply inserted to 
 be able to deviate considerably in either direction. A great many 
 mistakes have been made with regard to lateroversions owing to the 
 difficulty of diagnosis. 
 
 Anteversion and retroversion are the names given to inclinations 
 forwards or backwards beyond certain limits. When once produced 
 they may be carried a great length, especially retroversion. If the 
 fundus is inclined forwards or backwards twenty-five or thirty degrees 
 it is not in a bad position^ but if it goes to forty degrees without soon 
 returning to its normal position the deviation is naturally increased 
 till it becomes persistent. At forty-five degrees its anterior or posterior 
 surface is exposed to pressure from the viscera, and consequently it 
 will become increasingly deviated. Anteversion is necessarily arrested 
 at ninety degrees, the uterus then resting on the anterior wall of the 
 vagina and bladder. Retroversion encountering no obstacles may 
 reach 135 degrees,^ when the symptoms become more marked, such as 
 dragging at the umbilicus and groins, sacral pain, weight at the anus, 
 nausea, dyspepsia, &c.; reduction at the same time becomes more 
 difficult, owing to the uterus becoming enclosed by the surrounding 
 organs. 
 
 ' Sims, n]i. cit., p. 2o6. 
 
390 
 
 UTEEINE DISEASES IN DETAIL 
 
 Anteversion^ is very common. It is only au exaggeration of the 
 normal inclination of the uterus during foetal life and during preg- 
 nancy. At an early period of gestation the inclination forwards and 
 to the right becomes more marked, and sometimes exceeds the normal 
 limits, necessitating the use of an external support. It is very 
 common in the virgin and nullipara. A persistence of the foetal con- 
 dition is enough to produce it, or this state may be aggravated by 
 dysmenorrhoea or by the increased weight of the fundus of the organ, 
 or by a cicatricial contraction following inflammation of Douglas's 
 ligaments, which gives an essentially patJiological character to ante- 
 version. It may also be due to abnormal development of the anterior 
 wall, to the presence of a fibroid in this wall, provided that the tumour 
 
 Fig. 265. — Anteversion in the first montii of pregnancy : m, uterus; c, vagina, 
 vulval orifice ; it, meatus ; v, bladder, compressed by the body of the 
 uteras : E, rectum ; P, pubis. 
 
 has its seat in the body (for if it is developed in the cervix it may, on 
 the contrary, produce retroversion). Nevertheless, I do not agree 
 with West, that it is chiefly the weight of the organ which determines 
 anteversion ; the iitero-sacral ligaments must be shortened. The fundus 
 of the organ compresses and pushes the bladder before it and rests 
 against the pubic symphysis, sometimes even lying behind it. The 
 neck, on the contrary, rises behind into the concavity of the sacrum, 
 pushing back the posterior wall of the vagina and the anterior surface 
 
 ' Anteversion attracted attention before retroversion ; it was described ex- 
 actly by Levret. 
 
DEVIATIONS 
 
 391 
 
 of the rectum, which it depresses so as to hollow out a kind of resting 
 place for itself. The uterus may be kept firmly in this vicious position 
 by the shortening of the supra-pubic ligaments, especially of the 
 utero-sacral ligaments which, by raising the neck behind, make the 
 fundus descend in front. What Schultze has said of anteflexion may 
 be applied to anteversion, leading us to distinguish natural congenital 
 anteversion from pathological anteversion caused by posterior peri- 
 metritis with adhesions, cicatricial and retractile alterations of 
 Douglas's ligaments, and necessarily requiring a totally different treat- 
 ment. 
 
 Reiroversion is always pathological. It is more uncommon than 
 anteversion, because contrary to the normal inclination of the uterus ; 
 it is also more serious. It is common in the multipara and in the 
 aged. Eetroversion, although contrary to the normal inclination of 
 the uterus, is very easily produced in certain circumstances ; the pos- 
 terior wall of the uterus being naturally thicker than the anterior, all 
 congestion or hypertrophy of this wall with relaxation of the sus- 
 pensory ligaments disposes the womb to become retroverted ; a tumour 
 or any increase in the weight of the fundus or posterior wall has a 
 great influence, the form of the pelvis, the cavity of the sacrum, the 
 presence of Douglas's peritoneal cul-de-sac, helping the displacement 
 
 Fig. 266. — Retroversion of the uterus. 
 
 of the organ in this direction. It may occur suddenly as the result 
 of an accident or violent effort, not only during pregnancy (as occurs 
 most frequently) but also during a state of vacuity with or without 
 hypertrophy ; generally it comes slowly owing to gradual relaxation 
 of the ligaments ; it may date from a delivery, miscarriage, or me- 
 trorrhagia, it is increased at every menstrual period as well as by con- 
 stipation and the accumulation of urine, and it becomes incurable by 
 the formation of utero-intestinal and pelvic adhesions, succeeding 
 attacks of circumscribed peritonitis. It may be slight or well-marked 
 but, once produced, it goes on increasing ; sometimes the fundus rests 
 on the sacro-vertebral angle, sometimes it falls below this angle into 
 
392 UTERINE DISEASES IN DETAIL 
 
 the concavity of the sacrum,, and so low that it rests not only on this 
 bone but on the perinseum below Douglas's folds, exercising so 
 much pressure on the anterior surface of the rectum that a serious 
 obstacle is placed in the way of the evacuation of the faeces or the 
 entrance of an enema. The cervix^ although unable to rise to- 
 wards the symphysis of the pubis^ is nevertheless, owing to the 
 extreme declivity of the fundus and the elongation of the liga- 
 ments which allows it to get further and further away from its points 
 of attachment to the promontory, sometimes on the same level as the 
 fundus, sometimes higher than the fundus itself, the weight of which 
 forces the cervix to swing forwards and to push before it the neck or 
 fundus of the bladder; the supra- pubic and utero-sacral ligaments 
 must be considerably relaxed, softened and elongated before this 
 deviation can occur, therefore it usually precedes prolapsus. The 
 cervix, though it appears to rise, never does so (except in gestation), 
 but the whole organ descends and the fundus more so than the neck ; 
 the vesical adhesions persisting alone, seem to be the cause of the 
 cervix being dragged forwards and upwards ; the anterior wall of the 
 vagina is often shortened in long-standing retroversions ; it has even 
 seemed to me that sometimes a congenital shortness has not been 
 without influence in the production of retroversion. The weight of 
 the fundus^ and the pressure of the abdominal viscera suffice to pro- 
 duce and keep up this deviation, in which the ligaments play a passive 
 part (which is not the less the principal, owing to the absence of all 
 support for the organ in consequence of their relaxation), just the 
 contrary to anteversion, in which, by their retraction, they take quite 
 an active part. Lastly, hypertrophy of the lowest part of the uterus 
 is often observed as a consequence of retroversion ; in anteversion 
 we have seen it play the part of cause. Pregnancy is a serious compli- 
 cation requiring prompt reduction. 
 
 Later aversions of extreme degree are rare, though slight cases are 
 common enough, especially to the right. The fundus may incline to 
 either side so far that the corresponding angle may touch the pelvic 
 wall, whilst the neck, rising on the opposite side, touches the corres- 
 ponding surface of the cavity. According to Aran^ the broad liga- 
 ment corresponding to the inclination is frequently shortened, the 
 utero-sacral ligament of the same side atrophied or relaxed, the 
 utero-sacral of the opposite side stretched and shortened ; of the two 
 supra-pubic ligaments the one corresponding to the inclination is re- 
 laxed or shortened ; the other is stretched or elongated. Some 
 autopsies have enabled me to verify the reality of these alterations. 
 
 Diagnosis. — When we find that a considerable number of devia- 
 tions date from intra-uterine life, and therefore ought to be all the 
 more easily supported -, that the uterine cavities present neither devia- 
 
 ' The development of a tumour in the posterior wall of the body of the 
 organ may produce retroversion, whilst its development in the cervix behind 
 may produce real anteversion by pushing the body forwards, according to 
 nMario Sims, phenomena which are the reverse of those I have indicated for 
 anteversion. 
 
 2 Op. cit., p. 1022. 
 
DEVIATIONS 393 
 
 tion nor compression ; lastly, that when they are produced in a wide 
 pelvis and consequently cause no functional disturbance in neighbouring 
 organs, they may continue for a long time without giving any sign of 
 existence ; we need not be surprised that after having attached too much 
 importance to versions, a reaction has set in tending to ignore this part 
 of uterine pathology too completely. 
 
 But whilst causing little pain by themselves in some circumstances, 
 versions are still very painful affections to delicate women owing to 
 the reaction exercised on neighbouring organs when, for example, 
 they disturb the pathological evolution of some degeneration of the 
 tissue, of inflammation of the peritoneum, of the broad ligaments, &c. 
 It is the contrary with prolapsus and flexions (especially retroflexion), 
 which are painful in themselves. This is easily recognised when we 
 have to do with a compound deviation, especially with retroflexion 
 combined with retroversion and prolapsus, the most frequent perhaps 
 and the most painful ; when the retroflexion and prolapsus are cured, the 
 pain is alleviated, and although a considerable amount of retroversion 
 and prolapsus may continue the patients no longer complain of pain. 
 
 Therefore when serious symptoms are produced by deviations the 
 deviations must not only be very marked, but must occur in excep- 
 tional conditions, in impressionable women, or in a narrow pelvis, or 
 on a tumefied uterus surrounded by diseased organs. There must also 
 be uterine or peri-uterine inflammation, congestion, hypertrophic in- 
 duration, or some other morbid alteration of the uterus, its appendages, 
 its ligaments, its peritoneal covering, or of neighbouring organs. I 
 do not mean that in such cases the deviation plays no part. On the 
 contrary, I think that it contributes to increase the symptoms and to 
 keep up the morbid state which is alternately cause and effect, a very 
 important consideration both with regard to diagnosis and treatment. 
 I believe that deviation (supposing that it did not exist from the 
 beginning) when once produced is frequently accompanied by uterine 
 sufl'ering which did not exist before, especially when carried to such 
 an extent that the relations of neighbourhood are completely altered, 
 and that the neighbouring organs cannot come into contact in these 
 new relations without giving pain. I have often seen the pain dis- 
 appear as if by enchantment after reduction. I presume, therefore, 
 that in the majority of cases the symptoms are due at once to excessive 
 displacement and to some complication. I presume that an ordinary 
 deviation occurring gradually, as frequently happens, and free from 
 complication, does not usually determine any serious functional dis- 
 turbance. Lastly, I am certain that, when carrifid to the highest 
 degree, it is betrayed by pathognomonic signs (which are still more 
 marked in cases of flexion) which, apart from direct examination, 
 enable us to diagnose the direction and the degree of the version. This 
 remark is especially applicable to retroversion. 
 
 Subjective signs. — The common symptoms are general symptoms, 
 especially disorders of digestion, innervation and nutrition, which are 
 common to a great many uterine maladies, and local symptoms, such 
 as a feeling of weighf, of dull \)n\n or dragging in the pelvis, in the 
 
394 UTEEINE DISEASES IN DETAIL 
 
 loinSj in the abdomen^ groins and perinseum, increased by standing, 
 walking, fatigue, constipation, retention of urine, &c. The local 
 symptoms appear to depend less on the sensitiveness of the uterus or 
 on the action exercised by this deviated organ on its ligaments, than 
 on the pressure or painful traction which the abnormal position of the 
 womb and the change of its relations exercise on the neighbouring 
 organs, especially on the bladder and rectum. Disorders of the urinary 
 excretion and of defecation are the most common of all the probable 
 symptoms of uterine deviation. Sterility and the existence of more or 
 less persistent uterine leucorrhoea may also be placed among the 
 number of the symptoms which are produced in cases of deviation, but 
 which cannot be taken as proof of their existence rather than of that 
 of any other morbid state. 
 
 As for the special symptoms distinctive of the various kinds of devia- 
 tion, it is impossible to say that retention or incontinence of urine is 
 specially connected with anteversion and constipation with retro- 
 version. 1 have never observed anything especially distinctive with 
 regard to this : frequent desire for micturition, owing to the pressure 
 which the weight of the uterus exercises on the bladder, is certainly a 
 symptom of anteversion; difficulty in micturition and tenesmus, in 
 consequence of compression of the uterine cervix against the neck of 
 the bladder and the urethra, are also sure signs of retroversion. 
 Nevertheless, as the uterus frequently preserves its obhquity (fundus 
 to the right) in retroversion, the urethra escapes the pressure exercised 
 on it by the cervix being forced against the pubis. What is more 
 certain is that, in the majority of patients, the symptoms which appear 
 to be due to anteversion are alleviated by the dorsal decubitus, whilst 
 in patients suffering from retroversion the dorsal decubitus even in the 
 best conditions, with a perfectly horizontal posture, flexion of the 
 limbs and general relaxation of the muscles, is usually powerless to 
 dissipate pain. In some patients even the pain is increased by this 
 posture, so much so as to oblige them to turn on one side, and finally 
 on the abdomen. Another symptom which I have observed in retro- 
 version is a sensation of dragging at the umbilicus, extending from 
 this point to the pelvis, and aggravated by the dorsal decubitus. In 
 retroversion the pressure exercised on the hypogastrium (when the 
 patient is standing) from below upwards and from before backwards, 
 either temporarily by the hand or in a permanent manner by a hypo- 
 gastric belt, excites pain in place of alleviating it ; the contrary occurs 
 in anteversion. Lastly, in retroversion sterility is much more common 
 than in anteversion, owing to the mechanical difficulty placed in the 
 way of the entrance of the semen. 
 
 In lateral versions I have observed nervous symptoms, neuralgic 
 darting pains in the limbs, seemingly dependent on compression of the 
 nerves coming from the pelvis, on the side towards which the organ 
 inclines. I have merely mentioned what I have observed, leaving it to 
 future observers to clear up what is obscure in the matter. The co- 
 existence of a morbid condition complicating a deviation has been till 
 now a great obstacle in the way of determining the special character- 
 
DEVIATIONS 395 
 
 istics of each; but a strict analysis of facts has put us on the right 
 track, as will be seen still naore clearly when we come to consider 
 flexions. 
 
 Objective signs. — If it is difficult to judge of the existence and 
 direction of a deviation from the symptoms experienced by the patient, 
 it is on the contrary very easy to determine it by direct exploration. 
 Tlie association of palpation with vaginal and rectal touch, the use of 
 the sound (except in cases of pregnancy), the catheter, and the specu- 
 lum, leave us in no doubt as to the existence and direction of a 
 uterine version. It must not, however, be forgotten that in Levret^s 
 case the anteverted fundus was taken for a stone, and that the patient 
 died from the consequences of lithotomy performed owing to the 
 mistaken diagnosis ; a slight engorgement of the anterior wall of 
 the uterus and an unusual shortness of the round ligaments (pro- 
 bably also of the utero-sacral ligaments) were the only appreciable 
 causes of this displacement. 
 
 In anteversion the cervix can only be felt by digital touch in the 
 concavity of the sacrum where it is often difficult to catch the os which 
 looks straight backwards. When the finger can bring the cervix 
 forward the displacement of the fundus in the contrary direction is 
 easily perceived ; catheterism associated with hypogastric palpation 
 renders the direction of the displacement and the temporary replace- 
 ment of the organ still more evident. Eectal touch determines the 
 degree of compression exercised on the rectum by the neck, and dis- 
 closes the absence of the rest of the organ above this inferior segment ; 
 it shows that the shortened utero-sacral ligaments are stretched when 
 we try to replace the uterus; above all, it decides the question 
 whether there is any tumour behind the uterus either belonging to 
 that organ or foreign to it by which the deviation is caused. The 
 speculum only allows the anterior lip to be seen ; in order to bring 
 the whole organ into view the cervix must be caught by tenaculum 
 hook forceps or a sound and drawn forwards whilst the speculum is 
 inclined backwards, the buttocks of the patient being raised, or her 
 lower limbs flexed as far as possible. In using the sound the handle 
 must be considerably lowered so as to depress the fourchette, whilst 
 the hypogastrium must be compressed in order to raise the fundus ; 
 the buttocks of the patient must project over the edge of the bed 
 or the instrument will not enter the cavity of the womb ; then the 
 replacement of the organ should be attempted gently, with a view to 
 revealing the presence or absence of adhesions, the degree of retrac- 
 tion of the utero-sacral ligaments and the possibility of a return to 
 the normal direction. 
 
 In retroversion, after having vainly tried to discover the cervix in 
 the posterior vaginal cul-de-sac which often presents a bulging in 
 the form of a smooth and rounded tumour owing to the presence of the 
 retroverted fundus, we at last find it against the anterior wall and 
 discover the os behind the pubic symphysis. In bringing it down the 
 finger experiences the sensation of the gradual replacement of the 
 fundus. This sensation becomes more evident, and replacement easier 
 
396 UTERINE DISEASES IN DETAIL 
 
 if rectal is combined with vaginal touch. When this replacement is 
 effected, the association of abdominal palpation with vaginal and 
 rectal touch reveals in the hypogastrium the presence of the fundus 
 which before was absent. Various circumstances may have increased 
 the size of the uterus, especially gestation which may render replace- 
 ment painful and difficult. Examination of the cervix by speculum 
 often becomes even more difficult than in anteversion ; in order to 
 bring the diseased organ into view and apply remedies to it, I have 
 sometimes been obliged to place the patient in pronation on her elbows 
 and knees, or on one side, or in a standing position with the trunk 
 flexed on the thighs, the speculum being introduced from behind. In 
 using the sound the handle of the instrument must be raised towards 
 the pubis, whilst a finger introduced into the vagina or rectum raises 
 the uterus and ascertains the absence or presence of adhesions which 
 may retain the fundus in the vagino-rectal cul-de-sac. 
 
 It is unnecessary to dwell long on lateroversions, except to say 
 that they never reach the same degree that antero-posterior deviations 
 do, and that other causes are added to the preceding in producing 
 them, viz. the relaxation or contraction of the broad and round liga- 
 ments, alone or associated with relaxation or contraction of one of the 
 utero-sacral ligaments. 
 
 When the uterus resists reduction, it is important to diagnose care- 
 fully the irred.ucibility and the cause of the irreducihility . In the case 
 of anteversion, if the fundus of the uterus is fixed anteriorly by adhe- 
 sions, which is rare, it will be impossible to raise the organ by the usual 
 method, which consists in bringing the neck into the anterior vaginal 
 cul-de-sac behind the inner surface of the pubis vv'ith the index finger 
 of the left hand, whilst the fundus is pushed backwards by the other 
 hand acting on the hypogastrium through the abdominal wall ; if the 
 neck is retained posteriorly by the shortened sacro-uterine ligaments, 
 by introducing the index finger into the rectum or even by directing 
 it towards the posterior cul-de-sac of the vagina at the same time that 
 the cervix is depressed by means of the tenaculum hook, the sacro- 
 uterine ligaments will be felt stiff and resisting like two stretched 
 guitar strings. In the case of retroversion the sound must necessarily 
 be resorted to. Sims^ prefers his articulated one, in order to avoid 
 injuring the fundus in raising the organ; I prefer a flexible instrument 
 the curve of which can be adapted to circumstances ; whilst trying 
 to replace the uterus with this instrument, we can, by means of rectal 
 or vaginal touch associated with external palpation, determine the ex- 
 istence of any utero-peritoneal adhesions or of any tumour adherent 
 to the uterus, sessile, pediculated or independent of this organ. We 
 may remark that the means of examination just described and the 
 analysis of the symptoms serve not only to prove the existence of a 
 deviation and to show its direction, but they also make known its 
 condition, whether reducible or not, and the co-existence of various 
 concomitant pathological conditions, and whether they exist as cause, 
 effect, or as simple complication. The importance of this part of the 
 ' Ainnfivican Journal of Medical Science, Jan. 185.S. 
 
DEVIATIONS 397 
 
 diagnosis will be understood if we consider that the symptoms observed 
 in cases of deviation are due to these morbid states as well as to the 
 deviation itself, and that there is a possibility of rendering the deviation 
 tolerable by first curing the complication ; and in the second place, if we 
 reflect that, whatever be the sequence of the pathological phenomena, 
 even if the deviation should be the cause of several of the phenomena, 
 such as congestion, engorgement, hypertrophy of the uterus, &c., the 
 deviation is always the result of some cause, whether laxity or con- 
 traction of the ligaments, or increased weight and volume of the 
 uterus, or unequal relative proportion of the two segments, various 
 pathological conditions of the organ, functional disorders of the 
 neighbouring organs, peri-uterine inflammation and its conse- 
 quences, or tumours of the appendages or pelvic cavity. All the 
 indications which serve as a basis for the treatment of uterine devia- 
 tion arise from a well-made analysis of these various elements of the 
 question. 
 
 Treatment. — There are few uterine diseases which resist treatment 
 more than deviations. This is owing to the difficulty of discovering 
 the true causes, and still more of finding suitable means of combating 
 them successfully. 
 
 The best indications are those drawn from the nature of the malady. 
 Unfortunately this nature has been very little known till lately. This 
 ignorance of the indication as well as the difficulty of resolving it un- 
 fortunately led the last medical generation to form a hopeless prognosis, 
 which may be summed up in Velpeau's words : *' Versions do not kill, 
 but they are never cured." In fact when once produced they have 
 little tendency to improve ; on the contrary, they almost always become 
 worse, and exercise a more and more marked influence on the general 
 health, which is gradually disordered, as in all chronic uterine affec- 
 tions. Till lately they have resisted the (apparently) most rational 
 treatment, condemning women to a miserable life owing to the rest to 
 which they were forced to submit, and the necessity of using all their 
 lives means of retention as troublesome as insufficient. During the last 
 few years, however, owing to a more exact analysis, the true causes of 
 deviations have been discovered, and have been found to differ in each 
 case, so that there is now reason to hope that a curative treatment 
 may be instituted for each. 
 
 i have observed with great interest that several physicians have fol- 
 lowed me in the path of analysis which has led me to discover the true 
 cause of each deviation and each flexion, or they may have set out in 
 ignorance of my investigations arriving at an analogous result, which 
 is the best confirmation of the correctness of my conclusions. These 
 conclusions, of which I gave some indications in the first edition of this 
 work, and which I explained clearly in the second edition in 1871, have 
 since been developed in a paper on retroflexion read before the IVench 
 Association for the Advancement of Science in 1874. In Germany 
 and England the cause of flexions and versions has been appreciated in 
 the same way by very competent men, especially by Schultze and 
 Barnes. I can therefore confidently present tlie results at wliich I 
 
398 UTERINE DISEASES IN DETAIL 
 
 have arrived, and will here state them in so far as they relate to 
 versions. 
 
 Anteversion, so long as the mobility of the organ is preserved, is 
 only an exaggeration of the normal direction of the womb; when there 
 is immobility owing to neo-membranous adhesions above the bladder 
 or exudations and retractile cicatricial tissue in Douglases pouch, or 
 contraction and shortening of the utero-sacral ligaments, it is patholo- 
 gical and requires serious treatment. 
 
 Retroversion is always abnormal or pathological ; it involves a 
 direction of the organ quite contrary to its normal one, and may reach 
 a degree considerably exceeding the greatest degree of anteversion. It 
 is also due to the elongation of Douglas's ligaments, although other 
 causes may incline the organ in this direction. We must therefore 
 consider how these ligaments can be shortened. 
 
 The shortening or the elongation of these ligaments may be associated 
 with the shortening or elongation of the broad ligaments or some other 
 such alteration in the same or in a contrary direction, on those of the 
 same or a different side, whence a mixed inclination accompanied by 
 torsion, latero-position, &c. &c. 
 
 1 . Treatment of Versions in general 
 
 The indications are necessarily grouped under three heads, according 
 to whether they are addressed to the cause of the malady (medical 
 treatment), or only to its effects (mechanical treatment), for which the 
 indication may be either reduction or the maintenance of reduction 
 when once it has been effected. 
 
 I. General and local medical treatment is that which is addressed 
 to the cause. 
 
 The original cause of the deviation possibly being in the uterus, any 
 increase in volume or in the weight of the organ will be treated, accord- 
 ing to whether its nature be congestive, hypertrophic or inflammatory, 
 by resolvents, alteratives or antiphlogistics, as well as by antidiathetics 
 appropriate to the affection which keeps up the congestion. If the 
 tumefaction of the uterus depends on pregnancy it will be treated 
 simply by posture, and often this cannot be done till after reduction, 
 but it will very seldom be treated by abortion or evacuation of the 
 uterine cavity. If it depends on the presence of a tumour, it may in 
 some cases be treated by extirpation of the tumour. — If the cause 
 proceeds from an alteration in the means of suspension it will be 
 treated by resolvents, tonics and all general and local means suitable 
 for overcoming sometimes contraction (for anteversion), sometimes 
 elongation of the ligaments (for retroversion), such as restoratives, 
 iron, mineral waters, hydropathy, electricity, strychnia, &c. The 
 same means may be employed in different cases or in complex cases, 
 for they may be applied simultaneously with equal effect to total or 
 partial tumefaction of the uterus or to the alteration of its suspensory 
 organs, and it is unnecessary to say that posture may favour their 
 action. By the use of these means we usually succeed in obtaining a 
 
DEVIATIONS 399 
 
 tolerance analogous to that which characterises the arrival of the meno- 
 pause which puts an end to complications and reduces the version to 
 its simple state. 
 
 II. Reduction is directed to the effect, i. e. to the version. It may 
 be impossible owing to adhesions or even to extreme contraction of the 
 ligaments, as in certain anteversions. Even then we must not give 
 up hope of triumphing over them by resolvents. It may be difficult, 
 e. g. when the gravid uterus is fixed in the pelvis in a state of retro- 
 version : in this case the difficulty may reach impossibility, therefore 
 evacuation of the bag of waters^ by puncture has been tried, in order 
 to make reduction possible. Supposing reduction is possible, how 
 should it be performed when the uterus is empty and when it is full ? 
 When it is empty the hand, the sound or other instruments may be 
 used. When it is full it is sometimes indispensable, after employing 
 the instruments or manoeuvres of reduction, to subject the patient to 
 certain preliminary operations, catheterism, or vesical or uterine punc- 
 ture, &c. In all cases and before any reduction care must be taken to 
 empty the bladder and rectum. 
 
 Reduction requires that the patient should be placed in a special 
 posture, varying according to the direction of the inclination. In 
 reducing anteversion the most favorable position is the dorsal decu- 
 bitus with forced flexion of the lower limbs and elevation of the pelvis. 
 In retroversion it is the genu-pectoral posture. — The manoeuvres 
 of reduction are performed by the introduction of one or more 
 fingers or of the whole hand into the vagina, combined with hypo- 
 gastric palpation and pressure; in a w^ord, by bimanual palpation. 
 In rare cases, where the hand does not suffice to reach and push 
 back the uterus through the vaginal walls, some simple instru- 
 ment that could not hurt the vaginal mucous membrane can be used. 
 Marion Sims uses sponge-holders furnished with sponges, one of which, 
 resting in the posterior cul-de-sac of the vagina, raises the fundus of 
 the uterus in retroversion, whilst the other, resting afterwards on the 
 anterior lip of the cervix, assists the action of the other and completes 
 the reduction ; the latter may be replaced by a tenaculum hook fas- 
 tened into the cervix and drawing it backwards. If the introduction 
 of the hand into the vagina does not suffice we must try to effect re- 
 placement of the uterus by the rectum, introducing one or more fingers, 
 or the whole hand as Dusaussoy did, or an empty bladder, which is 
 distended with air when in place, or a wooden instrument, &c. These 
 vaginal or rectal manipulations may be aided not only by pressure on 
 the hypogastrium, but also by raising the uterus by means of a sound 
 introduced into the bladder. Lastly, in a state of vacuity, the 
 sound should be used after the other means to eS'ect reduction. In 
 every case it is the best means of determining whether reduction is 
 possible or whether it is hindered by utero-peritoneal adhesions or 
 extreme contraction of the ligaments ; but the possibility of these 
 serious complications must never be lost sight of, the sound being 
 
 ' Wm. Hunter, Med. Ohs. and Inquiries, iv, 40G. — Cliurcliill, op. cit., p. 
 428. Dublin, 1864. 
 
400 UTEEINE DISEASES IN DET2VIL 
 
 used with great care, so as to prevent the effects of a dangerous trau- 
 matism in the case of these obstacles existing. 
 
 III. Retention is easy in pregnancy^ i. e. when reduction itself has 
 been difficulty as occurs in cases of hernia or luxation necessitating 
 replacement of the organs in their natural relations. In proportion as 
 the foetus is developed and the uterus rises it becomes less and less 
 possible for this organ to enter the pelvic cavity, and consequently 
 for the deviation to be reproduced. — In all other cases, on the con- 
 trary, retention is very difficult. Therefore it is necessary to repeat 
 the manoeuvres of reduction from time to time, so that the advantages 
 of the instruments of retention may not be lost. The idea has been 
 entertained of making use of the instrnments of reduction for reten- 
 tion strictly so called. Such was the origin of the methods so much 
 talked of a few years ago, and which, like so many others, have been 
 alternately too much praised and too much decried. 
 
 1. Uterine pessaries. — The simplest of these instruments is Simp- 
 son's stem pessary, the ball of which by filling the uterine extremity of 
 the vagina suffices to keep the instrument in place and the uterus 
 reduced.^ I think it should be used as little as possible, its applica- 
 tion being reserved for flexions, and care being taken not to leave it 
 in the uterus for more than a few hours. In the following chapter I 
 will indicate the best way of making short and repeated applications of 
 the galvanic director and the advantages to be obtained from it. 
 
 2. Vaginal pessaries. — The dangers inherent in the use of intra- 
 uterine pessaries have led to their being almost completely abandoned for 
 vaginal pessaries. Globular pessaries have been tried, care being taken 
 to apply them in the anterior vaginal sinus in cases of anteversion,^ in 
 the posterior pouch or in the rectum in cases of retroversion, so as to 
 take up the place which the body of the organ would occupy in leaning 
 forwards or backwards, and consequently to prevent the return of this 
 inclination. This mode of retention, however, can only be eflfectual 
 when there is a considerable and painful distension of the vagina. A 
 good plug of cotton saturated with glycerine or charged with tannin 
 may render great service if placed behind the cervix in anteversion, and 
 before it in retroversion; in the latter case its action will be assisted if 
 the perinseum is raised by means of a good perinseal pad. The ineffi- 
 ciency of the globular pessaries has led to their form being modified so 
 as to make them bulge more at the side, where they have to exercise 
 pressure on a higher level in the vaginal cul-de-sac to prevent the 
 fundus from falling back into it. Even this, however, is insufficient. 
 Hence Hervez de Chegoin's idea of the shovel pessary (see Pig, 172, 
 p. 197), intended both to maintain the position of the cervix 
 
 ^ Valleix, ty giving more fixity to the instrument, by the form and adjust- 
 ment o£ his plate and by the supporting bandage which he added, spoiled in 
 place of improving it ; and the fatal results due to its use are to be attributed 
 to this absolute immobility which he gave it. 
 
 2 Steiger succeeded in curing an anteversion causing sterility, of many yeare 
 standing, in two months, by advising the patient to retain her urine as long as 
 possible. The distended bladder in this case acted better than the best pessary 
 would have done. 
 
DEVIATIONS 401 
 
 and to straighten the fundus; Kennedj''s pessary was of the same 
 kind. These pessaries suppose the integrity and resistance of the 
 perinseum which forms their basis of support. In the numerous cases 
 in which this support is wanting it must be replaced by a T bandage, 
 or else elastic pessaries of the same shape must be substituted. They 
 may also be replaced by the pessary of Simpson and Priestley {see 
 Fig. 173, p. 197), or better still, by Hodge's sigmoid parallelogram 
 (see Fig. l75, p. 197) in aluminium. In treating of prolapsus I 
 described its mode of action and the way in which it should be intro- 
 duced (Fig. 260). It is equally useful in the treatment of retro- 
 version, though it cannot be trusted to absolutely ; whilst its insuf- 
 ficiency for anteversion is evident. A lever pessary should be modelled 
 in tin mixed with a little lead to the size and form of the vagina of 
 each patient. When properly adjusted this malleable model is sent 
 to an instrument maker, who makes a replica in silver or aluminium. 
 This pessary often alleviates pain in retroversion, and it rectifies the 
 position of the organ sufficiently to facilitate conception by the mechan- 
 ism explained when treating of prolapsus (p. 379). I have modified 
 Hodge's pessary, making it suitable for retroversion and retroflexion, 
 by adding to it a cervical arch, which keeps the cervix back, preventing 
 it from coming forwards again, and which consequently prevents the 
 fundus from falling back. At the union of the cervical arch with 
 Hodge's lever two pieces of whalebone allow the two parts of the 
 instrument to approach each other in order to facilitate its intro- 
 duction by the vulva. 
 
 3. Means of retention to he applied in the neighbourhood of the 
 uterus. — The use of large tampons in the rectum has been pro- 
 posed by Huguier^ in the treatment of retroversion and retroflexion. 
 But for such high authority I should have thought such a means 
 impossible, on account of the pain and tenesmus that it would pro- 
 voke, not to speak of the repugnance it inspires. The hypogastric belt 
 (Fig. 148) is useful during pregnancy in supporting the uterus when in- 
 clined more or less forwards. In a state of vacuity it is also frequently 
 useful, because it supports the abdominal viscera and prevents their 
 weight from pressing painfully on the uterus, especially in the case of 
 anteversion. In the case of retroversion I am convinced that the use of 
 the hypogastric belt increases the pain, owing to the propulsion of the 
 viscera towards the vertebral column, which, combined with the weight 
 of these organs, produces a resultant directed into the cavity, i. e. 
 against the retroverted uterus. The uterus probably then supports a 
 more considerable pressure than when a portion of the visceral pressure 
 is not pushed back by the belt, but is freely exercised on the hypo- 
 gastrium. This explanation seems to me all the more likely as 
 patients affected with retroversion always complain of the use of a 
 hypogastric belt, and I have relieved a great many by simply making 
 them lay it aside. Many physicians are in the habit of prescribing it 
 for every deviation, with the mistaken idea of immobilising the uterus 
 and viscera without considering the real eff'ect that it produces. 
 I Be Vhysterometrie, p. 337. Paris, 1865. 
 
 26 
 
402 UTERINE DISEASES IN DETAIL 
 
 Thus, on the one hand the hypogastric belt, alone or aided by the 
 perinseal pad [see Pigs. 150, 151, 152, p. 192), on the other hand the 
 perinseal pad associated with the use of a Hodge's lever pessary in the 
 vagina, or better still my modification of it, are more generally effectual, 
 the former in anteversion, the latter in retroversion, I have sometimes 
 used them with great advantage for patients who could not walk with- 
 out them. In applying them I have never thought of immobilising 
 the uterus, but only of maintaining, by the equal pressure in aU direc- 
 tions which this organ then receives, the rectitude of its position or 
 at least its stability sufficiently to prevent its exercising pressure or 
 causing dragging pains or undergoing the same from neighbouring 
 organs ; in short, from experiencing or provoking pain. _ 
 
 4. Operations for retention. — Lastly, cauterisation maybe employed 
 as a natural means of retention which may become curative. It may 
 be applied in two ways : as a resolvent of an engorgement or chronic 
 hypertrophic congestion, or as a means of replacing the uterus in position 
 by the retractility of the cicatricial tissue which foUows the suppuration 
 produced by burning. The former mode, by diminishing the tume- 
 faction and weight of the organ, diminishes also its tendency to incline 
 towards the side on which its centre of gravity is deprived of support 
 or suspension. In such a case cauterisation ought to be applied largely 
 to the cervix or deeply to its tissue by ignipuncture applied to several 
 points of the most tumefied portion ; it may be destructive if the 
 latter is much swollen ; in any case it acts as an alterative, bringing 
 into play a work of absorption and resolution under the influence 
 of which the size of the organ may diminish in a few weeks and 
 especially in a few months in a notable manner, especially when this 
 action is seconded by hydropathy and resolvent medication. The 
 second mode, that oi replacing tke organ, -which 1 have employed for a 
 long time after the example of Amussat^, aims at forming a cicatricial 
 band, extending from the neck to one of the vaginal walls and occu- 
 pying the utero- vaginal sinus which corresponds to the inchnation. 
 That is to say when there is anteversion the caustic must be applied 
 in the anterior sinus, so that the cicatricial band in contracting may 
 bring the cervix near to the anterior wall of the vagina, and by 
 making the whole organ swing in its suspensory ring, separate its 
 fundus from the bladder and raise it in the cavity ; in cases where the 
 anteversion was not pathological I have had some success from the 
 use of this means. When on the contrary there is retroversion, the 
 caustic or fire must be applied in the posterior sinus, so that the 
 cicatrix in retracting brings the cervix near to the posterior wall of 
 the vagina, and removes the fundus from the rectum; but it is 
 dangerous to use this means in a case of retroversion on account of 
 the peritoneum being so near. The suture of a transverse fold of 
 the vagina may be resorted to in place of cauterisation, so as to 
 shorten one or other of the walls of this canal. Marion Sims has 
 performed this operation three times in cases where the anterior wall 
 
 1 Comptes rendus de VAcad. des scioices, iev., 1859. — Philippeaux, De la 
 cauterisation, p. 557. Paris, 1856. 
 
DEVIATIONS 403 
 
 of the vagina was extraordinarily long, and appears to have been suc- 
 cessful. There would be less chance of curing retroversion by per- 
 forming the same operation on the posterior wall, and it would be 
 more dangerous as I have just explained. 
 
 2. Treatment of Versions in particular. 
 
 Having described the course to be pursued in the general treatment 
 of deviations, we must now indicate the means to be employed in the 
 special treatment of each. 
 
 I. Anteversion, like anteflexion, is normal, and continues to keep 
 this character even when it has attained a considerable degree, 
 so long as the uterus preserves its mobility, a proof of the absence of 
 adhesions and of perimetritis. A hypogastric belt with a pad will 
 suffice to relieve the patient by supporting the viscera and so prevent- 
 ing them from pressing painfully on the posterior (now the superior) 
 surface of the uterus. When anteversion is pathological and the 
 peritoneal adhesions are in front (utero-vesical) between the fundus 
 of the uterus and that of the bladder, or behind (posterior perime- 
 tritis) between the cervix and the rectum, or if the pathological ante- 
 version is produced either by retraction and shortening of Douglases 
 ligaments consecutive to a subacute inflammation, or to a spasmodic 
 contraction of these ligaments, it will always be well to prevent the 
 viscera from painfully compressing the uterus by supporting them with 
 a hypogastric belt. 
 
 At the same time energetic general and local resolvent treatment 
 should be applied according to the sensitiveness of the patient, her 
 tolerance and the varying indications due to the varying circum- 
 stances of which I have spoken. Excepting the variations to be intro- 
 duced into this treatment, we may mention : repeated laxatives 
 and purgatives, diuretics, alteratives (iodide or bromide of potas- 
 sium long continued in large doses, chloride of gold and sodium, &c.), 
 alkalines, especially the natural and artificial baths at Yichy, with 
 vaginal injections combined with hydropathy, sometimes rest and the 
 dorsal decubitus continued for long, or sedative, antispasmodic, alkaline 
 injections, &c., on the bidet four times a day, the use of tampons 
 saturated with glycerine or belladonna, rectal injections of mercurial 
 ointment mixed with laudanum and belladonna, or a solution of iodide 
 of potassium, or suppositories of the same composition, sometimes 
 with the addition of hydrate of chloral, chloroform or laudanum as 
 antispasmodics, &c. Fortunately version, when simple, after all in- 
 flammation has disappeared, is not painful. By the use of the means 
 just mentioned a cure is generally obtained; but time is required, one 
 or two years (two seasons at Vichy), but the long-desired result is at 
 length attained. 
 
 II. Retroversion is alioays pathological^ for it is the opposite of the 
 normal conditions of stability of the organ. Rupture, elongation of 
 Douglas's folds, relaxation of the retractile muscles which support the 
 uterus are the most common causes. The use of the sound is almost 
 always indispensable to reduce it; one or more fingers should be 
 
404 UTERINE DISEASES IN DETAIL 
 
 introduced into the posterior vaginal cul-de-sac or into the rectum, 
 and everything that is possible should be done to liberate the wedged- 
 in organ, e.g. evacuate the bladder and rectum, not forgetting to make 
 the patient assume the genupectoral posture. 
 
 The importance of the genupectoral posture in the reduction of 
 deviations and prolapsus has been explained by H. P. Campbell.^ It 
 is particularly useful in the rednction of extreme retroversion, which by 
 this posture becomes an automatic reduction, to use the author's own 
 expression. I have certainly seen the uterus replaced with great ease 
 when this posture is assumed : all that is necessary is to introduce one 
 or two fingers into the vagina so as to separate the labia majora (the 
 patient can separate the vulval lips for herself by means of a simple 
 canula), and to allow the air to penetrate into the vagina. This dis- 
 placement of the centre of gravity and of the weight of the viscera, 
 which have a tendency to fall towards the umbilicus, the traction exer- 
 cised by the abdominal organs on the uterus by the close contact of 
 the one with the other, the atmospheric pressure acting through the 
 vagina, which it greatly dilates in the form of an arch, below which, 
 in the most dependent part, the vaginal portion of the cervix is seen, 
 are the three agents to which retroversion of the womb can offer no 
 resistance : if reduction is not effected spontaneously the impulse which 
 the fingers of the physician give to the uterus in forcing its fundus out 
 of the concavity of the sacrum obliges this organ to resume its normal 
 direction. I have insisted on the possibility of reducing retroversion 
 by this method in order that physicians may understand its importance 
 and explain it to their patients, so that the latter may be willing to 
 assume this posture as well as the abdominal decubitus, which is so 
 useful to them. After they have once become accustomed to it they 
 are so much relieved that they willingly continue it till they are com- 
 pletely cured. 
 
 As for the retention of the uterus in its normal position, the only 
 means of maintaining reduction is to keep the cervix back in the sacral 
 cavity. This can be done by means of a sponge {see Eig. 154, p. 193) 
 or tampon saturated with a solution of tannic acid or alum, or by 
 means of Hodge's pessary, as modified by myself, which forces the 
 cervix to remain against the sacrum. 
 
 It is well to use both alternately ; the pessaries retain the cervix 
 better, whilst plugs have the advantage of conveying astringent applica- 
 tions to these parts suitable for inducing contractility in Douglas's 
 ligaments and determining retraction or shortening, the only and indis- 
 pensable condition of permanent replacement of the organ. The good 
 of these pessaries and tampons is that, by retaining the cervix in the 
 sacral cavity they force the fundus forward, and so the whole organ 
 resumes its normal direction of anteversion; the abdominal viscera, 
 which formerly increased the retroversion, contribute now, on the con- 
 trary, by their pressure on the posterior (now superior) surface of the 
 
 ^ Pneumatic self replacement in dislocations of the gravid and non-gravid 
 uterus {Transactions of the American Gynecological Society, vol. i, p. 193. 
 Boston, 1877). 
 
DEVIATIONS 405 
 
 uterus^ to maintain this organ in the natural position to which we have 
 restored it. When the patient is not standing she ought to assume 
 the abdominal decubitus, which forces the fundus to gravitate 
 downwards. 
 
 It is important to ensure the persistency of the reduction by using 
 all possible means to excite the contraction of the ligaments and bring 
 about their shortening: astringents (alum, tannin, rhatany, &c.) applied 
 to the posterior cul-de-sac of the vagina, round the vaginal portion of 
 the uterus, or ergot taken in doses of from four to eight grains three 
 or four times a day for five or six days, and repeated after a week's 
 interval; the application of electricity by the interrupted current, one 
 of the poles being applied to the lumbo-sacral region, the other round 
 the cervix; immersion in a cold sitz-bath six times a day; hydropathy, 
 cold and astringent vaginal injections, sea bathing, salt or aromatic 
 baths or tonic and exciting frictions of the whole body every 
 morning. 
 
 "When retroversion has become irreducible owing to the formation of 
 adhesions as a consequence of posterior perimetritis, the deviation is 
 doubly pathological; pathological by its direction which is absolutely 
 the reverse of the normal state, pathological by the inflammation which 
 now complicates the retroversion, and sometimes is even in part the 
 cause of it. These peritoneo-cicatricial bands not only constitute a 
 malady in themselves, . but they form a pathological condition in a 
 second way, viz. as causes of irreducibility, and in a third sense by 
 continually threatening a return of inflammation, all the more easily 
 produced in that the compression, dragging and shocks which the 
 uterus receives from or produces on the neighbouring organs in its 
 vicious position (for the adhesions involve the contact of the fundus 
 with the lowest portion of Douglas's cul-de-sac') are so many exciting 
 causes of a fresh outburst of inflammation. — Therefore these retro- 
 versions are almost as painful as retroflexions. The extremely low posi- 
 tion of the fundus near the perinseum and anus, the weight and the 
 inflammatory pain of this heavy part, the pain produced by the least 
 shock or dragging on the adhesions (and every movement occasions 
 dragging or shock), continually provoke the slow return or sudden 
 outburst of new pain. — Therefore the most energetic antiphlogistic 
 and resolvent treatment must be associated with a wise mechanical 
 treatment, according to the indication and the variations which it must 
 undergo, depending on the stage of the malady. 
 
 At the commencement, antiphlogistics, sometimes leeches, repeated 
 laxatives, rectal injections of resolvent and sedative ointment {^see 
 p. 185) applied twice a week, alkaline, gelatinous, emollient and seda- 
 tive baths every day for several hours' duration with vaginal injections 
 all the time, and the abdominal decubitus, with, later on, Vichy waters 
 and hydropathy, bromide and iodide of potassium, sometimes even 
 blisters on the loins, thighs or sacrum, produce astonishing results. 
 We find after repeated attempts to efl'ect reduction that the deviation 
 becomes gradually mobile, moving gently under the simultaneous 
 pressure of both hands, and sometimes in the end allowing of reduc- 
 
406 UTEEINE DISEASES IN DETAIL 
 
 tion with the help of the sound : these cases I admit are rare^ but they 
 are to be met with in young women, and it is a great matter to know 
 that such a deviation when taken early is not incurable. — It is evident 
 that as long as the retroversion remains irreducible it is useless to 
 struggle against the adhesive perimetritis by the use of instruments 
 for restoring the uterus to position, the only effect of which would be 
 to keep up and to increase the inflammation. Patients may, however, 
 be relieved by the use of a perinseal pad attached to a good belt (not 
 a hypogastric belt with pad), which raises the perinseum, the pouch of 
 Douglas and the body of the uterus ; whilst the inflammation and the 
 adhesions produced by it are placed in the state of absolute rest which 
 is required by all inflamed organs. — When the adhesions have disap- 
 peared and replacement is obtained, reduction should be repeated as 
 often as necessary, and the patient should be taught to do it herself 
 with the help of her nurse or husband, according to Campbell's 
 method, by assuming the genupectoral posture at bedtime, and the 
 abdominal decubitus all the night. The reduction should be main- 
 tained as much as possible during the day by the use of my pessary, 
 whilst contraction of the suspensory ligaments and of the uterine tissue 
 itself may be excited by introducing the galvanic intra-uterine stem 
 for a few hours once or twice a week. The treatment of retroversion 
 is more difficult than that of any other version, and in many cases we 
 have to content ourselves with a palliative cure ; nevertheless, so much 
 progress has been made in this department of medicine during the last 
 few years by patient investigation of the anatomical alterations which 
 are the causes of this malady, that we have reason to hope we may 
 obtain a large number of cures in the future. 
 
 III. Latero-versions are always pathological, whether simple, i. e. 
 determined by the simultaneous contraction of the posterior ligaments 
 and the broad ligaments of the same side, or complex, with torsion of 
 the axis, determined by contraction of one of Douglas's ligaments on 
 one side and one of the broad ligaments on the other. In all cases 
 there has been parametritis or perimetritis, spasmodic contraction and 
 retraction, either cicatricial or consequent to subacute or chronic in- 
 flammation. There is really no other treatment for it than that which 
 I have already indicated for pathological anteversion (p. 408). 
 
 Elexions 
 
 1. Flexions in General 
 
 Flexions, inflexions, incurvations of the uterus are alterations in the 
 direction of the various parts of the axis of this organ with regard to 
 each other. According to my experience they are more common than 
 versions. They involve a modification in the form of the organ, but do 
 not imply a change in its position or direction. The uterus may 
 remain in its normal position whilst bent on itself, or it may simulta- 
 neously experience a double or treble change in its form, direction and 
 position. It must be admitted that version and flexion of the same 
 side are met with more frequently combined than separately. They 
 
FLEXIONS 407 
 
 may be congenital or accidental, simple or complex, having their seat 
 at one point or another and at various degrees, bending the organ 
 forwards, backwards, or on one side. 
 
 Congenital flexions occur from inequality of development or imper- 
 fection of histological formation. — Accidental or acquired flexions 
 involve a predisposition and a determining cause or pathological altera- 
 tion. They are the consequence of the accomplishment of the uterine 
 functions and of modifications produced in the tissue of the organ : 
 menstruation, pregnancy, delivery, abortion, predispose to them in con- 
 sequence of the tumefaction of the organ, the increased size of its cavity, 
 the relative defect in the resistance of its walls, the alteration of its 
 constituent elements, &c, ; so that a very slight cause, a vicious posi- 
 tion, pressure or shock, may suffice to flex the organ on itself, owing 
 to defective resistance of its tissue. Lastly, a uterine or peri-uterine 
 pathological alteration may produce the same eflfect independently of 
 any predisposition : a partial tumefaction of the softened organ, the 
 unequal increase of size in the two segments, a retraction or partial 
 fibrous transformation of one of the uterine walls, a fatty degeneration 
 and defective resistance of the tissue at the isthmus or some other 
 point, the elongation of the uterus or of one of its parts, peri-uterine 
 inflammation and its consequences, peritonitis whilst the fundus is in 
 retroversion or after labour and the formation of adhesions between the 
 fundus and the utero-rectal cul-de-sac, preventing the replacement of 
 the body whilst the cervix may resume its normal direction : such are 
 the causes which may flex the uterus on itself. 
 
 Simple flexions are rare, complications usually occurring as conse- 
 quences, if they had not previously existed as causes. — Flexions with 
 complications are more common. Amongst the maladies which most fre- 
 quently coexist with flexions are : uterine and peri-uterine inflammation ; 
 total or partial hypertrophic elongation of the uterus ; peritoneal adhe- 
 sions between the fundus or body of the uterus and the neighbouring 
 organs; engorgement, chronic congestion, repeated fluxions; tumours of 
 various kinds, intra- or extra-uterine, which may, by increase of weight or 
 pressure or from being wedged in, keep the uterus flexed on itself ; lastly 
 deviations and displacements, which may coexist with flexions either 
 together or separately, so that prolapsus, retroversion and retroflexion 
 may be met with simultaneously. These complications are so frequent 
 that several writers describe flexions with versions' and other mechanical 
 lesions of the womb; but although this combination is frequently 
 found in nature they should not be confused together in a common 
 description. Other physicians, rightly appreciating the great sym- 
 ptomatic difference which exists between anteversion and retroversion, 
 anteflexion and retroflexion, as well as the analogies between ante- 
 flexion and anteversion, retroflexion and retroversion, as concerns 
 diagnosis and treatment, have given a common description of inclina- 
 tions forwards (flexions and versions) and of inclinations backwards 
 (flexions and versions) ; it seems to me, however, that what i-^ gained 
 on the one hand by bringing together lesions which furnish similar in- 
 dications, is lost on the other by separating maladies giving rise in many 
 
408 UTERINE DISEASES IN DETAIL 
 
 points to common symptoms. Their coincidence can be seen and 
 explained. Thus, when flexion is very marked, especially backwards, 
 it increases the weight of the uterus and gradually determines retro- 
 version ; this retroversion becomes permanent owing to the elongation 
 caused by continuous traction on the uterine ligaments. This will be 
 still more the case when flexion is produced after delivery, when the 
 ligaments are soft and relaxed like the tissue of the uterus itself; 
 hence retroflexion and retroversion are often met with simultaneously, 
 for the same cause produces the same effects on the uterus and on the 
 ligaments, so that the organ is both flexed and deviated. In many 
 other circumstances, however, especially in congenital flexions, the 
 bent uterus is not deviated; the tissue of the organ only is altered, 
 that of its ligaments being healthy. 
 
 The seat of the flexion is variable. Usually it is at the isthmus. 
 The flexed uterus resembles a chemical retort. The reason why flexion 
 occurs most frequently at this point will be found, according to 
 Virchow, in the adhesions between the neck and the bladder. I think 
 a stronger reason may be given, viz. the relative defective resistance of 
 tissue at this point of junction of two different organs (body and 
 neck) united into one (uterus). It must not, however, be thought that 
 it is always so, and that uterine flexion necessarily means flexion of the 
 body on the neck. The alteration of tissue, weakness or contraction, 
 may be only in the body or only in the neck. Why should we not 
 admit this when we know that it is often produced on one of the seg- 
 ments of the uterus, the anterior or posterior, to the exclusion of the 
 other, and even, according to Martin, on one part of a segment (the 
 seat of "the placenta) to the exclusion of the others ? Thus there are 
 flexions of the body and flexions of the neck. Further, the flexion may 
 affect both body and neck. In the latter case it is produced in the 
 same direction, and gives to the uterus a horseshoe curve, the two ex- 
 tremities of which, fundus and os, are directed to the same side, a 
 deformity usually congenital, especially in anteflexion ; but it some- 
 times happens that two flexions are produced in opposite directions, 
 e.g. curving the body backwards and the neck forwards, so that the 
 fundus and cervix look in opposite directions, and the uterus, as a 
 whole, takes the form of an S. 
 
 Whether the flexion have its seat on the isthmus or on one of the 
 segments of the uterus, it may vary in degree, from the slightest curve 
 to the most marked flexion, the two portions of the organ forming 
 between them an obtuse angle in the first case, and an acute angle in 
 the second. Curvature or inflexion is almost a physiological state, 
 especially when it is forwards ; it is very common, and is frequently 
 associated with deviations. 
 
 Flexion properly so called is very frequent. It may require the help 
 of art and derive benefit from it. — Under the name of infraction 
 Sommer^ has described the very rare state in which the uterus is flexed 
 
 ^ Beitrdge zur Lehre der Infractionen und Flexionen der Gebdrmutter, 
 Deutsche KliniJc, 1850, S. 276. Quoted by Paul Picard, Des inflexions de 
 I'uterus a I'etat de vacuite. Paris, 1862. 
 
FLEXIONS 
 
 409 
 
 Fig. 267.— Flexion of the neck 
 forwards with conical neck 
 and narrow os. 
 
 on itself to such an extent that the two portions of the same surface 
 become parallel and contiguous. 
 
 Lastly, whatever the seat or the de- 
 gree, flexion may take place in different 
 directions. 
 
 Flexion of the necTc, the importance 
 of which seems to have been exag- 
 gerated in America,^ seems almost al- 
 ways in one direction, viz. forwards; it 
 also usually coincides with anteflexion 
 of the body, as well as with elongation 
 of the neck, narrow os, and several of the 
 conditions of mechanical dysmenorrhcea. 
 According to the authors who have de- 
 scribed it, it is the most common of all. 
 Flexion of the body is more variable. 
 
 Sometimes it is forwards and goes by 
 the name of anteflexion, which is the most 
 common amongst nuUiparse. In the foetus 
 this disposition may be regarded as nor- 
 mal, and depends either on the imperfect 
 development of the anterior wall at that 
 age, or on the thinness and softness of the 
 body coinciding with thickness and rigi- 
 dity of the neck ; in the adult it often depends on the persistence of this 
 fcetal disposition or on the retraction of the tissue of the anterior segment 
 of the organ, as well as of the utero-sacral ligaments, consequent on 
 retro-uterine inflammation, which has procured for this variety the name 
 of pathological, as distinguished from congenital, anteflexion. The fun- 
 dus touches the upper surface of the bladder ; the neck rests in the axis 
 of the vagina, lower than or on a level with the fundus, according to 
 the degree of the flexion ; usually it is flexed forwards, i. e. in the same 
 direction as the fundus, in the form of a horseshoe, very seldom back- 
 wards, in the form of the letter S. 
 
 Sometimes it is backwards, and is then designated retroflexion. 
 Seldom congenital, and therefore less frequent than anteflexions, occur- 
 ring generally after delivery or miscarriage, i. e. usually pathological 
 and more common then than pathological anteflexion, often met with 
 in old women, it necessarily involves a softening of the tissue on a 
 level with the isthmus or with the seat of the curvature, relaxation or 
 elongation of the suprapubic ligament, rupture or distension of the 
 utero-sacral ligaments ; in short, the opposite of anteflexion. The 
 fundus rests on the anterior surface of the rectum, in the peritoneal 
 vagino-rectal cul-de-sac (Fig. 1), where it may be easily felt, either 
 through the vagina or through the rectum, sometimes higher than the 
 neck, sometimes on the same level, sometimes lower. Tlie neck may 
 
 ^ Emmet, The Etiology of Uterine Flexures, with the Proper Mode of 
 Treatment Indicated {Transactions of the American Gynecological Society, 
 vol. i, p. 48. Boston, 1877). 
 
410 
 
 UTEEINE DISEASES IN DETAIL 
 
 also be flexed in the same direction or in the opposite one ; but this 
 coincidence of flexion of the neck with that of the body occurs less 
 
 Fig. 268. — Anteflexion sup- Fig. 269. — Extreme retroflexion, present- 
 
 posed to be congenital, in ing occlusions at several points in the 
 
 a girl of eighteen (after canal or cavity of tlie uterus. Pre- 
 
 Boivin and Duges). paration in the Middlesex Hospital 
 
 (after Barnes). 
 
 frequently in retroflexion than in anteflexion. Statistics show that re- 
 troflexion is much more frequent than anteflexion in multiparse ; whilst 
 all the physiological dispositions tend to anteflexion and anteversion, 
 all the pathological causes incline to retroflexion and retroversion. 
 
 In latero-fiexions and in intermediate curvatures the fundus of the 
 uterus is discovered by exploring on each side of the neck or of 
 
 Fig. 270. — Uterus strongly inclined to the right, or appearance of dextro- 
 flexion. Probably the left side is imperfectly developed (after Tiedeman). 
 
 Douglases ligaments, as we try to depress the lateral vagino-uterine 
 sinus with the finger. These flexions are much rarer than the pre- 
 ceding, and always result from some anomaly or pathological condition 
 of the ligaments or of the two segments of the uterus (Fig. 270). — 
 Torsion of the uterus is still rarer; iL coincides with latero-flexions 
 and seems to depend on the same causes, especially on the alteration 
 
FLEXIONS 
 
 411 
 
 and change in the length of the hgaments of one side occurring at the 
 same time with softening of the tissue of the uterus (Fig. 271). — 
 Alterations of the tissue of the uterus, ligaments or neighbouring parts, 
 and the other uterine lesions concomitant with flexions, are variable 
 in different flexions, in the same flexion at different periods, and in 
 different women. 
 
 In the first place one of the alterations must have existed before the 
 uterus could become bent on itself; in the second place the uterus 
 cannot long remain flexed in the period of sexual activity without, 
 under the influence of menstruation, coitus, &c., and by the fact 
 
 Fig. 271. — Dextroflexion and torsion of tlie uterus from right to left. Pre- 
 paration in the College of Sui'geons, London, by Protheroe Smith {British 
 Medical Journal, 1872, vol. i, p. 517), after Beigel, op. cit., vol. ii, p. 218, 
 1875. c, neck, with a probe introduced to indicate the direction of the 
 canal ; i, point of flexion at the union of the body and neck ; f, fundus ; 
 T, left Fallopian tube ; o, right ovary, diseased ; t', right Fallopian tube, 
 diseased. 
 
 of its flexion, producing some alteration in its substance or 
 surroundings. 
 
 The increased size of the uterus, the elongation of its longitudhial 
 diameter, the softening of its tissue,^ especially at the isthmus which 
 is the thinnest portion of the organ,^ the coincidence of these altera- 
 tions with elongation, laxity or atony of the means of suspension, 
 especially of the utero-sacral, broad and round ligaments are very 
 favorable if not necessary conditions in the production of uterine 
 flexions. This is why flexions so often occur after delivery or abor- 
 tions,^ and why in such cases flexions are seen combined with versions, 
 
 1 Kiwisch, Die Kranhheiten der GehdrTmdter, Bd. i, S. 101. Prague, 1851. 
 
 2 Rokitanski, Anat. patJiol., t. iii, p. 457. 
 
 ^ Scanzoni (op. cit. p. 8G) and Nonat (op. cit., p. 495) rightly observe that 
 abortion is more favorable to flexions than the puerperal condition, because in 
 
412 UTERINE DISEASES IN DETA.1L 
 
 anteflexion with anteversion, retroflexion witTi retroversion. This is 
 also why the adhesions and cicatricial bands which are produced after 
 puerperal metro-peritonitis themselves become causes of flexions all 
 the more hurtful because they give a fixed and irreducible curve to 
 the organ. Yirchow/ however, has exaggerated the importance of 
 these peritoneal alterations in attributing to them the majority of 
 uterine flexions. 
 
 It is not necessary for the uterine tissue to be really altered to allow 
 of a flexion taking place ; but even in cases where the uterine tissue 
 seems to be exempt from any alteration, and when the flexion is un- 
 observed, there must be some cause for it. This cause, in foetal life 
 and in childhood, seems to be the relative shortness of one wall (in 
 the case in question the anterior wall, hence anteflexion) ; afterwards 
 it may be traced to the relative thinness and weakness of the isthmus 
 and to the indifference of position of the fundus which yields to 
 pressure from the neighbouring organs, or to the relative weight of the 
 body of the organ, which, having a greater tendency in some cases 
 (especially after labour) to incline backwards, and finding no obstacle 
 in any direction, falls more and more behind the neck into the pouch 
 of Douglas. In early age the cervix offers more resistance than the 
 body to displacements caused by pressure from the neighbouring 
 viscera. The body, which is free, independent, and attached to the 
 neck by a narrow portion, is, on the contrary, inclined to yield to the 
 influence of this pressure and to incline forwards in growth, more fre- 
 quently backwards in advanced life, version being very often combined 
 with flexion in the same direction. There is, then, even in those kinds 
 of flexion which are not pathological when compared with the flexions 
 properly so called of adult age, a diminution in the relative resistance 
 of the various portions of the uterine tissue which accounts for the 
 flexion. 
 
 An alteration may even be produced in this tissue which I would 
 call active in comparing it with the passive alteration of defective re- 
 sistance ; I mean the shortening of one of the segments of the uterus, 
 due to the inequality of their development from defective organisation 
 in the uterine tissue, to the contraction or retraction of its fibres, to 
 the production of inodular interstitial tissue in its thickness. It is to 
 this cause that we may attribute the abnormal persistency of foetal 
 anteflexion (Cusco), some flexions of old age, and especially those rare 
 but authentic cases in which flexion, in place of occurring at the union 
 of body and neck, only affects the body, or the neck, or both at once, 
 either in the same or in a contrary direction. I have lately seen a 
 case of retroflexion at the menopause which I could only attribute to 
 atrophy of the posterior segment of the uterus, especially on a level 
 with the isthmus. Whether these alterations of tissue have or have 
 
 tte first months of pregnancy only the body of the uterus is developed, while 
 the neck is more firmly retained by vaginal adhesions and the isthmus relatively 
 narrower and less resistant than at a later period. 
 
 ' Ueber die KnicJcungen der Gebar'inutter, Verhandl. der Gesellsch. fur 
 GehurtsJc., iv, 80. — Gesammelte Abhandlung, ii, 822. 
 
FLEXIONS 
 
 413 
 
 not preceded^ prepared and determined the flexion, they do not fail to 
 accompany it. 
 
 The investigations which I have made on the alteration which the 
 tissue of the uterus may undergo on a level with the curvature and on 
 the side of the flexion have proved to me, as to Eobin, Aran, Virchow, 
 Sommer, Scanzoni, that there is either a softening of the uterine tissue, 
 which in this case is pale and its muscular fibres scarce or infiltrated 
 with fat, as in the period of retrograde evolution after delivery, or else 
 a retraction of this tissue, which is then hard, resistant and fibrous, 
 like a cicatricial band (Fig. 272). It cannot be denied that the mus- 
 cular tissue often becomes gradually thinner at the seat of flexion. 
 
 Fig, 272. — Ketroflexion in the second degree, with persistence of the cervico- 
 uterine canal (after Graily Hewitt). 
 
 being changed into soft cellular and fibrous tissue, which weakens and 
 shortens the flexed wall, thereby ensuring the permanence of the 
 flexion. Hence, in my opinion, the indication to stimulate the con- 
 tractility of this tissue and to excite hypertrophy in order to cure 
 the flexion. 
 
 When the flexion takes place at the isthmus it necessarily narrows 
 the OS internum. This diminution of size, which is at first purely 
 mechanical, may afterwards become organic and permanent (Fig. 273). 
 The wall of this orifice corresponding to the retreating angle of the 
 flexion, forms a projecting angle, a kind of spur, which makes the 
 passage of menstrual blood and leucorrhoeic mucus from the cavity of 
 the body into that of the cervix difficult, and the use of the sound 
 still more so. It is easy to understand how this difficulty, which is 
 overcome by uterine contractions during the period extending from 
 puberty to the menopause, remains purely mechanical, the width and 
 dilatability of the orifice being presented by the expulsion of blood 
 at the monthly period. But it is also evident that, during this period, 
 especially in early youth and old age, it must often happen that the 
 gradual alteration of tissue, especially of the fibrous tissue at the point 
 
414 
 
 UTEEINE DISEASES IN DETAIL 
 
 of flexion, must end by causing this organic contraction, and by 
 gradually producing obliteration. 
 
 The influence due, on the one hand, to external pressure, and on the 
 other to softness of tissue or muscular contraction and retraction, 
 accounts for one way in which alteration of the uterine axis is pro- 
 duced. I refer to torsion of this axis caused by a rotatory movement 
 in an opposite direction of the neck on the body, or more frequently 
 of the body on the neck. I have seen numerous examples of this kind 
 of torsion, which is a common cause of sterility, and which I have suc- 
 
 FiG. 273. — Eetroflexion in tte third degree, with occlusion of the cervico- 
 uterine canal owing to the close juxtaposition of the walls (after GraUy 
 Hewitt). In this, as in the preceding figure, the uterine tissue is pale and 
 anseniic at the point of flexion. 
 
 ceeded in curing by progressive dilatations ; it is easily recognised by 
 the spiral direction which has to be given to the sound to allow of its 
 passing from the cavity of the neck into that of the body, and it often 
 coincides with anteflexion or retroflexion. Like flexions, it depends 
 on the inequality of visceral pressure exercised on the two borders as 
 on the two surfaces of the uterine body, or on an inequality in the 
 shortening of the round or broad ligaments, which is more serious, as 
 in this case the torsion may be irreducible. Lastly, the tissue of the 
 uterus, when softened, congested, or otherwise altered before flexion, 
 has a tendency to become increasingly so from the effect of the flexion. 
 In cases where there was no change, as in flexions occurring in early 
 life, the uterus may remain for some time without undergoing any 
 of these alterations; but it is seldom that it does not ui the end 
 become affected, either from the fact of the declivity of the fundus, the 
 difficulties placed in the way of circulation and all the conditions which 
 favour its passive congestion, or above all from the effect of uterine 
 fluxion at every menstrual period, from the difficulty with which the 
 
FLEXIONS 
 
 415 
 
 blood is expelled from its cavity, from the modifications produced in 
 the womb by pregnancy, from the accidents following delivery, &c. 
 In consequence of these modifications and others occurring in the 
 immediate neighbourhood a great many complications are produced 
 which have to be taken into account in diagnosis and treatment. 
 
 Therefore in the adult woman retroflexion, which is frequent^ in 
 proportion to the number of rapidly succeeding pregnancies and the 
 degree in which the uterine tissue has been altered, is in its turn fre- 
 quently followed by chronic congestion, softening, hypertrophy, uterine 
 leucorrhoea, granulations, ulcerations, uterine and peri-uterine inflam- 
 mation extending even to the appen- 
 dages, and hard inflammatory swellings, 
 or latero- and retro- uterine adenitis, 
 limited peritonitis, adhesions, the for- 
 mation of bands keeping the fundus 
 attached to the neighbouring parts,^ 
 prolapsus of the ovary, &c. There are 
 great differences in patients. In some, 
 flexion may have existed for a number 
 of years without the uterus having con- 
 tracted adhesions with the neighbouring 
 parts and having ceased to be redu- 
 cible. In others adhesions may exist 
 from the commencement, having been 
 formed at the same time as the retro- 
 flexion was produced ; or it may be 
 that the uterus, which for years had 
 remained reducible, becomes in the end 
 adherent to the rectum or to Douglas's 
 ligaments, as a consequence of peri- 
 uterine peritonitis. 
 
 Consequently, there are three causes 
 which render flexions permanent : 1, 
 the alteration of the tissue at the point of flexion ; 2, adhesions 
 between the fundus and the rectum or bladder; 3, the consecu- 
 tive atrophy of the uterine wall at the side of the flexion. The 
 chief effects on the uterus are : 1, contraction of the os internum, not 
 only mechanical but organic, produced by the constant irritation and 
 thickening of the mucous membrane at this point, or retraction of the 
 muscular fibres ; the tendency to obliteration during old age is pro- 
 bably increased; 2, congestions and menorrhagic tendencies; 3, excen- 
 tric hypertrophy, the dilatation of the cavity of the body by retention 
 of the secretions. The neck, too, is sometimes irritated, secreting 
 mucus, with red and eroded borders, half opened orifice and unequal 
 
 ' Scanzoni, op. cit., p. 86. 
 
 ^ Picard (op. cit.) has two woodcuts of two anatomical preparations of flexions 
 rendered irreducible by membranous adhesions to the neiglibouring parts : an 
 anteflexion with utero-vesical peritoneal bands, and a retroflexion with utero- 
 rectal membranous adhesions. 
 
 Fig. 274. — Torsion of the body- 
 on the neck and contraction 
 of the isthmus, seen in a mul- 
 tipara of thirty-five years. 
 
416 
 
 UTEEINE DISEASES IN DETAIL 
 
 lips, the anterior shorter and smaller than the posterior in retroflexion 
 
 (Soramer, West), the posterior less in anteflexion ; in short, the thickest 
 
 lip is the one corresponding to the flexion. 
 
 As to the diff'erence in fre- 
 quency and gravity latero-flex- 
 ions, which seem to coincide 
 with a shortening of one of the 
 broad ligaments are excessively 
 rare; retroflexion is frequent in 
 the adult after delivery and even 
 in the aged; I have also seen 
 cases occurring in young girls 
 and in sterile married women; 
 flexion of the cervix is common 
 in youth at the time of puberty ; 
 but anteflexion, which is almost 
 the only one seen in childhood, 
 is on that account the most com- 
 mon of all. At the same time 
 anteflexion is never so marked as 
 retroflexion ; for there is nothing 
 behind to check prolapsus of the 
 body, whilst in front it is limited 
 by the bladder, and on the sides 
 
 by the lateral ligaments (broad ligaments) . 
 
 Fig. 275. — Retroflexion in the second 
 degree : projecting spur, partial hy- 
 pertrophy of the posterior lip of the 
 cervix. No peri-uterine alteration. 
 
 Fig. 276.— Eetroflexion in the 
 third degree, without hy- 
 pertrophy: projecting spur. 
 Muco-purulent uterine leu- 
 corrhoea. 
 
 Fig. 277.— Eetroflexion in the first degree 
 with retroversion. — c, contraction and 
 depression of the circular os ; A, pos- 
 terior neo-memhranous utero-perito- 
 neal adhesions. 
 
 piagnosis— subjective signs. — It is difficult to decide as to the 
 existence of a flexion from subjective phenomena alone, but not im- 
 possible. Evidently there are flexions which pass unnoticed, especially 
 before puberty or marriage, in old age, or in a very large pelvis ; but 
 
FLEXIONS 
 
 417 
 
 the majority give rise to symptoms more or less marked in proportion 
 to the sensitiveness of the patient, the narrowness of the pelvis, and 
 the pathological nature and degree of the flexion. 
 
 Fig. 278. — Retroflexion in the third degree, general hypertrophy of the uterus 
 and partial hypertrophy of the posterior lip. o, descent of the right 
 ovary ; Ai, adenitis and retro-uterine and latero-uterine inflammatory in- 
 duration ; u, projection of the fundus against the anterior wall of the 
 rectum and the posterior wall of the vagina. 
 
 Amongst the common symptoms which have seemed to me the most 
 frequent in flexions, as well as the most distinctive, are the following : 
 purely mechanical dysmenorrhoea, sometimes shght, at other times 
 excessive, the escape of the blood, especially of the first drops, being 
 preceded and accompanied at every menstruation with violent uterine 
 colics ; menorrhagia, the difficulty of the sanguineous evacuation in- 
 creasing the congestion, and the latter in its turn provoking haemor- 
 rhage, the intensity and duration of which is sometimes alarming; 
 pain in coitus, especially in cases of retroflexion complicated with 
 uterine congestion, metritis, perimetritis, peritoneal adhesions, &c. 
 Sterility is frequent,^ though by no means a necessary consequence of 
 
 ' According to Sims (op. cit., 237), two thirds of sterile women are affected 
 with flexions or versions, the deviations forwards being more numerous in 
 women whose sterility is natural, deviations backwards in women whose sterility 
 is acquired. 
 
 27 
 
418 UTERINE DISEASES IN DETAIL 
 
 flexions, for I have known women with flexions become pregnant ; 
 in some, gestation rectifies the displacement, whilst in others it aggra- 
 vates it, especially in the case of retroflexion. Leucorrhoea also often 
 
 Fig. 279. — Diagnosis of retroflexion by the touch. 
 
 accompanies it and makes the flexion more painful, while it is made 
 more persistent by the flexion which renders the discharge of the leu- 
 corrhceal mucus more difficult. I have had patients affected with 
 flexions in whom leucorrhoea was the only subjective symptom, and 
 who were cured of the leucorrhoea as well as of the flexion by repeated 
 cauterisations of the uterine cavity after temporary replacement of the 
 uterus. — Vesical and rectal disorders result from the pressure exercised 
 on the bladder or rectum. — The weight, the dull pelvic pain, the 
 lumbar dragging, are increased by walking and condemn a number of 
 patients to absolute rest; I have known several who for ten or fifteen 
 years were constantly confined to the sofa; in such cases, however, 
 the symptoms of engorgement, congestion, metritis, and other organic 
 alterations were so mingled with those of flexion as to make all 
 differential diagnosis impossible. 
 
 Objective signs. — Vaginal and rectal touch associated with palpation 
 usually suffice, except in very stout women, to allow of the uterus being 
 seized, to determine the absence of the body above the isthmus and 
 to give an idea of the new form and of the degree of inclination of 
 
FLEXIONS 
 
 419 
 
 the organ. Whilst the hand pressed on the hypogastrium cannot find 
 the body of the uterus on a level with the brim, as in the normal con- 
 dition, the finger introduced into the vagina feels a solid round tumour 
 behind or in front of the neck and projecting beyond it, which is the 
 uterine fundus, but which may be mistaken for the pregnant womb or 
 for a fibroid. 
 
 The speculum is of little use, except in cases of flexion of the neck, 
 where examination by means of Sims's speculum decides the degree of 
 the flexion, the form, position and dimensions of the orifice, as well as the 
 
 Fig. 280. — Diagnosis and reduction of retroflexion by the sound. 
 
 various complications, the coexistence of which it is so important to 
 know in order to establish the indications of treatment. As to the 
 use of the sound, in spite of what Scanzoni^ says, it is indispensable, 
 although an experienced physician can diagnose a flexion without it. 
 Not only is it the only means of diagnosis in doubtful cases, but it 
 enlightens us as to the direction, seat, degree and reducibility of the 
 flexion, the absence of peritoneal adhesions, the coexistence of a torsion 
 of the body on the neck, the irritability of the mucous membrane and 
 of the OS internum, the coexistence of endometritis, &c. I have seen 
 errors of diagnosis because this means had been neglected. Some 
 patients are so sensitive as to necessitate the administration of chloro- 
 form before having recourse to this means of investigation. 
 
 Treatment. — Slight flexions without complications are not serious, 
 
 ' Op. v\i., p. 29. 
 
420 UTERINE DISEASES IN DETAIL 
 
 and anteflexion less so than retroflexion. Flexions complicated either 
 bj metritis or by peritoneal adhesions are very serious. In such cases 
 they not only almost always produce sterility but may confine the 
 patient to bed or to the sofa. Therefore, in spite of the insufl&ciency of 
 our means of treatment, flexions should be submitted to a rational 
 treatment, in the treble view of destroying complications, rendering 
 them tolerable, and of favouring the natural processes which, in the 
 majority of painful flexions, give us reason to trust in the continuity 
 of the reduction and the permanence of cure. 
 
 The first indication to fulfil consists in subduing the complications 
 and reducing the flexion to its greatest degree of simplicity; very 
 often the complications and the flexion must be treated alternately 
 and almost simultaneously. From this point of view it is evident that 
 we have but a feeble influence on complications such as long-standing 
 peritoneal adhesions ; whilst, on the contrary, we can get a consider- 
 able hold upon uterine and peri-uterine inflammation, upon congestion, 
 engorgement, and the tumefaction and softening which characterise 
 defective retrograde evolution after labour ; but even as to the former, 
 we must never despair of modifying them, nor of obtaining a cure in 
 the course of time from therapeutic agency and from the favorable 
 intervention of physiological function. For instance, a pregnancy may 
 occur and overcome adhesions which have seemed incurable. Anti- 
 phlogistics, resolvents in the form of rectal injections of an iodide 
 solution, or of mercurial ointment, purgatives, repeated laxatives, 
 blisters, alteratives, various mineral waters, or hydropathy, may, 
 according to the case, fulfil this first indication. Sometimes we must 
 limit ourselves to the use of these means and to supporting the uterus 
 and perinseum by a hypogastric belt or perinseal bandage. When, on 
 the contrary, these complications do not exist or when they have dis- 
 appeared the flexion may be acted on directly. 
 
 Eeduction and retention are effected by local means aided by general 
 treatment which we shall review. 
 
 I. In reducing flexions we make use of the hands or of the sound, 
 or of both. The hand can effect little in the case of anteflexion ; but 
 in retroflexion, one or two fingers introduced into the vagina or rectum 
 can, by pushing the fundus towards the brim (while the genupectoral 
 attitude is assumed), easily manage to restore the longitudinal axis of 
 the uterus to its normal direction, even in cases of pregnancy, unless the 
 organ be wedged into the pelvis. I have recently reduced a retro- 
 flexion in a pregnant woman in the fourth month ; the body of the 
 uterus was fixed in the cavity ; the cervix, though not deviated, 
 seemed to have descended, and its anterior segment compressed the 
 urethral canal, causing retention of urine for forty-eight hours ; after 
 having catheterised with difficulty, and having drawn four quarts of 
 urine, I succeeded in replacing the organ. 
 
 The use of the sound is indispensable except in cases of possible 
 pregnancy ; it should be introduced with great caution for fear of 
 perforating the softened uterus ; but without this instrument reduction 
 would sometimes be impossible. After having penetrated into the 
 
FLEXIONS 421 
 
 cervix, we try to pass the contraction corresponding to the seat of the 
 flexion^ taking care to turn the curve of the sound to the side of the 
 uterine curve, and only to depress or raise the handle of the instrument 
 in proportion as the point penetrates without resistance, and as much 
 as possible without pain, into the cavity of the body, after which by 
 giving a different direction to the handle and turning the curve of the 
 instrument in an opposite direction from that of the flexion the organ 
 may be gradually straightened. In cases where excessive softening 
 of the uterine tissue or the resistance of recent peritoneal adhesions 
 are to be feared, the use of the sound should be associated with hypo- 
 gastric palpation, or with the catheter in anteflexion, and vaginal or 
 rectal touch in retroflexion. 
 
 II. To maintain reduction mechanical means may be used, or means 
 intended to modify the vitality and texture of the uterus. 
 
 1. Mechanical means may be divided into two classes according to 
 whether they are applied externally or internally. 
 
 The external or extra-uterine means are : tampons introduced into 
 the rectum above the sphincter as proposed by Huguieri for retro- 
 flexion ; often too painful to be borne. A tampon of cotton saturated 
 with glycerine applied either behind the cervix or before and below it 
 after reduction. Vaginal pessaries, whether free or retained, ought 
 always to be much more raised on one side than on the other so as to 
 prevent the descent of the fundus before or behind, according to the 
 side on which this eminence is placed, and so maintain the reduction : 
 amongst these pessaries the best are the triangular pessary of Simpson 
 and Priestley, Simpson's stem pessary, that of Kennedy (of Liverpool), 
 which is^copied from that of Hervez de Chegoin. Sponges or pessa- 
 ries (those of Hodge or Graily Hewitt) pushing back the cervix, so 
 as to prevent this organ from resuming its false position and the body 
 from falling forwards again. Lastly, hypogastric or pelvic belts either 
 simple or with an anterior or posterior plate, alone or associated with 
 a pad and perinseal bandage ; or the latter bandage may be used alone 
 in cases where hypogastric pressure cannot be borne. It is very 
 seldom that the hypogastric belt is not useful in cases of anteflexion ; 
 but it is painful and often intolerable in retroflexion ; the perinoeal 
 pad, on the contrary, alone or supporting a tampon saturated 
 with glycerine or an air pessary with unequal borders is of great 
 service. 
 
 Intra-uterine pessaries^ recommended by Simpson, Kiwisch and 
 
 ' See p. 192. 
 
 ^ The use of intra-uterine stems or the mechanical treatment of flexions is 
 recommended in Germany by Martin (Die Neigungen und Beugungcn des 
 Uterus. Berlin, 1870), Winkel {Bchandlung der Flexionen des Uterus mit 
 intra-uterinen Elevatoren, 1872), Schultze {Archiv f. GynaeJcologie, Bd. iv, 
 1872), Amann {Zur mechanisch. Beliandlung der Versionenund Flexionen des 
 Uterus. Munich, 1874), Schroder {Handhuch der A'ranlcheiten der weiblichen 
 Geschlectsorgane, 1874) ; in Sweden hy Eklund {De I'Etiolog. et du trait, des 
 retrof. utcr. Stoclvholm, 1875) ; in England by G. Hewitt {Obstetric. Transact., 
 vol. X, 18G9), Williams (Ibid._, 1874), Barnes {Diseases of Women, 1876) ; in 
 America by Thomas {Practical Treatise of Diseases of Women, 1876) ; in 
 
422 
 
 UTERINE DISEASES IN DETAIL 
 
 Valleix have been long abandoned in France. I ' am as ready as any 
 one to admit the danger of intra-uterine pessaries in some cases. I 
 have seen a patient^ who seemed to tolerate one of these stems for 
 twenty-four hours, die of metro-peritonitis in spite of the most ener- 
 getic and judicious antiphlogistic treatment. Patients have returned 
 to me from Valleix uncured of their maladies, whom he thought were 
 cured, as Kiwisch's patients went to Scanzoni. Nevertheless, I am 
 more than ever convinced that the use of such instruments should not 
 be proscribed. Their action is not merely mechanical; it excites 
 uterine contractility owing to the natural reaction of any physical im- 
 pression on our organs. This excitement, however, becomes injurious 
 when great irritability disposes the uterus to become inflamed, or when 
 inflammation has already attacked it or the neigbouring organs. There- 
 fore uterine or peri-uterine inflammation is always a contraindication 
 to their use. 
 
 In cases where these contraindications do not exist these stems may 
 be used, but loose means of retention should always be preferred to 
 those of absolute immobilisation, which unfortunately were formerly 
 used. The stem, whilst keeping both parts of the uterus straightened, 
 and being itself held sufiiciently in place by its bulb and a tampon 
 saturated with glycerine, should be left at liberty to oscillate in various 
 directions with the womb according to the movements of the patient, 
 instead of exposing the uterus to injury from every movement of the 
 body, as would be the case were the stem immovably fixed. 
 
 I have used this means of treatment in retro- 
 flexion since the stem was first introduced into 
 Prance, and have found it most successful when 
 the uterus is too flexible to be retained in po- 
 sition by any other means. 
 
 In describing the treatment of each special 
 flexion we shall determine what agents of re- 
 duction and retention should be specially em- 
 ployed. 
 
 2. The local and general modifications suit- 
 able for favouring and maintaining retention 
 are : posture, hydropathy, tonics, ergot, elec- 
 tricity, cauterisation, &c. 
 
 Posture is important especially in recent 
 flexions : it allows the tumefaction of the organ 
 to subside, it prevents congestion from increas- 
 ing, it helps resolution, it prevents the for- 
 mation of vicious adhesions. 
 
 In cases of anteflexion patients should lie on 
 
 the back, with the pelvis raised and the limbs 
 
 flexed. In retroflexion they should lie on the stomach. — Hydropathy, 
 
 general rather than local, or as regards the latter cold sitz-baths, 
 
 vaginal irrigations, the douche on the loins and sides, will aid in 
 
 Russia by Tarnowsky (M^ Gontcharoff , Flexions uterines au point de vue de 
 leur traitement. Paris, 1877), &c. 
 
 Fig. 281. — Galvanic 
 stem kept in place 
 by a tampon satu- 
 rated with glyce- 
 rine in a retroflexed 
 uterus previously 
 reduced. 
 
f^LEXIONS 423 
 
 raising the tone of the organ and in exciting uterine contractility. — 
 Tonics, including iron, mineral waters such as those of Lamalon, sea 
 bathing, &c., act in the same direction as hydropathy. 
 
 There are, however, three local modifications superior to the pre- 
 ceding if they answer to all that they appear to promise j these are, 
 ergot, electricity and cauterisation. — Ergot is an excellent means of 
 stimulating the contractility of the uterus when defective, especially 
 in retroflexion. This repeated provocation of muscular contraction 
 excites a hypertrophic tendency in this tissue, which is very useful in 
 overcoming the atrophy which has its seat at the point of flexion and 
 in all the corresponding wall. Considerable results are obtained by 
 giving three or four grains every day for a month, resting at the 
 monthly period. — Electricity has been employed by Fano^ to give 
 contractile power to the side of the uterus opposite the angle of flexion, 
 sufficient to shorten the fibres and so straighten the uterus. It is 
 evident that the action of electricity in this case may also aff'ect the 
 superficial muscular layer extending into the broad, utero-lumbar and 
 utero-pubic ligaments. One of the poles should be placed on the 
 cervix or in the uterine cavity or on the lip of the cervix corresponding 
 to the side of the womb opposite the angle of flexion, the other pole 
 on the hypogastrium, the inguinal regions, sides or loins, according to 
 the direction of the curve. In some cases this means seems to me 
 to have helped the others. — Cauterisation, especially when deep, so as 
 to destroy a part of the cervical tissue, as recommended by Grenet,^ 
 may in some cases be most useful. 
 
 Following the example of Amussat and Bonnet, since 1852 I have 
 cauterised the neck very high up, as well as the vagino-uterine cul-de- 
 sac on the side opposite the deviation, not only in versions but in 
 flexions. This operation has been so successful with me that I have 
 not feared to repeat it several times in the same patient. As for flexions 
 in particular, while accepting Grenet's explanation that cauterisation 
 produces a cicatricial tissue which shortens the fibres on the side of the 
 uterus to which it is applied, not forgetting the modification which 
 this operation never fails to effect in the uterine tissue, and which 
 manifests itself by a great tendency to resolution of the engorged parts, 
 I think that even deep cauterisation of the cervix on a level with the 
 cul-de-sac of the side opposite the flexion is especially useful in flexion 
 of the cervix, less so in that of the isthmus, and still less in that of 
 the body. 
 
 2. Flexions in particular 
 
 By proceeding to an analytical study of each flexion the differences 
 in the nature, characters, symptoms and treatment of each can be 
 brought into relief. In the first place we observe that flexions are not 
 indifferent, there being some which cause great suffering in the absence 
 of all complications. — We also discover that there are special symptoms 
 
 ^ Union medicale, 1859, and Vidal de Cassis, Pathologie externe, v, 384 
 Paris, 1861. 
 
 ^ Gazette des hojpitaux, Nos. 54 to 58, May, 1865. 
 
424 UTERINE DISEASES IN DETAIL 
 
 characteristic of each kind of flexion sufficient to lead us to suspect if 
 not to diagnose it. It is not only the direction of the flexion which 
 varies, but the cause and the nature of the alterations which produce 
 the change in the form of the uterus in both cases. We therefore 
 naturally conclude that the treatment of these flexions ought to differ 
 according to the nature which characterises the fundamental alterations 
 in each. This treatment, in place of being merely palliative, is in 
 many cases curative, and being founded on real knowledge of the ana- 
 tomical nature of the malady, when wisely applied never fails to give 
 real relief proportioned to the extent of the reduction and the perma- 
 nence of the retention. Emmet, in a recent paper,i gives the statistics 
 of all the cases he has had. In 345 flexions there were 182 of the 
 cervix, the others of the body, which gives 53 per cent, for flexions 
 of the cervix, 47 per cent, for the body ; and among the latter he 
 counted 91 anteflexions or 56 per cent., 39 retroflexions or 18 per 
 cent, (one third anteflexions, whilst as regards versions, retroversion is 
 as frequent as anteversion), 43 latero- flexions or 26 per cent, (which 
 seems to me an exaggeration), twice as many to the left as to the 
 right. • 
 
 " a. Flexions of the Cervix 
 
 These are rarely found in women who have been pregnant, but often 
 in girls, especially at puberty. Dysmenorrhoea and sterility reveal their 
 existence : the duration of menstruation in such cases would be less 
 than the average. The medium age of those affected is twenty-five 
 years, which is earlier than that of other flexions. 
 
 They seem to originate at puberty from unequal development of the 
 body and neck. When the body is anteverted, which is to some extent 
 the normal congenital position, the neck cannot be considerably de- 
 veloped in length without meeting the posterior vaginal wall which 
 deviates it, flexes it, and forces it to develop itself in the direction 
 which offers the least resistance, i. e. in the axis of the vagina, and 
 as this axis forms an open angle in front with the axis of the uterus, 
 especially when this organ is curved forwards, anteflexion of the 
 cervix necessarily follows. Such, according to Emmet, is the cause 
 of flexions of the cervix and of their frequency ; it will be seen that 
 this flexion is only the consequence of flexion of the body in the 
 same direction which gives the horse-shoe form to the uterus. This 
 continuity between the curve of the body and that of the neck is 
 probably'the reason why other gynecologists have not given the same 
 importance to flexions of the cervix, some attributing to the uterus 
 as a whole the flexion seated in the supra-vaginal portion of the 
 cervix, others forgetting that when the direction of the cervix is the 
 same as that of the vaginal axis, it necessarily follows that this organ 
 is flexed forwards, since its orifice ought normally to look towards 
 the posterior vaginal wall. There are certainly a great many cases 
 
 ' The etiology of uterine flexures, with proper mode of treatment indicated, 
 Transactions of the American Gynecological Society, p. 48, vol. i. Boston, 
 
 1877. 
 
FLEXIONS 425 
 
 described and treated as mechanical dysmenorrhoea which ought to 
 have been classed as flexions of the cervix : the only question is to 
 
 Fig. 282, — Anteflexion of a conical cervix with narrow os (after Barnes). 
 
 determine whether this alteration in the form of the neck is the 
 dominant element of this complex pathological state, or if it is not 
 rather the congenitally narrow os, the contraction of the sphincter, 
 combined with retraction of the fibres of the anterior segment, which 
 causes the inequality between the two walls and the curvature with 
 the anterior^ concavity, so well understood by Cusco. It is certain 
 that analogous means of treatment are applied to the malady described , 
 in most gynecological works as mechanical dysmenorrhoea, as in 
 Emmet's paper to flexion of the cervix, and there is no doubt that 
 flexion of the cervix rarely exists without narrow and conical os, ante- 
 flexion of the body, contraction of the external sphincter, of the 
 muscular fibres of the anterior segment and of the utero-sacral 
 ligaments, in short, without the concurrence of the majority of 
 the conditions belonging to anteflexion, and especially to pathological 
 anteflexion. 
 
 Diagnosis. — Flexion of the cervix, easily recognised by the long 
 neck lying in the axis of the vagina, is seen in girls at puberty or in 
 young married women, accompanied by dysmenorrhoea and sterility 
 and often by anteflexion of the body and elevation of the organ. 
 The pain shows itself chiefly at the commencement of the menstrual 
 period ; it is less severe in virgins than in married women ; in the latter 
 it is accompanied by hypertrophy and diseases of the body in addition 
 to anteflexion of the latter. If conception does not take place during 
 the first year of married life, the chances of its occurring later are 
 greatly diminished, flexion always having a tendency to increase, as 
 
426 
 
 UTERINE DISEASES IN DETAIL 
 
 well as the complications which accompany it, anteflexion of the 
 body, diseases of this organ, the transmission of irritation to the 
 ovary, &c. 
 
 The treatment is exclusively surgical. We must, however, assure 
 ourselves beforehand that there is neither uterine nor peri-uterine inflam- 
 mation. After all it is not very often indicated ; for Emmet admits 
 that he has not met with one serious enough to be operated on more 
 frequently than once a month. 
 
 This treatment consists in the division of the cervix proposed by Simp • 
 son, performed by him on the lateral parts of the orifice, by Marion Sims 
 on the posterior lip by means of his bistoury with a short revolving 
 blade, and by Emmet on the same lip (median incision), but by means 
 of strong bent scissors, which operate more quickly and are less apt 
 to cause hsemorrhage than the bistoury. After having made the 
 median incision, the borders may be rounded so as to form a concave 
 opening of the whole, at the base of which if necessary the canal 
 may be divided by means of the bistoury, or it may be dilated by 
 
 Tig. 283. — Median incision of the posterior lip, treatment of flexion of the 
 cervix ; s, speculum ; tr, uterus ; a, anterior lip ; p, posterior lip ; e, tena- 
 culum hook inserted into the anterior lip to draw the utems near the 
 operator ; c, scissors to divide the posterior lip p. 
 
 the repeated introduction of sponge tents of increasing size, a 
 method of treatment which rectifies and widens the cervico-uterine 
 canal sufficiently to cure dysmenorrhcea and to facilitate conception, 
 especially if coitus, in place of being performed in the ordinary way is 
 performed more bestiarum ; in this posture the penis and semen are 
 more sure of reaching the posterior utero-vaginal cul-de-sac on a level 
 with the opening made in the posterior lip by median incision, resec- 
 tion of the angles and borders, and dilatation of the rest of the canal. 
 Sometimes, as seen in Figs. 284 and 285, a portion of the too long 
 posterior lip should be excised (Eig. 284,1) after making the median 
 excision of this lip (Fig. 285, 2), which is the only way of ensuring 
 the direct penetration of the semen into the uterine cavity. It will 
 
FLEXIONS 427 
 
 be seen that the operation has to be varied according to the extent 
 of the flexion, the degree of the curve, the length and volume of the 
 
 Fig. 284.— 1. Portion of the pes- Fi&. 285.-2. Poi-tion o£ the pos- 
 terior lip which is excised tenor lip to be divided in 
 in case of extreme flexion of the centre after excision of 
 the cervix. portion 1. 
 
 flexed portion, and the complications, such as tumours, &c. When, 
 however, the principle is understood, it is easy to apply it to individual 
 cases. 
 
 h. Antejiexions of the Body 
 
 Anteflexion may be either congenital or acquired, limited to a 
 segment of the body of the organ or extended to the neighbouring 
 parts, and particularly to the suspensory ligaments. 
 
 a. Congenital physiological anteflexion. — This is an exaggeration of 
 the usual conditions of form and inclination of the uterus in the 
 foetus, in the child and young girl at puberty, often even in the adult 
 nullipara. If the relative excess of increase which the anterior seg- 
 ment should take at puberty to compensate for its original shortness 
 does not occur the temporary congenital anteflexion may become a 
 permanent one : in this case it may be said to be due to imperfect deve- 
 lopment of the anterior wall. At other times, in place of being deve- 
 loped this wall atrophies, thereby exaggerating the anteflexion in place 
 of correcting it. At other times the production of this physiological 
 anteflexion is much more complicated : under the influence of the 
 irritation which congenital anteflexion produces in the organ, of the 
 obstacle placed in the way of the accomplishment of the functions, 
 especially of menstruation, &c., contraction is produced in the unstriped 
 muscular fibres of this segment of the uterus, shortening them and 
 finally causing retraction, not only in the fibres of the organ but in 
 those arising from it which are inserted into the sacro-lumbar verte- 
 bra; this produces a direct exaggeration of the anteriorly concave 
 curve, and an indirect increase of this same curve by bringing the 
 upper portion of the neck nearer the sacro-vertebral angle, and conse- 
 quently a more marked aggravation of an anteflexion originally con- 
 genital, produced in fact by a purely physiological cause. 
 
428 
 
 UTBEINE DISEASES IN DETAIL 
 
 I. Pathological anteflexion . — This is the name given by Schnitzel 
 to acquired anteflexion ; it may be produced by several causes, for if 
 
 Fia 286. 
 
 -Usual anteflexion of tlie uterus in the fcetus and child, origin of 
 congenital physiological anteflexion (after Boullard). 
 
 it always arises more or less from peri-uterine inflammation, it is by 
 various consecutive phenomena that it does so. Sometimes it is pro- 
 duced directly from peri-uterine inflammation or true peritonitis, by 
 the formation of false membranes uniting the fundus of the bladder to 
 that of the uterus, the posterior surface of the one with the anterior 
 surface of the other. Sometimes it is produced indirectly, the peri- 
 uterine inflammation having its seat in the peritoneum or in the con- 
 nective tissue lining it ; it is then propagated to Douglas's ligaments, 
 and even where these ligaments are cured as well as the cellular tissue 
 and surface of the pelvic peritoneum there still remains a cicatricial 
 retraction, or at least a contraction and shortening of these ligaments, 
 bringing the cervico -uterine isthmus near the promontory and anterior 
 surface of the sacrum. This, however, cannot be efl'ected without 
 raising the isthmus and removing it from the fundus and cervix, with- 
 out making the organ project behind on a level with the isthmus while 
 concave in front, especially if the fundus is retained by vesical adhe- 
 sions and the neck by a hypertrophy frequently co -existing with these 
 alterations. This anteflexion, which is rightly called pathological, is 
 still less reducible than the former, but it is characterised by histolo- 
 gical alterations of the same nature, contraction, retraction of the 
 suspensory ligaments and induration of the uterus itself: partial 
 retraction of the broad ligaments may even be added, inclining the 
 fundus forwards, whilst the isthmus is raised behind ; there may also 
 
 • Zur Trage von der pathologischen Anteflexionen der Gebarmutter, Archiv 
 fur Gynehol, Bd. ix, S. 453. Berlin, 1875. 
 
FLEXIONS 
 
 429 
 
 be modular retraction of the connective tissue as a consequence of 
 cellulitis, in addition to the contraction of the suspensory and broad 
 
 Fig. 287. — Pathological anteflexion : shortening o£ ligaments of Douglas, 
 ascent of the cervix, pressure of the fundus on the posterior wall of the 
 bladder. 
 
 ligaments and tending to flex, contract and indurate the organ by curv- 
 ing it forwards on itself. 
 
 Treatment. — The chief indications are to subdue the inflammation 
 and then treat the consequences, especially muscular contraction, for 
 this contraction is the principal element of the malady. Prolonged 
 general baths either emolhent or alkaline, with vaginal injections all 
 the time, Yichy waters externally and internally, followed by hydro- 
 pathy, repeated mild laxatives, constant poultices on the abdomen 
 covered with oil silk, resolvent rectal injections of mercury and bella- 
 donna ointment, followed by small enemata of iodide of potassium, 
 bromide in large doses internally, sponge tents covered with belladonna 
 ointment, kept in place by tampons saturated with glycerine to moisten 
 the mucous membrane, cause an abundant secretion, and soften the 
 uterine tissue ; such are the chief means employed to fulfil the 
 indications : antiphlogistics, resolvents, antispasmodics, laxatives. 
 When we have to do with hard and contracted tissues, we must have 
 recourse to all that can soften and dilate them ; these are not the 
 cases for intra-uterine stems, hardly even for sponge tents ; but the 
 
430 UTBEINE DISEASES IN DETAIL 
 
 belladonna with which they are covered and the glycerine that is 
 added, by dilating the cervico-uterine canal and softening the tissues, 
 greatly compensate for the irritation and contractility produced. 
 
 Lastly, patients are often relieved and walking is facilitated by the 
 use of hypogastric belts (see Pigs. 150, 151), which remove the 
 weight of the abdominal viscera from the anteflexed uterus. 
 
 c. Later o-flexions of the Body 
 
 These can only arise from anteflexions, by limitation of the spas- 
 modic or cicatricial retraction of one of the suspensory or broad liga- 
 ments or, it may be, one of the round ligaments. It is hardly possible 
 to approach the description of these incurvations without entering on 
 the field of hypothesis ; in fact everything is hypothetical with regard 
 to them. The cause which produces them as well as the seat of the 
 pathological alterations, the very existence indeed of latero-flexion, is 
 doubtful. Latero-version is comprehensible, but latero-flexion is very 
 different, and as for the supposed cases which have occurred, we must 
 remember how easy it is to confound this diagnosis with that of the 
 uterus unicornis, which has sometimes been found to the right and 
 sometimes to the left (see Pig. 264). If such a case really occurred, 
 as the cause of the evil must have its seat in the ligaments, and as 
 this cause must be a retraction, either congenital or consecutive to an 
 inflammation (for a softening and relaxation of the tissues could not 
 force the uterus to incline in one direction rather than another), I 
 would institute the treatment I have described as applicable to ante- 
 flexion of the body. 
 
 d. Torsion of the Uterus on itself, and Torsion of the Body on the 
 
 Neck 
 
 The cause must be due to retraction of a layer of oblique fibres of 
 the uterus, or of ligamentary fibres variously associated together. We 
 have seen that the simultaneous retraction of the two ligaments of 
 Douglas consecutive to posterior perimetritis or parametritis, by 
 raising the upper portion of the cervix towards the sacrum, produced 
 an anteflexion (flexion with the concavity looking forwards), rightly 
 called pathological by Schultze. It is evident that if the simulta- 
 neous retraction of the two broad ligaments is added to that of the 
 utero-sacral ligaments, and if we suppose that that of the round liga- 
 ments is also associated, the fundus of the organ will be more and 
 more inclined forwards and the flexion increased. If, however, only 
 one of the utero-sacral is retracted anteflexion will be more marked on 
 one side than on the other, and the upper part of the neck, whilst 
 drawn towards the sacrum by the contracted ligament of Douglas, will 
 also be more drawn towards this side than to the other, giving to the 
 neck an inclination resulting in the oblique in place of the transverse 
 direction of the os. If the broad and round ligaments of the opposite 
 side are contracted at the same time, this rotation, this obliquity of the 
 OS uterinum, this torsion of the whole of the uterus will only be in- 
 creased. If, on the contrary, contraction of all the ligaments takes 
 
FLEXIONS 
 
 431 
 
 place on the same side there will be no longer torsion, inclination, 
 obliquity, but latero-position associated with anteflexion. Lastly, 
 whether the cervix be drawn towards the sacrum by the simultaneous 
 contraction of both utero- sacral ligaments, or whether only one of the 
 broad or round ligaments is contracted, there will be torsion of the 
 body on the neck at the isthmus, torsion which in certain cases will 
 be associated with that already produced by contraction of the fibres, 
 and which gives an oblique direction to the anterior surface of the 
 body in relation to that of the neck (see Fig. 371, p. 411). 
 
 It is important to diagnose these torsions : the obliquity of the os, 
 the difficulty of passing the sound, the inclination (Pig. 270) and 
 spiral movement required to make it penetrate, the discovery of hard, 
 stretched, contracted bundles of fibres behind or at the sides of the 
 uterus, will lead to a diagnosis and to a suitable treatment being in- 
 stituted to overcome the sterility, which is the usual consequence of 
 these torsions. Treatment is the same as for anteflexion, for contrac- 
 tion of the tissues is the principal element in both cases. Sometimes 
 ignipuncture may be indicated on a limited point of the uterus or on 
 the fibrous layer adhering to it and containing one of its ligamentous 
 bundles, in order to produce a limited inflammation, a spasmodic 
 contraction of this bundle, capable of counterbalancing the opposing 
 contraction which contributes most to produce or keep up the torsion. 
 Antiphlogistics, resolvents (alkaline waters and hydropathy) and 
 
 Fig. 288.. 
 
 -Retroflexion in the first degree : the cervix low, the fundus above 
 the ligfinients of DoiiirUis. 
 
432 
 
 UTEEINB DISEASES IN DETAIL 
 
 repeated dilatations with sponge tents associated with belladonna oint- 
 ment, glycerine, &c., are the principal means of treatment. 
 
 e. Hetfofiexion of the Uterus, 
 
 We now enter a field of histological alteration totally different, if not 
 diametrically opposed, to all the preceding. Till now, the only direct 
 agents of partial deviations and incurvations which we have met with are 
 retractions of tissue and shortening of the muscular fibres and liga- 
 ments. We shall now have to do with elongation, distension, softening 
 and rupture. In fact retroflexion is in every respect the opposite of 
 anteflexion. Not only is the organ curved in a different direction (the 
 concavity being behind in place of in front) but it is hardly ever 
 congenital, but always developed as the result of a morbid alteration, 
 this being the case even in congenital retroflexion ; retroversion is not 
 uncommon amongst girls and nullipara ; congenital retroflexion, on 
 
 Fig. 289. — Eetroflexion in the second degree : the cervix low, the fundus on a 
 level with the ligaments of Douglas. 
 
 the other hand, is exceedingly rare -^ the acquired form is very 
 common in multiparse and is almost always the result of labour or 
 abortion ; it is never caused by contraction, but is almost always 
 
 ' Grenser, " Die Riickwartslagerungen der Gebarmutter bei Jungfrauen und 
 Nullipai'en, nebst Bemerkungen zur Retroflexio uteri congenitalis," in Archiv 
 f. Gynaehol, Bd. xi, Heft 1. Berlin, 1877. 
 
FLEXIONS 
 
 433 
 
 characterised by thinness, softening, distension and even rupture of 
 the muscular fibres of the uterus and its ligaments; it rarely coincides 
 with elevation of the womb, usually on the contrary with prolapsus ; 
 the fundus reaches a much greater degree of prolapsus behind than 
 that which it acquires in front in anteflexion. 
 
 There are at least three degrees, according to whether the fundus is 
 above, on a level with, or below the ligaments of Douglas and the cer- 
 
 FiG. 290. — Retroflexion in the third degi-ee : the cervix low and directed for- 
 wards, the fundus below the ligaments of Douglas. 
 
 vix ; in the first degree the fundus is above the ligaments of Douglas 
 and the cervix ; in the second degree it is on a level with them ; in the 
 third degree it is below, and the whole organ is at the same time more 
 and more lowered by the extension and distension of these ligaments. 
 The day after delivery when the previously retroflexed uterus falls 
 down into the pouch of Douglas, it may fall so low as to be felt filling 
 this space through the perinseum, the anus, the lower part of the 
 rectum and the posterior portion of the vagina. This may be called a 
 fourth degree peculiar to the puerperal state. 
 
 The uterus often remains prolapsed and retroflexed for a long time 
 without any considerable alteration being produced in its tissue ; but 
 sometimes alterations are manifested very early, proving the necessity 
 of hastening reduction and retention, lest, by delaying too long, they 
 
 28 
 
434 
 
 UTERINE DISEASES IN DETAIL 
 
 become impossible. In Figs. 292 and 293 borrowed from Graily 
 Hewitt, retroflexion in the second degree is seen in which the cervico- 
 uterine canal is maintained free in all its extent ; and a retroflexion in 
 the third degree where the canal is obstructed at one point by the 
 
 Fig. 291. — Retroflexion in tlie puerperal condition, carried to a still higher 
 degree, the cervix being low and directed forwards, the fundus resting on 
 the floor of the perinfeum in the pouch of Douglas. 
 
 Fig. 292. — Eetroflexion in the second degree, with persistence of the corvico- 
 nterine canal (after Graily Hewitt). 
 
FLEXIONS 
 
 435 
 
 meeting of the two walls. Lastly, in the preparation represented in 
 l^ig. 294 of long-standing retroflexion of the third degree is seen not 
 only the occlusion but the obliteration of the cavity, by the adhesion 
 of the mucous membrane of one wall with that of the other side, 
 whilst alterations of this mucous membrane are revealed by the pre- 
 sence of small polypoid excrescences. There must have been sterility 
 owing to these various alterations. In all these preparations the 
 posterior lip is larger than the anterior. 
 
 We may also remark that the tissue of the organ is pale in place of 
 being red from venous congestion, as is the case in the softening which 
 characterises defective involution. The pale portion is anaemic owing 
 to the presence of adipose globules of fatty degeneration, and of white 
 globules, fibrils of laminar tissue, the result of fibro-muscular atrophy. 
 In place of being dense and hard this tissue is soft, and is torn rather 
 than cut by the bistoury; it is only after the retroflexion has existed 
 for a long time that, notwithstanding the same white aspect, the 
 tissue changes its nature and is formed of hard fibres of retractile 
 tissue, some of which are elastic and no longer allow of the straightening 
 of the organ. 
 
 Fig. 293. — Retroflexion in the third degree, with occlusion of the cervico- 
 uterine canal by juxtaposition of tlie walls (after Graily Hewitt). In 
 this figure, as in the preceding, the tissue of the organ is anemic and pale 
 at the point of flexion. 
 
 Other alterations are not wanting which may precede the develop- 
 ment of retroflexion or coexist with it, or at least with the softening 
 and tumefaction characteristic of the defective involution which is its 
 essential condition ; or they may be produced in consequence of the 
 hindrances placed in the way of the free exercise of the functions 
 of the uterus, of impeded circulation, of the long duration of the 
 retroflexion, &c. These alterations are pointed out in several of 
 the rough drawings which I am in the habit of making in recording 
 
436 
 
 TTTEKINE DISEASES IN DETAIL 
 
 cases, some of which I have given here ; they are peritoneal adhesions 
 of the fundus of the uterus with the extremity of the retro- vaginal 
 
 Fig. 294. — Extreme retroflexion, from nature. Middlesex Hospital museum, 
 
 Barnes. 
 
 pouch of Douglas, associated with leucorrhoea, granulations, vaginal 
 cysts, prolapsus of the ovary, adenitis or nuclei of chronic retro- 
 
 FiG. 295. — Retroflexion of the 
 second degree, "with bleed- 
 ing granular cervix. 
 
 Fig. 296. — Retroflexion of the first de- 
 gree, probably congenital : conicity 
 with hypertrophic elongation of 
 the cervix. 
 
 uterine inflammation, partial hypertrophy of one of the cervical 
 lips, &c. 
 
 The subjective symptoms of uncomplicated retroflexion are : sacral 
 pain at least nine times out of ten, pain at the anus, in the groins, 
 sometimes at the umbilicus, with sensation of dragging of the navel 
 towards the pelvis, especially in the dorsal decubitus, with nausea and 
 stomachic dyspepsia as in the commencement of pregnancy, especially 
 when the fundus of the uterus is large, very congested and very low. 
 
 The introduction of the enema pipe is often sufficient to produce 
 nausea in such cases by coming in contact with the fundus through 
 the rectal wall. There is also frequent desire to go to stool, accom- 
 
FLEXIONS 437 
 
 panied by constipation and all its serious consequences, so vividly 
 described by Barnes, frequent micturition^ increase of all the pains 
 
 Fig. 297. — Eetroflexion in the first degree : cyst at the extremity of the vagina. 
 
 after walking or exertion of any kind, even raising the arms or ad- 
 justing the hypogastric belt, &c. ; it is usually impossible to accom- 
 plish any movement necessitating effort and causing compression of 
 the uterus by the abdominal viscera. The dorsal decubitus does not 
 give any relief, and most patients find out for themselves that the 
 prone position is preferable. 
 
 The objective symptoms are easily discovered : vaginal touch prac- 
 tised when the patient is standing, and the same associated with pal- 
 pation when she is lying, will disclose a tumour behind the cervix 
 and continuous with it, the cervix being pushed forwards sometimes 
 even against the pubis. When these signs are observed there is great 
 probability of our having to do with a retroflexion. Nevertheless 
 we may be mistaken, diagnosis being only certain after the sound 
 has been used. This is necessary in order to ascertain whether there 
 is a retroflexion, whether it is reducible, and if it is so as a whole, 
 with more or less facility, more or less pain, &c. In trying to reduce 
 no risk is run by using the sound, whilst one or two fingers of the 
 other hand exercise pressure and raise the fundus, and the exactness of 
 the diagnosis is greatly increased. It is also important to ascertain 
 whether the ovaries have been dragged along with the prolapsed 
 fundus, and if there is adenitis or retro- or latero-uterine inflam- 
 matory induration at the base of the broad ligaments, complications 
 which are the source of important indications. 
 
 Treatment should be instituted as soon as possible in order to prevent 
 alterations of organic tissue or peritoneal adhesions which might pre- 
 vent reduction ; although it must be admitted that, when these altera- 
 tions do not exist from the beginning, there is less chance of their 
 being developed later than is generally supposed. Eeduction must 
 be made possible by the simultaneous or previous cure of complications, 
 such as leucorrhoea, uterine granulations, pelvic peritonitis, &c., as in 
 anteflexion. As a rule, neither inflammation nor retraction have to be 
 taken into account; in fact there is no retraction, and as for inflamma- 
 tion, if well managed it will rather help to cure than increase the evil, 
 
438 
 
 UTERINE DISEASES IN DETAIL 
 
 by giving to the uterus a rigidity which may prevent it from falling 
 backwards. Lastly, the contractility of the uterine tissue and its liga- 
 
 Fia. 298. — Eetroflexion in the third degree, proroinence of the anterior lip. 
 V, considerable congestion o£ the fundus ; o, prolapsus of the right ovary ; 
 A, inflammatory indurations and retro-uterine adenitis. 
 
 ments must be stimulated in order to produce this rigidity and retrac- 
 tion, which is the contrary indication from that of anteflexion. 
 
 1. In order to effect reduction the hands may be introduced simul- 
 taneously into the rectum and vagina, or one may be introduced into one 
 of these organs and the other be applied to the hypogastrium ; but it 
 is best to combine the use of the sound with that of the fingers in the 
 rectum or the posterior vaginal cul-de-sac. Reduction is facilitated by 
 the genupectoral posture, although this is not indispensable ; it often 
 suffices to place the patient on her back if the sound is ased. {See 
 Pig. 128, p. 145.) 
 
 3. After the fundus has been raised and the cervix has been pushed 
 back into the sacral cavity I introduce the galvanic stem pessary, 
 keeping it in place by a tampon saturated in glycerine. The patient 
 should then assume the 'ventral decubitus for a few hours. This 
 application may be repeated twice a week. The intra-uterine stem is 
 made in four sizes so as to suit all cases. If this is contra-indicated 
 by leucorrhoea or endometritis, a sponge or plug of cotton wool 
 saturated in tannin may replace it or my lever pessary with a 
 cervical arch {see Fig. 177, p. 198), the arch being placed in front 
 
FLEXIONS 
 
 439 
 
 of the cervix to keep it iu the concavity of the sacrum^ and to 
 incline the fundus forwards, which is the best way of prevent- 
 ing it from falling back again. The patient should continue 
 to adopt the ventral decubitus, sometimes 
 remaining in it day and night, at any rate 
 always at night, and to be sure that the uterus 
 is in its normal direction it is well to teach the 
 husband or nurse of the patient to introduce a 
 small Fergusson's speculum into the posterior 
 vaginal cul-de-sac every night at bedtime while 
 the patient is in the genupectoral posture, and 
 then to withdraw it very gently, inclining the ex- 
 ternal extremity as low as possible; in this way 
 the atmospheric air is admitted into the vagina, 
 the pressure reaching the extremity of this canal 
 and causing the intestinal mass and the fundus 
 to fall towards the lower abdominal wall ac- 
 cording toCampbelPs method already described. 
 3. It is not enough to reduce the retroflexion 
 nor to maintain it reduced ; the tissue must be 
 stimulated. Eetention therefore should be aided 
 by cold sitz- baths, cold astringent injections, 
 electricity, strychnia, ergot, &c, which excite contraction of the organ, 
 and restore to the tissue the rigidity without which cure would be 
 impossible. 
 
 Fig. 299. — Galvanic 
 stem pessary, re- 
 tained by a tampon 
 of cotton-wool in a 
 retroflexed uterus 
 previously reduced. 
 
 Fig. 300. — Galvanic stem pessary, retained by a tampon in tlie I'odnced uteras, 
 the patient being in the abdominal decubitus. 
 
440 
 
 UTERINE DISEASES IN DETAIL 
 
 4. Complications such as leucorrhoea, granulations, hypertrophic 
 congestion, &c., should be treated simultaneously by the usual means 
 (glycerine, plugs, cauterisation, ignipuncture, &c.). 
 
 5. Lastly, tonics and restoratives, hydropathy, sea bathing, iron, 
 bark and generous diet will greatly contribute to the success of the 
 treatment. 
 
 In closing I shall merely add a brief summary of two very curious 
 cases of gastrotomy performed for the cure of retroflexion. Koeberle^ 
 performed gastrotomy in a Polish lady of twenty-two years who had 
 suffered excruciating pain for two and a half years previously ; after 
 an incision of from one and a half to two inches of the peritoneum, 
 the uterus was drawn upwards with the fingers and the left ovary 
 with its ligament inserted into the abdominal incision ; the ligament was 
 left one and a half inches long so as to keep the uterus in normal 
 position ; the operation was followed by cure. 
 
 Sims^ performed the same operation on a widow of thirty-two 
 years, February 2£nd, 1875 ; he removed the left ovary, which was 
 the size of a nut and affected with cystic degeneration, including the 
 pedicle in the angle of incision, so as to retain the uterus in its normal 
 position. The operation resulted in the cure of the patient who had 
 suffered great pain for several years. I do not quote these operations 
 as examples to be followed, but as showing that flexions are painful 
 maladies, and that the pain may be cured by reducing the flexion. 
 These cases are worthy of notice from this point of view as vv^ell as 
 from the success attending enterprising surgery. 
 
 Inversion 
 
 Inversion is the position taken by the fundus and walls of the 
 uterus when this organ is turned back on itself like the finger of a 
 
 Fig. 301. — Eversion or ectropion of tlie mucous membrane of the neck. 
 
 glove, the internal and concave surface becoming external and convex, 
 and vice versa. 
 
 ^ TJeber eine radicale Operation zur Beseitigung der Betroversio tmd Retro- 
 flexio Uteri, erzdhlt von Schetelig in deni Centralblatt fiir medicinische Wis- 
 senschaften, June, 1869, S. 417. 
 
 ^ British Medical Journal, Dec. 15, 1877, p. 840. 
 
INVERSION 
 
 441 
 
 Uterine inversion^ like every displacement, presents several degrees. 
 Leroux, of Dijon^^ distinguished three degrees, which since then have 
 been generally admitted, and to which the names of simple depression, 
 introversion (Crosse) and inversion may be given. 
 
 I think two degrees are sufficient : complete and incomplete inver- 
 sion.^ 
 
 I call incomplete or partial inversion that in which the uterus is not 
 entirely inverted on itself. Whether there is simple depression of the 
 fundus of the organ, invagination of the fundus into the body, penetra- 
 tion of the inverted portion through the neck and even commencement 
 of the escape of the organ by the orifice — these are only shades or 
 degrees in the accomplishment of the phenomenon ; but these degrees 
 do not involve any difference with regard to the symptoms experienced 
 by the patient, the indications to be fulfilled nor the facility of reduc- 
 tion (l^ig. 302). I call complete or total inversion that in which the 
 
 Fig. 302. — Incomplete inversion of the uterus (after J. G. Forbes). 
 
 uterus, body and neck, is entirely turned back on itself, whether the 
 border formed by the cervix shares in the inversion or not (Fig. 303). 
 As for the vaginal inversion which drags the uterus out of the vulva 
 with it, it is a compHcation of uterine inversion (Fig. 304). 
 
 1 Op. cit., p. 59. 
 
 ^ In these degrees I do not include eversion or ectropion of the cervix, which 
 begins at the os externum in place of at the fundus. This eversion is seen in 
 the widely open, soft dilatable cervix, and is in such cases prodiiced at every 
 examination when the bivalve speculum is used, owing to the separation of the 
 two valves of the instrument ; the two columns of the arbor vitte are seen 
 with their secondary projections and the subdivisions of these prominences, 
 made unequal by the disseminated glands. It may be produced spontaneously 
 as the result of contraction of the upper circular ring of muscular fibres of 
 the cervix, coinciding with the softness of the lower vaginal portion of the 
 cervical lips. But it does not go farther, and such an eversion never ends in 
 real inversion of the organ as occurs when the malady commences by depression 
 of the fundus like the l3ottom of a wine bottle. 
 
442 
 
 UTEEINE DISEASES IN DETAIL 
 
 A combination of circumstances are required to produce uterine 
 inversion. It usually occurs after delivery (according to Crosse 350 
 
 FiQ". 303. — Complete inversion. From an original drawing by Biot for Crosse's 
 Essay on Inversio Uteri, representing a preparation in Dupuytren's 
 Museum, -| natural size. The patient died from exhaustion twenty-two 
 months after delivery, v, vagina ; u c, incised uterus, showing the cavity ; 
 6, border of the inverted portion, the round ligaments, Fallopian tubes 
 and the ovarian ligaments are drawn in it ; Z r, round ligaments ; t, Fal- 
 lopian tubes ; o o, ovaries ; h, cervix covered by peritoneum. 
 
 Fig. 304. — Complete inversion of the uterus, complicated with vaginal 
 invasination. 
 
INVEESION 443 
 
 times out of 400 inversions), and even after abortion or miscarriage.^ 
 It may, however, be produced in other conditions, e.g. it may be 
 determined by the existence of dropsy, the presence of a fibroid or 
 polypus, the natural expulsion of these products or attempted extrac- 
 tion of these tumours. 
 
 The previous development of the uterus by the product of concep- 
 tion, a polypus, water or blood, the weakening of the vital properties, 
 of the muscular contractility of this organ, and even a congenital vice in 
 its conformation, may be regarded as predisposing causes of inversion. 
 
 The determining causes are those in which the action of some power 
 is brought into play on the fundus of the organ, which it depresses, 
 attracts or pushes towards its cavity. Inertia of the uterus, shortness 
 of the cord, and especially adhesions of the placenta, may determine 
 inversion ; prolonged or violent expulsive efforts at or after delivery, 
 undue traction on the cord by the midwife or by the weight of the 
 child escaping suddenly, may also determine it. It appears also that 
 coincidence of inertia of the lower portion with violent contractions of 
 the upper part of the uterus, either during delivery or afterwards, may 
 produce spontaneous uterine invagination,^ as has been proved in a few 
 cases.^ 
 
 In the case of delivery the inversion may occur at two different 
 periods : — 1, when the fcetus is expelled, owing to uterine inertia and 
 to traction exercised by the foetus on too short a cord, especially if the 
 woman is standing ; 2, when the placenta is expelled, generally owing 
 to the persistence of the utero-placental connections and to the 
 solidity of the cord. In these cases inversion may at first be incom- 
 plete ; but it is almost always completed by uterine contraction under 
 the influence of the impulse given by the efforts of the patient, the 
 pressure of the intestines and abdominal viscera, &c. It is rather in 
 cases of polypi and fibromata* that incomplete inversions occur, which 
 may remain for some time in the same state. In some circumstances 
 inversion and even prolapsus uteri may be seen in nulliparae.^ 
 
 ' Partial inversion at the fifth month, by Dr. Spae, Northern Journal of 
 Medicine, July, 1845. — Complete inversion at the fifth month, by Dr. John 
 Brady, New Yorh Medical Times, Feb., 1856. — Complete inversion of the 
 uterus at the fourth month of gestation, replaced six days after the accident 
 by E. W. Wodson, M.D., of Woodville, Kentucky, American Journal of the 
 Medical Sciences, October, 1860. 
 
 ^ Leroux, Pertes, p. 56. — Ane et Baudelocque, according to Dailliez, op. cit. — 
 Mai-jolin and Dupuytren, in a nullipara. Diet, en 30 vol., art. Uterus, t. xxx, p. 
 295. Paris, 1846. 
 
 ^ Ruysch, Case x. — Ch. Cowan, in Montpellier medical, t. x, p. 563, June, 
 1863. — This opinion is also shared by Saxtorph, Radfort, Simpson, West. We 
 must, however, remember that the rarity of inversion in maternity hospitals is 
 itself a proof of the rarity of the spontaneous production of uterine inversion 
 during labour. As for the spontaneous production of uterine inversion occurring 
 gradually in the case of the expulsion of a polypus or in analogous circum- 
 stances, it can no more be doubted than the fact o£ spontaneous reduction under 
 the influence of the continued pressure of an air pessary. 
 
 ■* Thomas Denman, Collection of Engravings, &c. London, 1787, and Segard, 
 Stir les polypes uterins. These de Paris, 1804, No. 246. 
 
 * Sayi-e, of New York, quoted by Marion Sims, p. 147 ; McClintock, op. cit., 
 p. 98. 
 
444 UTERINE DISEASES IN DETAIL 
 
 Immediately after delivery the uterus usually diminishes in size 
 owing to muscular contraction, hardening in the form of a ball, the 
 globus of accoucheurs. If there is inertia, it remains soft and, under 
 the influence of the determining cause acting on it, begins by being 
 depressed at some point, usually at the fundus.^ The borders of this 
 depression are more raised on the side of the pubis than on that of 
 the sacrum, are inclined to one side or the other according to the 
 obliquity of the uterus and vary in their inclination, according to 
 whether the depression, in place of affecting the fundus itself, is pro- 
 duced on the posterior or anterior surface, or on one of the borders. 
 At this moment the placenta enters the neck ; it is solid to the 
 touch and apparently of larger size than normally. Traction on the 
 cord brings it down and in proportion as it descends, the peritoneo- 
 uterine fossa increases in depth and diminishes in width at its 
 entrance, the inversion increasing in proportion as the placenta pro- 
 ceeds. These facts are easily verified in thin women who have had 
 children. Simple depression of the fundus or of one of the walls is 
 not painful, especially when inversion is produced slowly by the 
 natural or artificial expulsion of a polypus, in place of occurring sud- 
 denly by that of the foetus; in such cases the woman may not be 
 conscious of any change. 
 
 If the inversion increases it determines painful dragging round the 
 pelvis. If it occurs suddenly it causes excruciating pain ; this is 
 followed by syncope and haemorrhage which increases in proportion as 
 the placenta is detached, diminishing momentarily after uterine contrac- 
 tion, but often causing great anxiety. The hsemorrhage by increasing 
 the weakness and inertia of the organ leads to the recurrence of 
 syncope and then exhaustion brings on convulsions. If the women 
 have sufficient blood and strength left, the haemorrhage may be 
 stopped for the time and recur again. But even then the patients 
 lose all hope of recovery and remain in a deplorable state of health 
 which increases every day. 
 
 Diagnosis — subjective signs. — The sudden sensation of displace- 
 ment at the time of delivery, the excruciating pain which announces 
 the fact, the sudden collapse, the abundant hsemorrhage which follows, 
 the absence of the globus uterinus in the hypogastrium, the sensations 
 of dragging, of weight, and, later on, of pain in every movement, 
 especially when coitus is attempted, serious hsemorrhage at the 
 monthly period followed by abundant leucorrhcea, ansemia and the 
 incapacity of the patient for walking or any kind of exertion are very 
 characteristic symptoms of inversion. As for the general symptoms, 
 some, such as ansemia, are the result of hsemorrhage ; others, such as 
 acute abdominal pain, troublesome dragging in the groins and pelvis 
 with indescribable discomfort in the hypogastric region, vomiting and 
 tenesmus, depend on the displacement itself; others again, such as 
 syncope and convulsions, are secondary. Cases have occurred, such 
 as the three mentioned by West, where the accident was unnoticed 
 
 ^ Traits des maladies des femmes grosses et de celles qui sont accouchees, 
 t. ii, p. 186. Paris, 1740. 
 
INVERSION 
 
 445 
 
 when it first occurred, and others, such as that of Madame Boivin, 
 those of Lisfranc, that of Woodman ^ and two others communicated to 
 
 Fig. 305. — Complete and recent inversion, from a preparation in wax in Du- 
 puytren's museum, moulded from a woman who died of haemorrhage 
 caused by inversion a few hours after delivery. (Heurteloup's case, taken 
 from Breschet's Repertoire d'anaiomie). e, rectum ; b, bladder: v, v, an- 
 terior and posterior projections of the peritoneal infundibulum, on a level 
 with the neck, into which the round ligaments, the Fallopian tubes T, and 
 the ovarian ligaments o, are dragged. 
 
 me by esteemed practitioners where the malady was merely inconve- 
 nient. These, however, are rare exceptions, and it is to be remarked 
 that these patients were aged. 
 
 Objective signs. — Inversion is easily diagnosed by touch combined 
 with palpation. The upper border of the tumour is hardly perceptible 
 by abdominal palpation. Adhesion of the placenta may drag the 
 fundus of the inverted uterus outside the vulva; in such cases the 
 serous, amniotic, smooth and polished surface covering the placenta is 
 seen. If the placenta has been detached from the uterus, the tumour 
 is smaller and its surface different in aspect, it is downy and shows the 
 orifices of the uterine sinuses. The tumour is elongated in proportion 
 as it has inverted and dragged with it the vagina. Hypogastric pal- 
 
 ' Obstetrical Transactions, 1867. Inversion had existed for five years in a 
 woman of fifty. 
 
446 
 
 UTEEIXE DISEASES IN DETAIL 
 
 pation allows of measuring the pelvis without finding the uterus in it, 
 and consequently of distinguishing the inverted uterus and its cap-like 
 
 OS from the foetal head or a mole 
 which may also appear at the vulva. 
 Differential diagnosis. — Involu- 
 tion of the uterus is effected more 
 slowly after inversion than after a 
 normal delivery. The uterus takes 
 five or six months to come back to 
 its normal size, endangering life 
 by repeated hsemorrhage when the 
 patient has had the good fortune 
 to survive the terrible haemorrhage 
 which usually accompanies inver- 
 sion. It is at this period that an 
 inverted uterus might be taken for 
 a polypus, when if ablation was per- 
 formed death would result, and the 
 application of a ligature would be 
 hardly less dangerous. When, how- 
 ever, inversion is recent, diagnosis 
 is easy. Examination of the ab- 
 domen shows the absence of the 
 uterus from the hypogastrium. This 
 must be due either to prolapsus or 
 inversion and vaginal touch decides 
 the question : in inversion there is 
 absence of the cervix from the 
 lower portion of the tumour, the 
 pear-shaped aspect of the latter 
 presenting its small extremity above 
 m place of below, as in prolapsus ; 
 a portion of the length of the vagina 
 usually remains contained in the 
 pelvic cavity ; sometimes in the 
 upper portion of the tumour there 
 exists a circular border formed bv 
 
 Fig. 306. — Antero-posterior longitu- 
 dinal section of the preparation 
 representing the case of uterine 
 inversion observed by Heurteloup 
 (Fig. 305). E, rectum; r, in- 
 vei-ted uterus, the convex surface 
 having become concave, contained 
 in the vagina v ; B, bladder ; p, 
 peritoneal infundibulum at the 
 neck. 
 
 the vaginal portion of the cervix. 
 When inversion is of long standing the tumour is usually contained 
 in the vagina. Its surface may be recognised by the help of the spe- 
 culum, its form, size and connections by touch. A red tumour is 
 perceived, which is rounded, sometimes soft and downy, sometimes 
 (.by and rugged, connected with the vagina by a broad and short 
 pedicle of large transverse diameter, separated from the vaginal cul-de- 
 sac or from the circular border of the vaginal portion of the cervix by 
 a groove which disappears on traction. This tumour presents no 
 orifice at all like the os. After a careful search the orifices of the 
 Pallopian tubes may be found; the characteristics of the internal 
 surface of the uterus may often be recognised, especially if the tumour 
 
INVERSION 447 
 
 is drawn outside and examined at tlie menstrual period. Catheterism, 
 rectal touch, hypogastric palpation, associated with vaginal touch, 
 enable us to make sure of the total absence of the uterus above the 
 pedicle of the tumour and of its presence somewhere in the pelvic 
 cavity, either in its normal direction or flexed forwards or backwards. 
 I know that distinguished practitioners have failed to diagnose inver- 
 sion and have cut an inverted uterus of some months' standing 
 believing it to be a polypus. A pediculated or non-pediculated fibroid 
 or polypus are all the more easily confounded with inversion that they 
 themselves may determine it, and so may present a complex malady 
 for the diagnosis of the physician. But although inversion may 
 resemble a polypus in form, size and consistency, it differs in the 
 following characters : the pedicle of the polypus is longer and thinner 
 than that of the inverted uterus, and descends from the border of the 
 orifice into which the finger can be introduced ; the sound, if not the 
 finger, can pass all round it (between this pedicle and the cervix which 
 serves as a sheath) reaching the uterine cavity at different heights ; in 
 fact, hypogastric palpation and rectal touch discover the fundus of the 
 uterus somewhere in the pelvic cavity. The case is more diflicult 
 when, after the ablation of a polypus, another intra-uterine tumour is 
 seen in the half open cervix, which may either be a second polypus or 
 the uterus partially inverted. In such a case Gueniot-^ determined 
 the diagnosis by ascertaining by means of acupunctv/re the insensibility 
 and density of the tumour, characteristic of a fibrous polypus, in con- 
 trast with the softness and sensibility which the inverted uterine tissue 
 presents. Prolapsus, as we have already said, forms a larger tumour 
 above than below, showing the os at its lower extremity. If it is 
 complete and complicated with prolapsus of the vagina, cystocele or 
 rectocele, it is still more easily distinguished from inversion because 
 the pressure of these tumours excites the desire of micturition, the 
 escape of the urine or the faeces. Simple cystocele and rectocele are still 
 more easily distinguished : the pressure of the os in the vagina and of 
 the fundus in the pelvic- abdominal cavity will always be certain means 
 of diagnosis. Nevertheless, it might be difficult after delivery to 
 recognise inversion in a woman who had during pregnancy a tumour 
 independent of the uterus, like an ovarian cyst, preventing examina- 
 tion of the pelvic cavity by hypogastric palpation. 
 
 Treatment. — Uterine inversion is one of the most serious maladies. 
 A number of women succumb immediately after the accident. Accord- 
 ing to Crosse- out of 109 patients who have succumbed to uterine 
 inversion, 72 died a few hours after delivery, 8 at the end of a week, 
 and 6 in a month. The patient dies from hEemorrhage, pain, con- 
 vulsions, or syncope caused by shock, from exhaustion, or from the 
 effects of violence, especially if the inversion has been taken for a 
 polypus and has been dragged, bruised or lacerated. \A^hen imme- 
 
 ' De I'acupuncturc consideree comme nioyen de diagnostic diffevential entre 
 covtains polypes fibreiix de la matrice et le renvevsement paiiial de cet organe. 
 Archives generales de viedecine, April, 1868. 
 
 ^ Transactions of the Prov. Med. and Surg. Association, vol. xv, p. 340. 
 London. 1817. 
 
448 UTERINE DISEASES IN DETAIL 
 
 diate danger is dissipated, there is during lactation an interval of 
 relative safety when serious symptoms frequently cease, only to reappear 
 later on. The inverted uterus may be strangulated especially if in- 
 version is incomplete ; Dewes completed inversion in a patient in 
 order to put a stop to strangulation. This accident may be serious 
 enough to produce gangrene of the organ (Crosse gives several cases) 
 and IS consequently very dangerous unless spontaneous elimination of 
 the gangrenous uterus terminates the malady favorably. I have seen 
 a case of this kind, otherwise I should have difficulty in believing it. 
 As for spontaneous reduction, it is extremely rare. Although the 
 patient has not succumbed to the shock, or to hsemorrhage, exhaus- 
 tion or gangrene, she is not on that account out of danger ; for she 
 is liable to profuse haemorrhage which recurs in the intercalary period 
 as well as at menstruation, and continues till after reduction of the 
 tumour or the menopause, patients during all this time running the 
 risk of a fatal loss of blood. I knew a lady who remained thirty 
 years in this state, and whose health only slightly improved after the 
 menopause. Stevens of New York has also seen chronic inversion ex- 
 pose a patient to very dangerous periodical haemorrhages which ceased at 
 the climacteric. An analogous case is given by Lee. In cases where 
 adhesions are not produced, or where a strong contraction to the 
 cervix has not effaced the entrance to the inverted uterine cavity, a 
 portion of the intestine may insinuate itself,^ become strangulated 
 and cause symptoms which may wrongly be interpreted as sympa- 
 thetic, such as pain in the bowels, tumefaction of the belly, vomiting 
 and hiccough, and which may terminate fatally. Lastly, supposing 
 that the life of the patient is not in constant danger it is one of great 
 trial. Besides the persistence of pain, hsemorrhage, leucorrhoea, and 
 weakness which make life miserable, she necessarily becomes sterile 
 and incapable of marital intercourse. Chevreuil's^ case, communicated 
 to Baudelocque, in which tubular pregnancy occurred in a woman 
 affected with uterine inversion is quite exceptional, as well as one 
 known to myself, where the patient was able to have intercourse with- 
 out much inconvenience in spite of inversion. Therefore, although not 
 dangerous in itself, inversion of the womb may suddenly become fatal 
 or cause accidents which last during life. The woman who has escaped 
 the immediate consequences is liable to greater ones later on. There- 
 fore great care should be taken to prevent the occurrence of inversion. 
 The woman should be dehvered when lying ; the uterine contractions 
 should be dimimshed,if they are too violent and too frequent; stimulated 
 if the organ is threatened with inertia ; only moderate traction should 
 be exercised on the chord ; the hand should be introduced into the 
 uterus to remove the placenta if it is adherent; after the delivery of 
 the afterbirth, the cervix should be titillated and friction should be 
 applied to the fundus through the hypogastrium to determine contrac- 
 
 * Baudelocque showed Dailliez (op. cit., p. 179) the drawing of an incom- 
 pletely inverted uterus, the cavity of which contained several intestinal circum- 
 volutions. 
 
 2 Dailliez, op. cit., p. 80. 
 
INVERSION 449 
 
 tion of the uterine fibres and the formation of the hard and resisting 
 glohts ; lastly, the patient should be advised to avoid efforts, falls, 
 jumping out of bed, and all movements which may occasion total 
 or partial displacement of the uterus whilst incompletely contracted. 
 If inversion is effected, reduction should be made as soon as possible. 
 
 I. Reduction of the tumour. — If inversion has taken place it must be 
 reduced by turning the uterus in on itself, so as to make each of its 
 surfaces resume the relative position which belongs to it ; such is the 
 chief indication. Now reduction varies according to the degree of 
 inversion, the absence or presence of the placenta, the position of the 
 uterus outside the vulva, or in the vagina, the period at which the 
 operation may be attempted, the manner of performing it, the instru- 
 ments and the methods which are applicable to it. 
 
 1. At the time of delivery inversion, as a rule, should be reduced as 
 soon as possible ; but this reduction, though comparatively easy when 
 attempted at once, may be more difficult after a few hours than after 
 a few days. It is the same with uterine inversion as with all trau- 
 matisms : simple at first, it soon becomes complicated with the usual 
 consequences, congestion, inflammation, &c., which may become the 
 source of special indications, resuming afterwards its primitive state of 
 simplicity with its natural consequences or the consecutive complica- 
 tions which are peculiar to it. Tiierefore the most favorable time for 
 reduction is the earliest possible. If this earliest time has been allowed 
 to pass we may be obliged to wait for some days. Lauverjat^ reduced 
 an inversion ten or twelve days after delivery. After this period any 
 time is good. Only it is prudent to choose the middle of the month 
 between two periods, so as to have to do with an uncongested organ 
 and to run less risk of inflammatory accidents. 
 
 There is great difi'erence of opinion among surgeons as to what 
 should be done in cases of adherent placenta : some think it should be 
 reduced with the uterus ; others that it should be removed before re- 
 duction is made. As a rule, I think that reduction is facilitated by 
 the removal of the placenta : the tumour is so large and its passage 
 through the cervix so difficult that we should try to diminish the size 
 of the organ to be reduced ; by operating promptly we may hope to 
 avoid much hsemorrhage, which, besides, can be more easily arrested 
 after than before reduction by compression of the aorta, friction of the 
 hypogastrium, titillation of the cervix, and the administration of ergot, 
 especially if the hsemorrhage is from the placenta ratljer than the 
 uterus. When inversion is complicated with prolapsus the difficulty 
 of reduction is not greatly increased ; if the uterus is in the vagina it 
 may be well to draw it outside the vulva, after performing taxis as I 
 have recommended. In any case, and at whatever period we are called 
 on to treat the malady, reduction of the prolapsus should always be 
 eft'ected even if that of the inversion cannot be. 
 
 When some hours have passed without reducing the tumour it may 
 be well to prepare the way for reduction by the use of difi'erent means, 
 
 * Nouvelle mcthode de j)ratiquer V operation cesarienne. Paris, 1788. — 
 Dailliez, op. cit., p. 82. — Churcliill, op. eit., p. 480. 
 
 29 
 
450 UTEEINE DISEASES IN DETAIL 
 
 according to the period when operation is called for : sometimes by 
 antiphlogistics, emollients and rest, if the tumour has been formed for 
 some time and is the seat of inflammatory phenomena ; sometimes by 
 sedatives, narcotics and belladonna, to prevent muscular contraction 
 and to relax the circular fibres of the cervix ; sometimes by direct com- 
 pression of the organ by an air pessary or by a stem, so as gradually to 
 force the resistance of these circular fibres of the cervix ; sometimes 
 by destructive cauterisation of the mucous membrane on the fundus 
 of the organ, so as to provoke contractions in the tissue proper which 
 determine spontaneous reduction; sometimes direct section of the cir- 
 cular fibres of the isthmus at the time when reduction is attempted, to 
 put a stop to the resistance of this contractile ring. 
 
 The posture of the patient most favorable to reduction is the dorsal 
 decubitus on the edge of the bed, the pelvis raised, the head and trunk 
 low, the legs held flexed and separated by assistants ; another assistant 
 should depress the hypogastrium and try with his hand to fix the cir- 
 cular border of the cervix in the cavity, to prevent it from rising, a 
 useless precaution when my method is followed. When no effort is 
 required to cross the sphincter of the cervix, the genupectoral position 
 would facilitate the reduction : it may therefore be utilised in certain 
 cases, especially in those of incomplete inversion. 
 
 As for the indrnments required for this operation there are none so 
 good as the hands ; they are the only instruments that should be 
 used : one to exercise pressure on the inverted uterus ; the other to 
 retain the cervix and fix the organ, without which we should have no 
 hold on it. 
 
 The hand exercising taxis may act in several ways, according to the 
 period when reduction is made or the method employed. It was with 
 the fist that Levret reduced the womb of a woman who had been de- 
 livered standing, and with two fingers that Baudelocque made it pass 
 through a somewhat contracted orifice seven hours after delivery. In 
 these cases pressure is exercised on the centre of the organ so as to 
 depress it in an opposite direction from the depression which has 
 characterised the commencement of the inversion. According to the 
 size of the womb at the time, we may push the fundus back with one 
 finger or with two like Baudelocque, or we may use all the fingers in 
 the form of a cone, or the fist like Levret. 
 
 When the inversion is incomplete, especially if there is only a simple 
 depression, spontaneous reduction may be determined by exciting 
 uterine contraction, or by introducing the hand into the uterine cavity 
 without detaching the placenta and especially without drawing on the 
 cord, which might complete the inversion; if necessary, the hand could 
 be introduced again into the uterus and detach the placenta, the uterine 
 contractions facilitating the detachment and expulsion. 
 
 When, however, reduction of a less recent and smaller tumour is 
 attempted, the two opposite peritoneal surfaces of which almost touch, 
 it is hardly possible to commence reduction by depression of the fundus. 
 In such cases the tumour should be taken in the hand and, if swollen, 
 should be pressed so as to let the blood ooze out, soften and relax it ; 
 
INVBESION 451 
 
 the borders should then be pressed by the tips of the fingers around 
 the pedicle, and the portion of the uterus which is continuous with the 
 vaginal portion of the cervix should be pushed back so as to begin by 
 reducing the portion nearest the orifice, i. e. the part inverted last, as 
 in reducing a hernia. 
 
 When reduction has not been made during the first few days there 
 is no reason to despair of efi'ectiug it after several months or even 
 years. I have succeeded in reducing an inversion of ten months ; ^ 
 Sims^ has reduced one of a year, so, too, has West j^ Barrier* one of 
 fifteen months as also White^ of Buffalo; Teale^ one of two and a half 
 years ; BockenthaP one of six years; Tyler Smith ^ another of twelve 
 years; and Noeggerath of New York one of thirteen years. 
 
 2. In complete and chronic inversion the real obstacles to reduction 
 are : the contraction and hardness of the uterine tissue, the constriction 
 and rigidity of the cervix, the mobility of the uterus, and especially 
 the defective fixity of the cervix. 
 
 There is a great difference between the cases in which the uterus re- 
 mains soft, probably from arrested involution, and those in which it is 
 hard, owing to involution having taken place as usual, as is proved in 
 the cases of several patients as well as in anatomo- pathological prepara- 
 tions. Eeduction is as difficult in the latter case as it is easy in the 
 former. Even when it has come back to its normal size the inverted 
 uterus still preserves a certain flexibility. But it is very difficult to 
 maintain this necessary flexibility ; for in spite of ansesthesia, it soon 
 contracts under the influence of pressure. After some attempts at 
 reduction it diminishes in size and hardens like an apple, making 
 further efforts useless. This latter difficulty is very serious, and can 
 only be avoided by shortening the operation and using all possible 
 means to facilitate it, stopping as soon as the uterus begins to contract, 
 and making fresh attempts after some days of rest; or else by proceed- 
 ing very slowly, determining, in imitation of nature, a gradual dilata- 
 tion of the cervix sufficient to allow of the reduction of the organ. 
 
 Hence two methods : a, the natural one, by slow and continuous 
 means; h, the artificial one, by rapid taxis. There is no doubt that 
 when the patient can support intra-vaginal pressure of the uterus it is 
 wise to adopt Tyler Smith's ^ plan, which has been followed by Teale,^^ 
 
 ' Acad, cle med., March, 1863. 
 
 ^ Sims, op. cit., p. 135. 
 
 3 West, op. cit., p. 228. 
 
 ■* Bulletin de I'Acad. de med., April, 1852. 
 
 ^ Atnerican Journal of Medical Science, July, 1858. — Report of the Inver- 
 sion of the Uterus, by Dr. Quakenbusch {Transact, of Med. Stat, of New 
 York, 1859, p. 170). Unfortunately the patient died of peritonitis sixteen 
 days afterwards. 
 
 « Medical Times, August 20, 1859. 
 
 ^ Zcitschr.filr Gebiirtslc.,!^^. xv, S. 318. 
 
 8 Med.-Chirurg. Transact., xli, 183. 
 
 ^ Medical Times and Gazette, April 24, 1858. — I have lately had a similar 
 case {Inversion uterine de quatre mois, reduction spontance, aprvs oize jours 
 de compression par le pcssaire a air splwrique de caoutchouc), described in a 
 paper presented to the Academy of Medicine in July, 1878. 
 
 '» Medical Times, August 26tli, 1859. 
 
452 
 
 UTERmE DISEASES IN DETAIL 
 
 West/ Bockenthal/ and myself in several cases, which consists iu 
 leaving in the vagina one of Gariel^s air pessaries applied close to the 
 uterus by the pressure which a T bandage exercises on it by means of 
 a graduated compress placed on a level with the vulva. I have cured 
 several patients in this way, and have seen others cured by physicians 
 to whom I recommended it. The continued pressure exercised by this 
 pessary on the inverted uterus, and through it on the cervix, deter- 
 mines on the latter organ an analogous effect to that produced by 
 pressure of the foetal head or by a polypus forced by the contractions 
 of the body towards the cervix, i.e. the slow and gradual dilatation of 
 the OS, the softening of the cervical ring and its disappearance so far 
 as to allow of the passage of the tumour produced by inversion through 
 this orifice and so of spontaneous reduction. 
 
 When pressure causes uterine contractions patients experience in- 
 termittent pain of the nature of labour pains. In such cases we should 
 try, morning aud evening, to push back the uterus, seizing if possible 
 the moment when the contractile cervical ring is sufBciently dilatable 
 to allow the body to pass through. Unfortunately all patients cannot 
 bear this continued pressure. In one case of inversion of seven and a 
 half months the pressure of the pessary maintained for twelve days by 
 West not only did not replace the uterus, but caused peritonitis, which 
 ended fatally four days after the removal of the pessary. 
 
 b. Artificial method hy rapid taxis. — To attempt to perform rapid 
 reduction without fixing the uterus, by persistently pushing back this 
 
 Fig. 307. — Gariel's pessary in the vagina, to compress the inverted uterus and 
 so cause spontaneous reduction, tr, uterus ; p, Gariel's pessary ; v, bladder. 
 
 organ into the abdominal cavity and exposing the vagina to unlimited 
 distension, is to run the risk of lacerating this or other internal organs 
 
 1 Medical Times and Gazette, October 29, 1859. 
 
 2 Ecduction after six years, Deutsche Klinih and Bulletin de therapeu- 
 tique, 1860. 
 
INVERRIONT ■ 453 
 
 dangerously, and of causing fatal accidents. This is what happened 
 to White of Buffalo who reduced in five minutes under chloroform 
 an inversion which had existed for fifteen months, but the patient, 
 who was thirty-two years old, died of peritonitis sixteen days after- 
 wards. 
 
 The rule of fixing the uterus by exercising counter-pressure on the 
 hypogastrium whilst the organ is pushed back is inapplicable on 
 account of the extensibility and defective resistance of the vagina. 
 Aran's idea of the cervical lips when kept in place by Museux's 
 forceps or tenaculum hooks being firm enough to support reduction 
 without being torn is absurd. Trying to obtain a point d'appui by 
 pushing the cervix back against the sacrum, as Barrier of Lyons did, 
 is to run the risk of feeling the organ glide on this inclined plane, and 
 so elude reduction. And to retain the cervix between two fingers 
 introduced into the vagina whilst a third pushes the fundus, is to 
 narrow the isthmus which we wish to enlarge by pushing back the 
 fundus, which cannot enter the cervix like a wedge till the latter is 
 freed from the pressure put on it. I have tried all these means and 
 have found them defective. 
 
 Therefore when the cervix is not dilatable (in spite of belladonna or 
 atropine applications) attempts to reduce according to the preceding 
 rules will be more likely to fail than to succeed, even when the tissue 
 of the body of the organ has preserved flexibility enough to be turned 
 back. 
 
 Incision may therefore be necessary in effecting reduction. Obser- 
 vation has proved to me that it is practicable, and that it may be done 
 without danger. I do not mean that it is always indispensable, nor 
 that taxis should never be attempted without incision. When neces- 
 sary, longitudinal incisions should be made, commencing from the 
 cervix and extending along the neck^ so as to divide the circular fibres 
 of the isthmus ; it is best to make two or more, some in front and 
 others behind.^ 
 
 As to the fixity of the cervix, whilst adopting Barrier's precept to 
 direct this part of the uterus towards the sacrum, I think this means 
 of immobilisation insufficient. Therefore, in lecturing on taxis as 
 applied to uterine inversion I have for many years insisted on the 
 necessity of keeping the cervix fixed with two fingers introduced into the 
 rectum, and have laid down the following rules with regard to the 
 operation. To seize the cervix the operator must necessarily first draw 
 it outside the vulva with Museux's forceps. Immediately afterwards he 
 introduces the index and middle finger of the left hand into the 
 rectum above the uterus, and by bending them forwards the cervix is 
 easily fixed through the rectal wall ; then seizing the uterus with the 
 
 ' As a rule I increase the number and diminish the deptli. I cannot agree 
 with Barnes (op. cit., p. 038) as to the depth of the incisions whicli he recom- 
 mends. Peritonitis, although not common, is to be feared. Besides this danger, 
 there is that of h:emorr]iage ; Gaillard Tliomas gives an example. I also 
 prefer making incisions before and behind ratlicr than laterally, as less likely 
 to endanger the opening of arteries of any considerable size. 
 
454 "UTERINE DISEASES IN DETAIL 
 
 right hand he pushes it back into the vagina, still keeping the neck 
 hooked down by the fingers of the left hand, and swings it round so 
 that the fundus of the organ contained in the palm of the right hand 
 is turned towards the pubis, in place of towards the rectum, the cervix 
 being directed towards the sacrum and retained on this side by the 
 fingers of the left hand. These fingers hold the cervical portion of 
 the uterus through the rectal wall, and, by separating, they press 
 strongly into the angular sinuses which the utero-sacral ligaments 
 form on each side by their insertions right and left of the postero- 
 lateral surface of the cervix ; we feel these ligaments stretched like two 
 guitar strings. Then with the thumb and index finger of the right 
 hand pressure is exercised on the pedicle of the tumour^ so as 
 gradually to increase the depth of the utero-cervical groove, and by 
 uniting efforts of taxis on the body with those of retention or immobi- 
 lisation of the neck, reduction of the uterus is gradually effected with- 
 out violence in a few minutes. 
 
 In reduction two phases may be distinguished : the first, which 
 consists in bringing the body of the uterus up into the cervix; the 
 second, in forcing the fundus to pass through the os internum. The 
 first is accomplished by pushing the body of the uterus upwards, 
 whether the neck is retained through the rectum or whether the vagina 
 is stretched so as to force the orifice to open first and the neck after- 
 wards. The second is effected more easily by compressing the fundus 
 laterally, and by thrusting the thumb into a horn of the uterus, which 
 makes one half of the organ slip through the os internum instead of the 
 entire fundus, which presents a much larger diameter. 
 
 When inversion cannot be reduced by any of these methods should 
 that of Thomas^ of New York be tried? It consists in making an 
 incision in the centre of the abdominal wall, introducing dilating 
 forceps into the inverted cervix, and when dilatation is completed re- 
 ducing the uterus by means of the other hand introduced into the 
 vagina. Thomas has succeeded in a patient twenty-three years old; 
 still I could not venture to recommend his method. 
 
 I have applied my method of reduction in the case of a young lady 
 who had sufl'ered from uterine inversion for ten months, and who was 
 greatly exhausted owing to repeated heemorrhage. Success was rapid, 
 complete and lasting; pregnancy followed. Unfortunately an abnormal 
 insertion of the placenta in the cervix caused repeated haemorrhage 
 and premature delivery at the seventh month; inversion was not re- 
 produced. In another, delivered three weeks previously, my method 
 of taxis led immediately to a radical cure. In another of my patients, 
 cured by the same method, after vain attempts had been made by 
 elastic compression, two pregnancies occurred followed by natural 
 delivery, proving the permanency of the cure. Tyler Smithes patient 
 has had several children since the operation. Another complete inver- 
 sion occurred after the first labour which followed reduction, but it 
 
 ^ American Journal of Obstetrics, Nov., 1869. — Union medicale, 11 Jan., 
 1870. Henry Miller, Thoughts of Chronic Inversion of the Uterus. Loiiis- 
 ville, 1870. 
 
INVEESION 
 
 455 
 
 was reduced immediately without any difficulty. A patient in whom 
 Marion Sims effected reduction after a year was also fortunate enough 
 to have another pregnancy. Reduction therefore restores to the organ 
 all its functions. 
 
 In quite recent inversion occurring after delivery the fundus of the 
 uterus may suddenly enter through the cervix under the influence of 
 
 Fig. 308. — Pcsition of the two hands in reducing uterine inversion by my 
 method : the two fingers of the left hand are curved to retain the cervix, 
 the fingers of the right hand push back the utenis, commencing with the 
 parts which have escaped last. It will be seen that the utero-sacral liga- 
 ments are exaggerated, and that the bladder has been left in its usual place. 
 
 taxis, as an india-rubber ball would do that was turned on itself. In 
 cases of chronic inversion, on the contrary, reduction is effected slowly. 
 
 The proofs of success after operation are the following : appearance 
 of the uterine tumour at the hypogastrium ; disajjpearance of the 
 pelvic and vaginal tumour; the presence at the further end of the 
 vagina of the cervical os, broad and open, leading into the uterine 
 cavity ; the introduction of a finger, or at least of the sound, into the 
 cavity, in order to be sure that reduction is complete. 
 
 However successful the operation may have been, reduction requires 
 to be maintained. The hand or finger should remain for some minutes 
 in the uterus to support the walls and excite contractions. The 
 patient should be advised to remain in the dorsal decubitus, the pelvis 
 higher than the trunk, and especially to avoid efforts in defecation and 
 micturition. Vaginal injections should be made and cold fomentations 
 applied, while rest should be ensured by sedatives and antispasmodics. 
 Lastly, stimulants should be administered in cases of inertia, especially 
 
456 UTERINE DISEASES IN DETAIL 
 
 ergot when the uterine globus does not form and harden. !Purther 
 precautions will be dictated by circumstances, and modified according 
 to the various accidents which may arise. It must not, however, be 
 forgotten that inversion may be reproduced. Leblanc of Orleans 
 mentions a case of inversion reduced immediately after delivery which 
 was reproduced ten days afterwards accompanied by acute colics and 
 hsemorrhage, and which was reduced with difficulty. 
 
 II. When reduction is impossible we must guard against accidents, 
 especially hsemorrhage, so as to make inversion bearable, or else ex- 
 tirpate the uterus in order to put a stop to serious accidents. In the 
 former case palliative treatment is adopted ; in the latter radical cure 
 is attempted. 
 
 1. Palliative treatment should always be preferred on account of 
 the risk attending radical cure by amputation of the uterus. If the 
 pain is moderate, if hsemorrhage is easily arrested, if there is not much 
 purulent leucorrhoea, if the patient can walk and take a necessary 
 amount of exercise, and especially if the menopause is near at hand, 
 palliative treatment only should be resorted to, such as means of re- 
 tention, tonics, general and local hsemostatics, more or less powerful 
 modifications of the uterine mucous membrane. A perinseal pad re- 
 tained by a T bandage and attached to a good belt may be of great 
 use by supporting the uterus in the vagina and preventing painful 
 dragging. Tonics are almost always necessary, owing to the debility 
 occasioned by repeated hsemorrhage. Generous diet, country life, a 
 great deal of time spent on the sofa in the open air, are the best means 
 which can be used. Haemostatics, which are even indicated in the 
 intercalary period, become indispensable when hsemorrhage occurs. 
 The horizontal decubitus with flexion of the limbs, cold vaginal injec- 
 tions, ice applied to the hypogastrium, to the internal and upper part 
 of the thighs, and even to the vagina, perchloride of iron administered 
 internally and locally, dilute sulphuric acid, ergot : such are the most 
 important medicaments to be used in palliative treatment. 
 
 Lastly, we may try to modify the uterine mucous membrane by 
 thickening the epidermis, transforming it into a cicatricial, hard, re- 
 tractile tissue, capable of opposing a barrier to hsemorrhage, and 
 reducing the size of the tumour gradually. In place of applying 
 perchloride of iron to this surface various caustics may be used, 
 such as the mineral acids, Yienna paste, Canquoin caustic, or the 
 actual cautery. Aran^ recommends chloride of zinc in the form of 
 Canquoin plaster so as gradually to reduce the inverted uterus to a 
 kind of stump. I have tried to obtain the same effect from the 
 actual cautery, but though I have applied it at white heat fourteen 
 times I have never succeeded in destroying the mucous membrane 
 which was always renewed. Ploret,^ who appUed chloride of zinc 
 to an irreducible inversion, taking care to maintain Canquoin plaster 
 on the uterus by means of a stem with a cup like extremity, to 
 prevent the caustic from being displaced and destroying the vagina, 
 
 ' Op. cit., p. 909. 
 
 2 Documents chirurgicaux, p. 168. Paris and Lyons, 1861. 
 
INVERSION 457 
 
 found that, under the combined influence of cauterisation and pressure 
 at the culminating point of the tumour, the latter became gradually 
 depressed till the inversion was reduced. This result is evidently 
 exceptional. 
 
 2. Badical cure or extirpation of the irreducible uterus was till a few 
 years ago thought to be an unjustifiable operation. Boyer^ prescribed 
 amputation as well as ligature. The bad results which have generally 
 followed ablation of the uterus in cases of organic lesion have 
 induced the majority of French surgeons to condemn the operation. 
 I think, however, that the recent progress made by surgery in this 
 direction, showing the possibility of removing the uterus as well as 
 the ovaries by abdominal section, justifies the assertion that ablation 
 of the inverted uterus by the vagina (a much less dangerous ope- 
 ration) should not be condemned without appeal. Not only has 
 it been proved by numerous examples, that life is compatible with 
 the loss of the uterus destroyed by spontaneous gangrene, but facts 
 also show that the extirpation of the inverted uterus is not a more 
 dangerous operation than the majority of those undergone by patients 
 affected with lesions comparable to uterine inversion in gravity. 
 West^ says that out of 59 cases in which it has been undertaken 
 it has been successful forty-two times, Forbes^ and McClintock* have 
 published papers describing the best methods of performing this 
 operation. 
 
 Simple excision with a bistoury, although successful once in the 
 hands of Velpeau,^ is too dangerous to be recommended. 
 
 The ecraseur seems to be preferable to excision, because less liable 
 to cause haemorrhage. This instrument, however, ]ed to fatal results 
 in the hands of Aran;^ and although successful in those of McClin- 
 tock''' and Sims,^ I think it is too dangerous to be recommended 
 even when used as suggested by Denuce, who made "the section in 
 twenty-four, thirty- six or forty-eight hours, and who was successful 
 with one patient. Hsemorrhage is not the only danger attending the 
 operation. The opening of the peritoneal cavity, the excruciating 
 pain produced by strangulation of the organ which has a tendency 
 to produce peritonitis, are reasons for making us condemn the 
 ecraseur almost as much as excision. Excision immediately preceded 
 by the application of a ligature^ is less dangerous than simple excision, 
 or even ecrasement, owing to the occlusion of the abdominal cavity 
 
 ' Traite des ^maladies chirurgicales, t. x, p. 510. Paris, 1825. 
 
 2 Op. cit., p. 230. 
 
 ^ Op. cit. : out of 36 cases, 26 were treated by ligature (21 cures), 2 by 
 excision (1 cure), 8 by ligature and excision (5 cures). 
 
 ■* Op. cit. : 3 cases of extirpation of tlie uterus witb success : 1 by ligature, 
 1 by ligature and the ecraseur, 1 by ligature and excision. 
 
 •'' Clinique chirurgicale, t. ii, p. 461. 
 
 « Op. cit., p. 914. 
 
 7 Op. cit., p. 85 ; it sliould be remarked that the patient was seventy years 
 
 old. 
 
 Op. cit., p. 135 ; the patient was thirty-nine. 
 
 English surgeons have performed the operation with the bistoury or strong 
 
458 UTEBINE DISEASES IN DETAIL 
 
 determined by ligature, the rapidity of the operation, the probable 
 cessation of strangulation from the suppression of the tumour situated 
 below the ligature, and from the absence of hsemorrhage which con- 
 striction seems to prevent. I do not, however, like the latter mode 
 of operation, because the rapidity of the operation does not admit of 
 adhesions being estabhshed to close the peritoneal cavity. 
 
 Excision immediately preceded by the application of a cautery 
 clamp on the pedicle of the tumour^ would be more efGcacious in 
 provoking the formation of these adhesions and so preventing peritoneal 
 accidents. But I should fear that it would not always prevent the de- 
 velopment of accidents characteristic of strangulation. 
 
 I greatly prefer excision by the actual cautery performed slowly and 
 at several sittings. I have performed the operation twice with great 
 success by means of the galvano-caustic wire applied for forty-eight 
 hours, taking care to make it red hot every two hours, and to increase 
 the constriction after it has cooled, so as only to let it penetrate each 
 time to the extent of the tissue destroyed by the fire. There is a great 
 chance of obtaining adhesive peritonitis by this method, and so avoid- 
 ing hffimorrhage. Having been so successful in these two cases I con- 
 sidered the operation a safe one ; unfortunately it was not so : in a 
 third case nervous symptoms manifested themselves, apparently caused 
 by strangulation, for which I could not account, and followed by 
 attacks of hysteria and fatal cerebral congestion ; consequently I have 
 abandoned this method in favour of the elastic ligature or of Paquelin's 
 thermo-cautery with the curved knife, which I have had made for 
 excision of the uterus. 
 
 The application of an elastic ligature romid the pedicle of the tumour 
 with the aim of destroying its vitality is a method which presents more 
 advantages and fewer dangers than any other. Constriction should be 
 moderate at first till it excites sufficient inflammation to cause the ad- 
 hesion of the adjacent surfaces of the peritoneum covering the inverted 
 organ. If pain or nervous symptoms occur, as frequently happens 
 after the application of the ecraseur or ligatures when rapidly tightened, 
 the ligature should be quickly relaxed, when these serious symptoms 
 usually cease. In a short time constriction may again be applied and 
 increased gradually, the organ being allowed a few hours' or if neces- 
 sary a few days' rest. Formerly I used a double flexible iron wire, the 
 two extremities of which are passed through a serre-noe^ul, so that 
 constriction may be maintained and increased gradually ; catgut may 
 also be used, or silver wire covered with silk, such as dentists use. 
 
 In one case in which I employed this method the uterus fell the 
 thirtieth day, the patient (who was only twenty-three) having run no 
 danger whatever. In this case the ligature did not act as a bistoury 
 
 scissors. Palaspiano in one case of inversion of six yeare' standing began with 
 a red-hot metallic ligature ; he next nsed a loop of wire which he drew very 
 tight, and cut the uterus below with scissors ; he was fortunate enough to save 
 his patient. During the next four months there was a sero-sanguineous dis- 
 charge from the stump by the vagina. 
 ^ Valette, Injon medical, April, 1871. 
 
INVERSION 
 
 459 
 
 or ecraseur by dividing the portion enclosed in the loop, but only by 
 causing ulceration of the part on which constriction was exercised, and 
 by simultaneously obtaining the sloughing of the tumour and the 
 formation of salutary peritoneal adhesions. Care must be taken to 
 maintain cleanliness of the vagina by frequent detersive lotions, so as 
 to avoid the accumulation of muco-purulent and putrid discharges. 
 The fall of the tumour may be hastened at last by rapid constriction 
 of the pedicle, the adhesions which have been established saving the 
 patient from the accidents to which she would have been exposed by 
 the premature use of the bistoury.^ 
 Since then I have employed the 
 elastic ligature by means of an 
 india-rubber tube, tightened mode- 
 rately the first day, and more every 
 succeeding day till the tumour falls, 
 which it generally does from the 
 twelfth to the eighteenth day. I 
 have employed this mode of opera- 
 tion twice ; one of my pupils by my 
 advice used it a third time. These 
 three patients recovered completely 
 without ever having run any dan- 
 ger. Before commencing, it is well 
 to make a groove round the pedicle 
 of the tumour with the actual cau- 
 tery or the thermo-cautery for the 
 elastic ligature, which has the 
 double advantage of acting as a 
 guide for the ligature and of mak- 
 ing its first application less painful. 
 The treatment of inversion, there- 
 fore, answers all the indications : 1, 
 for quite recent immersion artificial 
 reduction by my method (Fig. 310), 
 
 Fig. 309. — Inverted uterus, the abla- 
 tion of which is to be performed 
 by the elastic ligature ; c a, groove 
 of about two or three millimetres, 
 hollowed out all round the pedicle 
 on a level with the cervix by the 
 actual cautery, to receive the liga- 
 ture ; t c, india-rubber tube ; n, 
 knot of wax thread fastening the 
 ligature and keeping it distended 
 in order to maintain constriction. 
 
 the placenta being previously re- 
 moved if still adherent; 2, Later, 
 spontaneous reduction by GariePs pessary (Fig. 309) ; 2>,iftheuients 
 resists try artificial reduction by taxis, according to my method, with 
 the help of two fingers hooked into the rectum, taxis always aided by 
 chloroform, and, if necessary, by several incisions not too deep ; 4, 
 if the uterus still resists and if the danger of exhaustion from hamor- 
 rhage becomes urgent, ablation of the body of the uterus by the elastic 
 ligature applied in a groove traced by the thermo-cautery (Fig. 311). 
 A vaginal portion of the neck remains, differing in no respect from 
 that seen in the vagina in the normal condition. 
 
 ^ By adding my cases to West's statistics, we find that out of sixty-six abla- 
 tions of the inverted uterus forty-eiglit cures have been obtained, and propor- 
 tionally far more cures by ligature than by either of the otlier methods. 
 
CHAPTER III 
 
 MOEBID STATES WITHOTTT NEOPLASM — PLTJXION — CONGESTION — ENGOEGEMENT 
 — METEITIS — OTAEITIS AND SALPINGITIS — PEEI-UTEEINB INFLAMMA- 
 TION — OF LEUCOEEH(EA IN GENEEAL, AND TJTEEINE CATAEEH IN PAETI- 
 CULAE — HTPEETEOPHY AND ATEOPHT — GEANTJLATIONS AND FUNGOSITIES 
 ^XJLCBEATION AND ULCEES OF THE TJTEEINE CEEVIX 
 
 These are maladies wliich may be caused by purely local action or 
 by a general and even a diathetic affection reacting more or less on 
 the rest of the organism. But they are compatible with the preserva- 
 tion of form, structure and texture of the organ, and are neither accom- 
 panied by the production of new organic elements nor by the formation 
 of any tumour. They answer to the class of maladies designated under 
 the name of vital affections as contrasted with organic lesions. 
 
 The first is only the exaggeration of a physiological condition, uterine 
 fluxion. Muxion by being repeated gradually produces the second, 
 congestion. The reproduction or permanence of these two conditions 
 or of one of them suffices to produce the third, engorgement. Pluxion 
 and congestion are the usual if not necessary elements of inflammation ^ 
 leucorrJma, Jiypertj-ojiliy , granulations,' fwigosities, and ulceration, 
 which ai-e also often connected with the existence of a diathetic affec- 
 tion. There is a sort of connection between these morbid links owing 
 to the mutual influence which they exert on each other. T^iuxion, for 
 example, when repeated becomes a cause of congestion. Engorgement 
 is usually a consequence of the repetition of morbid acts which keep 
 up these two conditions, rather than a malady occurring spontaneously. 
 Inflammation, while developed in a direct manner^ hardly ever exists 
 without being kept up by a congestive state or without determining 
 a permanent congestion of the organs in which it is located. Leucor- 
 rhoea produced by uterine catarrh or endo-metritis, is often complicated 
 by a condition of inflammation, fluxion, congestion or engorgement. 
 Hypertrophy, when not consecutive to inflammation, is not produced 
 without previous congestion. 
 
 Granulations and fungosities, whilst sometimes arising as simple 
 papillary hypertrophy of the mucous membrane, are seldom produced 
 without having been preceded by more or less extensive inflammation, 
 folliculitis, uterine catarrh, leucorrhoea, &c. Lastly, ulcers often offer 
 a combination of several of the morbid states just referred to ; they 
 are necessarily accompanied by a secretion, are frequently covered with 
 granulations, excite round them hypertrophy of the neck which is their 
 usual seat, and seldom last any time without being accompanied by 
 inflammation and congestion. 
 
FLUXION 461 
 
 Fluxion 
 
 Uterine fluxion {homflnere, to flow) is the temporary accumulation 
 of blood in the uterine vessels. This morbid condition is characterised 
 by a movement of the blood towards the womb, and is accompanied 
 by symptoms of molimen, analogous to those which in some women 
 announce the menstrual period. 
 
 Uterine fluxion is most frequently acute; but it may become chronic 
 by indefinite repetition. Even in the latter case the characteristic 
 which distinguishes it from congestion is the rapidity of its appearance 
 and disappearance. It may be followed or not by haemorrhage, accord- 
 ing to its intensity, its unusual prolongation, and the seat towards 
 which it tends. It may either affect the uterus alone, or the uterus 
 and appendages simultaneously, most usually the latter. It disap- 
 pears on the dead body ; in autopsies we constantly find the size of 
 the uterus less than it appeared formerly. Injection of the tissues, 
 tumefaction, redness extending to the cervix and often to the vagina, 
 a mucous or sanguineous discharge sometimes established as at the 
 approach of menstruation : such are the immediate consequences of 
 uterine fluxion. The physiological fluxion which precedes menstrua- • 
 tion may be taken as the type of morbid fluxion. The temporary 
 modifications produced in the organ by fluxion can readily be under- 
 stood by studying the uterus in women who have died during men- 
 struation, and in whom the sudden suspension of life has prevented 
 the dissipation of the uterine plethora or congestion caused by fluxion . 
 One of the best proofs that fluxion is a different morbid state from 
 congestion is that the best means of treatment for the latter are, by the 
 admission of all practitioners, not only the worst means of treatment 
 for the former, but the best means that can be employed to produce 
 it. For instance, the repeated application of leeches to the cervix, 
 anus, labia, groins, hypogastrium and loins is an efficacious means of 
 subduing congestion, and disgorging the congested uterus of blood; 
 on the other hand, all practitioners know the tendency they have to 
 induce or increase the menstrual flux when administered at the oppor- 
 tune moment, i. e. immediately before the period. 
 
 1 have seen with interest that the existence of fluxion is not only 
 accepted by several pathologists who had formerly ignored it,^ but also 
 that its reality is placed beyond all doubt by Yirchow in his scientific 
 researches on pathological anatomy and histology. "The vessels," 
 Billroth^ tells us, " dilate or become distended when irritated, and are 
 disgorged anew soon after irritation has ceased. It is as easy to 
 observe the fact as it is difficult to discover the cause. The exagge- 
 rated afflux of blood is the reaction or response of an irritated vascular 
 
 ' Nonat et Linas, Traite pratique des maladies de I'uterus, p. 1C7. Paris, 
 1869. — Revdllout, Des Tuvieiirs Jiuxionnaires de I'uterus {Gazette des Iwpitaux, 
 1869, 1874). — Jaccoud, De la Congestion, in his work entitled Pathologie 
 medicale, t. i. 
 
 2 j)ie cdlg. chirur. Pathologie u. Therapie, p. 62. Berlin, 1876. 
 
462 UTEEINE DISEASES IN DETAIL 
 
 part to the irritation : ubi stimulus, ibi jiumis. The names active 
 hypereemia^ active congestion, which have been employed to designate 
 this afflux of blood do not express the mode of production, and Yirchow 
 has rightly brought into use the old ievm fluxion." 
 
 Diagnosis. — Uterine fluxion is met with in nulliparae as in other 
 women ; it is common amongst girls, and in them seems to be pro- 
 duced by difficulty in the estabhshment of menstruation. The cli- 
 macteric is also marked by the appearance of irregular uterine fluxions 
 and hsemorrhages. 
 
 Subjective signs. — Heavy dull pain developed rapidly in the lumbo- 
 sacral region, intra-pelvic weight, a feeling of internal fulness and heat : 
 such are the local symptoms in the beginning. If the fluxion con- 
 tinues there are dull colics in the sides, umbilicus, and hypogastrium, 
 returning momentarily, or even periodically in the form of spasms. 
 If the afflux of blood increases the symptoms become more marked; 
 the patient experiences the sensation of a weight, as well as discomfort 
 which seems to be produced by a large foreign body, a burning heat 
 in the pelvis, dragging in the loins and groins, acute colics, deep pelvic 
 pulsations synchronous with those of the pulse. At this stage there 
 is often great difficulty in sitting, standing, walking, &c. In the most 
 serious cases the internal heat felt in the abdomen is constant and in- 
 creases at intervals, extending from this point, as from a centre, 
 towards the umbilicus, and more frequently along the anterior portion 
 of the thighs to the knees. This burning heat is coincident with 
 irritation of the vulva, frequent desire for micturition accompanied by 
 a burning sensation, which is sometimes so acute as to force tears ; 
 the urine is passed in small quantity always loaded with urates or 
 phosphates, and sometimes containing more or less mucus. Consti- 
 pation is sometimes very obstinate. Occasionally, when the fluxionary 
 movements are exaggerated the motions are accompanied by mucous 
 excretions forming a kind of membrane. At other times there are 
 diarrhceic evacuations somewhat like those of dysentery, or it may 
 be that only at intervals there .is an unnaturally frequent and very 
 painful desire to pass urine and go to stool. 
 
 General symptoms precede and accompany these local symptoms. 
 Those which precede them are the special phenomena indicating an 
 afflux of blood towards the uterine economy, with symptoms of 
 molimen more marked than the prodromata of menstruation; 
 shivering, spasm, vague nervous phenomena, irritability, and a tendency 
 to tears. Those which accompany them are phenomena of reaction, 
 showing that the organism shares the sufferings of the uterus ; nervous 
 erethism, circumscribed pains, neuralgia, gastralgia, migraine, dys- 
 pepsia, vomiting; in fact when fluxion occurs frequently, or when it 
 lasts for some time, the phenomena of fluxion observed in the pelvic 
 organs are repeated in the most important organs of the economy, the 
 heart, lungs, brain, &c. 
 
 Objective symptoms. — The hypogastrium is enlarged, moderately 
 warm, only slightly painful, but sensitive to pressure. The vagina is 
 usually warm and moist, sometimes the seat of abundant leucorrhoea. 
 
FLUXION 463 
 
 The uterus is larger^ heavier, less mobile, considerably lower and in- 
 clined forwards, slightly painful to pressure, or at least to movements 
 directly conveyed to it or transmitted through the body. The size of 
 the uterus is variable, a symptom which distinguishes fluxion from 
 congestion. In some cases tumefaction is rapid. In women recently 
 delivered it may become enormous in a few hours, passing the brim. 
 The body spreads out above the neck, projecting beyond it like a 
 bladder, a proof that in fluxion as in congestion it is the body rather 
 than the neck that is affected. 
 
 Usually the vagina and vulva participate in the fluxionary move- 
 ment, presenting a violet or dark red colour. Afflux of blood may 
 also take place towards the most important organs of the economy ; 
 these symptoms also distinguish fluxion from congestion. According 
 to the seat of the localisation, they produce troubles characterised by- 
 flushing of the face, giddiness, syncope, cardiac pain, a feeling of 
 suffocation, epigastric constriction, &c., alternating with the uterine 
 phenomena or accompanying them. These uterine or visceral fluxions 
 when chronic are often followed by hsemorrhage, which however is rare 
 in acute fluxion. It at first takes the form of menorrhagia, coinciding 
 with more marked fluxionary symptoms. Menstruation soon becomes 
 deranged and advances a few days, a week, then a fortnight, and as it 
 also lasts longer, patients end by losing blood continually. 
 
 The hEemorrhage may gradually diminish so that patients may think 
 they have got rid of it ; but the least effort, fatigue, travelling, or ex- 
 cessive intercourse, bring it back more violently than ever, together 
 with other visceral haemorrhages, which gradually produce aneemia. 
 
 Treatment. — lluxion is always serious, even in the simplest form and 
 in the acute stage, because it shows a special tendency of the uterus to 
 become the terminal point of sanguineous raptus ; but when it becomes 
 habitual it demands still more attention from the physician, because the 
 uterus is apt to become congested and hypertrophied ; because it gives 
 rise to hsemorrhages producing angemia, and sometimes to leucorrhoea, 
 throwing women into a deplorable state of weakness ; lastly, because 
 owing to this abnormal activity of circulation, there is a tendency 
 to the development of morbid products within the substance of the 
 uterus. 
 
 As for the indications to be fulfilled, we must first discover whether 
 the uterine fluxion is secondary, that is, whether it is caused by an 
 alteration of the uterus or its appendages, or whether, on the con- 
 trary, it is primary, as is usually the case. We must then take into 
 account the circumstances determining it either during menstruation 
 or in the intercalary period or after delivery or abortion. These circum- 
 stances are : premature or excessive intercourse, falls on the seat, 
 mechanical action of all kinds, overfatigue, cold, moral excitement, 
 especially when of a sad nature, &c. Acute fluxion must also be 
 distinguished from chronic; the former usually occurs in girls, the 
 latter may be chronic from the commencement, owing to atony of the 
 constitution, or it may assume the character of chronicity from the 
 repetition of the haiinorrhage and the consequent anfemia, or from 
 
464 "UTERINE DISEASES IN DETAIL 
 
 defective nutrition caused by dyspepsia. Acute fluxion becomes 
 chronic, and fluxions in other organs follow as a result of the dis- 
 order produced in the vascular system, which finally seems to escape 
 the control of any regulating influence. The treatment of uterine 
 fluxion ought to be an application of the methodic treatment of 
 fluxions in general, the principles of which I have already laid down. 
 1. If fluxion is imminent or quite recent, recourse should be had 
 to revulsives, e. g. bloodletting from some point more or less distant 
 from the seat of fluxion. General bleeding is especially indicated 
 when the fluxion depends on constitutional plethora, or when the 
 patient is in good health. I have several times drawn blood from the 
 arm in young women affected with recent fluxions, always taking care 
 not to exceed the strength of my patients. Another revulsive recom- 
 mended by Hippocrates, and which is very beneficial, provided its 
 action is sustained for several hours or even days, is the application 
 of cupping glasses to the breasts. In delicate ])atients cupping and 
 other cutaneous revulsives should be preferred to blood-letting. 
 Sinapisms applied to the breasts, the upper part of the trunk, the 
 arms, the wrists, and if necessary large blisters on the arms, produce 
 energetic and salutary revulsion. I have once seen the vomiting 
 caused by antimony effect speedy revulsion and dissipate a recent 
 uterine fluxion. However^ the shock produced bj the vomiting and 
 the debility caused by the antimony might dispose the vascular system 
 to an irregularity of action favorable to the recurrence of the same 
 fluxion. 
 
 Lastly, we may have recourse to intestinal revulsives, but two im- 
 portant conditions must be observed. The first is only to use them 
 after bloodletting or cutaneous revulsives, lest the concentration which 
 follows the action of purgatives should be unfavorable. The second 
 is to avoid drastics (especially aloes), which congest the lower portion 
 of the intestine and favour the development of haemorrhoids, thus 
 increasing the uterine fluxion in place of dissipating it. Saline pur- 
 gatives, magnesia, castor oil, should on all accounts be preferred. 
 Whilst revulsive treatment is being employed the patient should re- 
 main in bed, the pelvis slightly raised by a hard pillow, the head 
 elevated, the legs flexed on the thighs and the thighs on the pelvis. 
 Cold compresses or bladders of ice should be applied to the abdomen 
 and thighs, especially if fluxion is accompanied by hseinorrhage. 
 It is also useful to prescribe diffusible stimulants; 48 drops of liquid 
 ammonia in 2 ounces of syrup to be taken in drachm doses in the 
 24 hours in a glass of orange water, or from 4 to 7 drops of acetate 
 of ammonia given in an aromatic infusion and repeated 3 or 4 times 
 a day. 
 
 2. If the fluxion is fixed in the uterus, revulsives should be pre- 
 ceded by derivatives with the view of deviating the flow of blood 
 which habit and length of duration prevent being carried in another 
 direction. Cupping glasses and leeches to the loins, groins and hypo- 
 gastrium are the best derivatives in such a case. Lastly, when 
 fluxionary movements are frequently renewed, and have produced 
 
FLUXION 465 
 
 congestion, it may be advisable to treat the fluxion as a true conges- 
 tion, by depletives and derivatives before resorting to revulsives. In 
 such cases leeches may be applied to the cervix, even in women who 
 are apparently exhausted, provided that tonics and generous diet are 
 prescribed at the same time. 
 
 Whether simple derivatives are employed, or depletives and deriva- 
 tives simultaneously, the effect produced is to disgorge the uterus and 
 to deviate the flow of blood directed towards this organ. But the 
 fluxion although mobilised is not necessarily dissipated. It is then 
 that revulsives should be resorted to. Bleeding is too weakening and 
 its action not sufficiently sustained for it to triumph over an evil 
 which has taken root in the economy. Although the fluxion is 
 mobilised, we can only hope to uproot it by the use of means the 
 action of which is more continuous and energetic. Therefore hydro- 
 pathy is the best revulsive, care being taken after applying the douche 
 to warm the skin by exercise, or if the patient is too weak for that, 
 by stimulating frictions, or a short time spent in dry hot air; and 
 after the douche has been administered for two or three minutes good 
 reaction should be determined, either by dry frictions or by exercise. 
 These means of revulsion repeated twice a day produce surprising re- 
 sults in a few weeks. In cases where the patient was weakened by 
 repeated haemorrhage, and where the fluxion was directed alternately 
 to the uterus and other viscera, this means has always seemed to me 
 heroic. Hydropathy is beneficial not only by effecting a revulsion 
 over the whole cutaneous surface, but by giving tone to the whole 
 organism and producing a sedative effect on the nervous system. 
 The habitual use at table of mineral waters such as those of Lamalou, 
 Oreza, Boulou, or Vals, mixed with a little wine, is of great service. 
 It must be remembered that, in the treatment of long-standing 
 fluxions, those revulsives should be used which strengthen, not those 
 which debilitate. In proportion to the strength of the organism and to 
 the equilibrium existing between its various functions and between its 
 various organs, vrill be the chance that the fluxion when once dissi- 
 pated will neither resume its usual course nor be directed towards 
 some other viscus. 
 
 The other indications to be fulfilled although secondary are im- 
 portant. 
 
 Rest, which is necessary in the acute stage, may be so also in the 
 chronic state if walking causes pain and increases the evil. In the 
 contrary case, exercise in addition to hydropathy acts as one of the 
 best tonic revulsives and one of the best hygienic means for regulating 
 the equilibrium of all the organs. 
 
 The bowels must be kept regular, as the only means of keeping 
 up the appetite, facilitating digestion and overcoming constipation ; 
 the latter is a dangerous complication of all uterine diseases, but par- 
 ticularly of fluxion and congestion, which are increased by it. There- 
 fore laxatives should be employed in place of purgatives ; I find gr. -^ 
 of extract of belladonna with gr. 2| of medical soap made into a 
 pill and taken every night very effectual, with a spoonful of castor 
 
 30 
 
466 UTERINE DISEASES IN DETAIL 
 
 oil once a week, or rhubarb and magnesia in equal quantities in a cup 
 of acorn coffee or a glass of Hunyadi Janos water. Laxatives should 
 be given alternately with enemata of oil or a solution of manna, 
 treacle, or glycerine, so that the large intestine may be emptied. 
 Besides these two indications there is a third which may require to 
 be fulfilled : that of cooling the uterus frequently, either directly by 
 vaginal irrigation, or by acting upon the neighbouring organs by 
 small enemata taken at bed time. Lastly, the debility which often 
 accompanies the cessation of the fluxion involves the necessity of care 
 during convalescence. After the disappearance of acute symptoms 
 patients recover slowly in proportion as menstruation is established 
 once more in a regular manner. The return of health is still slower 
 after exhaustion caused by chronic uterine fluxion. 
 
 Congestion 
 
 Congestion (from co7igerere to accumulate) is the persistent accumu- 
 lation of blood in the vessels and capillaries of the uterus. Sometimes 
 it is the result of simple fluxion strong or repeated, sometimes of a 
 hindrance in the general circulation. It plays an important part in 
 the majority of uterine diseases because of forming an integral part of 
 the uterine functions. 
 
 In fact every menstrual period is composed of three successive acts : 
 fluxion, congestion, hsemorrhage. Congestion, whether the result of 
 fluxion or uterine erection, necessarily precedes hsemorrhage; perio- 
 dical uterine congestion is therefore physiological. When the abund- 
 ance of the menstrual hsemorrhage is proportioned to the intensity of 
 the uterine congestion all abnormal symptoms disappear with the 
 discharge. But if resolution is not complete, the uterus remains the 
 seat of a congestion which increases every month, giving rise to a per- 
 manent morbid condition : chronic congestion.^ 
 
 It becomes morbid by becoming exaggerated, by being prolonged, 
 or by encountering diseased organs. 
 
 The conditions producing congestion may be local or general. The 
 local conditions are : a vascular system excessively developed, especially 
 the venous system without valves and of feeble contractility ; a dis- 
 position of muscular tissue favouring stasis of blood in the veins as in 
 all the erectile tissues ; the position of the organ which is low, pressed 
 from above downwards by the weight of the abdominal viscera, subject 
 to erections and to monthly congestion and hsemorrhage, as well as to 
 increase of size, dilatations of the venous system, and to enormous 
 hypertrophy at every pregnancy. 
 
 The general conditions are those which produce irregularities and 
 difficulties in the circulation with slackening of the blood current, such 
 as diseases of the heart, lungs and liver. — Congestion may be idiopathic 
 or symptomatic; sometimes it constitutes a simple morbid state, existing 
 
 ' rieury, Traite d'hydrotherapie, des Congestions sanguines chroniques de 
 V uterus, p. 446. Paris, 1852. 
 
CONGESTION 467 
 
 by itself — primitive or idiopathic congestion, facilitating unfortunately 
 the localisation of diathetic affections on the uterus or its appendages ; 
 sometimes it is a consequence or complication of an existing malady — 
 secondary or symptomatic congestion. It may also be active or 
 passive. The active form, due to the persistence of the fluxionary 
 movements, is a result of the constant afflux of blood and of the dis- 
 tension of the vessels in an organ which never empties ; the passive is 
 due to atony, to defective contractility of the vessels, which once filled 
 are not emptied, or to the difficulty placed in the way of the return of 
 the blood owing to pressure or alteration of the uterine vascular 
 system, or to an obstacle in the general circulation. Both may be 
 either acute or chronic : passive congestion is usually chronic. It 
 may present numerous varieties, from feeble sanguineous congestion 
 to hsemorrhagiparous congestion. After death it usually persists, its 
 anatomical alterations being injection, softening, flexibility of the 
 uterine tissue, especially of the body ; dilatation of the vessels, form- 
 ing sinuses, which on section allow the escape of black blood and the 
 entrance of a director into their orifice ; red-brown colour of the 
 mucous membrane of the body, with swelling and thickening, the dis- 
 semination of red points (so many little clots), oozing of drops of 
 blood from the surface of the mucous membrane, especially on pres- 
 sure, a violet colour of the vaginal surface of the cervix, contrasting 
 with the relative paleness of the mucous membrane lining the cavity. 
 In the tubes and ovaries there are found softening, red-brown colour, 
 tumefaction, and sometimes hypertrophic thickening ; sometimes 
 uterine and even vaginal leucorrhoea with congestive coloration of the 
 upper portion of the vagina ; sometimes also in the Fallopian tubes 
 sanguinolent or opaque, white or yellowish liquid mucus, containing 
 hardly more than epithelial cells ; sometimes, lastly, in the thickness 
 of the broad ligaments, dilated venous bundles, resembling the pam- 
 piniform plexus in man, forming tumours of varying dimensions, 
 attaining half the size of the fist and reaching the renal region, coin- 
 ciding with great congestion of the uterine tissue, and very m.arked in 
 aged women who have succumbed in the midst of symptoms of 
 obstruction of the venous, abdominal or general circulation. 
 
 Diagnosis. — Uterine congestion occurs most frequently in multi- 
 parse. Therefore we can form a good idea of several of the alterations 
 characterising it, not only by examination of the uterus during men- 
 struation, but by autopsies of women recently delivered ; it must not, 
 however, be forgotten that in women who have aborted there is in the 
 uterine tissue, in addition to the congestive state, the remains of the 
 hypertrophy which modified it during pregnancy. 
 
 Subjective signs. — Dull pain in the lumbar region, weight at the 
 sacrum, anus and perinseum, a sensation of fulness in the pelvis, in- 
 ternal heat : such are the first local symptoms of recent congestion, as 
 of fluxion. What distinguishes congestion from fluxion is the usual 
 absence of symptoms of molimen and sanguineous rapius, unless the 
 fluxion which has caused the congestion persists or returns repeatedly. 
 It is the same in a number of cases where congestion may be produced 
 
468 UTERINE DISEASES IN DETAIL 
 
 without fluxion passively from defective tone or contraction of the 
 capillaries, or where it becomes passive after having been active from 
 a gradual loss of tonicity in the vessels ; or where it may be in a sense 
 hypostatic owing to some obstacle placed in the way of the uterine or 
 general circulation. 
 
 The symptoms of fulness persist in the pelvis with sensations of 
 dragging in the loins or groins, and troubles in the neighbourhood ; 
 there is frequent desire for micturition, obstinate constipation often 
 accompanied by tenesmus, irritation of the vesical and rectal mucous 
 membranes with evacuation of more or less considerable quantities of 
 mucus accompanying both micturition and defeecation. The lumbar 
 pains increase, those of the groins extend down the thighs to the knees, 
 in addition to which there is often in the left iliac region or above it 
 a fixed pain which seems to depend on congestion of the left ovary, or 
 on the dragging which the uterus, when prolapsed and with its fundus 
 inclined to the right, may exercise on the ligaments of the left side ; 
 lastly, there is the sensation of a large body threatening to fall, com- 
 pressing the bladder and rectum, weighing even on the anus, and 
 seeming to make an effort to pass the vulval orifice. The sudden con- 
 traction of the abdominal wall, and the shock which follows it in 
 yawning, coughing, or in the expulsion of faecal matter, &c., is accom- 
 panied by a painful sensation as if a heavy body was falling out of the 
 pelvis. Uterine congestion lasts indefinitely; nothing indicates that it 
 is cured spontaneously. Haemorrhage is sometimes added to the other 
 symptoms as in cases of fluxion ; but usually menstruation occurs rarely 
 and irregularly, sometimes being altogether wanting, although the 
 characteristic pains of molimen may be present ; sometimes occurring 
 too frequently, every three weeks, every fortnight, or every week, but 
 consisting of a very small quantity of blood. This diminution in the 
 quantity of menstrual blood is characteristic of dysmenorrhoeic conges- 
 tion. In addition there are uterine colics and sometimes even a kind 
 of uterine tenesmus, the consequence of expulsive pains which oblige 
 patients to bend forwards. Usually some of the general symptoms 
 of uterine maladies are also produced, such as dyspepsia, disturbances 
 of nutrition and consecutive nervous phenomena; and later on, debility, 
 anaemia, palpitations of the heart, a small dry nervous cough, incapacity 
 for any exertion, emaciation, dry skin, with the sallow hue of the face 
 and dull eyes characteristic of the/aeies uterina. 
 
 Objective signs. — Hypogastric palpation associated with vaginal 
 touch shows an increase of size in the uterus, but of the body more 
 than the cervix. The pain caused by this examination is less owing 
 to the sensibility of the uterus than to the difficulty which the increase 
 of size puts in the way of displacement, and to the dragging which 
 movements conveyed by the finger exercise on the neighbouring organs, 
 the broad ligaments, bladder and rectum. Often the uterus is pro- 
 lapsed so much that the cervix rests on the perinseum. At the same 
 time the natural anteversion is increased. It is, however, necessary to 
 remark that congestion, which is so common after delivery and abor- 
 tion, at a time when the uterus may be found in another position owing 
 
CONGESTION 469 
 
 to the softness then characterising its tissue, only exaggerates this 
 vicious position; and lateral inclinations, retroversions and retro- 
 flexions may also become exaggerated by increased weight and soften- 
 ing of the tissue of the organ. 
 
 Fia. 310. — Reduction in the size of the uterus in the intercalary period. 
 
 Congestion is often also more localised than fluxion. It more 
 frequently occupies the whole of the organ than a portion of it; 
 it may, however, unlike fluxion, occupy one portion to the exclusion 
 of the other or in a more marked degree, and more frequently the 
 body than the neck, and one wall more than the other. The neck 
 may be so much congested that it cannot be embraced by any speculum ; 
 it may present a dark red or violet colour, and offer to the touch a 
 large soft swelling, with the orifice half open and projecting outwards 
 circularly, especially on a level with the two lips in multiparse, giving 
 to the cervix the appearance of a mushroom, or of a cone with the base 
 downwards. In the utero-vaginal cul-de-sac, on one or both sides 
 of the uterus, bundles of venous vessels may be felt gorged with blood, 
 such as are sometimes seen in the broad ligaments in old women where 
 congestion is of long standing. Sometimes a certain amount of mucus 
 is seen escaping from the cervix. The cavity is also enlarged as occurs 
 likewise at the time of erection accompanying menstruation or coitus. 
 This can be ascertained by the use of the catheter, which can be moved 
 with great facility in the uterine cavity. This increase in capacity is 
 so marked that it is observed even in nulliparse. 
 
 Treatment- — When uterine congestion is symptomatic its cure is 
 subordinate to that of the malady on which it depends. An alteration 
 of the uterus, a fibroid for example ; a disease of the ovary or Fallopian 
 tube; a disease of the bladder or rectum; peritonitis; chronic enteritis 
 may keep up a congestive state in the womb which we may try to 
 alleviate but cannot hope to cure, until the original malady which has 
 
470 
 
 UTERINE DISEASES IN DETAIL 
 
 gradually produced the uterine congestion has been cured. Sometimes 
 congestion complicates uterine diseases without being exactly sympto- 
 
 FiG. 311. — Considerable increase in the size of the uterus, either from tem- 
 porary menstrual congestion or from morbid and permanent congestion, 
 particularly of the body. 
 
 matic. In such cases it both hinders cure and increases the diseased 
 condition. Hence the necessity of treating the congestion with the 
 view of lessening the disease. As for idiopathic congestion, it weakens 
 patients, disturbs the functions of the uterus, and disposes it to disor- 
 ganisations which may result from the localisation of the diathetic 
 affections to which the patient is exposed. 
 
 The capital indication therefore is to put a stop to the accumulation 
 of blood in the uterine economy, to abstract blood from the organ and 
 prevent its being filled anew by giving a different direction to the cur- 
 rent, whilst diminution in the size of the uterus is hastened by the use 
 of resolvents. The best means of abstracting blood is to apply leeches 
 to the cervix. This treatment is sometimes followed by immediate 
 relief if applied according to the rules I have laid down, namely, that 
 it should be performed immediately after the end of the monthly period, 
 and that a sufficient quantity of blood should be drawn to produce real 
 depletion of the organ. The application should be repeated the follow- 
 ing day if the quantity already drawn has been insufficient, and it 
 should be followed the next day by a purgative chosen with reference 
 to the constitution and temperament of the patient, season of the 
 year, &c. 
 
 The dysmenorrhoeic symptoms of congestion may require the use of 
 
CONGESTION 
 
 471 
 
 narcotics as temporary palliatives : gr. ^ of extract of opium in a pill 
 every six hours^ or 15 drops of laudanum in an enema, or gr. ^ 
 
 Fig. 312. — Hypertrophic congestion of the cervix and os uteri in a multipara. 
 
 of extract of belladonna twice a day. Narcotics, however, as a rule 
 are contra-indicated in the treatment of this disease. Congestion being 
 in some degree renewed at every monthly period, the same treatment 
 must be repeated for a considerable time ; leeches to the cervix after 
 menstruation, purgatives, rest, &c. Usually three or four applications 
 of leeches made three or four months consecutively suffice for the 
 treatment of chronic congestion, or an interval of two months may be 
 left between two applications. Often, however, I have been obliged 
 to make a greater number; no rule can be laid down. If the men- 
 strual haemorrhage is abundant it is sufficient to administer a purga- 
 tive once or twice a few days after menstruation. 
 
 Rest, baths, vaginal irrigations favour the action of these means. 
 Above all patients should be enjoined to give rest to the organ, i.e. to 
 interrupt marital intercourse ; for the absence of acute pain and the 
 chronicity of the evil often cause this precaution to be disregarded to 
 the injury of health and the hindrance of treatment. 
 
 If these means are insufficient derivation and revulsion should be 
 exercised by means of blisters, or of frictions with croton oil or antimo- 
 nial ointment on the hypogastrium in cases of acute and painful 
 congestion ; and by means of alkaline and sulphur baths, dry friction 
 of the whole body, in fact by hydropathy, in the more frequent cases 
 of chronic congestion, the least painful form of congestion but the 
 most difficult to cure. These means do not act merely as revulsives, 
 they also favour the resolution of the engorgement which often com- 
 plicates chronic congestion. Hydropathy in such cases is very effec- 
 
472 UTERINE DISEASES IN DETAIL 
 
 tual after leeching, purgatives and irrigations ; I mean general hydro- 
 pathy, the local douche is always dangerous. 
 
 Sea bathing, tonics, iron, and residence in the country are necessary 
 when the malady is quite chronic, when the patient is exhausted and 
 ansemicj and when she has rested sufficiently long to dissipate the pain 
 and help the action of the local means used to deplete the organ 
 during the first period of treatment. As soon as walking can be 
 allowed, the patient should be provided with a hypogastric belt to 
 prevent the pain and increased congestion produced by the weight of 
 the abdominal viscera on the womb. 
 
 Engoegement 
 
 Engorgement {infarctus) is a permanent tumefaction constituted by 
 infiltration of organic, amorphous, liquid or semi-liquid matter between 
 the normal anatomical elements of the organ. It should be admitted, 
 as well as congestion and fluxion. 
 
 According to my friend and colleague M. Charles Robin,^ the word 
 engorgement means a state histologically characterised by the presence 
 of amorphous matter, half solid or liquid, which has exuded between 
 the anatomical elements, and which keeps them apart. This matter 
 when liquid or half liquid holds in suspension molecular granulations, 
 generally fatty. ... In the half-solid condition in the hard portions 
 near the inflamed parts it has scattered throughout it fatty nitrogenous 
 molecular granulations, with or without those granular globules, called 
 globules of inflammation. . . . According to the conditions which have 
 caused the engorgement, especially in amorphous matter, it is produced 
 or is not produced from fibro-plastic elements which, added to those 
 existing normally in the tissue, make the engorgement pass into the 
 chronic state of induration or hypertrophy. 
 
 As to the distinctive signs between engorgement and the other 
 maladies characterised by tumefaction, it is sufficient to say that, 
 although increased size is common to engorgement, fiuxion, conges- 
 tion, inflammation and hypertrophy, there is in engorgement an 
 absence of the inflammatory pain so characteristic of metritis, of the 
 dark red or violet colour of congestion, with its varicosities, of the 
 uterine or visceral sanguineous raptus of fluxion, and of the consis- 
 tency and induration of hypertrophy. 
 
 Lastly, why should the effect of treatment not be invoked as a final 
 proof of the existence of uterine engorgement ? I have seen cases in 
 which I have not used any of the means necessary in the treatment of 
 metritis, fluxion, congestion or hypertrophy, cured under the influence 
 of simple resolvent treatment, determining the absorption of the in- 
 filtrated fluids into the normal tissue of the organ. I remember seeing 
 a case of tumefaction of the uterus which had lasted for several years, 
 and which had occurred after a difficult labour. The information given 
 me by the patient was insufficient to allow of my determining its exact 
 nature, but the most prominent symptom was phlegmasia alba dolens. 
 ' See Diet. Nysten, article Engorgement. 
 
ENGORGEMENT 473 
 
 There was no symptom of metritis, hypertrophy, fluxion, nor even of 
 congestion. The health was very good, but walking was all but im- 
 possible, and the increased size of the womb was the only apparent 
 cause of the trouble, to which I had no hesitation in giving the name 
 of engorgement. I could not persuade the patient to submit to treat- 
 ment of any kind, but at last she agreed to try the waters of Yichy for 
 a month. Soon afterwards she wrote me word that the uncomfortable 
 sensation she experienced in the pelvis and the impossibility of walking 
 disappeared daUy as if by enchantment; and for several years the cure 
 has been maintained. 
 
 Diagnosis. — Engorgement may arise spontaneously, but is often the 
 consequence of congestion or inflammation. It may exist alone or co- 
 exist with congestion (soft, fungous, bleeding engorgement), with 
 hypertrophy (hard hypertrophic engorgement), and even with fluxion 
 and inflammation ; but it is rare in the latter case that the characters 
 of these two morbid conditions do not efface those of engorgement 
 itself. Lastly, it may depend on purely local conditions, but usually 
 it is kept up by a diathetic affection. 
 
 Siuhjective symptoms. — The patient experiences a disagreeable sensa- 
 tion of fulness and weight in the pelvis, dragging in the loins, but 
 less than in congestion, dragging in the groins propagated to the 
 anterior and internal surface of the thighs, heavy pain at the sacrum 
 and perinseum, but less than in congestion and fluxion. There is no 
 sensation of heat in the vagina and vulva, but often pruritus. Some- 
 times a uterine mucous or muco-purulent secretion gives rise to leu- 
 corrhoea. Usually there is no hesmorrhage nor want of regularity in 
 the monthly periods, the discharge is generally rather diminished than 
 increased -, engorgement may, however, produce menorrhagia or exces- 
 sive menstruation. Dysmenorrhcea and menorrhagia arise from the 
 engorgement favouring congestion and preventing its coming to a 
 crisis as soon as usual. The symptoms in neighbouring organs are 
 the same as in congestion. But the bladder and rectum usually tole- 
 rate engorgement better than metritis, fluxion or congestion; consti- 
 pation, however, is usual. Lastly, other symptoms will be added to 
 those naturally arising from the preceding when the patient's local and 
 general conditions are such as to favour the development of engorge- 
 ment. These conditions are : repeated deliveries or abortions, exces- 
 sive intercourse, &c., as well as a rheumatic, dartrous, or scrofulous 
 diathesis. 
 
 Objective signs. — Palpation associated with vaginal touch reveals 
 an increased size of the organ. The fundus projects slightly beyond 
 the pubis, unless there is marked prolapsus. The finger when in the 
 vagino-uterine cul-de-sac sometimes feels the body projecting beyond 
 the neck. The vaginal portion of the neck, as if ccdematous, some- 
 times acquires such large proportions that the largest speculum cannot 
 embrace it. The lips are often turned outwards in consequence of 
 tumefaction opening the os widely in women recently delivered. One 
 lip is often much larger than the other, but the engorgement is 
 general, only being a little more marked on one lip than on the rest of 
 
474 UTERINE DISEASES IN DETAIL 
 
 the neck. This swelling of the neck is not accompanied by redness, 
 but occasionallj the neck is red and congested ; more frequently it is 
 soft, but not bleeding, and pale, but in neither case is there any sensa- 
 tion of heat to the touch. Often the uterus is displaced or deviated, 
 as it is after any increase of size which adds to its weight, but we must 
 beware of thinking that displacements are the necessary results of 
 engorgement- The sound shows an increase in the length as well as a 
 dilatation of the uterine cavity, though this dilatation is less than in 
 hypertrophy proper. Lastly, there may exist evident signs of various 
 complications, e.g. a varicose dilatation of the veins of the neighbour- 
 ing organs, of the broad ligaments, vagina, bladder and rectum, 
 showing the co-existence of congestion with engorgement, or vaginal 
 leucorrhcea, chronic catarrh of the bladder, &c. 
 
 Differential diagnosis. — Engorgement must be distinguished from 
 cedema, jBuxion, congestion, inflammation, hypertrophy, inflammatory 
 induration, which may easily be confounded with it, as well as from 
 scirrhous induration, fibroids and pregnancy, which, however, are more 
 easily distinguished. In all these morbid conditions there is total or 
 partial increase of size of the uterus. The elements of the differential 
 diagnosis wnll be detailed and grouped in tables in the description of 
 metritis. 
 
 Treatment. — In the first place we must remember that engorgement 
 is curable whilst hypertrophy, with which it may easily be confounded, 
 is not so. Further, many women who have reached the climacteric 
 do not ask to be treated for engorgement, because pain has disap- 
 peared or can be alleviated by palliatives. This age is favorable to 
 the tolerance of the disease, whilst youth is favorable to cure, being 
 characterised by an activity of circulation which facilitates the absorp- 
 tion of the fluids interposed amongst the normal uterine elements ; 
 moreover the very functions of the uterus, menstruation and preg- 
 nancy, may be. turned to account as means of cure, the retrograde 
 evolution which takes place in the uterus after every pregnancy and 
 after every menstrual period being very favorable to the complete 
 resolution of the organ. There are four indications to be fulfilled : — 
 
 1. The first consists in turning aside the fluxionary movements, dissi- 
 pating the congestion, and removing all causes of hypersemia which 
 facilitate the increase or prevent the resolution of the engorgement. 
 It will be fulfilled by the same means already indicated as the most 
 suitable for subduing fluxion and congestion. Bloodletting should be 
 very cautiously practised, whilst cutaneous and intestinal revulsion, 
 including hydropathy, should be resorted to. 
 
 2. The second consists in rendering the exuded fluids capable of 
 being absorbed and in stimulating the normal processes of the organ 
 and economy, by which means we may hope to produce this absorp- 
 tion. It is in a measure special to engorgement and hypertrophy. 
 In order to bring about absorption of the fluid infiltrated into the 
 normal tissue resolvent medicaments should be used, or rather medi- 
 cations capable of producing this result by the modifications which 
 they bring about in the functions, and by the special activity and 
 
ENGORGEMENT 475 
 
 direction which they give to general and local nutrition. These 
 include the various preparations of mercury and iodine, especially 
 iodide of potassium given internally. The same preparations as well 
 as ointments of the iodides of sulphur and mercury may also be 
 administered by the rectum or vagina or in frictions. A tampon 
 saturated in a glycerole of iodide of potassium (60 grains of iodide to 
 the ounce, Scanzoni) is an excellent application, to which we may 
 add : warm sitz-baths twice daily, vaginal injections and wet abdom- 
 inal compresses, the water used for the baths, injections and fomen- 
 tations being medicated by the addition of a solution of iodine or 
 bromine ; painting the hypogastrium with the tincture of iodine, or 
 the application of an ointment of the iodide or bromide of potassium ; 
 whilst internally we may prescribe the prolonged use of mild laxatives, 
 alkalijie mineral waters (Vichy, Plombieres, Vals, Andabre) and iron, 
 especially the iodide ; from the alkaline the patient may pass to 
 chalybeate waters (Lamalou, Bussang, Oreza^ Sylvanes) taking the 
 precaution to begin by mixing one third of the iron water with two 
 thirds of the alkaline water; lastly, when possible, a few months 
 should be spent at some watering place where the patient can take 
 baths, drink the waters, and practise hydropathy simultaneously. 
 The best in such circumstances are sulphur, alkaline and iron baths, 
 especially those of Vichy, Vals, Boulou, Lamalou, Sylvanes and 
 Andabre, or sea bathing and hydropathy. The Arabic treatment, the 
 cura famis, has even been recommended ; it is seldom, however, that 
 the latter is indicated. 
 
 3. The third indication consists in treating the diathesis which has 
 given rise to the development of engorgement in the uterus. Accord- 
 ing to whether it be rheumatic, scrofulous or herpetic we should 
 recommend sulphur or alkaline baths, hydropathy, sea-bathing, pre- 
 parations of iodine, or arsenic in small doses occasionally interrupted, 
 and continued long enough to produce a deep and lasting modification 
 in the economy. In such cases one of the most energetic and 
 efficient means is the cauterisation of the cervix, especially by igni- 
 puncture. Some of the ointments enumerated, especially that of the 
 red iodide of mercury, cause suppuration. A blister may also be 
 applied to the cervix, but the least painful as well as the most efficient 
 application is that of the actual cautery in the form of ignipuncture 
 followed by baths, purgatives, alteratives, hydropathy and resolvents 
 of every kind. By taking the precaution of making the punctures at 
 some distance from the orifice the danger of contraction is avoided. 
 
 4. The fourth indication is palliative treatment consisting in alle- 
 viating pain by baths, sedatives, antispasmodics ; in treating constipa- 
 tion by mild laxatives, facilitating digestion by bitters and tonics, and 
 in supporting the abdominal viscera by a hypogastric belt, when, as is 
 frequently the case, they cause pain by their pressure upon the womb. 
 
476 ^ UTEEINE DISEASES IN DETAIL 
 
 Metritis 
 
 Metritis is inflammation of the uterus. It occupies an important 
 place in uterine pathology. Inflammation of the appendages, ovaries 
 and Fallopian tubes, and of the peri-uterine tissues (peri-uterine in- 
 flammation, peri-uterine peritonitis) are also common diseases, the 
 reaction of which on the organism is perhaps still greater than that of 
 metritis strictly so called. As these diseases may co-exist or succeed 
 each other in the same patient, I think their common nature is more 
 important than the difference of seat, and therefore I shall describe 
 ovaritis and peri-uterine inflammation immediately after metritis. 
 
 Pathological anatomy. — The lesions produced by metritis are : in- 
 creased size of the organ, infiltration of fluids into the interstitial 
 tissue, and the consequent softening or induration of the latter, 
 according to the period in which the disease is seen ; infiltration under 
 the serous fold facilitating detachment of the peritoneum, which is 
 red, injected, rough, or covered with false membranes ; hypersemia of 
 the mucous membrane and organic tissue, the capillaries and veins in 
 the latter being gorged with blood. The mucous membrane is red 
 and dotted, with but few traces of the arbor vitse. In cases where 
 the mucous membrane alone is diseased there is in addition consider- 
 able tumefaction of the membrane, the appearance of papillse, the 
 projection of follicular orifices surrounded by a vascular network 
 gorged with blood, softening, epithelial denudation and even ulcera- 
 tion, not to speak of granulations and fungosities which may also be 
 developed in the chronic state. Sometimes these alterations are 
 arrested suddenly at the os internum, whilst the mucous membrane of 
 the cervix is healthy or almost so. However, endometritis hardly 
 ever exists without being accompanied by some parenchymatous 
 metritis. Lastly, lesions depending on suppuration, phlebitis, &c., as 
 the results and complications of inflammation in all other organs, 
 may be observed in the uterus as a consequence of metritis. Pus is 
 sometimes found in the uterine cavity or in the parenchyma \ but 
 suppuration is very rare in the non-puerperal condition. We must 
 therefore ascertain whether some debris of membrane or placenta has 
 not remained in the uterine cavity, or if the interstitial pus has not 
 formed round a clot in a venous sinus or if the suppuration does not 
 arise from a lymphatic vessel. 
 
 These lesions characterise acute and chronic metritis alike. Only 
 in the former they disappear more quickly whether the disease termi- 
 nates by resolution or suppuration. Therefore they are more fre- 
 quently observed in a uterus affected with chronic inflammation. The 
 softening and induration which characterise the first and second period 
 of inflammation in all the tissues also characterise both periods in 
 chronic metritis. 
 
 Scanzoni^ has rightly distinguished '^ a period of softening or iii- 
 filtration, in which a more or less extensive hypersemia is observed, a 
 ' Die Chronisclie Metritis. Wien, 1863., S. 35 et seq. 
 
METRITIS 
 
 477 
 
 sero-sanguinolent infiltration of the uterine tissue which after this 
 imbibition becomes soft, relaxed and thickened, from a second period 
 
 A 
 
 Fig. 313.— Chronic cystic polypous endometritis (after Virchow). The os ex- 
 ternum is dilated in the form of a funnel, and the two lips are the seat of 
 a considerable swelling. A number of Naboth's eggs, isolated or grouped 
 together, rise above the swollen and hypersemiated tissue (acne). To the 
 right of the section we see that these mucous cysts do not belong only to 
 the surface, but extend to a considerable depth. Higher up in the cervical 
 canal the folds are strongly marked, and give rise to a series of vesicular 
 or fleshy polypi, especially to the left, where a large pediculated pyriform 
 one is found, which reaches almost to the os internum. Some small 
 mucous cysts are also to be seen in the os internum. Then comes the 
 slightly dilated cavity of the uterine body, which was filled with fluid, and 
 the mucous membrane of which is smooth (hydrometra levis). A little 
 above the os internum and to the left on the wall a large fibroma mollus- 
 cum (m) is seen containing mucous cysts which before incision almost 
 entirely stopped up the internal os. Higher up at m' is a smaller one, 
 near the orifice of one of the Fallopian tubes. The uterine wall as a whole 
 is thinner ; but in /and/' it contains two interstitial myomata (fibroids) 
 of small size. A third, rather larger, causes the projection indicated by 
 the shining spot on the posterior portion which is not incised. 
 
 of tliichening or induration in which general or partial anaemia of the 
 organ, desiccation, firmness and hardness of the tissue are the prin- 
 cipal lesions. 
 
 In the first period (of softening and hypersemia) tliere may be excess 
 and disturbance of the secretions of the mucous foUicules, neoplasms 
 of all kinds may be formed, especially adenomata, follicular tumours 
 
478 UTEEINE DISEASES IN DETAIL 
 
 and fibro-myomaia, or a general hypertrophy of the organ may be pro- 
 duced. The woodcut taken from Yirchow presents a striking and 
 common example. These neoplasms may be developed in consequence 
 of the hypertrophic tendency of the tissue, owing to local disease of 
 the excretory canal of the glands, of the fibro-plastic elements of the 
 mucous membrane, of the smooth fibres of the tissue, &c. Its for- 
 mation, however, is favoured by inflammation. The intervention of 
 inflammation may be recognised in the fact that, in place of being 
 formed on one point or on one tissue only, the neoplasms are developed 
 at every point and on all the tissues at once. 
 
 In the second stage (induration), in place of presenting an infiltra- 
 tion of amorphous matter as in engorgement, the tissue of the uterus 
 is hardened. It is the index of resolution, but of incomplete resolu- 
 tion. The hypersemia aTid softening disappear, the plastic inflamma- 
 tory activity is extinguished ; but the absorption of the neoplastic 
 elements is not complete; it does not extend to the connective tissue 
 as to the other elements. Therefore induration persists as the trace 
 of proliferation of this fibrillar tissue ; there remains in the uterus a 
 network of fibrous tissue analogous to cicatricial tissue. 
 
 According to Scanzoni, independently of this induration of tissue 
 producing partial or general ansemia of the organ, the most important 
 anatomical modification in chronic metritis is the congestion of the 
 engorged and dilated vessels. This congestion is due to the disturb- 
 ances observed in the circulation of the neighbouring organs, and to 
 the want of tone in the walls of the vessels which do not present 
 sufficient resistance to regulate the circulation. It is. evident that this 
 congestion is more considerable during the period of softening, but to 
 some extent it persists during the period of induration, especially at 
 the commencement. T/iis congestion is especially venous, and is the 
 most difficult to dissipate ; therefore Scanzoni, generalising too much, 
 regarded chronic metritis as incurable. 
 
 It is rare for the anatomical alterations to be disseminated uniformly 
 through the various portions of the uterus, and for them to reach all, 
 especially when the metritis is chronic. In the latter case we not only 
 ascertain that these lesions may be limited to the body or to the neck 
 of the organ, but usually also, according to the ingenious comparison 
 of Gallard [Legons cliniques snr les maladies des femmes, pp. 143, 
 153, 172, &c., Paris, 1873), in the uterus as in the heart, inflamma- 
 tion may reach the external or serous envelope, the internal or mucous 
 covering, and the intermediate or parenchymatous tissue. It is more 
 uncommon to see inflammatory lesions aff'ecting exclusively the mus- 
 cular tissue than the mucous or serous tissue, except in the acute 
 stage ; they may even sometimes exclusively affect the cellular tissue 
 interposed between the organ and its serous covering (parametritis). 
 The principal and characteristic alterations, however, may be limited 
 sometimes to the mucous membrane (endometritis or mucous metritis), 
 sometimes to the muscular tissue, whilst reacting on the peritoneum or 
 being somewhat propagated to the internal membrane (idiometritis or 
 parenchymatous metritis). 
 
METRITIS 479 
 
 The majority of pathologists have not pushed their researches further 
 as to the diversity of the alterations which may be produced, and yet 
 it seems to me that in place of being satisfied with distinguishing 
 mucous from parenchymatous metritis, it is necessary further to deter- 
 mine the element principally affected or exclusively altered in each of 
 these tissues according to the seat of the evil. 
 
 This last division, founded on the histological localisation of the 
 morbid product,^ is perhaps the most important to know, as regards 
 not only the histological element affected by inflammation, but also 
 the pathological evolution which this element undergoes, and which 
 more or less profoundly modifies its structure and functions, sometimes 
 in one direction, sometimes in another. The agreement between each 
 histological alteration and each symptomatic table, subjective and ob- 
 jective, is the best source of pathological determination and thera- 
 peutic indication. Therefore it may be said that the diversity of 
 histological alteration ansioers to the diversity of nature of the 
 inetritis. 
 
 If we have to do with a case of endometritis we sometimes find the 
 alteration very superficial, limited to the epithelium, which may be 
 now removed or destroyed by an erosion, now stimulated to prolifera- 
 tion, which gives to the membrane a granulated aspect (grey granula- 
 tions of small superficial dimensions) ; at other times the alteration 
 will invade the glands, increasing the secretion (leucorrhoea), or exciting 
 a proliferation capable of producing various kinds of tumours (granula- 
 tions vi^ith a hole, or a trace of one, at the projecting portion, a cyst, 
 Naboth's eggs, adenomata, follicular polypi sessile or pediculated). 
 It gains in extent, reaching the vascular system, sometimes simply con- 
 gesting it (venous congestion of troublesome persistency), sometimes 
 disposing the superficial congested network to lacerations and haemor- 
 rhage (hsemorrhagiparous endometritis), or it determines by a conges- 
 tion, which is the result of persistent and localised erection, small 
 fungous tumours or bleeding granulations having a more or less distant 
 analogy to a hsemorrhoidal tumour or a tumour partly erectile. At 
 other times the alteration while producing superficial lesions gains in 
 depth, affecting specially the dermis of the mucous membrane when, 
 owing to its proliferative or destructive tendency, it produces true 
 papillary granulations, more or less voluminous and confluent, some- 
 times hard, sometimes fungous (if they are associated with excessive 
 vascularity), or on the contrary with more or less large and deep ulcers 
 of variable form, according to the diathesis on which they depend. If 
 the alteration affects the cellular tissue, the elements of the connective 
 tissue, and the fibro-plastic or embryonic elements, the fusiform bodies, 
 &c., the proliferation of these elements may give rise to superficial 
 granular vegetating hypertrophy, simple, fungous or polypiform, or to 
 deep hypertrophy affecting the whole thickness of the mucous mem- 
 
 * Memoire sur la diversite des alterations histologiques dans I'injlammation 
 de I'uterus, presented to the Acadeinie des Sciences, May 20, 1877, and read 
 before the French Association foi' the Advancement of Science at the Mont- 
 pellier meeting, August, 1879. 
 
480 UTERINE DISEASES IN DETAIL 
 
 brane and the whole extent of one region ; for instance, one segment 
 of the body, one of the lips of the cervix, a general hypertrophy, 
 leading in the first period to softening, and later on to induration. As 
 for suppurative phlebitis, lymphangitis, peri-uterine or retro-uterine 
 adenitis, they are met with as serious complications of certain kinds of 
 metritis, especially of puerperal metritis or (adenitis especially) as an 
 indication of ulceration persistent for a long time over a considerable 
 extent of the mucous membrane, necessitating special applications to 
 this mucous membrane, and often keeping up in patients pain which 
 till now has not been accounted for, but the interpretation of which 
 appears to me now undoubted. 
 
 If we have to do with parenchymatous metritis without superficial 
 anatomical lesions which are necessarily absent, we find according to 
 the case pathological alterations analogous to those just described in 
 the thickness of the mucous membrane, affecting the like histological 
 elements, the vascular system, the fibro-plastic elements, the laminar 
 tissue, &c., and special alterations affecting the constitutive element 
 par excellence of the uterine muscular tissue, I mean the smooth fibre. 
 The principal anatomical alterations of the smooth muscular fibre are 
 either a simple hypertrophy without localised and limited proliferation 
 (hypertrophic parenchymatous metritis), or a special localised prolifera- 
 tion, producing globular tumours, simple or multiple (fibroids, fibro- 
 mata, myomata, leiomyoraata), among which the myomata (prolifera- 
 tions of the smooth muscular fibres) should be distinguished from 
 fibromata or fibroids or fibro-plastic tumours (proliferation of connec- 
 tive tissue and embryonic fibro-plastic elements), both possibly being 
 interstitial, subserous, submucous (sessile or pediculated). Others 
 consist in a softening with serous infiltration or fatty degeneration 
 (softening parenchymatous metritis). Others again consist in a more 
 or less painful contraction of these fibres v\'ith consecutive retraction 
 or induration (indurated parenchymatous metritis, retractile, often 
 painful). — As for the alterations of the cellular and especially of the 
 vascular system, they resemble those of the same elements in the 
 mucous membrane : there may be, though rarely, suppuration and 
 even an abscess ; the same venous congestion is produced, associated 
 with a venous congestion coexisting in the mucous membrane, sharing 
 in the same characteristics of incurability, redoubled when the venous 
 congestion extends to the two principal histological layers of the uterus. 
 In the other organic alterations there is nothing which, from the point 
 of view of curability, is beyond the power of medical art. 
 
 Divisions. — The divisions that have been established between the 
 various kinds of metritis depend on the meaning attached to the term 
 metritis in the domain of uterine pathology. 
 
 1. With regard to its extent, it may be general or limited according 
 to whether it affects the whole uterus or only one of its parts. 
 
 2. As to its localisation metritis may be total or partial. Some 
 physicians designate metritis of the cervix by the term external 
 metritis. It is certain that partial inflammation may be limited to the 
 
METRITIS 481 
 
 neck or to the body, may affect either the parenchyma or the mucous 
 membrane. 
 
 3. With regard to its, progress, metritis may be in both cases oxute, 
 subaaUe, or chronic. That occurring after delivery is generally acute. 
 Chronic metritis is the form most commonly met with in the non- 
 puerperal state, the chronic form being assumed even from the begin- 
 ning. The acute or subacute form, however, is sometimes met with, 
 especially when the metritis is due to traumatism : excessive inter- 
 course, dysmenorrhcea, the fatigue attending a wedding tour, the 
 sudden suppression of menstruation, &c. Mikschik has published an 
 interesting work on acute metritis in the non-puerperal state. ^ It is 
 based on 18 cases, 13 of which were women who had never 
 conceived : all fell suddenly ill during menstruation ; the majority had 
 taken cold, and in 6 there had been a traumatism at that time. 
 Except where complications exist in connection with the appendages 
 cure is always obtained. This form of metritis according to Mikschik 
 is rare, only occurring twice in every 100 cases. Tilt^ is of the same 
 opinion, and so am I. Slawjansky's ^ opinion that cholera can develop 
 hgemorrhagiparous endometritis has never been confirmed. 
 
 4. With regard to the diversity of causes, metritis has been divided 
 into piLcrperal and non-puerperal. Chomel goes further, distinguish- 
 ing puerperal metritis, which is developed immediately after delivery, 
 from post-puerperal metritis developed some days later. I cannot see 
 any other difference between puerperal and non-puerperal metritis 
 than that resulting from the extreme tendency of the former to suppu- 
 ration and from the frequency of complications, such as lymphangitis, 
 phlebitis, peritonitis, &c., which increase the gravity of the prognosis. 
 
 I shall not here refer to the question of puerperal fever, which has 
 not been settled. In any case it must be admitted that if puerperal 
 metritis has been included in the description of puerperal fever and 
 has altered its features, it has also been proved that newly delivered 
 women may succumb to serious fever, which often coincides with 
 pathological alterations in the uterus as in other organs, indeed, more 
 than in other organs, but which may also leave no trace in the womb, 
 as has been proved by autopsies,* and which consequently is not merely 
 
 ^ Acute metritis in non-pregnant women, Zeitschr. der Gesellsch. der Aerzte 
 zu Wien, 1855, Bd. xi, S. 500. 
 
 ^ Transact, of the Obstetric. Sac, vol. xiii, p. 197. 
 
 ^ Archivf. Gynaehologie, Bd. iv, S. 212. 
 
 '' Many physicians believe that puerperal fever is an essential disease charac- 
 terised by an alteration in the blood. To sum up the facts on which their 
 opinion is based, it is sufficient to refer to the case of the midwife who suc- 
 cumbed to puerperal fever, or at least to a disease which presented all the 
 characters of it, although she was a virgin and was not menstruating at the 
 time. I may also remark that Lorain in his thesis {De V etat puerperal cliez le 
 fcetus et le nouveau-ne. Paris, 1855) has shown the solidarity existing in this 
 respect between the mother and child. Besides, it is doubtless the same with 
 puerperal fever as with contagious erysipelas and purulent infection. 1. It 
 may be developed in a woman (recently delivered) from uterine phlebitis or 
 angioleucitis, from the absorption of pus, from suppurative metro-peritonitis, 
 from ovaritis, from an abscess of the broad ligaments, from a consecutive 
 purulent infection. 2. It may afterwards be propagated by the miasma to 
 
 31 
 
482 UTERINE DISEASES IN DETAIL 
 
 a fever symptomatic of metritis or uterine phlebitis. However, it is 
 not with the existence of puerperal fever but of puerperal metritis 
 that we have to do. As the latter cannot be disputed, the only 
 question to be decided is, whether puerperal metritis and non-puer- 
 peral uterine inflammation are not the same disease with complica- 
 tions. 
 
 5. Non-puerperal metritis may be divided into traumatic metritis 
 and diathetic or specific metritis, of which there are various kinds : 
 rheumatoid, catarrhal, diphtheritic, &c. 
 
 6. "With regard to the termination metritis has been divided into 
 leucorrliceic, suppurative, ulcerous, gangrenous, granular, fungous, 
 softening, congestive, hypertrophic, indurated, &c. 
 
 7. Prom the point of view of histological diversity the term endo- 
 metritis is used to denote inflammation affecting the mucous mem- 
 brane ; some writers have also called it internal or catarrhal metritis, 
 wrongly confounding it with uterine catarrh. Idiometritis (Her- 
 vieux) or parenchymatous metritis is used to describe inflammation 
 of the muscular tissue of the organ ; parametritis (Matthews Dun- 
 can) to denote inflammation of the cellular tissue surrounding the 
 uterus j and exometritis inflammation of the peritoneal covering which 
 is easily propagated to the broad ligaments, whilst it frequently 
 spares the uterine tissue. 
 
 8. "With regard to the localisation of the pathological process on 
 one of the constitutive elements of the principal tissues of the organ, 
 distinctions have been established between the various histological 
 varieties which seem to me the most important of all ; the principal 
 are : glandular qx follicular, granular , fungous, vasc^dar, hemorrhagic, 
 congestive, venous, proliferant, hypertrophic, softening, indurated, 
 &c. The importance of this classification, based upon pathological 
 anatomy, is recognised in the diagnosis, prognosis and treatment, 
 and really dominates the pathology of metritis. 
 
 9. With regard to complications, metritis may be simple or complex. 
 The complications are inflammation of the ovary, of the Pallopian tube, 
 peri-uterine inflammation, peritonitis, abscesses either peri-uterine, 
 pelvic or iliac ', lastly, lymphangitis, phlebitis, phlegmasia alba dolens 
 and purulent infection, which are the most serious complications of 
 metritis, at least of puerperal metritis. 
 
 Causes. — Metritis, like all other uterine diseases, occurs most fre- 
 quently during the period of greatest sexual activity. According to 
 Nonat the greatest number of uterine inflammations is from fifteen to 
 
 ■wMch it lias given birth, and determine septicaemia in pnei-peral women or in 
 those who have been operated on in a hospital. 3. It may even, in women of 
 the latter class, be localised on the uten;s, this organ being predisposed by 
 recent delivery, or being already a centre of suppuration. 4. It is all the 
 more likely to end fatally in that it attacks patients doubly with septicismia : 
 by direct purulent infection from the uterus, and by indirect or epidemic in- 
 fection. To sum up, I agree with Hervieux {Traite clinique et pratique cles 
 tnaladies puerperales suites des couches, p. 82. Paris, 1870) that a midwifery 
 hospital, permanently occupied, is a productive cause of miasma, and that the 
 propagation of this miasma by infection or contagion produces puerperal j)oison 
 and puerperal fever. 
 
METRITIS 483 
 
 forty-five years, and the age at which women are most exposed to 
 metritis is from twenty to thirty years. 
 
 Debilitated constitutions and lymphatic temperaments seem more 
 disposed than others to metritis. The uterus seems specially disposed 
 to become inflamed in certain women, from a kind of weakness or 
 natural susceptibility, according to Henry Bennet,^ but I think there 
 is a natural susceptibility of the organ which, according to Nonat, 
 sometimes runs in families, and which predisposes to other uterine 
 diseases as well as to metritis. 
 
 It is difficult to decide whether the kind of life led by the poor or 
 rich, the action of certain kinds of food (coffee), certain garments 
 (stays), climate (damp, sudden or prolonged cold), certain diseases 
 {e.(j. diathetic conditions, cardiac, gastric, pulmonary or hepatic dis- 
 eases), certain medicaments (vaginal injections or emmenagogues^) 
 predispose to metritis. 
 
 The influence of determining causes is more evident. All that con- 
 gests or irritates the organ may develop inflammation of the uterus. 
 Menstrual disorders, and especially the sudden suppression of the 
 catamenia, abortion, natural and artificial delivery, including subse- 
 quent accidents such as retention of the placenta, laceration of the 
 cervix, disappearance of the lochia or milk, inflammation of the 
 placental wound, arrested histological involution of the uterus, &c., are 
 the most frequent causes. Also excessive intercourse, especially during 
 wedding tours, rising too soon after a confinement or resuming marital 
 intercourse too early, disproportion in the size of the penis, masturba- 
 tion, the prolonged presence of foreign bodies in the vagina, such as 
 pessaries or sponges, the uterine douche, the introduction of dilating 
 bodies to induce abortion, drawing the uterus down to facihtate the 
 extirpation of a polypus, incision of the cervix or forced dilatation, the 
 use of the sound, the ill-timed introduction of an intra-uterine stem, 
 frequent cauterisation of the cervix, especially when done in the con- 
 sulting room and without the use of the precautions I have indicated^ 
 may cause metritis. 
 
 Other traumatisms, such as a fall on the pelvis or abdomen, a blow, 
 shock or wound received on the hypogastrium or in the vagina, may 
 also be determining causes of metritis ; for in spite of its internal 
 position in the pelvic cavity, and the thickness of the hard and soft 
 parts protecting it, the uterus is exposed not only to indirect but 
 occasionally to direct traumatisms.^ 
 
 ^ Op. cit., p. 34. 
 
 - Kiinding {Schweiz. Zeitsch., 1839, Bd. i, 2*^ Heft) has seen a woman who, 
 after the use of savin and other abortives, presented symptoms of chronic 
 metritis and peritonitis. At death, which occurred in the forty-first week o£ 
 pregnancy from exhaustion, the uterus was found adherent to the neighbouring 
 parts and had not increased in thickness as in pregnancy. As for the fcetus it 
 died in the seventh month. 
 
 ^ Tacheron, Annales d'Hygiene, April, 1834 ; Revue viedicale, 1835, t. i, p. 
 117 ; Gazette mklicule, 1841, p. 219 ; Ibid., 1845, p. 716 ; Planchon, Traite 
 complet de V operation ccsarienne, p. 77 ; Deneux, Essai stir les ruptures de la 
 matrice, p. 35 ; Czazewski, Journal de Malgaigne, Dec, 1846 ; Revue medicale, 
 1841, t. iii, p. 389 ; Ibid., 1844, t. iii, p. 83 ; Journal de medecine, 1786, t. Ixvi, 
 
484 UTERINE DISEASES IN DETAIL 
 
 Poma^ asserts that he has seen a case of metritis caused by the in- 
 troduction of a leech into the uterus ; the disease did not decKne for 
 a fortnight till after the expulsion of a large clot containing a leech in 
 good condition. 
 
 Inflammation already existing in neighbouring organs may be pro- 
 pagated to the uteruSj such as ovaritis, inflammation of the Eallopian 
 tubes, vaginitis and peri-uterine phlegmons, which act as tumours 
 hindering the circulation, as centres of fluxion or congestion, and 
 especially as seats for the propagation of inflammation by continuity. 
 As for the rectum and bladder, the inflammation is propagated rather 
 from the uterus towards these organs than from these organs towards 
 the uterus. 
 
 Course. — It may be either acute or chronic, sometimes even sub- 
 acute. 
 
 The acute stage may be very serious, progressing rapidly, terminat- 
 ing by suppuration or gangrene, or be complicated by phlebitis, 
 lymphangitis or by purulent or putrid absorption. These terminations 
 and complications are peculiar to the puerperal state. Other compli- 
 cations occur frequently in non-puerperal acute metritis. Inflammation 
 of the peritoneum, of the annexes, and peri-uterine inflammation must 
 be placed in the first rank. Metritis, indeed, in place of being simple 
 is frequently metro-peritonitis, the most superficial layer of the uterine 
 tissue and the serous fold covering it being either simultaneously in- 
 flamed from the beginning or the inflammation may have extended 
 from the muscular to the serous tissue owing to want of care and 
 prudence on the part of the patient. It is the same with inflammation 
 of the annexes, especially with ovaritis, which is frequently met with, 
 and sometimes in a more marked degree than the concomitant 
 metritis. Peri-uterine inflammation is a complication which is not 
 very rare, and which aggravates metritis, necessitating more energetic 
 treatment. 
 
 When inflammation of the mucous membrane has reached such a 
 degree that the membrane is ulcerated at several points and stripped 
 of its epithelium, these bleeding surfaces may, though rarely, contract 
 adhesions at points of contact.^ 
 
 At the OS internum the contact is so close, that the alteration of the 
 mucous membrane may produce definite occlusion of this orifice. This 
 accident is usually prevented by the continual interposition of mucus 
 between the surfaces of the mucous membrane of the isthmus. The 
 
 p. 354 ; Emmet, Principles and Practice of Gynecology, 1879 ; Gazette medi- 
 cale, 1836, p. 536 ; Ibid., 1834, p. 87 ; Ibid., 1835, p. 265 ; Ibid., 1839, p. 185 ; 
 Ohservateur des Sciences medicales de Marseille, 1822, t. iv, p. 251 ; Deutsche 
 Klinih, 1862, No. 11 ; Larcher, Archiv. gen. de medecine, 1869. 
 
 1 Gazz. di Milano, 1846, No. 38. 
 
 2 I bave seen three cases of the kind in autopsies on aged women, another in 
 a young woman, and one in a patient afEected with syphilis. The occlusion of 
 the orifice from such adhesions is not rare in old women. I have an example 
 of the kind in one of my patients at present, a young woman. Ulcerations of 
 the OS externum from the lower portion of the cervical canal have contracted 
 adhesions, and caused obliteration after three or four years of continued in- 
 flammation. 
 
METRITIS 485 
 
 length, liowevePj of the isthmus may dispose it to be obliterated more 
 easily. This is what sometimes happens when internal metritis has 
 lasted a long time, and when the patient has reached an age when the 
 natural contraction of this orifice and even its obliteration are not 
 rare. There results, as may readily be supposed, a distension of the 
 cavity of the body, owing to the mucus or muco-pus abnormally 
 retained. The body then takes a more and more globular form, and 
 its wails may be thinned. The external os may also become oblite- 
 rated, though more rarely. Its two lips are then united by a mem- 
 branous adhesion or by a fibro-cellular band. The cavity of the neck 
 is distended, the mucus secreted is accumulated, the internal os is 
 enlarged, and the cavities of the body and neck communicate freely 
 with each other. One of the most interesting cases of this kind is that 
 published by Yoisin of Limoges.^ 
 
 Inflammation of the peritoneum has a greater tendency even than 
 that of the uterine mucous membrane to produce consecutive adhe- 
 sions. Therefore metritis when complicated with peritonitis cannot 
 be subdued too energetically ; for the (almost fatal) consequences of 
 the latter are adhesions between the peritoneal fold covering the 
 uterus and that covering its annexes or the neighbouring organs. 
 Hence, if the womb be deviated or flexed, fixity of this organ in an 
 abnormal situation may indefinitely keep up the diseases which are 
 the consequence of this situation, such as engorgement, congestion, 
 dysmenorrhoea, &c. Hence also adhesions of the womb with the 
 rectum, and the double hindrance to the functions of the uterus and 
 this intestine, as well as loss of mobility of the Fallopian tube and its 
 fimbriated extremity, the union of the uterus sometimes with this 
 organ, sometimes with the ovary, pains produced by the disturbance 
 of their functions, especially at the menstrual periods, the impos- 
 sibility of ovulation and the transport of the ovum in the normal 
 manner, and consequently sterility. 
 
 When metritis pursues its course without being aggravated by any 
 of these comphcations, it terminates like all inflammations by resolu- 
 tion. The latter may be complete or incomplete. Even when com- 
 plete, the inflammatory symptoms do not commence to decrease for 
 seven or eight days, and cannot disappear under a fortnight. Usually it 
 is not till the end of the third week that we can hope for the disap- 
 pearance of the evil. Complete resolution cannot be depended on 
 before the return of the next menstrual period. If it occur normally 
 cure may be considered as ensured. If, however, fluxion and uterine 
 congestion produce pain and especially if they rekindle fever, resolu- 
 tion is not complete ; a relapse is to be feared or the transition to the 
 chronic state. Incomplete resolution is usually the consequence of 
 bad treatment or want of prudence on the part of the patient, as for 
 example, rising too soon, walking, resuming ordinary work, &c. ; but 
 it depends also on the constitution of the patients, women of lym- 
 phatic temperament, weak constitution, deteriorated organisation, and 
 
 1 Gazette medicale cle Paris, 1835, p. 444. — See pi^ 272, 273, figs. 211, 212. 
 
486 UTEEINE DISEASES IN DETAIL 
 
 those who are already affected with some disease, especially a diathetic 
 disease, such as scrofula, being specially disposed to it. 
 
 The cJironic form of uterine inflammation, whether it result from 
 the acute state, or whether it have assumed this form from the begin- 
 ning, may recommence under the influence of various causes especi- 
 ally traumatic, and lead, although rarely, to one of the fatal termina- 
 tions or one of the complications of the acute state. Or it may 
 persist indefinitely^ producing softening of the organ, favouring the 
 indefinite duration of the leucorrhoea, facilitating the development of 
 granulations and fungosities, causing the uterine tissue to pass from 
 softening to total or partial induration by the organisation of the 
 plasma exuded and interposed in its elements, sometimes producing a 
 simple increase of nutrition and consequent hypertrophy, and not 
 apparently capable of spontaneous cure. Cure may be apparent, i.e. 
 an amelioration may take place, so far as disappearance of the sub- 
 jective symptoms of the disease is concerned ; and patients may think 
 themselves perfectly cured, whilst examination shows that lesions are 
 still considerable ; this improvement continues sometimes for years, 
 till under the influence of some external cause all the former sym- 
 ptoms reappear with more or less intensity.^ Even when cured, 
 engorgement and other ineffaceable traces of its existence may be left 
 behind. The principal anatomical cause of this rarity in the cure of 
 chronic metritis is the persistence of the vascular dilatation kept up by 
 too long a congestion and by the loss of the normal tonicity of the 
 arterial and venous walls which is the consequence of it ; therefore it 
 is especially this particular form of metritis (with venous congestion) 
 which may be considered incurable. The curability of the majority 
 of other forms, after a more or less prolonged treatment is an ascer- 
 tained fact. 
 
 Diagnosis — suljective signs. — The commencement of acute metritis, 
 especially of puerperal metritis, is marked by more or less intense and 
 prolonged shivering. This shivering may be wanting in non-puer- 
 peral acute metritis, but not so often as Aran says. It is followed by 
 fever, often by the suspension of the lochia, and by continuous hypo- 
 gastric pain, differing from uterine colics and extending to the iliac 
 regions, especially to the left. Fever is never absent in acute metritis. 
 "Whenever the pulse exceeds 100 or 120, we must be on our guard ; 
 the cause of the fever must be accounted for and treated from the 
 first. If this fever is accompanied by erratic shivering and later on 
 by sweating or vomiting, we must be doubly careful, for these 
 symptoms rarely fail to announce phlebitis. 
 
 Often the local phenomena precede the general symptoms. Of all 
 these phenomena the most marked is hypogastric pain — a very acute 
 pain, quite different from the uterine colics which follow delivery, 
 being continuous, and becoming worse every hour, occurring in non- 
 puerperal acute metritis as well as in puerperal metritis. This may be 
 accompanied, especially in internal metritis, with real expulsive colics, 
 forcing patients to roll themselves into a ball to prevent all tension of 
 ' Scanzoni, op. cit., p. 189, et seq. 
 
METRITIS 487 
 
 the abdominal muscles, which, as well as the least pressure, suffices to 
 increase the pain. Arterial pulsation is also often present, which the 
 physician may occasionally ascertain by placing the finger in the 
 utero- vaginal sinus, to the right and left of the cervix, as deeply as 
 possible. 
 
 Tliis pain is propagated into the iliac regions, especially on the left 
 side, all round the uterus, to the whole hypogastrium, or towards the 
 rectum, the vagina, the bladder, according to whether the peritoneum 
 or the neighbouring organs participate most in the inflammation. It 
 radiates towards the groins, the thighs, the umbilicus, the sacrum and 
 the loins. It may or may not be accompanied by pelvic heaviness, 
 and in that it differs from congestive pain. The patient experiences a 
 burning heat in the hypogastrium, as well as at the vagina and vulva. 
 This heat is by its nature and intensity characteristic of acute metritis. 
 There is no discharge from the vagina, the lochise are usually sup- 
 pressed ; soon afterwards a mucous discharge appears, which rapidly 
 becomes mucoso-purulent, or even sanguinolent in cases of simple 
 acute metritis. In puerperal metritis the discharge is grey, purulent, 
 often foetid. When metritis appears in the midst of menstruation the 
 catamenia cease suddenly. When it exists before the arrival of the 
 menses it is aggravated by the fluxion which the menstrual period 
 brings back, all the more so that there is more frequently suppression 
 of the periodical sanguineous discharge than menorrhagia. 
 
 The neighbouring symptoms are pain in micturition, urine red, 
 scanty and scalding; generally constipation, sometimes a glairy 
 diarrhoea, with straining, tenesmus and burning pain. 
 
 The general symptoms are : fever, which never fails, and which lasts 
 till resolution of the metritis, or till it has passed into a chronic state ; 
 anorexia, foul tongue, thirst, hiccough, sometimes vomiting, which 
 may be a symptom of peritonitis. Lastly, more serious general 
 symptoms, a small as well as frequent pulse, profuse clammy perspira- 
 tion, delirium, &c,, may be added to the preceding, and increase the 
 gravity of the prognosis, for they are the signs of very serious compli- 
 cations, such as purulent absorption or puerperal fever. The same 
 signs, in a less degree, characterise non-puerperal acute metritis. 
 
 In the chronic state metritis is manifested by almost identical signs, 
 though less serious, especially the local symptoms, which may be con- 
 cealed by the predominance of general symptoms, occasionally to such 
 a point that, patients may be mistaken as to the seat and nature of 
 their malady. However, there is always pain in the regions already 
 indicated, as well as in the loins and its various radiations, sometimes 
 even radiation towards the coccyx, known as coccygodynia (I have 
 never observed it) ; but the hypogastric and left iliac pains are the 
 most prominent. This left iliac pain usually accompanies hypogastric 
 pain, and sometimes even, when metritis has passed into the chronic 
 state, it affects the patient more than hypogastric pain, which in a 
 measure is effaced by it. It is difficult of explanation, but it is a very 
 frequent, if not a constant fact ; whether it is that the rectum or 
 sigmoid flexure congests the left appendages more than the right, or 
 
488 UTEEINE DISEASES IN DETAIL 
 
 \bat the latter, especially the ovary, have more tendency to partici- 
 pate in inflammation, as in the male orchitis is developed more 
 frequently to the left, or that the fundus of the uterus being 
 inclined to the right, produces pain by the dragging of the left 
 appendages. 
 
 Pain is aggravated by pressure, constriction, walking, sometimes by 
 the least shock, e.g. that produced by a false step or going down 
 stairs. In all cases of uterine or peri-uterine inflammation patients 
 invariably sit down cautiously, and instinctively protect the hypogas- 
 trium from the smallest shock. The pain is increased still more by 
 walking, leaping, the shaking of a carriage, riding, sudden movements, 
 coitus, especially when the penis impinges too strongly against the 
 cervix. It is also increased by constipation and by fulness of the 
 rectum and bladder. This pain is continuous and dull ; it is heavy, 
 and accompanied by a feeling of discomfort in the pelvic cavity, weight 
 at the perineeum, anus and sacrum; but it is also accompanied by 
 shooting pains, like those which characterise the pain of acute metritis, 
 recurring at longer or shorter intervals, and with arterial pulsation 
 often felt by the patients, and sometimes by the physician to the right 
 or left of the cervix. There is a persistent and uncomfortable heat 
 in the abdomen, and especially in the uterine region, often extending 
 to the vulva, with vulval pruritus, &c. 
 
 Sometimes the vulva and vagina are dry; at other times there is 
 leucorrhoea^ rarely abundant, muco-purulent or quite purulent, more 
 or less acrid, but always less so than in the acute form. It is seldom 
 accompanied by vaginitis : the latter usually only comphcates the 
 superficial inflammation of the cervix, which is a natural extension of 
 it. Sometimes there are no menstrual disorders, excepting slight 
 pains at the monthly period. At other times there are dysmenorrhcea, 
 uterine colics at every monthly period, increased hypogastric and in- 
 guinal pains, as well as lumbar pain. At other times there are dis- 
 orders, consisting chiefly in irregularities ; irregularity in the monthly 
 period and in the quantity of blood evacuated. With regard to the 
 irregularity of recurrence, the menses sometimes recur too seldom 
 (symptom of parenchymatous metritis), sometimes too frequently 
 (common symptom of endometritis). With regard to the irregular 
 quantity, they may be diminished or suppressed (symptom of paren- 
 chymatous metritis), or increased to the point of producing menor- 
 rhagia and even metrorrhagia (phenomena occurring in cases of general 
 metritis^ and especially in those of endometritis) , 
 
 Sterility is an almost unavoidable consequence of metritis : some- 
 times mechanical, from obliteration of the orifices, adhesions, fixity^ 
 vicious positions contracted by the Fallopian tubes, the ovaries and 
 the uterus in their reciprocal relations, or in their connections with 
 other organs ; often a vital consequence, if I may so express myself, 
 from the condition in which the state of inflammation places the uterus, 
 rendering it impossible for it to accomplish the numerous and delicate 
 physiological acts which preside at fecundation, conception, pregnancy. 
 Chronic metritis is therefore an obstacle to conception. This rule has 
 
METRITIS 489 
 
 only a few exceptions ; and even then pregnancy is interrupted at an 
 early stage by an abortion. 
 
 Is it, however, possible for metritis to be developed or increased 
 during the course of a pregnancy ? At first sight it would seem that 
 it was not ; and the fact is that inflammation is developed very rarely 
 in such circumstances ; I have, however, collected a small number of 
 examples. I have seen a case of metritis occur at the beginning of a 
 pregnancy soon producing abortion, and followed by the evacuation of 
 fetid pus. Purulent infection was manifested soon afterwards and 
 the patient succumbed. 
 
 The neighbouring symptoms recall those of acute metritis and 
 uterine congestion : on the side of the rectum, hEemorrhoids, constipa- 
 tion, with fictitious and troublesome desire to go to stool, tenesmus, 
 sometimes even glairy enteritis ; on the side of the bladder, frequent* 
 desire for micturition accompanied by heat, &c. 
 
 In short the general symptoms are often so developed that they 
 throw the others into the shade, and may mislead patients as to the 
 seat and reality of the evil. Patients often tell their physician of 
 their weakness, headaches and dyspepsia, and are surprised to discover 
 that the real seat of the trouble is the womb, and that these trouble- 
 some phenomena which have tormented them and made them lose flesh 
 for so many months, or even years, are only symptoms of chronic 
 metritis. The disorders of the digestive organs are vomiting, anorexia 
 and especially dyspepsia. Nausea may be considered a characteristic 
 symptom of inflammation of the body of the uterus. The nervous 
 troubles assume all the forms of hysteria, not that they depend on real 
 hysteria, which may though seldom coincide with chronic metritis, 
 but because the alterations of the functions of the nervous system, 
 those especially of which the uterus is the starting-point, most fre- 
 quently take this character. These are abdominal pains, gastralgia, 
 pharyngeal constriction, intercostal neuralgia, which may make patients 
 think that they have a cardiac or pulmonary disease, headaches or 
 the facial neuralgia of a more or less limited kind, and lastly what is 
 called the hysterical nail [clou liysteriqiie) ; visceral neurosis may exist ; 
 neuralgia in the limbs is rare. These disorders of the digestive and 
 nervous systems produce impoverishment of blood, ansemia, chloro- 
 ansemia and more or less debility. 
 
 Objective sigtis. — Pain, tumefaction, heat, redness, all the objective 
 signs of inflammation, are easily seen in metritis, and as they help to 
 distinguish metritis from other morbid states of the uterus with which 
 they may be confounded, it is important to be able to determine with 
 precision their existence in the inflamed uterus. 
 
 The pain is well marked ; it has its seat in the uterus. It exists in 
 puerperal and non- puerperal metritis, in acute and chronic inflamma- 
 tion, in metritis of the mucous membrane as well as of the paren- 
 chyma ; in the latter especially the diagnosis of it is important, as the 
 absence of purulent leucorrhoea might throw doubts on the existence 
 of the metritis. 
 
 Pressure on the hypogastrium and left iliac fossa allows the real 
 
490 
 
 UTERINE DISEASES IN DETAIL 
 
 seat of pain to be determined ; whilst pressure exercised with the 
 finger on the body or neck provokes pain in the uterus to the exclusion 
 of all the neighbouring parts. The association of hypogastric palpa- 
 tion with vaginal touch is necessary to determine exactly the seat and 
 nature of the pain. It is important to distinguish the pain elicited by 
 movements and transmitted to the uterus from that produced by 
 pressure exercised on the organ. Very often pain is caused by 
 pressing on a congested or deviated uterus, whilst none is caused by 
 pressing on a uterus affected with chronic inflammation, especially if 
 owing to its elevation or some other cause it is not easily reached. 
 Pressure upon the cervix from the finger introduced into the vagina, 
 either upwards or from side to side, will often give great pain, 
 however slightly the organ is congested, deviated or flexed, or if the 
 appendages or neighbouring organs be the seat of some disease. If 
 the touch is practised in the same way in a case of chronic metritis in 
 a woman of average sensibility, whose peri-uterine organs are in good 
 condition, pain may not be elicited ; that is because the uterus rises, 
 swings from side to side and yields easily to the pressure of the finger, 
 and does not encounter any painful organ in its movements. If, on 
 the contrary, the uterus is retained in the pelvis by methodic hypo- 
 gastric pressure whilst the anterior or posterior surface of the cervix 
 is reached by vaginal or rectal touch, the uterus is held between the 
 hand and finger, and it alone is subjected to pressure. Now, even in 
 cases of chronic metritis, whilst pressure on all the neighbouring points 
 fails to produce pain, that exercised on the uterus determines, on the 
 contrary, sudden acute pain, which extorts a cry from the patient, and 
 which is comparable to that produced by the slightest pressure on an 
 abscess or any inflamed and painful part. This precision in determining 
 the seat of pain is of first importance in the diagnosis and treatment of 
 chronic metritis. 
 
 Fig. 314. — Cervix uteri in a 
 virgin (after H. Bennet). 
 
 Fig. 315. — Cervix uteri in a virgin, in- 
 flamed and ulcerated, normal linear 
 form (after H. Bennet). 
 
 The tumour or increased size of the organ is easily ascertained by 
 the same means. In puerperal metritis this tumefaction is consider- 
 able : the uterus is large at the time ; when inflammation begins retro- 
 evolution is arrested, and the afflux of fluids contributes to preserve 
 the dimensions that it was on the point of losing. In non-puerperal 
 
METRITIS 491 
 
 metritis, acute or chronic, the uterus in spite of its tumefaction does 
 not always pass beyond the pubis. Sometimes, however, in forty- 
 eight hours it may reach the size of an ostrich egg. It is important 
 to notice that, in spite of this increase of size, the uterus preserves its 
 mobility. This tumefaction determines a swelling in the hypogastrium, 
 varying with the patient and the species of metritis. In parenchy- 
 matous metritis the abdomen is moderately distended. Whilst in 
 endometritis there is a distension of the lower half of the abdomen 
 due to reflex tympanitis very variable in intensity. The tumefaction 
 of the cervix and body, ascertained by the combination of rectal and 
 vaginal touch with hypogastric palpation, leave no doubt as to the 
 increased size of the uterus. This tumefaction is sometimes so great 
 as to cause descent of the organ. It may be measured by seizing 
 the uterus between the finger of one hand introduced into the vagina 
 and the palmar surface of the other hand pressing the hypogastrium 
 methodically. Lastly, the vaginal portion of the neck is rounded, 
 projecting, and the os gaping ; this tendency is specially remarkable in 
 the case of metritis of the cervix. In the virgin, the cervix although 
 tumefied, sometimes preserves an almost conical form ; even when the 
 inflammation does not reach it, it does not share in the increased size 
 of the rest of the organ, so that by simple inspection we might 
 be misled as to the real state of the uterus. The os, which is ex- 
 ceptionally circular on an inflamed virginal cervix, is increased in size, 
 and the inequality in the tumefaction of the tissue circumscribing it 
 gives rise to kinds of radiating folds starting from the centre and 
 diverguig at a short distance from the border. In the married woman 
 it is rounder, assuming the form of a cone with its base downwards ; 
 its lips are projecting and irregular. In the multipara it is infinitely 
 more marked, and not only is the circumference of the cervix irregular, 
 but it is marked by deep cicatrices, traces of lacerations which have 
 occurred at delivery.^ 
 
 The heat is intense, especially in newly- delivered women, in whom 
 it may be perceived by placing the hand on the abdomen. In other 
 cases of acute metritis it may be less ; but if we place the hand flat 
 on the abdomen above the umbilicus, descending gradually to the 
 pubis so as to pass over the hypogastric and iliac regions slowly, we 
 cannot fail to perceive it, especially at the hypogastrium ; but it is 
 much more appreciable in the vagina and on the vaginal portion of 
 the cervix. Sometimes it is accompanied by dryness ; at other times, 
 on the contrary, by a more or less abundant secretion. 
 
 The redness is not easily perceived at first ; for there are patients 
 to whom touch is so painful as to be almost impracticable ; and there- 
 fore the introduction of the speculum is impossible for the time. 
 However, these cases are rare, and we should have recourse to these 
 means of exploration as soon as possible, in the first place, because 
 they are necessary to confirm the diagnosis, and because as regards 
 treatment, it is important to know whether we have to do with a case 
 
 ' Fig. 312, p. 471, will give an idea of the aspect which tlie cervix f requentlj 
 presents under such circumstances. 
 
492 UTEEINE DISEASES IN DETAIL 
 
 of metritis^ peritonitis^ peri-uterine phlegmon, &c. ; in the second 
 place, because we cannot otherwise apply the most efficient means of 
 treatment, viz. leeches. Besides, by taking the precautions indicated 
 elsewhere in introducing the speculum it can be used without much 
 pain, and the local application of leeches will alleviate the suffering 
 sooner than anything else. The redness is less dark and venous than 
 in congestion, but it is very pronounced and accompanied by a dispo- 
 sition of the mucous membrane to bleed on the slightest friction. The 
 blood is often red, vermillion, very different from that which flows 
 from the congested cervix. Sometimes without having even wiped the 
 cervix we perceive the surface deprived of epithelium, red, bleeding, 
 with real erosions, exulcerations, and even ulcerations of variable 
 form, granular fungus, &c. When the vaginal portion of the cervix 
 is not diseased, but when the mucous membrane of the uterine cavity 
 is inflamed, and when this inflammation extends to near the orifice, if 
 we look through the os (the eversion of the swollen irregular lips 
 facilitates the observation) we shall see that this mucous membrane 
 is of a bright red, contrasting singularly with its usual colour. 
 
 When the metritis is accompanied by more or less intense vaginitis, 
 the surface of the vagina touching the cervix is, like it, bright red 
 and covered with small granulations either confluent (granular vagini- 
 tis) or discrete (folhculitis of the cervix) : whilst redness, project- 
 ing papillse, and superficial erosions may extend to the internal surface 
 of the labia majora. 
 
 A leucorrhoeic discharge, not only vaginal but uterine, may or may 
 not accompany metritis, and we must beware of looking upon this 
 leucorrhoea as well as upon the other symptoms just referred to as a 
 real sign of metritis ; for all these symptoms may exist without it 
 and it may exist without them. With regard to the leucorrhoea we 
 must ascertain if the discharge is superficial and due to granulations, 
 follicular or otherwise, of the vaginal portion ; or if it is profound, 
 whether it comes from the cavity of the neck or the body ; if mucous, 
 thick and viscous (coming from the neck) ; or if clear, aqueous, sanguino- 
 lent,ormuco-sanguineous (coming from the body), which maybe due to a 
 catarrh, to simple fluxion, &c. ; or if it is muco-purulent or purulent 
 mixed with globules of blood, or yellowish white, very yellow, yellow 
 green, and more or less creamy (which is often a symptom of metritis, 
 especially of internal metritis). 
 
 As a rule we must abstain from using the sound : it is useless, and 
 may be dangerous. We run the risk of finding a uterus at the period 
 of inflammatory softening, and by pushing the sound in a direction 
 not exactly that of the axis of the organ may partially perforate the 
 tissue. It is only in doubtful cases of chronic metritis limited to the 
 body or in cases of chronic endometritis that the use of the sound is 
 practicable, and only then with great prudence. It measures the 
 increased length of the uterus, which sometimes reaches 3| or 3| 
 inches, and also the increased capacity of the organ, the instrument 
 being easily turned in every direction, owing to the excentric hyper- 
 trophy usually observed in metritis, especially in chronic internal 
 
METRITIS 493 
 
 metritis. At the same time it allows of the increased sensibility of the 
 organ being perceived; for its introduction is not made without 
 causing sharp pain especially in passing the os internum. It gives an 
 idea of the facility with which the mucous membrane bleeds ; for in 
 'this case it is often accompanied by a comparatively abundant hsemor- 
 rhage, which is presumptive of the existence of uterine fungosities, 
 especially when the sound encounters difficulties in traversing the 
 internal surface of the organ. 
 
 Abscess of the parenchyma of ike uterus. — The formation of pus and 
 the presence of an abscess in the uterine tissue may be observed after 
 abortion, delivery or operations performed on the uterus and genital 
 -organs, but it is so rare after non-puerperal acute metritis that it has 
 been denied. I do not say that a concomitant catarrh may not be 
 mistaken for it ; nevertheless, the following facts seem to me very 
 conclusive. Frederick Bird ^ gives the case of a woman of thirty- 
 seven who succumbed to chronic metritis ; the fundus was three times 
 its normal thickness; an abscess developed in the posterior wall 
 opened by a short and narrow passage into the rectum ; it did not 
 ^ communicate with the uterine cavity. Scanzoni ^ relates another case 
 in a young woman, after a sudden suppression of menstruation; 
 violent metritis followed, treated for eight days without obtaining any 
 amelioration; on the contrary, sensibility of the uterine region 
 increased, shivering occurred frequently, and a tumour of the size of 
 an egg, moderately resistant and easily defined, was developed above 
 the horizontal portion of the right pubis. Symptoms of violent peri- 
 tonitis appeared suddenly on the twenty-second day to which the 
 patient succumbed on the thirty-first day. The autopsy showed the 
 cause of death to be the rupture of an abscess of the size of a 
 goose's egg, situated in the right and upper portion of the uterus, 
 the pus from which had made a way for itself through the ex- 
 ternal layers of the substance of the uterus and its peritoneal 
 envelope.^ 
 
 In exceptional circumstances the malady not only assumes a 
 ' chronic form, but the purulent collection may reach very considerable 
 proportions.* Uterine abscesses may be opened artificially or spon- 
 taneously into the uterine cavity, the rectum, the vagina, the ab- 
 dominal cavity, the bladder, or even through the abdominal parietes, 
 previously united to the uterus by means of adhesions.^ 
 
 ' Gaz. med. de Paris, 1843, p. 645. 
 
 - Op. cit., p. 159. 
 
 ' Lados has also published a fact of this kind, Gaz. medicale de Fans, 1839, 
 p. 605. 
 
 * Hervez de Chegoin, SocUte de chirnrgie, Dec. 2, 1868. 
 
 5 Besides the case just related, in which probably a phlegmon was formedin 
 the pregnant uterus, I have collected some other undoubted cases of uterine 
 abscess: one opened into the uterine cavity, another into the vagina in the 
 middle of the posterior cervical lip, another into the utero- vaginal groove of 
 the posterior lip, another into the anterior groove, and three others laterally. 
 Only it was doubtful (especially with regard to the latter) whether these were 
 uterine abscesses ; a phlegmon of the broad ligament might be suspected. I 
 have only diagnosed a uterine abscess when the sound reached a centre evidently 
 
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496 UTEEINE DISEASES IN DETAIL 
 
 When a uterine abscess is formed, there may be much difficulty in 
 determining the nature of the tumour due to this cause. In addition 
 to the presence of the tumour, there is intense fever, with irregu- 
 larities, sometimes shivering, perspiration and all the other symptoms 
 denoting the formation of pus. Scanzoni thinks that diagnosis is 
 only possible when, after having observed the symptoms of acute 
 metritis, the presence of a tumour of rapidly increasing size at first 
 hard and then fluctuating is discovered through the superior vaginal 
 wall or the anterior abdominal wall. But even in such cases we must 
 admit that diagnosis may remain doubtful till the pus has spontane- 
 ously made a passage for itself or till its presence has been proved by 
 an exploratory puncture, which should only be made with great pre- 
 caution. 
 
 Abcesses of the uterus, formed by a purulent collection within the 
 uterine wall or between the uterus and its peritoneal covering are 
 closely connected, by their symptoms and general course, with pelvic 
 abscesses. The only difference is that in cases of the former kind, the 
 tumour appears to be a tumefaction of the uterus itself, more limited 
 and more circumscribed than in those of the second series. 
 
 The prognosis, always doubtful, may be very serious. The treat- 
 ment is that of acute metritis. If the abscess is accessible to the 
 bistoury an exploratory puncture may be made, and when it is found 
 to contain pus it may be opened. 
 
 Differential diagnosis. — Tlie differential diagnosis of metritis, espe- 
 cially of acute metritis, is usually easy; but it is not always so. 
 The accompanying table sums up the differential diagnosis between 
 metritis and the other uterine maladies which may be confounded 
 with it. 
 
 The other uterine disorders which must be distinguished from me- 
 tritis are : hysteralgia, hematometria, hydrometria, pregnancy, flexions, 
 uterine catarrh, ulcerations, fibromata, polypi, cancer. The elements 
 of differential diagnosis will be given in the description of each. 
 
 2. Maladies of the appendages and peri-titerine maladies — infiam- 
 mations and tumours of the Fallopian tubes and ovaries. — There is no 
 tumefaction and no uterine pain unless the inflammation extends to 
 the womb ; but there is a tumour behind the organ or on one side of 
 it, which is usually accessible to the finger in the utero-vaginal sinus. 
 The seat of this tumour, which is usually limited to one side, is espe- 
 cially observed when vaginal touch is associated with palpation. 
 
 Peri-uterine inflammation. — The uterine tissue is not painful to 
 pressure ; but we cause acute pain if we try to move the womb, or 
 press on the tumour formed behind or around it ; the uterus itself is 
 immovable. This immobility is a sign of great importance, and con- 
 trasts with the mobility which the uterus preserves in metritis. 
 
 Hematocele is developed rapidly as a rule, and is accompanied with 
 suppression of the menses. There are general symptoms of hsemor- 
 
 contained in a segment of the organ, or when an injection could not apparently 
 reacli the peripheric portions. In this way it is possible to diagnose with 
 precision. 
 
METRITIS 497 
 
 rhage and peritonitis. Tumour behind or on one side of the womb, 
 raising the vagina. Uterus displaced, usually upwards behind the pubis, 
 and immovahly fixed. 
 
 Peritonitis. — Acute abdominal pain on the slightest contact. 
 Bilious green vomiting, hiccough, abdominal distension. Face drawn 
 and anxious, ejes sunk, pulse frequent, small, abdominal in character, 
 extremities cold, &c. Neuralgia, whether lumbo-abdominal or ileo- 
 sacral, is rarely accompanied by fever, is situated almost always on 
 one side, and presents well marked and characteristic joa^M/M^ spots. 
 
 Treatment of metritis ought to be energetic : essentially antiphlo- 
 gistic in acute metritis, equally antiphlogistic in the commencement of 
 chronic metritis, the complications being treated at a later period, the 
 principal aim being to regulate the uterine functions and restore the 
 constitution. 
 
 Treatment of acute and subacute metritis. — It consists in blood- 
 letting, the use of emollients, revulsives and sedatives. 
 
 I. General bloodletting may be resorted to, but I think it has been 
 abused. Blood should only be drawn from the arm in cases of acute 
 metritis unless the patient be very plethoric or the case otherwise 
 exceptional. Bloodletting should be essentially revulsive, and conse- 
 quently performed according to the rules of revulsion, i.e. at the 
 commencement, if the fluxion is strong or imminent, or immediately 
 before the monthly period, or after local sanguineous evacuations have 
 prepared the mobilisation and revulsion of fluxion considered as an 
 element of the inflammation itself. In no case should the bloodletting 
 be spoliative, especially in chronic metritis. "We must remember that 
 the majority of such patients would be the better for more blood, and 
 that when any is abstracted it is to put a stop to the fulness of the 
 organ, or give another direction to the blood, but never with the 
 object of diminishing its quantity. We must on the contrary hasten 
 to repair the loss by means of tonics and iron, if we would ensure any 
 good results from bleeding. 
 
 The application of leeches or cupping glasses to the hypogastrinm 
 or inner surface of the thighs is indicated when there is not only 
 metritis, but inflammation of the neighbouring parts of the peritoneum. 
 We sometimes require to have recourse to them when the narrowness 
 and sensitiveness of the vagina make the introduction of the speculum 
 impossible, as is usually although not always the case in virgins. In 
 puerperal metritis, when the uterus has just been depleted by the loss 
 of blood following delivery, leeches applied to the abdomen produce a 
 salutary derivation. From fifteen to twenty-five should be applied 
 several times. If after two or three days pain still continues another 
 application should be prescribed, unless the state of the pulse abso- 
 lutely forbids it, for in some cases it causes the pain and tumefaction 
 of the uterus to disappear as if by enchantment. In this way puer- 
 peral metritis may in a few days yield to energetic and well-directed 
 treatment. 
 
 The application of leeches to the cervix is preferable to general 
 bleeding in simple metritis, whether acute or chronic ; it alleviates the 
 
 32 
 
498 UTERINE DISEASES IN DETAIL 
 
 pain at once and weakens less. In chronic metritis it may be advisable 
 to repeat the application several months successively till pain on 
 pressure has ceased or diminished considerably. These sanguineous 
 emissions are essentially depletive; they have a decisive action on 
 pains experienced by patients, and the immediate effect is prodigious ; 
 but the quantity of blood drawn should be considerable, and this effect 
 should be aided by that of intestinal and cutaneous derivatives and re- 
 vulsives. Yirchow^ rightly says : " As a rule local bloodletting should 
 not be considered as a direct and sufficient antiphlogistic means, but 
 rather as a preparatory one. Its action is only transitory ; but when 
 used opportunely it prepares for the action of other remedies." Lastly, 
 scarifications on the vaginal portion of the necJc also cause direct san- 
 guineous evacuation. We are obliged to have recourse to them in 
 patients who are ansemic or disposed by a kind of hsemorrhagiparous 
 diathesis to profuse hsemorrhages, or when inflammatory congestion 
 does not go beyond the cervix, or when the lips of the inflamed neck 
 are covered with erosions, ulcerations or papillary or follicular granu- 
 lations. Yirchow makes the just remark that scarifications do not act 
 exactly like leeches. By means of scarifications we penetrate into the 
 interior of the inflammatory centre and cut the vessels directly. In 
 this way we obtain not only direct depletion of the internal tissues and 
 the evacuation of exudations which are in process of formation, but 
 we apply the most energetic irritation (traumatic) to the walls of the 
 vessels, and thus provoke their contraction as well as arrest the circula- 
 tion for a long time. 
 
 II. Before resorting to revulsives which follow the application of 
 leeches we should have recourse to emollients employed even before 
 and simultaneously with bleeding. In acute metritis a severe diet 
 must be prescribed, absolute confinement to bed, the dorsal decubitus 
 with the head flexed on the trunk, the legs on the thighs and the 
 thighs on the pelvis, prolonged tepid baths, general at first, and then 
 sitz-baths, emollient and narcotic cataplasms, fomentations with a de- 
 coction of poppy-heads and belladonna, enemata, emollient at first 
 afterwards laxative, injections of liquid cataplasms, to remain some time 
 in the vagina (Valleix), baths or fomentations of the cervix (Melier), 
 emollient injections (tepid milk, mixture of oil and water, decoction of 
 ,toauve, &c.), narcotic, and when necessary detersive injections and 
 better still, continuous hot irrigations, either in the bath or in bed by 
 means of the double vaginal irrigator, or on the bidet with the hydro- 
 clyse. All these means tend to favour the action of bloodletting. 
 
 It is essential that the baths, irrigations and injections should be 
 hot (35° to 40° C. ', 95° to 105° P.) at the commencement of inflam- 
 mation. They act by temperature, imbibition, moistening of the 
 tissues, and by their emollient or sedative principles, and by the clean- 
 liness which they keep up in the vagina and on the cervix, by washing 
 away the acrid secretions, the irritating mucous discharges from the 
 uterus. The continuous irrigations are especially useful, which the 
 patient may suspend and resume from time to time during the day. 
 ^ Kanctibuch der spec. Path. u. Therapie. Erlangen, 1854, Bd. i, S. 84. 
 
METRITIS 499 
 
 Emmet recommends hot injections in place of tepid or cold ones, as an 
 excellent means of restoring tone (bj reflex action) to the veins that 
 have lost it, and of dissipating the venous congestion, which is, in his 
 opinion, the essential element of this so-called inflammation. 
 
 In cases of puerperal metritis, when the abundant leucorrhoea 
 becomes sanious, and gangrenous residues are added to the pus, the 
 injections should be made disinfectant, detersive and antiseptic, by 
 adding quinine, chloride of lime, coal tar, carbolic acid, or permanga- 
 nate of iron. 
 
 In proportion as the acute character and the accidents thereby pro- 
 voked diminish or disappear and the metritis passes into the chronic 
 state or shows a tendency to resolution, the temperature of the injec- 
 tions should be lowered considerably. Irrigations with tepid and even 
 cold water in sitz-baths are at that time useful. They should be 
 repeated twice a day for half an hour or an hour each time. 
 
 III. Among revulsives repeated purgatives hold undoubtedly the 
 first place. When the inflammation is violent and is propagated to 
 the peritoneum, or when it is manifested during the puerperal state, 
 mild laxatives are preferable. Castor oil besides acting as such keeps 
 up a slight revulsion on the digestive canal without exposing it to in- 
 flammation. Calomel is recommended with the same object. Like 
 Aran I prescribe calomel in doses of from 1^ to 3 grains, repeated 
 every twenty-four hours, but without allowing it to affect the gums or 
 produce mercurial action in the mouth, which can always be prevented 
 by using a saturated solution of chlorate of potash as a gargle and wash- 
 ing out the mouth after meals. Mercurial frictions may be used simul- 
 taneously with calomel or alone. They form one of the best means of 
 subduing acute or chronic metritis. Even in puerperal metritis the fre- 
 quent and abundant application of mercurial ointment, pure or with 
 the addition of a twentieth part of extract of belladonna, has an 
 undoubted effect. In the acute stage we must not |fear to use 5j 
 or more in the day, and to keep it on for some days, unless a miliary 
 eruption be produced by the mercury. Purgatives, in addition to 
 chlorate of potash used as a gargle as well as internally, prevent saliva- 
 tion. After every mercurial application a large hot linseed poultice 
 made with the decoction of poppy- heads is placed on the abdomen, if 
 the patient can bear it. In chronic metritis I continue the mercurial 
 frictions for a long time, but in small doses, not as antiphlogistics but 
 as resolvents. Every evening the patient should apply the ointment 
 to the abdomen, groins, and to the upper portion of the inside of the 
 thighs ; over this she lays a piece of linen covered with cotton wool 
 and, when moisture of the skin is desired, oil silk or waterproof above, 
 the whole being easily kept in place by a small pair of knitted swim- 
 ming drawers, which also prevents the patient's linen from being 
 soiled. The resolvent effect of this treatment is wonderful. To return 
 to purgatives, I ought to add that in a great number of cases laxatives 
 are not sufficient. In simple acute metritis, after applying leeches to 
 the cervix, a purgative is indicated. Care must be taken to repeat the 
 leeches till the sanguineous evacuation has been sufficient ; but when- 
 
500 UTERINE DISEASES IN DETAIL 
 
 ever the depletive effect is produced and pain alleviated recourse 
 must be had to a purgative the following day. If the patient can bear 
 a strong purgation it need not be feared, and may be repeated. Epsom 
 or Glauber's salts, seidlitz water, rhubarb and senna, castor oil with 
 the addition of one or two drops of croton oil, produce a strong re- 
 vulsion on the digestive canal very favorable to the resolution of the 
 inflammation. This should be repeated after every application of 
 leeches, especially in chronic metritis. I may also mention ipe- 
 cacuanha, strongly recommended by Trousseau in subacute metritis 
 depending on the puerperal condition ; according to Pajot also it is 
 an admirable medicament. 
 
 The cutaneous revulsives most frequently employed are blisters. 
 They may be applied to the inner surface of the thighs or to the calvps 
 after bleeding, purgatives and mercurial frictions. Usually they are 
 applied to the hypogastrium and, when repeated, produce excellent 
 effects ; but they act more efficiently against the complications of 
 metritis, peri-uterine inflammation, ovaritis, &c., than against metritis 
 itself. They are equally useful in acute and chronic metritis. Later 
 on, painting with croton oil, antimonial ointment or tincture of iodine 
 may be substituted. 
 
 IV. .A last indication of antiphlogistic treatment properly so called 
 is to soothe pain. If it has not yielded to leeching, and if the nervous 
 element predominates after bleeding, sedatives and narcotics should 
 be resorted to. Small enemata with 10 or 20 drops of laudanum, 
 opium suppositories, blisters sprinkled with morphia, frictions with 
 various sedative liniments, and lastly opium or morphia in hypodermic 
 injections, may be administered according to the case. Even in puer- 
 peral metritis about | of a grain of opium may be given in a day. When 
 patients suffer much the dose may be increased and continued till pain 
 ceases ; f of a grain of Ext. Opii can easily be taken every six hours ; 
 by repeating the dose more frequently I have been able to give 1\ 
 grains in a day. Preparations of opium have the advantage of not 
 only alleviating pain but of diminishing intestinal contractions which 
 are the cause of pain. When opium does not agree, the hydrochlo- 
 rate of morphia may be tried : f of a grain may be dissolved in 1^ 
 ounce of water, and a teaspoonful given every hour till a sedative effect 
 is produced, or a few drops of a stronger solution may be given 
 subcutaneously. 
 
 I do not speak of anaesthetics, as the effects are too transitory to be 
 of much use except in those cases where the patient cannot tolerate 
 opiates. 
 
 As for superficial transcurrent cauterisation, which has been recom- 
 mended to alleviate pain after inflammation has disappeared, it seems 
 to me that it may always be advantageously replaced by one of the 
 means just mentioned, especially by subcutaneous injections of morphia 
 and atropine. 
 
 The introduction of fragments of ice into the vagina have also been 
 suggested ; this, however, I think less indicated in metritis than in 
 metrorrhagia, as it might be accompanied by a dangerous reaction. 
 
METRITIS 501 
 
 For vulval pruritus^ starch and subnitrate of bismuth should be used 
 or white precipitate of mercury (one in ten), oxide of zinc, borax, alka- 
 line lotions or Gowland^s solution (chlorohydrate of ammonia and 
 bichloride of mercury aa gr. f, emulsion of bitter almonds ^vij. M.), 
 
 Lastly, we must favour the effects which we are entitled to expect 
 from this treatment by hygienic measures. Occasions of catching 
 cold should be avoided, especially by patients suffering from endo- 
 metritis, as this is very apt to be succeeded by leucorrhoea or real 
 uterine catarrh; they should wear flannel and use every means to 
 restore the constitution. 
 
 Treatment of chro7iic metritis and its complications. — The treat- 
 ment is the same as that just described, only in cases of chronic par- 
 enchymatous metritis and especially in metritis of the cervix, it is 
 usually advisable to commence with ignipuncture of the cervix, a kind 
 of scarification the derivative effect of which may be advantageously 
 followed up by the administration of alteratives, alkaline baths and 
 hydropathy. — This, however, is insufficient without treating the leu- 
 corrhoea, metrorrhagia, fluxion, congestion, engorgement and hyper- 
 trophy which may persist after the cessation of pain and the 
 inflammatory symptoms properly so called, without speaking of ovaritis, 
 peri-uterine inflammation, and other complications which yield less 
 easily than metritis itself. 
 
 Metrorrhagia when acute usually yields to bleeding, rest, emollients, 
 tepid baths, in short to antiphlogistic treatment. When chronic, 
 whether permanent or recurring frequently, or at intervals of three or 
 four months with numerous acute phenomena, of which I have seen 
 cases, it ought to be treated at first by tepid injections on the bidet 
 or in a general bath, and even by very hot injections, as advised by 
 Emmet, or by hot applications to the loins, hypogastrium, &c., 
 according to Chapman^s method {see p. 341). But in the chronic form of 
 metritis or when all inflammation appears to have been dissipated, and 
 when hgemorrhage is the only persisting result of it, it should, on the 
 contrary, be treated by refrigeration (cold applications, compresses, 
 bladders of ice, sulphuric ether, &c., to the abdomen ; injections and 
 enemata of cold water, injections on the bidet with ice-cold water, 
 vinegar, alum, &c., continuous introduction of pieces of ice into the 
 vagina, or cold sitz-baths of running water, at first for a minute, 
 but gradually prolonged to a quarter of an hour) ; by astringents 
 (tincture of cinnamon as used by Becamier, tannin, rhatany, alum, 
 ergotine, ergot by preference when the tissue is soft, perchloride of 
 iron internally as well as in injections) ; by cardiac sedatives (digi- 
 taline, or the infusion of the leaves, either in large doses as recom- 
 mended by Howship, Dickinson and Trousseau, or in small doses 
 as given by Gallard, 3^ to 7 gr. of leaves infused in '^vf of water and 
 taken in the day, which seems to me sufficient ; I may add bromide 
 of potassium, of which from 30 to 90 gr. may be given daily) ; bv 
 the scraping off of uterine fungosities with Recamier's curette ; lastly, 
 by direct cauterisation of the uterine mucous membrane [see chapter 
 on Heemorrhage). 
 
502 UTEEINE DISEASES IN DETAIL 
 
 LeucorrJma, ulcerations, granulations, fungosities and other altera- 
 tions of the mucous membrane necessitate the application of the same 
 topics indicated apropos of each of these maladies. 
 
 Chronic congestion, engorgement, hypertrophy of the uterine tissue 
 particularly require alteratives, more or less energetic resolvents, direct 
 and indirect, external and internal, employed in various ways during a 
 long time, or frequently resumed, leaving the patient intervals of rest. 
 
 Energetic resolvents, alteratives properly so called, iodine and its 
 preparations, repeated purgatives, tonics (iron and bark), mineral 
 waters (sulphur, iron, or alkaline according to the diathesis of the 
 patient, alkaline especially as resolvent of engorgements, such as 
 Vichy, Eoyat, Neris, Carlsbad, Ems) ; lastly and above aU if there is 
 no contra-indication, hydropathy, all help in fulfilling every indication 
 in the treatment of chronic metritis. Hydropathy may be associated 
 with the use of an internal medicament or some mineral water. Eor 
 instance, I often prescribe sulphur water internally in cases of chronic 
 metritis and leucorrhcea kept up by a catarrhal or rheumatic condition 
 simultaneously with the cold douche, in order to determine a good 
 reaction. When parenchymatous metritis is followed by a state of 
 engorgement or hypertrophy, alkaline waters, Yichy especially, are 
 preferable. 
 
 As local means, in cases of leucorrhceic endometritis especially, 
 intra-uterine injections, astringent or caustic applications to the 
 uterus, injections of tannin, nitrate of silver in powder, iodoform, or 
 the actual cautery may be of use exceptionally. I shall indicate the 
 manner in which these difi'erent means should be employed, in describ- 
 ing the special treatment of endometritis. 
 
 Lastly, if it is important to superintend the convalescence of acute 
 metritis in order to avoid relapses or the transition from the acute to 
 the chronic stage, it is of equal consequence to watch over the cure of 
 chronic metritis, especially at the monthly period, to avoid the conse- 
 quences of an abnormal fluxionary movement and the persistent con- 
 gestion of the organ, if not the recurrence of metritis. Although we 
 do not admit the incurability of chronic metritis, like Scanzoni, we 
 acknowledge that after some amelioration of the local disease and 
 general state the slightest cause suffices to produce a relapse. 
 We must also use every effort to remove all traces of leucorrhoea, 
 congestion or engorgement, consequences of metritis which tend to 
 be perpetuated and to bring back the metritis itself, by continuing 
 for a long time the cold irrigations, the resolvent frictions, the pur- 
 gatives, and especially hydropathy ; taking two courses of mineral 
 waters when indicated ; above all keeping up the strength by tonics, 
 restoring the constitution by iron and by a generous diet, and remem- 
 bering that, like the fluxion and congestion which are their constitu- 
 tive elements, chronic phlegmasias are perpetuated and have a con- 
 tinual tendency to be reproduced in the affected organs in delicate 
 patients. The only means of facilitating their displacement, of hast- 
 ening their disappearance and preventing their return is to give 
 sufficient strength to the patient to maintain this state of equilibrium. 
 
METRITIS 503 
 
 Treatment of the various hinds of Metritis. 1. Puerperal me- 
 tritis. — This is often fatal by its natural consequences and by its 
 complications. However rapid its evolution may be, in this kind 
 as in others, the inflammation may have its seat more especially in 
 one or other of the histological zones, mucous membrane, muscular 
 or cellular tissue, and merit the names of endometritis, idiometritis, 
 exometritis, given by Hervieux. Endometritis is characterised in the 
 first stage by hypersemia, redness, thickening of the mucous mem- 
 brane especially on a level with the placenta, by the viscous, 
 reddish thick coating which covers this membrane, by the projec- 
 tion of its utricular glands, softening, epithelial denudation, exul- 
 cerations, sometimes by clots and even fibrinous concretions closing 
 a gaping vascular os. In the second stage which is very common 
 being the termination by suppuration, the uterine cavity is lined 
 by a fluid sometimes reddish brown, sometimes yellow and puru- 
 lent, of thick consistency especially on a level with the placental disc, 
 of a strong smell, infiltrated into the very tissue of the softened 
 mucous membrane, and even into the vessels which are more or 
 less occluded by sanguineous clots or puriform concretions. A 
 very serious complication of suppurative endometritis is diphtheria 
 and the most serious termination is mortification, either from 
 putrid softening or necrobiosis, or from gangrene properly so 
 called. 
 
 Idiometritis, by the admission of Hervieux, is rarely met with 
 unaccompanied by endometritis. When the inflammation, passing the 
 limits of the mucous membrane, has invaded the muscular tissue of 
 the uterus, the latter organ remains large, tumefied, red and soft. If 
 the inflammation pursues its course it may terminate by suppuration 
 and even by gangrene. Usually, it is in the sinuses and in the veins 
 that pus is found, but the muscular tissue itself may be invaded by 
 suppuration which comes from the veins or from the mucous mem- 
 brane. The pus, infiltrated at first between the bundles of muscular 
 fibres, at last collects and forms real abscesses. 
 
 Puerperal exometritis seems to me more frequently connected with 
 a phlegmon of the broad ligaments, of which it is frequently the 
 starting point, than with other anatomical forms of puerperal metritis ; 
 nevertheless, it cannot be denied that inflammation is in certain cases 
 more or less limited to the cellular tissue forming the immediate enve- 
 lope of the uterus or of the veins, or oftener still the lymphatic net- 
 work contained in it. Hervieux says : " The possible complications 
 of puerperal metritis are so numerous, that in order to indicate them 
 all the cadaveric alterations to which puerperal poisoning may give 
 rise must be enumerated. Phlebitis, and especially uterine phlebitis, 
 general or partial peritonitis, phlegmon of the broad ligament, salpin- 
 gitis, ovaritis are its usual concomitants ; then pulmonary conges- 
 tion should be mentioned, the visceral purulent diathesis, the peri- 
 pheric purulent diathesis, fatty degeneration of the liver, hyperplasia 
 tumefaction of the spleen, parenchymatous inflammation of the 
 kidneys, all lesions denoting a state of general intoxication of the 
 
504 UTERINE DISEASES IN DETAIL 
 
 organism" (Traiie cliniqiie et pratique des maladies piier per ales ^ 
 p. 259). 
 
 According to the intensity, acuteness and degree of complication of 
 the malady, puerperal metritis may run through all its phases in two 
 or three days ending fatally very quickly ; or its duration may be 
 prolonged to the point of producing suppuration and allowing the 
 effects of art and nature to triumph in some cases over the complica- 
 tions (diphtheria, gangrene, lymphangitis, phlebitis, peritonitis), how- 
 ever redoubtable they be ; or lastly, it may remain in a state of rela- 
 tive simplicity which allows of the hope of resolution in ten days, 
 except in cases where the cellular peri-uterine tissue or one of the 
 broad ligaments participates in the inflammation and recovery is 
 necessarily slower. The best preventive means are : proper care at 
 delivery ; avoiding contusions, lacerations of the neck, tractions on the 
 cord ; taking care to leave no fragments of the placenta in the uterus ; 
 arresting haemorrhage by the administration of ergot continued long 
 enough to favour the contraction of the uterus as much as possible. 
 Treatment consists at first in the application of leeches or cupping 
 glasses, repeated when necessary, at the seat of pain, followed by the 
 administration of ipecacuanha in a dose sufficient to produce vomiting, 
 of emollient and sedative cataplasms covered by oil silk, and large 
 bKsters, as well as leeches or cupping glasses applied to the hypogas- 
 trium; a thick layer of mercurial and belladonna ointment (Ung. 
 Hydrarg. 5 iij, Ext. Bellad. gr. Ixxv to cl) may also be applied to the 
 abdomen, covered with oil silk and left for several days (taking care to 
 avoid salivation by frequently gargling with a solution of chlorate of 
 potash, and by great attention to the cleanliness of the mouth, for 
 notwithstanding the contrary opinion of many physicians of high 
 standing, among others of Hervieux, op. cit., p. 270, I cannot believe 
 in any good effect being produced by mercurial salivation). Mild pur- 
 gatives should also be given, not only to prevent constipation but also 
 to produce a revulsive and eliminating action ; which need not prevent 
 the strength being kept up in the interval by a diet appropriate to the 
 state of the patient, wine and brandy being given in small doses 
 frequently repeated ; bark and quinine may also be resorted to when 
 the phenomena of suppuration and puralent infection seem to in- 
 dicate it. Digitalis and aconite may also be used to moderate the 
 fever. But above all excessive cleanliness must be kept up in the 
 vagina and uterine cavity, and the surface of the latter should be 
 modified by vaginal and intra-uterine detersive injections, too often 
 even now neglected by practitioners. Anxious as I am to warn my 
 young confreres of the dangers of these injections into a uterus in a 
 state of vacuity with a narrow os {see Leucorrhoea), I am equally 
 desirous of persuading them to have recourse to them as one of the 
 most valuable means at our command in cases of puerperal metritis. 
 I may take this opportunity of adding the results ^ of my experience to 
 those of Hervieux, of Pontaine his Eesident [Etudes stir les injec- 
 tions uterines apres I' accouchement, theses de Paris, 1869), and of 
 others in contributing to introduce into practice a means which,^ 
 
METRITIS 505 
 
 although presenting some danger, is often the most powerful and 
 perhaps the only one which we possess to prevent the terrible conse- 
 quences of puerperal metritis, whether suppurative, diphtheritic or 
 gangrenous. Therefore whenever a purulent ichorous fluid more or 
 less foetid is discharged from the uterus we must not hesitate to have 
 recourse to intra-uterine injections simultaneously with the other 
 means of treatment already enumerated. An ordinary gutta-percha 
 male catheter of medium size is sufficientj for the cervix is widely open 
 at this time and the fluid injected into the uterus comes back again too 
 easily to admit any danger of its flowing towards the Pallopian tubes. 
 The patient lies on her back on the edge of the bed, or better still on 
 the side (the English position) ; the index finger of one hand is placed 
 on the cervix whilst the extremity of the catheter is placed against 
 this finger with the other hand, and is easily insinuated into the 
 uterus ; the canula of a syringe, irrigator or hydroclyse is fitted into 
 the catheter ; and after making sure that no air has been admitted, 
 we gently and slowly inject from half a pint to two pints of a tepid 
 detersive fluid, which is received into a basin as it returns from the 
 vulva. As soon as the water when expelled is free from all patholo- 
 gical elements, we can cease the injection. One or two intra-uterine 
 injections may be made daily in addition to the vaginal lotions and 
 injections which ought to be much more frequently repeated. The 
 best are : chlorinated water (Sod. Hypochlorit. gr. xv, Infus. Chamom. 
 3j), aromatic infusions, or water to which has been added a little coal 
 tar or a few drops of carbolic acid, permanganate of potassium, tinc- 
 ture of iodine, salicylate of soda, &c. 
 
 II. Post-puerperal metritis. — It usually affects the whole of the 
 uterus. It is generally due to the imprudence of the patient, to her 
 having risen too soon, or to her having resumed marital intercoarse 
 too early after delivery, or to a return of uterine fluxion, a tardy 
 haemorrhage, &c. Unless it be developed subsequent to a late phle- 
 bitis of the uterine tissue owing to the formation of a clot in a sinus, 
 it never has the gravity of puerperal metritis, for it neither has its 
 acute character nor its suppurative nor gangrenous terminations, nor 
 its numerous and terrible complications. But it often becomes the 
 starting-point of a chronic metritis all the more lasting from the 
 organ affected being much larger than in a state of vacuity and in a 
 condition of congestion and nutritive activity unfavorable to the reso- 
 lution of the phlegmasia. Thus it often commences by assuming the 
 subacute form, it is perpetuated indefinitely in the chronic form, and 
 even when it is extinct it may be the starting point of an almost 
 irremediable alteration, the persistence of an abnormality in the 
 size and structure of the organ. It is then troublesome from this 
 double point of view : that it is frequently the starting-point of 
 chronic metritis, and that it often becomes, even when dissipated by 
 suitable treatment, a cause of arrest of the retrograde evolution of 
 the uterus. On these accounts post-puerperal metritis requires prompt 
 and energetic treatment. Leeches may be indicated ; hot cata- 
 plasms night and day; daily tepid baths, emollients and later on 
 
506 UTEEINB DISEASES IN DETAIL 
 
 alkaline baths with injections, mercurial and belladonna ointment 
 on the belly, blisters, repeated purgatives, later on resolvents, ergot, 
 and lastly, general revulsive frictions, tonics, electricity, and hydro- 
 pathy during convalescence constitute the most efficient means of 
 treatment. 
 
 III. Partial metritis of the hody of the uterus. — It frequently 
 follows post- puerperal metritis or neglected abortion, but is more fre- 
 quently a consequence of dysmenorrhoea, either in virgins or in newly- 
 married women, owing to increased menstruation excited by coitus. It 
 may be acute, but generally it follows a chronic course. The subjec- 
 tive symptoms are : pain, invariably hypogastric, frequently left iliac, 
 sometimes right iliac, very rarely lumbar; discomfort and weight in 
 the pelvis ; pain referred to the sacro-iliac articulations, the groins 
 and thighs ; most frequently dyspepsia, nausea, chloro-ansemia, with 
 general symptoms analogous to those of pregnancy and dependent 
 on reflex action provoked by abnormal vital activity of the body of 
 the uterus. The malady is easily diagnosed by associating touch with 
 palpation. 
 
 Treatment. — Leeches or cupping glasses to the hypogastrium, groins 
 or vulva, repeated when necessary and followed the next day by a pur- 
 gative ; general baths, prolonged horizontal decubitus ; the continuous 
 application of mercurial and belladonna ointment ; daily laxatives ; 
 later on alkaline waters, resolvents, alteratives and tonics, according 
 to the constitution and temperament of the patient or the diathesis 
 which may help to keep up the disease ; afterwards ergot, general 
 cutaneous frictions and hydropathy. 
 
 IV. Partial metritis of the cervix. — It frequently follows lacerations 
 of the cervix during delivery, various traumatisms to which this organ 
 is subject, excessive coitus, &c. The subjective symptoms are : con- 
 stant Irmbar pain, left or right iliac and hypogastric pain rarely; 
 pelvic discomfort communicated to the anus, rectum and bladder, 
 sometimes c-^en to the stomach and nervous system, but more rarely 
 than in met;ritis of the body. Occasionally enormous tumefaction of 
 the cervix ^ith heat and pain ; frequently alteration in its form with 
 sometimes softening of its tissue, sometimes induration, according 
 to the period of the inflammation ; often cervical leucorrhoea, ulcera- 
 tions, granulations, fungosities, epithelial or mucous polypi, the last 
 consequences of this inflammation. 
 
 Treatment. — Scarifications more or less deep and numerous, or 
 leeches to the cervix followed by purgatives, prolonged emollient baths 
 with vaginal injections and even continued tepid irrigations in bed, or 
 injections for a quarter of an hour and repeated every hour, with decoc- 
 tions or emollient, sedative, narcotic solutions (marshmallow, starch, 
 henbane, belladonna, poppies, hemlock, bromide of potassium) ; laxa- 
 tives ; afterwards, resolvent applications to the cervix with tampons 
 saturated in glycerine or covered with mercurial and belladonna 
 ointment, iodide of lead or red oxide of mercury; application 
 to the cervix of calomel, tincture of iodine, iodoform ; alkaline baths 
 with injections; later on, astringent injections and even the actual 
 
METRITIS 507 
 
 cautery simultaneously with alkaline waters, iodide of iron, effervescing 
 iron waters, bark, cold injections, hydropathy. 
 
 Y. Endometritis. — It is sometimes acute, sometimes chronic ; even 
 under this latter form it may not go much beyond the elements of the 
 mucous membrane or submucous tissue, not reaching the muscular 
 tissue, or at least not reaching it sufficiently to give rise to other in- 
 dications than those which naturally proceed from inflammation of the 
 mucous membrane, leucorrhoea, ulcerations, granulations, fungosities, 
 &c. — Metrorrhagia is frequently a symptom, but not so pathogno- 
 monic as Gallard says, for it may occur after simple fluxion, or a 
 congestive state of the mucous membrane, as well as after an acute 
 inflammatory condition of this membrane; it depends also some- 
 times on a softening which has nothing inflammatory and often on 
 bleeding fungosities developed in the body, analogous to those ob- 
 served so frequently on the cervix causing a flow of blood on the least 
 fluxionary movement. Owing to the existence of these fungosities and to 
 the accompanying hypertrophy or simple swelling of all the mucous 
 membrane, this fluxionary movement is followed by a persistent con- 
 gestion and by a hsemorrhage sometimes very persistent and very 
 abundant, recurring every month and even oftener, and lasting some- 
 times uninterruptedly from one period to another, weakening patients 
 greatly; but these fungosities themselves are not necessary conse- 
 quences of inflammation ; like polypi they may be developed inde- 
 pendently of it, and strictly speaking without the intervention of endo- 
 metritis; admitting that endometritis is their starting-point, they are 
 only developed as an effect of the modifications which inflammation has 
 produced on the mucous membrane, in consequence of its softening and 
 hypertrophy, and therefore they are much more characteristic of the 
 chronic than of the acute form of endometritis, and consequently the 
 haemorrhages to which they give rise are symptoms of chronic as well 
 as of acute endometritis ; lastly, I repeat that metrorrhagia in itself has 
 no pathognomonic signification, for it may be the consequence of non- 
 inSammatory fungosities, or of the fluxion, congestion and softening just 
 referred to, or it may be produced simply by the existence of an intersti- 
 tial fibroma or intra-uterine polypus or cancer, not to speak of the general 
 alterations of blood which may cause hsemorrhage from the uterus as from 
 other organs. — Leucorrhoea is a more characteristic symptom of endo- 
 metritis than metrorrhagia ; it coincides with the latter or alternates with 
 it, or it is manifested alone ; it may be simply mucous or more or less 
 purulent, limited to the uterus and even to one of its segments (body 
 or neck), or be extended to the vagina, sometimes accompanied by 
 erosions and various eruptions on the uterus, vagina and vulva, by 
 vulval pruritus and even by cutaneous eruptions. — There are also 
 heat, enlargement of the os internum (unless polypoid fungosities or 
 swelling of the mucous membrane obstruct it in part), marked pain, 
 sometimes very acute, ehcited by the sound, and a tendency to bleeding 
 after this little operation. 
 
 Treatment. — Leeches to the cervix, superficial scarifications of the 
 vaginal portion or of the intra-cervical mucous membrane, purgatives. 
 
508 UTEEINE DISEASES IN DETAIL 
 
 cutaneous revulsives to the abdomen (blisters, iodine, &c.), per- 
 chloride of iron, digitalis, later on ergot (especially if the organ is 
 soft) to subdue the hsemorrhage, as well as refrigerants, ice and (in 
 the chronic period) even scraping with Recamier's curette, cauterisa- 
 tion with nitrate of silver, and intra-uterine injections with tincture of 
 iodine, solution of nitrate of silver, &c.^ (A. Guichard, Recherches 
 sur les injections intra-uterines en dehors de I'etat puerperal. These 
 de Paris, 1870. Dupierris, De I'effieacite des injections iodees de la 
 cavite de ruterus. Paris, 1870). I have described how these injec- 
 tions should be made in the puerperal state, and shall here merely 
 refer to the precautions to be taken in making them when the uterus 
 is in a state of vacuity. Above all the orijices should be sufficiently 
 large or dilated so that the fluid can easily return however small be 
 the quantity injected, and the contractions produced by its presence in 
 the womb can easily expel it. In addition, the acute injiammatory 
 symptoms should have been previously siibdued. "We may then use a 
 metallic or gutta-percha catheter (the latter is often insufficient on 
 account of its softness) of calibre equal to the ordinary sound, and by 
 means of a small syringe a quantity of fluid in proportion to the 
 capacity of the uterine cavity may be injected very gently ; usually a 
 few drops is sufficient to reach the whole mucous membrane. I am 
 accustomed to administer previously a small sedative enema with 
 fifteen drops of laudanum, in order to diminish the pain of the uterine 
 colics which the presence of fluid in the cavity of the womb does not 
 fail to produce, and shortly afterwards I prescribe a prolonged emol- 
 lient bath with vaginal injection, emollient cataplasms on the 
 abdomen, and rest in bed. Later on, we may prescribe daily astrin- 
 gent vaginal injections. In this chronic period of the malady we 
 must also consider the general phenomena and diathetic conditions 
 which follow, complicate or keep up the endometritis : dyspepsia, 
 chloro-ansemia and herpetism must especially be treated. With this 
 object we have recourse to pepsine, alkaline drinks, laxatives, iron 
 preparations associated with tonics (rhubarb, bark, quassia), sedatives 
 (one or two drops of laudanum or of a solution of gr. 1 1 of morphia 
 in Tillxxv of cherry laurel water (Gallard) or gr. \ of powdered bella- 
 donna root before food), stimulants (bark, wine, absinthe, cinnamon, 
 pepper, cofi'ee, before or after meals), arsenical preparations, balsams, 
 (tar-water, tolu, &c.), sulphur waters and hydropathy. 
 
 YI. Parenchymatous metritis. — It may also be acute or chronic, 
 but of all the forms it is the one which persists the longest, and which 
 is met with most frequently in the chronic state. There are, accord- 
 ing to the period or the individual tendencies, softening or induration 
 of the tissue simultaneously with increased size of the organ, amenor- 
 rhcea, or diminution of menstruation, especially at the period of indu- 
 
 > AtHll {The Duhlin Journal of Medical Science, Jan., 1873) cauterises the 
 mucous membrane with nitric acid by means of the intra-uterine speculum in 
 cases where other means have failed. According to Blanchard {De la cauterisa- 
 tion de la cavite uterine dans la metrite chronique. Theses de Paris, 1873) 
 Laroyenne of Lyons obtains good results fi-om this cauterisation, which proves 
 the innocuity of nitrate of silver in these cases. 
 
METRITIS 609 
 
 ration, sometimes also dysmenorrhoea. The uterine cavity is sensibly 
 increased, and the orifices, especially the internal, are almost always 
 enlarged by excentric dilatation of the walls. Hypogastric, lumbar, 
 inguinal and pelvic pain are present with a feeling of fulness and 
 weight increasing often considerably at the monthly period and per- 
 sisting afterwards. To these are added dyspepsia, chloro -anaemia, 
 debility and frequently emaciation and serious alteration of the health, 
 especially when the disease is of long standing. 
 
 Treatment. — Leeches and deep and repeated scarifications of the 
 cervix followed by prolonged alkaline and emollient baths with injec- 
 tions ; and purgatives replaced afterwards by daily laxatives, emollient 
 cataplasms, mercurial ointment applied to the abdomen and injected 
 per rectum. Later on, cauterisation of the cervix, several punctures 
 of from 5 to 10 millimetres being made with a fine point at red 
 heat so that a resolvent and derivative action may be exercised at 
 several points. Simultaneously and afterwards, tonics, solvents, 
 mineral waters and hydropathy. 
 
 The manner in which I associate these various methods is the fol- 
 lowing : I apply leeches to the cervix or practise scarification, once or 
 twice after menstruation if pain is increased at that time, administer- 
 ing an emollient bath the next day and a purgative the day following j 
 I prescribe three alkaline baths (Sod. Bicarb, ^vij and 2 lbs. of bran) a 
 week, with vaginal injection during the bath and rest in bed for an 
 hour afterwards ; every morning friction of the whole body with 
 flannel saturated with a solution of ammoniated camphor or the 
 tincture of some aromatic tonic (bark, benzoin, &c.) j ten minutes 
 before each meal to take from a quarter to a whole glass of Vichy, 
 Andabre, Boulou, or Vals mineral water or an artificial alkaline water 
 (75 grains of bicarbonate of soda to the quart), at the commencement 
 of every meal some iron preparation (iodide of iron), and during the 
 meal an effervescing iron mineral water (Bussang, Orezza, Lamalou, 
 Vals, &c.) ; and a tablespoonful morning and evening of the following 
 prescription : B: Pot. lod. ^j, Aquse ^^j, increasing the dose of iodide 
 30 grains every week till 30 or 45 grains are taken every day ; if the 
 patient cannot take this preparation I substitute the chloride of gold 
 and sodium (gr. -^-^ to gr. % a day) or an arsenical preparation if 
 nutrition requires to be stimulated, the patient being thin and pale or 
 presenting symptoms of herpetism ; or bromide of potassium or 
 sodium if she is nervous or hysterical ; the application of some resol- 
 vent ointment (mercury or the iodide of lead and potassium) to the 
 hypogastrium and groins, or as an injection into the rectum and even 
 into the vagina ; an india-rubber abdominal belt to keep up a con- 
 stant moisture round the pelvis and to retain the cataplasms in place 
 at the menstrual period or when pain is increased ; lastly, to terminate 
 the treatment by hydropathy (general, never local, exceptionally sitz- 
 baths of running water), alternating or associated with mineral waters, 
 either sulphurous, such as Vernet, Luchon, Aix, or saline, such as 
 Royat, Plombieres, la Bourboule ; or alkaline, such as Vichy, Anda- 
 bres, Sylvanes ; thus, I often prescribe the association of Vichy 
 
510 UTERINE DISEASES IN DETAIL 
 
 waters internally and in baths (with injections) in the morning, and 
 general hydropathy in the afternoon, and I have seen the good effects 
 produced by these means in terminating a treatment successfully 
 begun. It is especially in cases of venous congestive metritis^ which 
 is so difficult to cure, that courses of hydropathy, repeated twice a 
 year and associated with the use of alteratives, exercise and good 
 hygiene are indispensable in restoring patients to health. 
 
 Ovaritis and Salpingitis. 
 
 1. Ovarian Inflammation. 
 
 Ovaritis or oophoritis is inflammation of the ovary. There are not 
 only differences of degree but differences of nature between this 
 inflammation and catamenial fluxion. Tilt^ seems to have ignored 
 this fact in creating the term subacute ovaritis, divided into amenor- 
 rhceic, dysmenorrhoeic, and menorrhagic ; it seems to me to be rather 
 an irregularity of the ovarian catamenial fluxion, or a chronic ovaritis, 
 producing menstrual disorders which may affect the three principal 
 forms which we have specially described. Aran ^ on the other hand 
 has exaggerated the difficulty there is in separating physiological or 
 slightly disordered ovulation from ovaritis. The ovarian functions 
 being the most important amongst those of the genital organs, all the 
 others being in a measure subordinate to them, it is not surprising 
 that diseases of the ovaries, and especially their inflammation, should 
 react still more than those of the uterus, and sometimes in the most 
 troublesome way, not only on the genital economy but on the whole 
 organism. With the ovaries, as with the uterus, morbid states without 
 neoplasms are not limited to inflammation. Pluxion, congestion, en- 
 gorgement, hypertrophy, neuralgia seem to me as much entitled to 
 have a place here as acute and chronic inflammation. Nevertheless I 
 have not thought it necessary to multiply descriptions and devote a 
 chapter to every distinct morbid condition. I have abstained from 
 doing so for two reasons : the first is that some of these morbid con- 
 ditions, such as fluxion and congestion, are recognised by signs analo- 
 gous to those of uterine fluxion and congestion and require almost the 
 same treatment ; the second is that the others, such as engorgement, 
 hypertrophy, neuralgia, cannot always be distinguished from maladies 
 of the neighbouring organs. I shall content myself, therefore, 
 apropos of the differential diagnosis of ovaritis, with giving a brief 
 sketch of these various morbid states and of the treatment required. 
 
 Pathological Anatomy. — According to Boivin and Duges^ and 
 Chereau,* the anatomical alterations of ovaritis may be connected with 
 
 1 On Uterine and Ovarian Inflammation, p. 294. London, 1862. 
 
 2 Op. cit., p. 572. 
 
 ' Op. cit., t. ii, p. 564. 
 
 4 Memoire pour servir a V etude des maladies des ovaires. Pans, 1844. 
 
OVARITIS AKD SALPINGITIS 511 
 
 four principal stages : hypersemia, tumefaction and softening, suppu- 
 ration, grey softening and putrilaginous or gangrenous decay. To 
 these must be added induration, which Chereau rightly describes as 
 characteristic of chronic ovaritis, and which is always accompanied, in 
 this disease, by alterations of another kind. 
 
 Before describing the anatomical characters of these alterations, the 
 periods of the malady to which they are related, and, as far as possible, 
 the symptoms leading us to suspect them, I copy Scanzoni^s ^ excel- 
 lent description of an inflamed ovary met with accidentally in a woman 
 suffering from pneumonia. " The autopsy showed, in the pelvis, to 
 the right of the uterus, a coagulated mass of fibrin of the size of the 
 fist, easily separated from the adjacent organs, and which evidently 
 resulted from an effusion. After its removal the bvary was seen pre- 
 senting a longitudinal diameter of 2$ inches, whilst the transverse dia- 
 meter was 1 J inch, and the thickness of the organ about 1| inch. The 
 ovary had an ovoid form, it was considerably enlarged, its surface was 
 deep-blue and covered with numerous dilated veins, and towards the 
 internal angle of the posterior surface the place of an ovarian vesicle 
 which had burst a short time previously was recognised by its dark- 
 red colour. The consistency of the organ was pasty, almost fluctuat- 
 ing at some points. In cutting it a considerable mass of blood flowed 
 and the section showed the same violet colour and some venous vessels 
 greatly engorged. The vesicle in question on which the point of 
 rupture was easily seen was the size of a pea; it contained in its 
 centre a little black liquid blood, whilst the walls were covered by a 
 thick layer of fibrin. Two neighbouring vesicles presented almost the 
 same dimensions, projecting slightly above the surface of the ovary ; 
 on opening them a serous sanguineous fluid was discharged. Towards 
 the other extremity of the organ, where the congestion was less strong, 
 the red less intense, and the consistency ^firmer, there was in the 
 parenchyma an abscess of the size of a bean containing sanious pus 
 mixed with blood. Beside this rather large abscess there were other 
 smaller ones, the size of which varied from that of a millet seed to a 
 pea, all situated deeply in the parenchyma and all containing sanious 
 pus. The whole tissue was infiltrated with serosity, and the majority 
 of the vesicles were visibly enlarged by an abundant accumulation of 
 fluid. The pathological alterations observed in this ovary correspond 
 exactly with the description of acute ovaritis given by some writers ; 
 considerable increase in the size of the organ, marked hypersemia, 
 traces of efiusion into the vesicles, purulent centres in the parenchyma 
 and fibrinous exudation on the peritoneal covering of the organ." 
 
 Gallard^ remarks that this description represents a type of ovaritis 
 extending to the whole organ and to all its elements : in fact, the 
 alterations are threefold -, they affect the vesicles, the parenchyma and 
 the envelope. Is it always so ? May the inflammation be limited to 
 one of these tissues in place of extending to all simultaneously ? It 
 is difficult to believe that it runs its course in one of these tissues 
 
 1 Op. cit., p. 392. 
 
 ' Gazette des hopitaux, July, August, October, 1869. 
 
512 UTERINE DISEASES IN DETAIL 
 
 without affecting the others. However, I have seen alterations of the 
 organ so limited to one or other of these elements that it seems to me 
 beyond doubt that this anatomo-pathological distinction can be made : 
 in some cases the peritoneum covering the organ is alone inflamed ; 
 adhesions unite it to the neighbouring organs, and bands retain the 
 ovary in a vicious position, without any real change in the latter ; 
 the inflammation may also commence in a follicle and remain for a 
 long time confined to the membranes composing it ; the solid organic 
 alterations so often met with in the ovary show us that the starting- 
 point of the inflammatory phenomena is at other times limited to the 
 parenchyma of this organ.^ I think, therefore, we must admit general 
 ovaritis and partial ovaritis, commencing in one of the three elements 
 of the organ. Usually the latter soon extends to the whole of the 
 ovary, for acute general ovaritis is much the most frequent ; but the 
 three forms usually co-exist, and treatment can hardly vary even if 
 differential diagnosis were possible. 
 
 A more practical division is that of five degrees of intensity in the 
 inflammation at five periods of the malady : 1st congestion, 2nd red 
 softening, 3rd induration, 4th suppuration, 5th grey or gangrenous 
 softening. 
 
 Besides these alterations, pathological anatomy shows that others 
 exist, which cannot be connected with any of the five degrees enume- 
 rated above, because several of them are met with in various periods 
 of the malady, without belonging especially to any one of them. Such 
 are displacements of the ovaries, their adhesions to neighbouring organs 
 (Eallopian tubes, uterus, bladder, intestine, &c.), perforations of ovarian 
 abscesses, the presence of pus in the lymphatics and in the ovarian 
 veins, the varicose dilatation of veins, &c. A second remark is that 
 the alterations due to inflammation are manifested in various degrees 
 on different points of the ovary : adhesion here, suppuration there ; 
 induration at one point, softening in another : this depends not only 
 on the course which the malady follows in the organ, but also on the 
 difference of structure of the various elements of which the ovary is 
 composed. One last remark : ovaritis alone or simple is excessively 
 rare : the peritoneum is always affected like the pleura in pneumonia ; 
 the Fallopian tube participates almost always in the inflammation, the 
 uterus is often involved, primarily or consecutively, the broad ligament 
 rarely escaping. 
 
 Etiology. — Ovaritis is most frequently developed in the puerperal 
 state, and as a consequence of menstrual disorders. With the puer- 
 peral state are connected abortions, hard labour, obstetrical operations, 
 want of care, fatigue, chills, &c. With disturbance of the menstrual 
 function are connected all the causes which increase catamenial fluxion 
 and ovarian congestion, e. g. hot baths, eramenagogues, &c., and those 
 which increase the ovarian congestion by suddenly suppressing the 
 catamenia, e.g. coitus during menstruation, a sudden chill, especially 
 •of the feet or lower part of the body, emotion, violent grief, &c. 
 
 ^ Eveiy day brings additional proof of the diversity in the seat of ovaritis. 
 Bouveret, Annales de Gynecologic, t. iv, p. 427. — Darolles, ibid., t. vi, p. 419. 
 
OVARITIS AND SALPINGITIS 513 
 
 Ovaritis is developed also by the propagation of a pre-existing 
 inflammation in the uterus, or of a metritis produced by a traumatism, 
 and even by an inopportune cauterisation. Cauterisation by causing 
 the metritis to pass from the chronic to the acute stage leads to the 
 propagation of the inflammation to the Fallopian tubes and to the 
 ovary. A violent inflammation of the vagina, especially if virulent, 
 contagious and disposed to be propagated to the uterus or to the Fal- 
 lopian tubes, may reach the ovaries. Therefore ovaritis may be due 
 to the extension of blennorrhagia to one of the ovaries, the inflammation 
 either reaching by degrees the internal parts of the uterine economy 
 including the ovary, or else by a kind of metastasis favoured by a 
 natural sympathy and the vascular communications between these two 
 organs, it is transported suddenly from the vagina to the ovary, as in 
 man from the urethra to the testicle. Ricord has described this kind 
 of ovaritis as comparable to blennorrhagic orchitis. Bourraud^ has 
 related some interesting cases, and I have seen some also. 
 
 Thus delivery and the puerperal state, menstrual disorders and uterine 
 inflammation are the principal causes of ovaritis. Direct traumatic 
 causes may also produce the development of ovaritis, but the ovary, 
 owing to its internal position and mobility, usually escapes their action. 
 The general causes deserve our attention. Maladies may attack the 
 ovary like other organs : amongst acute maladies we may mention 
 variola as a sequel to which Beraud^ has observed variolous ovaritis, 
 which he compares to the variolous orchitis described by Velpeau and 
 Gosselin ; amongst chronic diseases we may count scrofula {see later, 
 on Tuberculisation of the Ovary), syphilis (Nekton has mentioned 
 syphilitic ovaritis), gout and rheumatism (I have seen several cases of 
 rheumatic ovaritis). 
 
 According to some physicians, ovaritis is often double ; but Scanzoni^ 
 says that it very often afi'ects only one ovary, and I can aflirm that, if 
 both are aff'ected, one is always much more diseased than the other, 
 perhaps the left ovary more frequently than the right,* but the ovaritis 
 on one side does not only coexist with ovaritis on the other, it coexists 
 still more frequently with inflammation of the Fallopian tube or cor- 
 responding broad ligament. 
 
 Ovaritis may be either acute or chronic ; it is sometimes difficult to 
 distinguish the two forms, all the more so that chronic ovaritis easily 
 returns to the acute stage. Puerperal ovaritis is the most intense and 
 the most dangerous form of acute ovaritis ; it often terminates fatally 
 in a few days. The most persistent chronic ovaritis often commences 
 before marriage. 
 
 Diagnosis. — The diagnosis of chronic non-puerperal ovaritis in the 
 first stage is difficult, and yet it is very important. A girl, two or 
 three days after her period has commenced, feels pain in the iliac fossa, 
 with radiations, nausea and vomiting; this pain becomes permanent 
 
 * Be I'ovarite blenorrhagique, Theses. Paris, 1847. 
 
 ^ Archiv. gener. de Mklecine, 1859, 5* scrie, t. xiii, p. 588. 
 
 » Op. cit.,'p. 399. 
 
 ■* Chereau, op. cit., p. 155. 
 
 33 
 
514 UTERINb] DISEASES IN DETAIL 
 
 although diminished in degree, being increased at the monthly period j 
 menstrual disorders occur ; the patient is nervous and irritable ; she 
 becomes emaciated, a dark ring forms under the eyes, her face is sallow ; 
 she probably has ovaritis. Marriage, often recommended with the idea 
 that it will regulate menstruation, increases the pain, leucorrhoea 
 is set up and the young wife is sterile : ovaritis is more and more 
 probable. 
 
 The importance of an early diagnosis is evident when we think of 
 the many dangers to which the patient is exposed for want of it ; for 
 ovaritis is a much more common disease than is supposed ; very often 
 the ovaries are not examined, and very often the uterine complications 
 are cured while the principal malady is ignored, ovarian inflammation 
 being increased and suppuration produced by cauterising the cervix. 
 Uncertainty of diagnosis would be less prejudicial in the latter case 
 than in that of ovaritis at the commencement. The temporary fluxion, 
 the more or less permanent congestion of the ovary, may indeed be 
 taken for the beginning of inflammation of this organ. It is all the 
 more desirable to recognise and to distinguish them as the treatment 
 is not identical, although necessitated in botli cases by the fear that 
 the persistence of fluxion or congestion may favour the development of 
 inflammation. 
 
 If, however, the diagnosis of the first stage is difficult, especially of 
 chronic ovaritis in a girl, it is quite different with confirmed ovaritis 
 especially of the acute form. The obscurity of the diagnosis depends 
 on two almost opposite causes : either on the latent form or on the 
 extreme intensity of the symptoms, in fact on a want of equilibrium 
 which hinders observation. 
 
 Peritonitis especially, according to whether it is developed or not, 
 may either produce this intensity of symptoms or leave them in 
 obscurity. Acute and chronic ovaritis are very different with regard 
 to the intensity of the symptoms and the order of their manifestations. 
 Puerperal ovaritis is only the subacute form, generally accompanied 
 by puerperal peritonitis. 
 
 Acute ovaritis — subjective signs. — Acute ovaritis may from its com- 
 mencement be true acute ovaro-peritonitis. Its reaction on the 
 organism is immediate, causing rigor, fever, nausea, vomiting, pain more 
 or less acute, spontaneous or provoked, often very acute as in peritonitis, 
 continuous, but with exacerbations which may be accompanied by 
 hysterical fits. Added to these there is frequent desire for micturi- 
 tion, constipation, pain on going to stool, the impossibility of stand- 
 ing J the patient is almost bent double when trying to walk ; it seems 
 as if a bar of iron depressed the belly, from one iliac fossa to the 
 other ; whilst raising the leg on the affected side, and decubitus on 
 the healthy side cause acute pain followed by dragging ; the lochial 
 and menstrual discharges are either suppressed or diminished. 
 
 In simple acute ovaritis the general reaction is less ; sometimes 
 there is a little fever in the evening; no vomiting, but distaste for food, 
 dyspepsia, constipation, pain on going to stool and at micturition, with 
 discomfort at some point of the abdomen. Chereau describes the 
 
OVAEITIS AND SALPINGITIS 515 
 
 following as symptoms of ovaritis occurring after suppression of the 
 menses : aching in all the limbs, headache, thirst, and disorders of 
 digestion. Standing, walking on an uneven road, a false step, 
 extension of the leg on the same side as the ovaritis provoke pain, 
 which is still more true of peri-uterine inflammation. The pain is so 
 limited, that the patient may be able to place her finger on the start- 
 ing point, which is situated in one of the iliac fossse above the Fal- 
 lopian ligament. From there it radiates towards the hypogastrium, 
 the lumbo-sacral region, down the thigh to the calf, sometimes with 
 numbness of the leg. 
 
 The termination of acute ovaritis may be added to the other sub- 
 jective signs as a help to diagnosis. Ovaro-peritonitis may rapidly 
 reach suppuration, general peritonitis and death; or the phenomena 
 may be alleviated, simple acute ovaritis alone remaining, with pre- 
 dominance of local symptoms. Eeduced to this degree it may ter- 
 minate by resolution, in spite of menstrual exacerbations, the only 
 termination which can pass for a cure. It is only obtained in acute 
 ovaritis at the period of congestion ; it is hardly possible when the 
 malady has reached the stage of red softening, Recovery may take 
 place in from three months to a year, with the exception of the per- 
 sistence of abnormal sensibility and of some remains of ovarian 
 trouble. Sometimes it reaches suppuration very quickly. The for- 
 mation of pus is announced by increase of pain, erratic rigors, per- 
 spiration in the evening, more acute pain on pressure, diffuse tume- 
 faction in the pelvis, or a circumscribed tumour, rarely as large as the 
 fist, allowing obscure fluctuation to be perceived when pressed 
 between the finger introduced into the vagina and the hand placed on 
 the hypogastrium. When pus is formed in the ovarian vesicles it 
 may remain encysted for a long time ; when produced in the paren- 
 chyma it makes more rapid progress. It may invade the whole ovary 
 without going beyond it, retained by the fibrous covering, the resist- 
 ance of which is increased by the false membranes deposited on its 
 surface and forming a kind of lining. This resistance, increased by 
 that of the adhesions which the ovary has contracted with the neigh- 
 bouring parts of the serous membrane, fortunately as a rule prevents 
 the abscess from opening into the peritoneum. 
 
 Termination by suppuration is relatively very rare, it being only on 
 account of the extreme frequency of ovaritis that it has been met with 
 so often.^ It is serious for the ovary, for the neighbouring organs, for 
 the whole organism which may succumb to peritonitis or pyaemia. It 
 causes emaciation and discoloration of the face. Additional adhesions 
 are established between the ovary and the neighbouring organs at each 
 succeeding monthly period. Nevertheless the sac of the abscess 
 becomes thinner and finally ruptures, the pus being effused all around. 
 According to Chereau, Tilt and others the abscess generally opens into 
 the rectum. I have collected six such cases. Dupuytren, Andral, 
 
 ' I think there has been an error of diagnosis in several cases ; it is easy to 
 confound abscess of the ovary with inflammation of the broad ligament or 
 iliac fossa ; abscess of the ovary often remains encysted. 
 
5] 6 UTERINE DISEASES IN DETAIL 
 
 Montault^ Nauche, Boivin, Churchill, Peudefer, Bennet and others 
 have described cases of the kind. Of all spontaneous openings it is 
 the most desirable. However more than one patient has succumbed 
 to this accident, either immediately or after some time from the effects 
 of exhaustion caused by the purulent secretion. Bennet^ mentions the 
 case of a girl of fourteen, who after having menstruated once or twice 
 was seized with haemorrhage followed by angemia ; later on by emacia- 
 tion, pain in the left iliac region, development of the corresponding 
 ovary, discharge of pus and death with hydrencephalic symptoms. — 
 Opening into the rectum causes tenesmus and a kind of dysentery 
 from the contact of the pus with the intestine. When the abscess is 
 not acute and cannot close immediately after being emptied, there is 
 either an incessant excretion of pus or an alternation of occlusion with 
 opening of the purulent centre, giving rise to the incessant recurrence 
 of pain, fever, and all the accidents caused by each new distension of 
 the abscess with pus and each new laceration of the imperfectly 
 cicatrised wound. 
 
 Opening of the abscess into the vagina is rather less frequent. 
 Husson, Dance, Cruveilhier have mentioned cases. I have seen three. 
 This result appears favorable to cure ; only it is sometimes difficult to 
 discover the opening : we must remember this when desirous of en- 
 larging the natural opening, or of making injections into the cavity of 
 the abscess. — Exceptionally ovarian abscesses may open into the. 
 bladder, but this involves an abnormal position of the inflamed 
 ovary. Andral and Murat have related two cases and Gallard a third, 
 in which nothing was wanting but confirmation by necropsy. — The pus 
 may pass into the oviduct and remain there, dilating it (Laumonier) , or 
 be discharged into the uterus and thence externally (Chambon de 
 Monteaux, Chereau) ; or into the body of the uterus, and thence into 
 the vagina (Boivin). — It may make a way for itself into the csecum 
 (Dupuytren), into the colon (Montault), or following the round hga- 
 ment or the crural vessels, be discharged by the inguinal canal or by 
 the crural arch ; or after previous peritoneal adhesions it may escape 
 through the abdominal parietes, at the iliac fossa (I have seen two 
 such cases); Bennet (the Lancet, July, 1848) also mentions two 
 cases. — The abscess may very exceptionally open into the peritoneum, 
 causing fatal peritonitis. The pus has even been seen to make two 
 ways for itself, e.g. by the bladder and the uterus (Boivin). 
 
 After the abscess has opened, pus may be reproduced indefinitely, 
 being discharged by the opening and causing hectic fever; the dis- 
 charge is sometimes continuous, sometimes intermittent, and may 
 issue from several points successively. It may, however, be cured 
 even after capillary puncture, and the general health may be 
 restored. 
 
 Objective signs. — Pressure from above downwards, on the painful 
 point of the abdomen, increases pain so much as to extort a cry 
 from the patient. Sometimes the ovary may be felt by abdominal pal- 
 pation : I have often discovered it, high up, when the patients felt it 
 ' Neii) York Journal, Sept., 1846. 
 
OVAlilTIS AND SALPINGITIS 517 
 
 themselves. It is perceived all the more plainly, because often retained 
 on a level with the iliac fossa by adhesions. 
 
 The vagina is hot, sometimes dry, sometimes moist ; the uterus fre- 
 quently deviated, but not so much so as in hematocele ; the cervix 
 having variable disorders, being usually engorged or oedematous. The 
 uterus has lost part of its mobility owing to adhesions between the 
 ovary and the neighbouring organs ; in one direction especially it has 
 become fixed ; when we try to remove it from the diseased ovary great 
 pain is elicited. 
 
 In the vaginal cul-de-sac answering to the abnormal fixity of the 
 uterus the finger sometimes encounters resistance, sometimes a small 
 tumour ; at this point resistance is experienced and excruciating pain 
 sometimes produced by pressure. It is by rectal touch, however, in 
 following the lateral borders of the uterus that we can best discover a 
 tumour of the size of a nut or a small egs,, very painful, the situation 
 of which is variable, depending on the point at which the inflamed 
 ovary is adherent; by associating abdominal palpation with touch a 
 still more precise diagnosis can be made. 
 
 Chronic ovaritis — subjective signs. — The pain which Scanzoni de- 
 scribes as a disagreeable sensation is not always so acute as has been 
 said; it is sometimes sharp, sometimes burning, extending up the 
 loins during menstruation : patients say that it seems to them as if a 
 hot coal were placed in the pelvis. It continues in a modified degree 
 during the intercalary period; it causes permanent discomfort with 
 darting exacerbations after exercise or fatigue. It is in the middle of 
 or a little above the fold of the groin, not extending to the iliac fossa 
 nor generally causing tension of the abdominal parietes. It radiates 
 from this point, principally along the corresponding thigh to the knee, 
 causing numbness or even coldness of the leg ; it is increased by walk- 
 ing, standing, rising, effort of any kind, pressure from above down- 
 wards, coitus and menstruation. In cases where the ovary adheres to 
 the posterior surface of the lower border of the uterus, so that the 
 penis touches it during coitus, such terrible pain is caused that inter- 
 course becomes impossible. This pain is particularly sharp some days 
 after menstruation, or for one or two days before it, and very often is 
 not alleviated by the catamenial flow. The first symptoms of chronic 
 ovaritis are menstrual disorders^ menorrhagia or amenorrhoea, or 
 menorrhagia and amenorrhoea may alternate with pain in the ovarian 
 region during the period, a symptom often occurring in young girls. 
 These disorders seldom consist in amenorrhcea, but rather in a diminu- 
 tion, delay, or suppression of some months. In some chronic cases 
 there is menorrhagia, hsemorrhage even occurring in the intermen- 
 strual period, which is always in advance; but in that case there is 
 also metritis, or at least leucorrhoea, itching, heat, with vulval and 
 vaginal desquamation. The symptoms of neighbourhood are : frequent 
 desire for micturition, scalding urine loaded with urates and phos- 
 phates, constipation, hsemorrhoidal tumours, tenesmus, uterine colics, 
 constriction of the vagina or vulva. These are often unimportant on 
 account of the small size of the tumour. The general subjective signs 
 
518 UTERINE DISEASES IN DETAIL 
 
 are those of chronic metritis, but more numerous and occurring more 
 rapidly and perhaps still more marked, especially those of the nervous 
 system. Disordered digestion causes nausea, sympathetic vomiting, 
 principally at the commencement of the malady or at the time of the 
 painful attacks ; it causes epigastric sensibility, loss of appetite, ema- 
 ciation, depression, suffering, paleness, palpitation, breathlessness, 
 arterial pulsation, fainting, in short chloro-aiiEemia, especially in patients 
 suffering from leucorrhoea and menorrhagia. Disorders of the nervous 
 system are not less serious. Diseases of the ovaries like those of the 
 testicles, seem to affect the patient morally still more than do those of 
 the uterus. Women so affected become morbidly sensitive; they 
 experience an indefinable discomfort and suffer from erratic pains on 
 the track of the intercostal, lumbar and sacral nerves, principally on 
 the left side, with painful irradiations into the corresponding leg; 
 spasms of the pharynx, glottis and sphincters of the bladder, anus and 
 vulva and various hysterical phenomena such as hypersesthesia and 
 anaesthesia, in fact all the cortege of hysteria except the convulsive fits, 
 which are rare. The gravity of these symptoms is not surprising 
 when we remember that of all the maladies of the uterine system, 
 chronic ovaritis is one of those which furnishes the most dangerous 
 cases. 
 
 Ovaritis primarily chronic has an extremely slow course, but it is 
 increased by menstruation and coitus. There is exacerbation at every 
 monthly period, till at last fever breaks out, and pain increases so as 
 to become intolerable. This passage to the acute state is serious, 
 because it sometimes determines formidable accidents : the rupture of 
 an ovarian abscess, circumscribed peritonitis becoming generalised on 
 the slightest cause, increasing debility, pysemia itself and finally death. 
 Aran gives the case of a woman in whom the introduction of a pessary 
 led to these fatal results. Whilst an inflammatory centre exists in the 
 ovary or in one of the pelvic organs, an acute attack may occur 
 at any moment. A more gradual but not less dangerous conse- 
 quence of ovaritis is the development of a cyst. But even when it 
 does not pass to the acute form causing perimetritis or general perito- 
 nitis, chronic ovaritis, owing to its duration, has not the less serious 
 consequences : the gradual debility of patients and the serious disturb- 
 ance of their general health dispose them to contract other diseases, 
 and expose them to the attacks of the various diatheses, especially the 
 tuberculous. 
 
 Supposing the patient escapes all these dangers, chronic ovaritis 
 may terminate by induration and atrophy. This transformation of the 
 organ is not strictly speaking a cure ; but it may cause the cessation 
 of painful phenomena and the general disturbance of health. Follow- 
 ing red softening, it is characterised by a hyperplasia and a new 
 formation of connective tissue ; this tissue ends by stifling the other 
 elements : the ovary either remains voluminous while becoming fibrous 
 or cartilaginous, or it may atrophy and shrink, the ovarian vesicles 
 and ovules disappearing. The small vesicles as well as the large are 
 surrounded by peritoneal adhesions, the visible remains of the inflam- 
 
OVARITIS AND SALPINGITIS 519 
 
 mation which has caused the degeneration. Fatty degeneration may 
 also produce atrophy. Wlien both ovaries are affected complete and 
 irremediable sterility is the result, for the malady goes on increasing 
 with time in place of being cured. 
 
 Objective signs. — Palpation is insufficient, for, as in acute ovaritis, 
 the ovary is hidden in the pelvis, lying close to the uterus or adhering 
 to it. The small size of the tumour allows of its escaping observation 
 in a superficial examination. Vaginal and rectal touch alone lead to 
 diagnosis. The passage of the finger through the vulva sometimes 
 provokes very acute pain, on account of the contraction of the 
 sphincters. The vagina is very rarely hot and is often moist from 
 mucus. The cervix looks healthy, half open, and somewhat cedema- 
 tous. Usually the uterus is inclined to one side, its mobility being 
 diminished ; it is impossible to pusb it from the painful to the 
 opposite side without causing dragging, which increases the pain as 
 well as the curve existing in the corresponding vaginal cul-de-sac, but 
 without allowing the discovery of an indistinctly circumscribed 
 tumour which can only be diagnosed by rectal touch. The inflamed 
 ovary is more accessible to our investigations than the healthy one, on 
 account of its size and weight which make it fall behind the uterus, 
 retroverting the latter slightly. This displacement of the ovary into 
 the posterior cul-de-sac may be considered as the rule though there 
 are numerous exceptions. The diseased ovary, whilst descending 
 lower than the healthy one, is prevented by the utero-ovarian liga- 
 ment from being precipitated to the bottom of the posterior peritoneal 
 cul-de-sac : it is situated behind and on one side of the uterus answer- 
 ing to the vaginal insertions of the cervix where it may be retained by 
 adhesions. Hence a dragging on the uterus, and a slight unsteadi- 
 ness of this organ; if this slight retroversion is not produced, the 
 ovary remains elevated. Hence the utility of rectal touch so strongly 
 recommended by Lowenhardt, of Preslaw, in 1835, and since then by 
 Lisfranc, Aran, and all gynsecologists ; hence also the importance of 
 the association of rectal with vaginal touch recommended by Gallard.^ 
 Unless adhesions keep the ovary in place, this organ escapes from the 
 simultaneous pressure exercised by the two fingers that have seized it. 
 We may add that, in order that the fiogers may reach and seize the 
 retro-uterine tumour supposed to be the ovary, hypogastric pressure 
 must be combined with this double touch in order to press the viscera 
 into the pelvic cavity. 
 
 By what signs can we know that this tumour is really the ovary ? 
 It is an ovoid body, sometimes elongated, a little flattened from before 
 backwards, adhering to the lateral or posterior part of the uterus, or 
 separated from this organ by a more or less deep groove, sometimes 
 mobile, sometimes not. In consistency it is hardly elastic, never 
 indurated ; its surface, sometimes smooth and polished, sometimes 
 indented and irregular, sometimes elastic, is usually rounded and 
 resistant. The sensibility is extreme and is revealed by pressure, 
 sometimes causing acute pain; for notwithstanding what has been said 
 ' Gazette des hopitaiix, July, August, 1869. 
 
520 UTERINE DISEASES IN DETAIL 
 
 by some writers, the ovary is very sensitive normally, and when this 
 sensibility is increased by inflammation, pressure becomes most 
 painful. The greater size of the tumours of ovaritis prevent their being 
 confounded with those of retro-uterine adenitis which occupies almost 
 the same place and is also very painful. 
 
 Differential diagnosis. — Ovaritis must be distinguished : 1, from 
 other ovarian diseases ; ?-, from uterine and peri-uterine diseases. 
 
 1. The ovarian diseases which have to be distinguished from 
 ovaritis are fluxion, congestion, cedema, apoplexy, engorgement, 
 hypertrophy, &c. Morbid fluxion of the ovaries, like that of the 
 uterus, occurs chiefly at puberty, at menstruation, on the occasion of 
 venereal orgasm, &c. It exceeds the fluxion which is normal to those 
 organs under such circumstances. It is manifested not only by pain, 
 but also by stronger venereal excitement, discomfort in the iliac and 
 lumbar regions, symptoms of neighbourhood, &c. Ovarian conges- 
 tion may be met with in girls ; it is sometimes produced by a con- 
 genital tendency, or in consequence of the sudden suppression of the 
 menses, or of the existence of dysmenorrhoea ; it persists or is repro- 
 duced under the influence of a general state such as plethora, 
 impoverished constitution, &c., or from a diathetic affection such as 
 rheumatism. It has many symptoms in common with uterine con- 
 gestion (pain, heat, persistent discomfort in the iliac region and in the 
 cavity), and as the latter difi'ers from metritis, so ovarian congestion 
 difi'ers from ovaritis in the symptoms being less acute and continuous; 
 the heat is less intense and the pain less excruciating, even when 
 provoked by compressing the organ directly. 
 
 Serous infiltration, a kind of oedema of the ovary, has been 
 described by Morgagni^ as occurring in a woman who succumbed 
 after delivery. According to Cruveilhier ^ it must not be confounded 
 with ovarian inflammation ; but it seems to me difBcult to distinguish 
 it from the softening which characterises one of the stages of this 
 inflammation and which may be accompanied by an interstitial san- 
 guineous effusion followed by the coagulation of the fibrin and infil- 
 tration of a yellowish serosity between the tissues of the organ. 
 
 Haemorrhage of the ovaries may be interstitial or vesicular, may take 
 place slowly or suddenly (apoplexy), be contained within the envelope 
 of the organ or be effused externally (hematocele), may accompany 
 other lesions or result from a simple alteration of the vascular system 
 (congestion, lacerations of the capillaries, &c.). It usually occurs 
 suddenly during the menstrual period, after physical or moral emotion, 
 on the occasion of venereal excesses, sometimes during pregnancy. 
 The sudden appearance of symptoms of peritonitis added to those of 
 internal haemorrhage distinguishes haemorrhages with effusion of blood 
 into the peritoneum from interstitial haemorrhages and from simple 
 ovaritis. 
 
 Does engorgement exist ? Is it a step towards induration, described 
 as one of the terminations of inflammation and as characteristic of 
 
 ' De sedibxis, &c. Epist. xlvi, §. 27. 
 
 ^ Anatomie pathologique, 13^ liv., p. 13. 
 
OVAEITIS AND SALPINGITIS 521 
 
 chronic ovaritis ? It is difficult to judge the question, and still more 
 so to diagnose such a morbid state. 
 
 Hypertrophy may either affect all the various elements of the ovary 
 or each separately. In describing organic lesions we shall see that it 
 gives rise not only to unilocular and multilocular cysts, to cysto- 
 fibromata, to cysto-sarcomata, but also to simple fibromata, and that 
 the ovary, by hypertrophy of the fibrous tissue and atrophy of the 
 Graafian vesicles, may be transformed into a more or less voluminous 
 body, hard, compact, fibrous, fibro-cartilaginous and even stony at 
 some points. These transformations may be consecutive to ovaritis. 
 The slow development, the tumour, the tolerance of the malady by the 
 organism are the elements of a difi'erential diagnosis between these 
 degenerations and ovaritis strictly so called. Tubercle and cancer are 
 not so well tolerated ; in addition to the symptoms of ovaritis there 
 are the local symptoms produced by the increased size of the ovary or 
 the extension of the malady to the neighbouring organs, and the general 
 symptoms resulting from the progress of cachexy. 
 
 Ovarian neuralgia is distinguished by the absence of all signs of 
 inflammation except pain ; this pain itself has special characters : it is 
 excruciating, it darts upwards to the loins and sometimes downwards 
 to the vagina, urethra, and pubic symphysis ; it is not increased by 
 pressure, frequently even appearing to be diminished by sustained 
 pressure ; the ovary cannot be reached per vaginam, for it does not 
 usually descend as in ovaritis, but seems on the contrary in some 
 patients rather to have ascended ; the pain may be strong enough to de- 
 termine nausea, vomiting or hysterical symptoms ; it comes by fits, not 
 always coinciding with the monthly period ; it is often accompanied by 
 neuralgia in other regions, especially by lumbo-abdominal neuralgia. 
 Lastly, a suppurating cyst must not be confounded with an abscess 
 resulting from ovaritis. The cyst is always much larger than the 
 abscess ; it has no tendency to open spontaneously ; it is situated in 
 the abdomen in place of being contained in the pelvis ; it has given 
 signs of its presence and developed to some extent before suppurating ; 
 the local and general symptoms of inflammation and of the formation 
 of pus have therefore followed the development of the tumour in place 
 of preceding it. Besides those cysts the internal membrane of which 
 becomes inflamed and suppurates after puncture, there are some which 
 are primarily purulent. I once removed an ovarian cyst which con- 
 tained nothing but pus; it was formed after delivery; everything was 
 going on well till the eleventh day, when the patient succumbed to 
 serous diarrhoea. 
 
 2. Ovaritis must also be distinguished from uterine and peri-uterine 
 inflammation. Not only may ovaritis be confounded with maladies of 
 the neighbouring organs, but it is also almost necessarily accompanied 
 by inflammation of the Pallopian tube and peritoneum. The frequency 
 of ovaritis has been exaggerated by Boivin and Duges, Chereau and 
 Lisfranc, whilst that of peri-uterine inflammation, abscesses of the broad 
 ligaments and pelvic peritonitis has been exaggerated by more modern 
 practitioners. For while it is easy to diagnose a retro-uterine phlegmon 
 
522 UTERINE DISEASES IK DETAIL 
 
 it is very difficult to distinguish a' lateral one from ovaritis. It is cer- 
 tain that in a number of cases peri-uterine phlegmasias are constituted, 
 as we shall afterwards show, by inflammation of the peri-uterine cel- 
 lular tissue, of the pelvic peritoneum, ovary and Fallopian tube, or 
 even of the uterus, without its being possible to establish exactly 
 which tissue was first affected and which most acutely inflamed. 
 
 Neuralgia, especially lumbo-abdominal neuralgia, presents circum- 
 scribed points of pain which do not exist in simple ovaritis. Metritis 
 is distinguished from ovaritis by the following characteristics : the 
 pain is median, sharp, increased by pressure, especially by bimanual 
 palpation, and also by movements transmitted to the organ, which is 
 not the case in ovaritis, unless the body of the uterus is pressed 
 against the inflamed ovary. 
 
 Peritonitis is characterised by acute pain produced by the slightest 
 contact and forbidding any thorough examination by pressure of the 
 abdominal parietes or by vaginal touch. In place of simple nausea 
 or vomiting of food there is bilious green vomiting, hiccough, &c. A 
 peri-uterine phlegmon determines a considerable elevation of the tem- 
 perature of the vagina, puffiness of the tissues, which are hard and 
 resistant although oedematous and the formation of a tumour which is 
 fixed and does not fly from the finger, adhering to the neighbouring 
 tissues and making them adhere together. The uterus is no longer 
 mobile, but fixed in the midst of inflamed tissues. The tumour pro- 
 jects into the vagina, forming a protuberance all round the cervix or 
 in one of the culs-de-sac which becomes eff'aced ; it presents arterial 
 pulsation on its surface. Retro- or peri-uterine adenitis, whilst occu- 
 pying almost the same place, is less extensive than ovaritis; I do not 
 doubt, however, that it has sometimes been confounded with it. In 
 addition to the difference of size, the simultaneous presence of analo- 
 gous small tumours in the neighbourhood should allow of its being 
 distinguished. 
 
 I must now indicate the differential characters which enable us to 
 distinguish chronic ovaritis or an ovarian abscess from a pelvic abscess 
 or from a phlegmon of the iliac fossa. The form of the tumour and 
 its relations facilitate this distinction. The form of the tumour is 
 ovoid and circumscribed in place of being diffused ; its relations with 
 the neighbouring parts are more clearly defined ; there exists a more 
 or less marked interval between the tumour formed by the ovary and 
 the pelvic organs or ilium. We must, however, remember that these 
 characters disappear as soon as the ovaritis has determined around it, 
 as frequently happens, more or less extensive pelvic peritonitis with 
 suppuration, or at least exudation, adhesions, &c. 
 
 Treatment. — It cannot be denied that acute ovaritis is one of the 
 most dangerous of diseases, while chronic ovaritis is one of the most 
 difficult to treat and to cure, and that during its whole course it ex- 
 poses patients to continual danger from peritonitis. Therefore it must 
 be treated in spite of its reputed character of being incurable ; for even 
 if treatment is insufficient to restore the organ to its original integrity 
 it may at least prevent serious terminations and enable the system 
 
OVARITIS AND SALPINGITIS 523 
 
 to tolerate the malady. Lastly, by the alterations which it determines 
 in the ovary or the vicious adhesions which it establishes between this 
 organ and the neighbouring parts, it becomes an almost incurable 
 cause of sterility : an additional reason for treating it intelligently and 
 energetically. In the treatment of ovaritis especially patients must be 
 warned that months and years are required to effect a cure. 
 
 As a rule perfect rest should be prescribed for the genital system, 
 even in the treatment of chronic ovaritis ; but exceptions may be 
 made in the case of some women as described at page 167. As for 
 the desirability of marriage as advised by Gallard for girls suffering 
 from commencing ovaritis, with the double view of preventing sterility 
 (which the malady could not fail to produce at a later period) and of 
 favouring resolution (by the repose from ovulation given to the organ 
 during the nine months of pregnancy), I think it is important to 
 make the distinction between inflammation of the ovary strictly so 
 called, which is always aggravated by marital intercourse, and the 
 simple congestion or fluxion of this organ which not only can tolerate 
 coitus, but may be favorably influenced by pregnancy. 
 
 The indications for treatment are reduced to the two following : to 
 subdue the inflammation by antiphlogistic treatment proportioned to 
 its intensity ; to promote resolution of the diseased ovary and of the 
 plastic products formed in its parenchyma or around it, and if neces- 
 sary to evacuate pus, while supporting the strength of patients, 
 favouring nutrition and restoring the constitution. 
 
 I. Antip/dogistic treatment ought to be proportioned to the intensity 
 and to the complications of the acute form. In acute ovaritis compli- 
 cated with peritonitis, in ovaro- peritonitis properly so called, it cannot 
 be too energetic. In simple acute and in chronic ovaritis, the long 
 continued use of the same means should be substituted for the energy 
 used during a few days in complicated acute ovaritis. Bloodletting 
 constitutes the first and the most energetic means. Bleeding is seldom 
 indicated ; but leeches and scarifications may be applied largd manu, 
 and repeated at longer or shorter intervals according to the case. 
 
 In superacute ovaritis, 15 or 30 leeches may be applied to the 
 ihac fossa or hypogastrium, or the scarificator may be used, so as to 
 keep up a flow of blood for some hours. The perfect calm following 
 this first application and the use of other means must be distrusted. 
 When abdominal palpation causes pain, or if in the absence of this 
 sign the temperature of the vagina continues high, and the tumour 
 occupying the lateral portion of the pelvis outside the uterus is still 
 sensitive to pressure, bloodletting should again be resorted to. If 
 necessary, leeches and the scarificator may be applied three or four days 
 successively, diminishing the number each day. In simple acute and 
 in chronic ovaritis, the diminution of pain allows of the application of 
 leeches not only to the abdomen but to the cervix, which is preferable, 
 because depletion of the utero-ovarian vascular system being quicker 
 a smaller number of leeches produces more effect, besides which 
 ovaritis is frequently accompanied by hypersemia of the uterus or even 
 by metritis. Alleviation is often immediate; but sometimes on the 
 
524 UTERINE DISEASES IN DETAIL 
 
 contrary fresh applications must be made several days running or at 
 short intervals. In chronic ovaritis it is well, as a rule, to leave an 
 interval of a month at least between two consecutive applications, and 
 they should always be made immediately after and not before men- 
 struation. We must take advantage of the time when menstrual con- 
 gestion has terminated, to empty the utero-ovarian vascular system. 
 If the patient is plethoric and it is desirable to bleed before the 
 monthly period, blood should be drawn from the arm as a means of 
 revulsion to prevent the approaching catamenia from being as consi- 
 derable as usual. 
 
 The application of leeches in cases of subacute ovaritis should be 
 immediately followed by the use of auxiliary means, such as rest, 
 diluents, emollient and sedative cataplasms, an emeto-cathartic if there 
 is gastric derangement, or a simple laxative or enema if there is intes- 
 tinal irritation, and sedatives and resolvents in peritonitis, i. e. opium 
 and mercurial frictions. There need be no fear of giving opium in 
 large doses if the precaution is taken to administer it less frequently 
 as soon as a sedative effect is produced, and to cease it entirely if the 
 patient shows a tendency to remain drowsy. Here as in other cases, 
 opium may when necessary be replaced by morphia either administered 
 internally or by hypodermic injection, but opium when tolerated is 
 preferable. It is of course needless to employ it in chronic ovaritis. 
 Frictions should be made with mercurial and belladonna ointment. 
 On such occasions it should be used like leeches laj'ffd manu, i. e. one 
 ounce of ointment should be spread on the abdomen every five or six 
 hours, and covered by a large poultice of linseed meal hot and very 
 moist, in which a few drops of laudanum may be sprinkled. A thick 
 layer of cotton wool should be placed over this with oil silk above all. 
 The following morning patients take a bath, and after having dried 
 the abdomen well keep it covered all day with a flannel bandage unless 
 there is an indication to have the belly constantly covered with 
 ointment and cotton wool to keep up a moist heat favorable to 
 resolution. 
 
 Baths and irrigations are valuable auxiliaries which should be pre- 
 scribed as soon as they can be used without fatigue to patients. We 
 begin with prolonged warm general baths (emollient, gelatinous or 
 alkaline) with vaginal irrigation every day or every other day; they 
 should soon be replaced by hot irrigations. At a later period, though 
 rarely in cases of chronic ovaritis without exacerbation, tepid and cold 
 sitz-baths may be substituted with cold irrigations and enemata, 
 which constitute a suitable means for subduing the continual tendency 
 to renewed fluxion towards the ovary, and for facilitating resolution 
 of the chronic phlegmasy by their tonic and slightly revulsive action 
 on the skin. 
 
 II. Resolvent medication ought to follow antiphlogistic treatment 
 especially in chronic ovaritis ; it should be continued for a long time, 
 for it requires months and even years to obtain a cure. We can 
 measure the progress made towards health by the amelioration eff"ected 
 in the performance of the menstrual function. 
 
OVARITIS AND SALPINGITIS 525 
 
 Resolvent medication consists in the internal use of alteratives, mer- 
 curials, iodide of potassium, oxide of gold, &c.; and of the external 
 use of the same medicaments, frictions of mercurial ointment, tincture 
 of iodine, and even blisters, the utility of which is undoubted, although 
 not equally successful in all patients, and less so in cases of ovaritis 
 than in peri- uterine inflammation or pelvic phlegmon ; cauterisation is 
 preferable, and igni-punctures from being less painful and causing less 
 cicatricial deformity are doubly preferable, because they can be resorted 
 to again. In cases of ovaritis I have found the use of rectal injections 
 of resolvent ointment of great use : this means is very superior to sup- 
 positories, as it enables us to apply the medicament in sufficient 
 quantity to the diseased organ and to vary the composition according 
 to the condition and tolerance of the patient. We must also remember 
 that the choice of these medicaments is not indifferent, that after in- 
 flammation is once fixed in the ovary the organ often remains diseased, 
 in spite of the most energetic and most rational antiphlogistic treat- 
 ment, because this inflammation has sufficed to determine on the ovary 
 the localisation of a diathetic condition to the cure of which even 
 ovaritis is secondary. 
 
 In chronic ovaritis I have frequently observed what I have also 
 remarked in orchitis : that the rheumatic, herpetic, scrofulous or 
 tuberculous diathesis may localise itself on the diseased ovary and keep 
 up hypersemia, fluxion, prolonged pain, or produce still more serious 
 alterations. Copland^ has described rheumatic ovaritis, giving two 
 cases; Gallard^ has published another; and 1 have collected several. 
 Henry Bennet^ describes a case of death due to a tuberculous deposit 
 in the ovary ; in three cases of the same kind the pus made way for 
 itself through the abdominal wall. It is evident that the means of 
 treatment ought to vary according to the nature of the diathetic affec- 
 tion, which takes a more or less considerable part in the prolongation 
 of the ovaritis. For instance I have succeeded in curing chronic 
 ovaritis of two years' duration in a very scrofulous woman by iodide 
 of potassium in large doses, followed by the administration of oxide of 
 gold continued for a long time, associated with residence at the sea- 
 side during the summer, the patient taking two baths a day and resting 
 for eight days every month. I have cured three cases of chronic ova- 
 ritis with sulphur water taken internally as well as in baths, combined 
 with cold douches on the loins, in which alkaline baths, associated 
 with the ordinary resolvents, had produced no effect. In one case, 
 about which I was almost in despair as to the cause (there only being 
 very slight external manifestations of the herpetic diathesis), I tried 
 arsenical preparations followed by a season at Avene (Herault) and 
 was successful. 
 
 The addition of carbonate of soda or sea-salt to sitz-baths may be 
 made when acute ovaritis passes into the chronic stage. General 
 baths (alkaline or chlorinated, or both), natural waters such as those 
 
 ' Gazette mf-dicale de Paris, 1830, p. 302. 
 ^ Gazette des hnpitaux, October, 1869. 
 ^ The Lancet, July, 1848. 
 
526 UTEEINE DISEASES IN DETAIL 
 
 of Plombieres, Vichy, Vals and Boulou, purgatives from time to time, 
 irrigations with cold water, cold applications to the abdomen, cold 
 sitz-baths and douches, in fact hydropathy : these are the resolvents 
 usually indicated associated with the medicaments just referred to in 
 the treatment of chronic ovaritis. 
 
 III. The frequent complications which exist in the uterus, the co- 
 existence of leucorrhoea, ulceration of the cervix and vulval pruritus, 
 require treatment suitable for these various morbid states. There is 
 one more indication to be fulfilled, viz. to facilitate digestion, relieve 
 nervous symptoms, stimulate nutrition and improve the condition of 
 the blood by exercise, generous diet, tonics, iron, and hydropathy. 
 
 Lastly, if an abscess has formed projecting into the vagina or 
 rectum, the rapid increase of which may cause the fear of its opening 
 in an unfavorable direction, after having made an exploratory/ puncture, 
 the pus should be evacuated by the vagina and detersive or slightly irri- 
 tant injections made into the centre. When the abscess points towards 
 the abdominal wall it should be opened with Yienna paste according 
 to the method employed in opening abscesses of the liver, so as to 
 prevent the effusion of pus into the peritoneal cavity : the scar is in- 
 cised and excised every day, in order to apply more Yienna paste to 
 the wound and so get nearer the centre, after having determined 
 adhesions in the neighbourhood. 
 
 Faures^ describes a case of ovaritis followed by suppuration, in 
 which the artificial opening of the abscess above the crural arch was 
 followed by cure. I have lately seen a similar case, and another in 
 which, after numerous applications of the cautery to the left hypo- 
 gastric and iliac regions, the abscess opened spontaneously near the 
 linea alba; the patient was cured. 
 
 2. Inflammation of the Fallopian Tube 
 
 Salpingitis (inflammation of the Fallopian tube), hardly mentioned 
 by West (1858) and Nonat, is described by Scanzoni, Aran and 
 Becquerel. 
 
 Inflammation is easily developed in the Fallopian tube, on account 
 of the continuity of this canal with the peritoneum on the one hand, 
 and with the uterine mucous membrane on the other; but it rarely 
 occurs unaccompanied by ovaritis or pelvi-peritonitis. Usually there 
 is simultaneous inflammation of the Fallopian tube and ovary, this 
 double inflammation being very similar to peri-uteriue inflammation. 
 When salpingitis exists alone it may pass unobserved : lesions charac- 
 terising it are met with in women who have never complained, and 
 yet, according to statistics, diseases of the oviducts alone are more 
 frequent than those of the ovaries alone. Scanzoni^ thinks that 
 inflammation of the Fallopian tube, and especially inflammation of its 
 mucous membrane, which he calls catarrh, almost always accompany 
 an analogous affection of the mucous membrane of the uterus or 
 vagina. Salpingitis is often double. It exists simultaneously or suc- 
 
 ■^ Gazette hebdomad., v, 547. 
 ^ Op. cit., p. 86-5, et seq. 
 
OVARITIS AND SALPINGITIS 
 
 527 
 
 cessivelj on both sides. It may be either acute or chronic. In acute 
 inflammation the Fallopian tube becomes entirely or partially fixed and 
 adherent to the neighbouring organs, is still more flexuous than 
 normally, is distended by fluid and tumefied ; the walls become thick, 
 soft, dark red in colour, with or without vascular arborisation. The 
 fringes of the fimbriated extremity which are reddish, infiltrated and 
 sometimes adherent to the neighbouring organs, are usually bent down 
 and applied to one of the organs to which they adhere. The mucous 
 membrane is red, swollen, moistened with a fluid composed chiefly of 
 epithelial cells and sometimes of pus. When the fimbriated extremity 
 is obliterated, especially if the ostium ulerinum is so also, there is an 
 
 Fig. .316. — Fallopian tubes thickened by inflammation and distended by a col- 
 lection of fluid (after Hooper, The Morbid Anatomy of the Human Uterus 
 and its Appendages, with Illustrations of its Organic Diseases, pi. in -4. 
 London, 1832). 
 
 accumulation of fluid distending the cavity of the Fallopian tube. It 
 is exceptional to see these morbid products discharged into the peri- 
 toneum,^ and when peritonitis is developed it is usually due, not to an 
 effusion, but to the propagation of inflammation by continuity of 
 tissue. 
 
 In chronic inflammation the Fallopian tube is two or three times 
 the size of the organ normally, in colour it is slaty grey, the walls are 
 4 or 5 millimetres in thickness, of firm consistency, almost obliterat- 
 ing the cavity in which pus is not accumulated unless there are adhe- 
 sions ; the mucous membrane is greyish, thickened and resistant. 
 
 ' Puech has published a remarkable case of this kind {Gazette des hupitaux, 
 1860. pp. 517 and 522). 
 
528 UTERINE DISEASES IN DETAIL 
 
 Salpingitis may be complicated by inflammation of the uterine 
 mucous membrane, by obliterations from adhesions formed with the 
 neighbouring parts, or by the fringes of the fimbriated extremity 
 adhering together, and by the accumulation in its cavity of a serous 
 or sero- mucous fluid incorrectly called dropsy. The usual seat of this 
 dropsy is the abdominal extremity of the tubes. Scanzoni says that 
 they may be folded back at several points, divided into five, six, or 
 even a larger number of sacs of various sizes, resulting from as many 
 obliterations of the canal. He has seen one of these tumours equal 
 in size the head of a child of ten years ; but they do not generally 
 exceed the size of the fist. At other times external adhesions close 
 the tube and there may be dropsy without inflammation ; sometimes 
 the fluid is contained in a cyst of the tube or in multiple cysts which 
 do not communicate with each other. 
 
 A considerable number of cases are recorded in which the fluid 
 contained in the tube appears to have made a way for itself through 
 the uterus or vagina. 
 
 Although this profluent dropsy of the tubes as Eokitansky calls it 
 has been proved to exist, Kiwisch observes that the same symptoms 
 may result from the perforation of an ovarian cyst or from hydrorrhoea 
 of the uterusj and that it is surprising that a discharge from the 
 abdominal extremity of the tubes into the peritoneal cavity has not 
 been observed, since it is nearer the seat of the dropsy. In such 
 cases, however, this extremity is often obliterated, and Scanzoni,^ who 
 mentions these objections, gives the details of an autopsy proving the 
 possibility of such discharges by the uterine extremity of the tubes 
 into the womb and vagina. These cases, however, are very rare. 
 
 The causes of salpingitis are uncertain ; abortion, delivery, previous 
 inflammation of the uterus seem to determine it. It may possibly 
 result from ovaritis, pelvic peritonitis, or even be idiopathic, but more 
 frequently it is propagated from acute endometritis. 
 
 hiagnosis. — There is the same uncertainty with regard to the dia- 
 gnosis. Acute inflammation may be confounded with ovaritis, metri- 
 tis (especially when internal) pelvic or generalised peritonitis; chronic 
 inflammation with chronic internal metritis which is often concomitant. 
 Kiwisch gives as a sign of inflammation and dropsy of the tubes the 
 presence of elongated, mammillated, elastic tumours in emaciated 
 women on the lateral and upper portions of the uterus on both sides. 
 1 agree with Aran and Scanzoni that this sign is not sufficient ; for 
 other pelvic organs, multiple adhesions, the ovaries, the inflamed and 
 tumefied broad ligments may be taken for the tubes. In the case of 
 salpingitis the kind of mammillated, undulating, irregular and painful 
 cord formed by the congested tube, is perceived higher up than in the 
 case of phlegmon of the broad hgament : it is attached to the ovary 
 and uterus, and occupies less than phlegmon of the broad ligament 
 the corresponding side of the pelvic cavity. It is not uncommon to 
 observe it on both sides simultaneously or successively, the inflamma- 
 tion extending from the uterus to the tube, to the ovary of one side, 
 
 » Op. cit., p. .367. 
 
OVARITIS AND SALPINGITIS 529 
 
 and soon afterwards, at a monthly period, when the patient is thought 
 to be cured, it reaches the tube and then the ovary of the other side. 
 I have diagnosed salpingitis from these signs, the autopsy proving 
 that I was correct. In order to be certain, we must be able to recog- 
 nise the ovary and distinguish it from the diseased tube, which is very 
 difficult especially in the pathological state. In a doubtful case the 
 probability is in favour of ovarian disease, as the latter is more com- 
 mon than salpingitis. Aran describes a case of tubal abscess mis- 
 taken by himself for abscess of the ovary. Digital touch associated 
 with palpation indicates the form and seat of the inflammatory tubal 
 tumour. A bougie might be introduced into the tube if the uterus 
 had been previously dilated by a retentum. Scanzoni says that simple 
 catarrh of the tubes (inflammation of the mucous membrane) is never, 
 during life, accompanied by symptoms allowing of its being diagnosed, 
 and frequently dropsical dilatations of the tubes have persisted for 
 years, without presenting any morbid phenomenon of importance. My 
 own observations have convinced me that this malady always proceeds 
 in this way when there is no peritoneal inflammation; when there is, 
 the symptoms are very marked, especially when perforation of a tubal 
 abscess is the cause of the peritonitis. Accumulations of pus in the 
 tube, real abscesses, which Scanzoni thinks are almost always con- 
 nected with the puerperal state, expose to the same accidents as 
 ovarian or pelvic abscesses. Observation has proved that they may 
 open into the rectum (Scanzoni relates a case), vagina or peritoneum, 
 and that in the latter case death is almost inevitable. Verjus ^ 
 describes a case; fifteen days after an abortion death occurred in con- 
 sequence of an abscess of the left tube the size of a chestnut having 
 opened into the peritoneum. 
 
 Peritonitis may result from salpingitis in three ways : 1 , by the 
 inflammation being propagated from the fimbriated extremity to the 
 peritoneum; 2, by discharge of the tubal pus through the gaping 
 fimbriated extremity ; 3, by perforation of the tube.^ In addition to 
 the case previously mentioned (527 note) I have collected three other 
 examples of perforation of tubal abscess into the peritoneum. 
 
 Therefore chronic salpingitis, like chronic ovaritis, exposes women 
 who suff'er from it to the constant danger of peritonitis which may 
 break out on the slightest cause, the most insignificant surgical opera- 
 tion on the uterus causing death in twenty-four or thirty-six hours ; 
 for this reason the physician before performing any operation on the 
 uterus ought to ascertain that there is no inflammation of the uterus, 
 its appendages, or the pelvic peritoneum. 
 
 The treatment of acute salpingitis is the same as that of perito- 
 nitis, and that of chronic salpingitis the same as for endometritis and 
 chronic ovaritis. 
 
 ' Theses cle Paris, 1844. 
 
 ^ Forster, Wiener vied. Wochenschrift, 1859, Nos. 44 and 45. 
 
 34 
 
530. UTERINE DISEASES IN DETAIL 
 
 3. Inflammation of the Fallopian Tube and of the Ovary 
 
 The features most deserving of interest in these cases of salpingitis 
 and ovaritis are the coexistence of the one with the other, or the 
 simultaneous existence of oophoritis or salpingitis on both sides, or 
 the successive development of inflammation in both organs alternately 
 on either side. This propagation of uterine inflammation to the ovi- 
 duct and thence to the ovary, sometimes on one side, sometimes on the 
 other, is certainly one of the most singular and characteristic features 
 of these kinds of maladies. It probably depends, on the one hand, on 
 the organic sympathy connecting the various parts of the genital 
 economy, and facilitating the development of these inflammations, so 
 well observed by Gosselin apropos of perimetritis. On the other hand, 
 it depends on the influence which a diathetic afi'ection exercises on the 
 development of inflammation successively on the various points of the 
 genital economy and even of other organs. It is characteristic of dia- 
 thetic afi'ections to prolong their duration till the cause of the malady 
 has been extinguished by treatment, and to provoke manifold simulta- 
 neous or successive localisations of the same affection on several organs 
 or several tissues, till this affection has been exhausted or completely 
 neutralised by general treatment. 
 
 In syphilis, and even in venereal affections such as leucorrhoea, I 
 have observed the propagation of the malady to the oviduct and to the 
 ovary. In herpetism I have observed the same thing and have seen 
 the most curious cases of successive or alternating localisations on the 
 vagina, uterus, Fallopian tube, ovary and vice versa, on one side or the 
 other, or on both. Rheumatic inflammations do not escape this law. 
 But the most curious fact of all is that, in patients in whom I have 
 been unable to discover any other symptom of a diathetic affection 
 (owing to this organic sympathy connecting the various organs of the 
 genital economy by an invisible link) , I have seen inflammation just as 
 it was thought to be extinguished revive in the most unexpected way, 
 and be propagated suddenly to the Pallopian tube on one side and then 
 to the ovary, always taking advantage of the monthly congestion as 
 the best opportunity for these unexpected recurrences ; then again, 
 when we had reason to hope that its action was exhausted on the ovary, 
 it revived in the uterus at another monthly period, producing metritis, 
 differing more or less in its form from that which had been treated 
 three or four months ago ; at the following periods this metritis was 
 propagated from the uterus to the oviduct of the other side, then at a 
 later period to the ovary of the same side, and only finally exhausted 
 after all parts of the internal genital economy had been attacked by 
 inflammation, sometimes frequently. I have seen several cases of this 
 kind, some more or less incomplete with regard to the various parts of 
 the affected ovaries or oviducts, others more or less complete, all parts 
 of the ovaries and tubes having been affected successively, some even 
 repeatedly, as if the remains of the inflammatory congestion furnished 
 
PERI-UTERINE INFLAMMATION 531 
 
 materials for the revival of the former inflammation, or for the develop- 
 ment of a new inflammation. 
 
 I remember a patient who came from Algiers to consult me for 
 chronic metritis, from which she had suffered for several years, in 
 whom this propagation occurred; the various parts of the internal 
 genital economy being alternately and successively affected right and 
 left without any apparent cause and lasting for eight months. In such 
 a case it would have been most dangerous to have cauterised the cavity 
 of the body. 
 
 In such patients, I have profited by the displacement of the inflam- 
 mation, to discover the symptoms which pain and tumefaction of tube or 
 ovary determine. The difference between the symptoms of salpingitis 
 and those of ovaritis are easily recognised when we have the opportunity 
 of observing them from month to month, sometimes incompletely de- 
 veloped, sometimes at the summit of their intensity, now on one side, now 
 on the other, now on both simultaneously, alone, or associated with those 
 of pelvic peritonitis, cellulitis, phlegmon of the broad ligaments, &c. Such 
 cases help to dissipate the obscurity which in other circumstances may 
 conceal the real signs on which we have based the diagnosis of salpin- 
 gitis and ovaritis. It is only after having had the opportunity of 
 observing them and submitting them to rigorous analysis that we 
 have been able to arrange the elements of this diagnosis in descriptions 
 representing the various aspects which these maladies assume. 
 
 The diagnosis and treatment of this disease is the same as for peri- 
 uterine inflammation, which it produces easily, as I shall now have 
 occasion to show. 
 
 Peri-uterine Inflammation 
 
 I willingly retain this expression adopted in the previous editions of 
 this work to designate the malady described till lately by surgeons 
 under the name oi pelvic abscess, which only describes one of its ter- 
 minations, and by contemporary gynsecologists as pelvic cellulitis 
 (Gendrin), peri-uterine phlegmon, peri-uterine engorgement (Nonat), 
 inflammation of the annexes, phlegmon of the broad ligaments (Henry 
 Bennet), perimetritis (Scanzoni), pelvic peritonitis (Burnutz and 
 Goupil), names which recal not only the ideas which these various 
 practitioners had as to the seat of the malady,^ but also the inflamma- 
 tions which may attack the various tissues and various regions round 
 the uterus. Matthews Duncan^ has proposed the name oi perimetritis 
 for inflammation of the peritoneum surrounding the uterus smd para- 
 metritis for that of the cellular tissue in connection with the uterus. 
 The expression peri- uterine inflammation is more correct because more 
 vague, including all the others without prejudging anything as to the 
 seat of the malady. Now, this seat may vary, the disease attacking 
 one or other of the organs subject to it, or all at once. 
 
 I In Germany it is described under the name of jjeri-ocip/i-onfis, or peri- 
 salpingitis, according to whether the ovary or tube has been the starting point. 
 ^ A Practical Treatise oyi Perimetritis and Parametritis. Edinburgli, 1869. 
 
532 UTERINE DISExiSES IN DETAIL 
 
 Seat and pathological anatomy. — I shall describe cellulitisj perito- 
 nitis and adenitis. 1. Peri-uterine cellulitis and pelvic cellulitis. I 
 do not think pelvic cellulitis can be denied. I shall not content 
 myself with simply stating that I have seen it, and that Nonat 
 thought that all peri-uterine inflammation might be included under 
 the head of peri-uterine phlegmon, but I shall refer to the chief 
 observations which have been made on it recently. Gosselin has 
 described cases of peri-uterine phlegmon. Gallard ^ has devoted his 
 inaugural thesis to the description of this malady. Aran has seen the 
 two peritoneal folds of the broad ligament separated from each other 
 by a thick layer of pus : three times partial engorgements of cellular 
 tissue, diagnosed during life, have been verified after death in two 
 newly-delivered women (infiltration of blood and pus), and in an old 
 woman (fibro-plastic indurations) ; in another puerperal woman, with 
 internal uterine gangrene, there were found plastic lymph and serosity 
 in the recto- and vesico-vaginal septa and in all the pelvic cellular 
 tissue. Peri-uterine cellulitis is accepted by English surgeons as well 
 as by the German school. Graily Hewitt ^ summing up the ideas of 
 his countrymen on this point says : inflammation, swelling, and the 
 formation of pus in a large number of cases certainly originate in the 
 connective tissue surrounding the uterus. This tissue becomes the 
 seat of oedema or of infiltration of fluids. West,^ whose remarks on 
 pelvic abscesses are very instructive, agrees with Pirogoff that this 
 state is correctly designated by the expression acute purulent oedema. 
 Virchow ^ has lately published the results of the investigations he has 
 made on this subject : the cellular tissue, according to him, becomes 
 at first tumefied, thickened, hardened and oedematous, a fluid being 
 discharged from it when it is incised. Although not so frequent as 
 Nonat supposes, peri-uterine cellulitis has been long known.^ Nume- 
 rous cases have been recorded of phlegmons of the broad hgaments, 
 especially in the puerperal state, developed and propagated to a greater 
 or less extent in the surrounding cellular tissue, and even turning into 
 an abscess without causing an attack of peritonitis. I have seen a 
 phlegmon of the right broad ligament open into the rectum, another 
 of the left ligament into the vagina, without having given rise to any 
 symptom of peritonitis ; in three patients I have seen indurations and 
 cicatricial bands, causing a lateral and persistent displacement of the 
 uterus, twice to the right, once to the left, with a slight obliquity in 
 
 ^ De V inflammation du tissu cellulaire qui entoure la matrice, &c. Paris, 
 1855. 
 
 ^ The Diagnosis and Treatment of Diseases of Women, p. 227. London, 
 1863. 
 
 3 Op. cit., p. 432. 
 
 * Virchoio's Archiv, 1862, Bd. sxiii, S. 415. 
 
 ^ Grisolle, Des Abces de la fosse iliaque, in Archiv. gener. de medecine, 
 1839, and Pathologie interne, 8« edit., 1862, t. i, p. 598.— Marchal de Calvi, 
 Bes Abces phlegmoneux intra-j)dviens, these pour I'agregation. Paris, 1844. — 
 Behier, Clinique medicale, 1864. — Briand, Thhse de Paris, 1866. — Trousseau, 
 Des Inflammations ijeri-hysteriques, Clinique medicale, t. ii, p. 747. Paris, 
 2 edit., 1865. — Frarier, Mtudes siir le 'plilegtiion des ligaments larges, These 
 de Paris, 1866. — Guichard-Choisitj, These de Paris, 1862. 
 
PBEI-UTERINE INFLAMMATION 533 
 
 two cases, maladies of eight, ten and twelve years" standing in which the 
 CO -existence of pelvic peritonitis could not be presumed at any period. 
 The correctness of this diagnosis was confirmed more than once by 
 autopsy. 
 
 Frarier describes a case^ of suppurating plegmon of the right broad 
 ligament after confinement which opened into the bladder : the autopsy 
 proved that the peritoneum and the intestines did not participate in 
 the inflammation. Behier has published a case^ of suppurative 
 phlegmon of the left broad ligament, occurring two days after a first 
 delivery, extending to the left iliac fossa, without alteration of the 
 peritoneum covering it. I have seen an equally conclusive case. 
 
 There are also examples of ante-uterine and retro- uterine cellulitis 
 without any symptom of peritonitis, and even without any organic 
 alteration of the serous membrane. Simon^ has published a case of 
 extra-peritoneal, inter-utero-vesical abscess, occurring in the course of 
 mahgnant variola amidst symptoms of purulent infection. Alph. 
 Guerin* has met with a similar abscess resulting from direct trauma- 
 tism, from the ablation of a polypus situated in the anterior wall of 
 the cervix, Naudier {Annates de GynScologie, vi, 293) has described 
 an abscess of the retro-uterine cellular tissue in a woman who had 
 hypertrophic elongation of the neck ; the abscess, which was evacuated 
 through the anterior wall of the rectum, extended behind the whole of 
 the vagina, the whole posterior surface of the uterus and laterally to 
 the interior border of the left ovary ; pelvic peritonitis had only slowly 
 followed the formation and evacuation of this abscess ; the annexes of 
 the uterus and the parts surrounding Douglases space could not be 
 considered as the starting-point of this retro- uterine cellulitis : the 
 case proves these two points. I have seen an abscess formed between 
 the cervix and the bladder projecting towards the vagina and opening 
 into the bladder^ where it discharged pus for a long time, causing 
 attacks of pain from time to time. I have also seen an abscess deve- 
 loped rapidly behind the neck of a prolapsed uterus in a patient who 
 had been imprudent enough to go out the day after leeches had been 
 applied to the cervix ; it opened into the rectum on the fourteenth day, 
 was discharged at once and was cured in three weeks. In neither of 
 these cases were there any symptoms of peritonitis. 
 
 It is therefore evident, not only that the cellular tissue of the broad 
 ligaments may become inflamed, especially in the puerperal state, 
 without the peritoneum participating in this phlegmasia \ but also that 
 inflammation of this tissue which usually extends laterally (internal 
 iliac fossa, cervical arch, abdominal wall) may be propagated towards 
 the centre, round the cervix ; and further, that the inflammation may 
 even, in very rare cases, be developed primarily in the cellular tissue 
 loosely connecting the cervix with the peritoneum. 
 
 PJdegmon of the t)road tigameuis (including parametritis) may con- 
 
 ' Gazette hebdomadaire, t. ix, p. 82. 
 
 ^ Cliniqioe medicate, Obs. 38. 
 
 3 Bulletin de la Societe anatomique, 1858. 
 
 ■• Bulletin de la Societe de chirurgie, 1866. 
 
534 UTEEINE DISEASES IN DETAIL 
 
 sist in a simple gelatinous infiltration of these organs, cellulitis being 
 arrested at the first stage; an induration remains the resolution of 
 which occurs afterwards, gradually diminishing the size; most fre- 
 quently the inflammation pursues its course, becoming acute, and an 
 abscess is formed ; these phenomena rarely occur without pelvic perito- 
 nitis being produced simultaneously. Phlebitis is a frequent compli- 
 cation of phlegmon of the broad ligaments. Trousseau^ has insisted 
 on this point: "Phlegmon of the broad ligament occurs in newly- 
 delivered women after contusion or inflammation of the uterus and its 
 annexes. After suppuration of the placental surface, phlebitis and 
 lymphangitis occur. An incision made on the borders of the uterus 
 at an autopsy reveals small abscesses in the venous tissue. The cellu- 
 lar tissue round these veins is cedematous, and if patients do not 
 succumb to purulent infection on account of adhesive phlebitis below 
 the purulent collection, the intra-venous abscesses will most frequently 
 be the origin of abscesses of the broad hgament. The same remark 
 may be made of suppurative lymphangitis.'^ 
 
 According to the same writer phlebitis is the most common cause 
 of phlegmon of the broad ligaments ; but it may also be the conse- 
 quence of it. It may be said that it is primary in puerperal phleg- 
 mons, consecutive in non-puerperal. When the autopsy shows circum- 
 scribed phlebitis, obstructing clots, pus existing or not in the cellular 
 tissue, phlebitis has been the cause of the phlegmon ; when it shows 
 pus in the cellular tissue, traces of phlebitis, absence of clots, purulent 
 infection, phlebitis has been the result of the phlegmon, the inflamma- 
 tion having commenced in the cellular tissue of the organ. 
 
 Pelvic cellulitis may be divided like pelvic peritonitis according to 
 whether it extends over the whole pelvis, which it rarely exceeds, or 
 whether it is confined to one region : sometimes round the uterus or 
 along one of its surfaces, or round its cervix ; sometimes, on the 
 contrary, as far as possible from the womb, in the iliac fossa ; some- 
 times in the broad ligament, either in all its extent or at its base, or 
 at the summit in its three folds or only in one. Both broad ligaments 
 are seldom inflamed simultaneously. The inflammation is usually 
 limited to one of these organs, i.e. to one of the sides of the genital 
 economy. 
 
 2. Peri- uterine peritonitis and pelvic peritonitis. — Autopsies have 
 proved that more or less extensive inflammation of the peritoneum not 
 only frequently complicates the inflammatory tumours of which I have 
 just spoken, but also in great part constitutes inflammatory peri-uterine 
 tumours ; this inflammation may be simply sero-adhesive or may 
 become sero-purulent ; whatever the termination may be, it is com- 
 plicated by numerous adhesions uniting together the various surfaces 
 of the peritoneal covering of the pelvic organs, e.g. the annexes to 
 each other or to the uterus, or to the neighbouring organs, contained 
 also in the pelvis, the intestinal circumvolutions, the rectum, bladder, 
 &c. : the more adhesions there are the larger the tumour appears. It 
 
 Glinique medicale, 2^ edit., t. iii, p. 747. Paris, 1865. 
 
PEEI-DTERINE INFLAMMATION 635 
 
 is to Bernutz ^ that we owe the elucidation of this important point in 
 uterine pathology. He has proved by three autopsies that the 
 inflammatory tumour which, during life, had presented characteristic 
 signs of peri-uterine phlegmons, was not situated in the pelvic cellular 
 tissue, but that it was constituted by peritoneal adhesions uniting the 
 viscera of the pelvis together. 
 
 Bernutz and Goupil ^ have not been content with proving the exist- 
 ence of pelvic peritonitis, but have denied that of peri-uterine phleg- 
 mons, having always seen partial peritoneal inflammations in peri- 
 uterine inflammatory tumours. Moreover, they have also seen in this 
 pelvic peritonitis, a phlegmasia of the peritoneum by propagation, 
 having as starting-point an inflammation of the internal genital organs 
 of woman, just as we see inflammation of the testicle in man produce 
 that of the serous membrane covering it. Only, if there is an 
 analogy in the morbid process which takes place, there is none in the 
 consequences; the transmission of the inflammation existing in the 
 uterus to the neighbouring peritoneum provokes a plastic exudation 
 which not only determines numerous sympathies by its extent, but 
 also gives rise to the production of adhesions connecting the uterus 
 with neighbouring organs and more or less compromising its func- 
 tions. In this way tumours are developed perceptible to vaginal 
 touch or hypogastric palpation, formed partly of fibrinous exudations, 
 and partly of agglomerated viscera. Lastly, according to the same 
 writers this inflammation of the pelvic peritoneum which is always 
 symptomatic, arises more frequently from inflammation of the ovaries 
 and tubes than of the uterus. But the chief symptoms of these peri- 
 uterine affections belong to pelvic peritonitis, whilst the uterine or 
 tubo-ovarian aff'ection, although the most important, being the cause 
 of the development of inflammation of the pelvic serous membrane, is 
 only indicated by obscure symptoms, at least in the present state of 
 our knowledge. Pelvic peritonitis, however, does not merely dominate 
 symptomatology, so as to allow peri-uterine inflammation to be dis- 
 tinguished from isolated inflammation of the ovary or tube, but it 
 dominates therapeutics, being really the source of the chief indica- 
 tions. It is what seems to me to constitute the most important 
 practical consequence and therefore the chief interest of the valuable 
 investigations of Bernutz and Goupil. 
 
 Aran ^ went further than Bernutz and Goupil in reference to the 
 subordinate place he gave to pelvic peritonitis beside ovaritis and sal- 
 pingitis. He considers partial peritonitis only secondary. The true 
 element of peri-uterine inflammation is alteration of the uterine 
 appendages, ovary and tube, constituting an inflammatory centre, 
 small in proportion to the tumour formed round this focus by the 
 pelvic organs including the intestines adhering together. It is prob- 
 ably always from the ovary or tube that the inflammation first arises. 
 
 ^ ArcMv. gener. de medecine, 1857. 
 
 ' Glinique medicale sur les maladies des femmes, t. ii, premier memoire : 
 De la pelvi-peritonite et de ses diverscs varietes. Paris, 1862. 
 3 Op. cit., p. 667. 
 
536 
 
 UTERINE DISEASES IN DETAIL 
 
 After acute pelvic peritonitis, especially when this is puerperal, in 
 addition to the characteristic alterations of ordinary peritonitis we find 
 in the pelvic cavity, below the intestinal circumvolutions which adhere 
 loosely together and to the neighbouring organs, a globular tumour 
 as large as a hen's egg, attached to the uterus, from which it may or 
 may not be separated by a groove, sometimes confounded with this 
 organ, which it is difficult to recognise. The displaced uterus is drawn 
 towards and attached to the tumour or pushed back in a contrary 
 direction, according to the seat of the tumour. This tumour is formed 
 of thick false membranes hollowed out here and there into cavities, 
 containing a citrine, purulent serosity or pus ; above them, the in- 
 flamed peritoneum is seen and a serous infiltration of the sub-peri- 
 toneal cellular tissue ; in the centre of the tumour we find the ovary 
 and tube inflamed, as well as the broad ligament, the peritoneum of 
 which is injected and the cellular tissue infiltrated with sanguinolent 
 serosity and pus. The ovary and tube being prolapsed, the tumour 
 often rests on the pelvic floor. The purulent collections contained in 
 the cavities with tomentous walls which are formed by adhesions, have 
 frequently been mistaken for infiltrations of the cellular tissue of the 
 pelvis. Suppuration of the pelvic cellular tissue, however, is quite 
 exceptional. When the annexes are inflamed on both sides the tumour 
 
 Tig. 317. — Retro-uterine and tubal tumours held back bj false membranes to 
 the ovaries, uterus and adjacent tissues, the result of peri-uterine inflam- 
 mation (after Hooper). Compare this woodcut with Fig. 1, representing 
 the general view of the same organs in their normal condition. 
 
 is enormous and surrounds the uterus in a kind of ring. In the 
 chronic state, the false membranes in place of being soft, whitish or 
 yellowish, have become thick, resistant, grey or black, forming short 
 bands extending from the annexes and from the uterus to the neigh- 
 bouring organs, which they unite together enclosing spaces which are 
 
PERI-UTERINE INFLAMMATION 537 
 
 empty, or which contain citrine serosity or pus. The uterus more or 
 less inclined, deviated or flexed, tumefied, but seldom atrophied, is 
 sometimes affected with internal inflammation. The alterations of the 
 annexes are fully developed : the tubes contain pus or a more or less 
 considerable quantity of serosity which may give rise to the degenera- 
 tion incorrectly called tubal dropsy ; the ovaries, which are seldom 
 atrophied, usually form purulent sacs, the envelope of which resists 
 laceration or rupture for a long time. The abscesses which, after 
 pelvic peritonitis, open into the peritoneum, rectum, vagina, bladder or 
 externally, are generally abscesses of the ovary or tube, less frequently 
 peritoneal purulent collections encysted by the adhesions of false mem- 
 branes. These latter are discharged usually at the commencement, 
 the false membranes being then imperfectly organised, and as a rule are 
 emptied into the peritoneal cavity by laceration or fissure. The 
 former are evacuated by the rectum or vagina, from the effect of ulce- 
 ration, after previous adhesion of the two cavities, between which a 
 communication is set up, that of the abscess on the one hand and of 
 the rectum or vagina on the other. The opening becomes a fistula, esta- 
 blishing a permanent communication between these cavities, and even 
 allowing stercoraceous matter to pass from the rectum into the cavity 
 of the abscess. In this way pelvic peritonitis or perimetritis may pass 
 through the various stages of adhesive, sero-adhesive, sero-eucysted, 
 purulent peri-metritis, and even of hsemorrhagiparous pachy-peritonitis 
 {see p. 545). 
 
 Lastly, although it may be limited to one side, the side of the 
 diseased ovary, the starting-point of the inflammation of the serous 
 membrane, peritonitis is often propagated to the other side, and 
 seldom is limited to the side first attacked ; usually it spreads round the 
 uterus surrounding all the internal genital economy. 
 
 3. Peri- uterine Adenitis and Angioleucitis. — Peri-uterine cellu- 
 litis and pelvic peritonitis, with all their varieties, are the only 
 maladies included by gynsecologists under the common name of 
 peri-uterine inflammation. For several years I have taught in my 
 lectures that a third inflammatory malady exists, which ought to 
 be included in the peri-uterine inflammations; it is adenitis and 
 peri-uterine angioleucitis, which is often acute and the prognosis 
 of which is very serious when it is puerperal ; more frequently 
 it is chronic and is then less important in itself than from the 
 ulceration of the uterine mucous membrane of which it is the certain 
 sign. 
 
 In fatal puerperal inflammation pus is not found in the veins. 
 Although, however, inflammation of the veins is exceptional even in 
 puerperal affections, that of the lymphatics is common, as was proved 
 by the autopsies made by Champioimiere, Leopold and others. In 
 puerperal metritis, inflammation may attack the lymphatics more vio- 
 lently, so that after death the latter may be found filled with pus, not 
 only below the mucous and serous membranes of the uterus and in the 
 thickness of the organ, but also in some points corresponding especially 
 with the posterior region of the uterus and near its cervix, where. 
 
538 UTERINE DISEASES IN DETAIL 
 
 according to Championniere, may be found ganglia gorged with pus 
 and clusters of lymphatic vessels distended with this fluid, which may 
 be mistaken for suppurated ganglia, not only on the dead body, but 
 even during life, causing errors of diagnosis. 
 
 In other circumstances, and in the non-puerperal state, adenitis 
 and angioleucitis may present themselves in the acute form in the 
 same organs, the inflammation either being developed under the in- 
 fluence of traumatic causes and especially of acute metritis or ovaritis, 
 or it may have originated from acute peri-uterine inflammation, in the 
 participation of which the ganglia and lymphatic vessels do not escape, 
 and in which the adenitis and angioleucitis developed in such con- 
 ditions survive for a longer or shorter time, varying in intensity and 
 duration. 
 
 In other circumstances again and more frequently, angioleucitis and 
 adenitis especially occur in the chronic form and are all the more in- 
 teresting to describe, as they appear to have almost escaped observation 
 till now. After having made a careful vaginal examination, especially 
 posteriorly and laterally, as well as at the base of the broad liga- 
 ments, I have often found behind and to the sides of the uterus, 
 usually to the right, sometimes at one point only, small rounded 
 tumours, a little indented, smooth at certain points, irregular at others, 
 the form, hardness, mobility and sensitiveness of which contrast 
 strikingly with the characters of softness, insensibility, &c., of the 
 surrounding tissues. These small tumours of various sizes are less 
 voluminous even than the ovaries, even when the latter are not en- 
 larged by inflammation, and are usually less painful than these organs, 
 though sometimes, on the contrary, they are excessively so, less mobile 
 also, and appear to be connected loosely with the uterus, the vaginal 
 cul-de-sac, and especially with the innermost layer extending above 
 them. 
 
 I could not have interpreted the tumours just described otherwise 
 than as remnants of inflammatory indurations or as adenitis and 
 angioleucitis, i.e. tumours formed by clusters of vessels, or lymphatic 
 ganglia tumefied and rendered painful by inflammation, even if an 
 autopsy had not allowed me on one occasion to verify my suppositions 
 in a woman of forty, who I knew had suffered for long from leucor- 
 rhcea and ulcerous endometritis, and who was carried off by pleuro- 
 pneumonia, in whom I found adenitis and its usual cause (chronic 
 ulceration of the mucous membrane); autopsies also on newly 
 delivered women who had succumbed to puerperal disease and in 
 whom suppurative adenitis was found occupying the same regions, in 
 like manner justified my opinion. In presence of such symptomatic 
 and microscopic proof, hesitation is no longer possible. I observed 
 this retro-uterine adenitis in patients who had for long suffered from 
 some affection of the internal genital organs, vaginal and uterine 
 leucorrhoea, or from long existing ulceration of the cervix which still 
 existed on the mucous membrane of the cavities. These patients 
 came to consult me because they had been treated for a long time by 
 their own doctors, who now assured them that they were cured ; and 
 
PEEI-UTEEINE INFLAMMATION 539 
 
 they were cured except in the uterine cavities : the sound, the passage 
 of which was often painful, brought back pus or leucorrhcea, some- 
 times a Kttle blood, which made me suspect a suppurating ulcer 
 situated on the mucous membrane of the cervix or body, another 
 example of the services rendered by the sound. I have usually 
 regarded this chronic adenitis as well as cervical and other forms of 
 adenitis as symptomatic of inflammatory suppurative action on one of 
 the mucous membranes where the afferent vessels of the tumefied 
 ganglia had their absorbent network. From this point of view, the 
 verification of retro- or latero-uterine adenitis is interesting even if 
 only as a symptom of a chronic suppurative phlegmasia the seat of 
 which is easily determined. It is also interesting in itself; for it con- 
 stitutes a malady, the intensity, extent, and progressive tendency of 
 which requires great attention. 
 
 Apart from the symptoms, either direct or sympathetic of the 
 uterine malady, and of the ulcer which has caused it, peri-uterine 
 adenitis has special symptoms characterising it : lumbar or lumbo- 
 sacral pain, sometimes extending to the anus ; continuance of the 
 pains previously experienced by the patient which are increased by 
 marital intercourse even when most of the apparent uterine symptoms 
 have disappeared ; pain elicited by digital touch, especially when 
 pressure is exercised by the finger behind the uterus and laterally, 
 and when an attempt is made to depress the retro- or dextro-uterine 
 cul-de-sac. 
 
 Course. — Like all phlegmasias, peri-uterine inflammation may be 
 ac2de or chronic. The term super-acute has been added to designate 
 acuity of the highest degree, and that of sub-acute to mark a kind of 
 transition between the acute and the chronic forms. I do not think 
 it necessary to multiply divisions ; but I maintain the marked differ- 
 ence, with regard to causes, symptoms and treatment between the 
 acute and chronic forms. 
 
 It has also been proposed to distinguish puerperal from non- 
 puerperal peri-uterine inflammation. Marchal de Calvi^ and H. 
 Bennet ^ attach importance to this distinction. The latter says, 
 that the puerperal state, which may be said to extend to the 
 fourth, fifth, or even sixth week after delivery, is one of the most 
 dangerous conditions. So long as it lasts all inflammatory affec- 
 tions present a special gravity and especially those of the organs 
 which, directly or indirectly, have participated in parturition. If 
 inflammation occurs in the ovaries or broad ligaments immediately 
 after delivery, it is frequently as a complication of metro-peritonitis 
 and as merely an after symptom of this formidable affection. A 
 number of writers on puerperal fever have noticed the frequency of 
 suppuration of the ovaries and broad ligaments in cases of metro- 
 peritonitis terminating in death. But even when the broad ligaments 
 are inflamed several weeks after delivery, the general symptoms are 
 more intense, the local tumefaction more considerable, and the inflam- 
 
 ' Annales de la chirurgiefr. et etr., July and August, 1844. 
 ^ Op. cit.rp. 39. 
 
540 UTERINE DISEASES IN DETAIL 
 
 mation presents a greater tendency to extend to the adjacent tissues 
 than in the non-puerperal form of the affection. It is also much 
 more difficult to arrest its progress ; the inflammatory and suppurative 
 action continues to extend long after the first collection is evacuated, 
 and in a number of cases it gives rise to adhesions and abdominal per- 
 forations. This serious form is quite exceptional in the non-puerperal 
 state, whilst in the puerperal it is so common that till now it has 
 been considered as the only one under which the affection is 
 manifested. 
 
 I share Bennet's opinion, but do not see why the two forms should 
 be described separately. Peri-uterine inflammation may arise in the 
 puerperal state as in any other ; it is certainly produced oftener in the 
 former state ; it is then more serious and has a more rapid course, 
 terminating often in suppuration. But its coincidence or its relations 
 with the puerperal state do not change its character; it passes fre- 
 quently from the puerperal or post puerperal to the chronic form, and 
 there may be great uncertainty as to its real origin : lastly, it is dia- 
 gnosed in the same way, and the indications off'er differences of degree 
 rather than of nature. 
 
 Frequency. — Peri uterine inflammation is very common : indeed it 
 forms about one third of uterine diseases. It is very difficult to make 
 an exact calculation, because peri-uterine inflammation in place of 
 occurring alone may complicate the majority of uterine diseases. Aran 
 thought that with inflammation of the uterus (parenchymatous and 
 mucous) it forms two thirds of uterine diseases. It is certain that out 
 of 100 women there will be 55 with peritoneal adhesions and showing 
 traces more or less intense of pelvic peritonitis. Of this number there 
 are far more married women than virgins and more multiparse than 
 primiparse. 
 
 Etiology. — Menstrual disorders and their causes physical and moral, 
 long-contmued excitement of the genital organs, pregnancy, labour, 
 extension of inflammation of the uterus or its annexes to the neigh- 
 bouring parts. It will be seen that the causes are almost the same for 
 metritis, perimetritis, ovaritis, &c.; it is the predisposition which 
 varies and determines the localisation. But this etiology may acquire 
 some interest from a little more precision. Now we know from ob- 
 servation and statistics that peri-uterine inflammation is common espe- 
 cially from 20 to 30, which is not surprising, seeing that ovarian and 
 tubal inflammation are also common at this age and are usually the 
 starting-points of pelvic peritonitis. Another interesting result is that 
 about two thirds of these diseases are the consequences of labour, 
 abortion, and consecutive inflammation : West thinks that labour, 
 abortion and consecutive inflammation enter into the etiology of peri- 
 uterine inflammations at the ratio of 77 per cent. ; Gallardand Bernutz 
 reduce this influence to 45 or 44 per cent., which gives an average of 
 60 per cent, between the two extremes, which is very nearly the pro- 
 portion of the number of cases (55 per cent.) in which Aran found 
 peritoneal adhesions and traces of pelvic peritonitis. This cause of peri- 
 uterine inflammation may sometimes be ignored because symptoms are 
 
PERI-UTERINE INFLAMMATION 541 
 
 not always developed immediately after delivery, sometimes only 
 appearing much later; but in taking care to trace the morbid mani- 
 festations to their source we discover the frequency and importance of 
 this cause. It is probable that the operations necessitated by difficult 
 labour and the imprudence often committed by newly-delivered women 
 in resuming marital intercourse and their ordinary work too soon have 
 a considerable share in the development of perimetritis. Often, how- 
 ever, these are not the causes of the malady. ChurchilP has given a 
 good description of the various ways in which peri-uterine inflamma- 
 tion may commence. I agree with Aran that very often there is either 
 a latent morbid state or a morbid predisposition existing before de- 
 livery, labour being only the determining cause. 
 
 Menstrual disorders which may be placed in the second rank as 
 causes, in the proportion of 20 per cent, according to Bernutz and 
 Goupil, in that of 9 or 10 per cent, according to Aran, are frequently 
 only symptoms of uterine inflammation already existing, of a previous 
 latent morbid action, which has necessarily caused either dysmenor- 
 rhoea or menorrhagia. 
 
 The same remark is applicable to leucorrhoea and blenorrhagia which 
 may also become causes of pelvic peritonitis, especially in women who 
 have had diseases of the annexes, mechanical influences having their 
 share also. Bernutz attributes a great deal to blenorrhagia after the 
 third week and more as the monthly period approaches, in the propor- 
 tion indeed of 29 per cent., whilst West and Aran reduce this propor- 
 tion to 1 or 2 per cent., and I think certainly that it has been 
 exaggerated by Bernutz. 
 
 The neighbouring inflammations, those of the rectum or intestines, 
 dysentery, metritis especially, the persistence of ovaritis and salpingitis 
 cause the development of perimetritis and determine its chronicity. 
 Mechanical influences (cauterisation, the use of the sound, pessaries, 
 injections) have not apparently a greater share than 1 per cent, in the 
 etiology of peri-uterine inflammation. 
 
 Diagnosis — subjective signs. — The symptoms of peri-uterine inflam- 
 mation greatly resemble those of ovaritis and salpingitis, but there is 
 one dominating element which for the time effaces all the others : peri- 
 tonitis or pelvic peritonitis. 
 
 Acute peri-uterine inflammation breaks out suddenly, after abortion 
 or delivery, by shivering, heat, perspiration, nausea, vomiting, or the 
 appearance of fits of intermittent fever which might be mistaken for 
 ague ; or it may be preceded for days, weeks or even months, by 
 vague discomfort, symptomatic of inflammation of the appendages, such 
 as loss of appetite, diarrhoea, constipation, vague and dull pains. Then 
 comes the pain characteristic of perimetritis, sometimes limited to 
 one point of an iliac fossa, generally more diffuse, occupying a portion 
 of the belly, very acute if not spontaneous on pressure near the Fal- 
 lopian ligament. In addition to pain there is great heat, swelling, 
 tension of the lower half of the abdomen, the muscles of which contract 
 as if to shelter the organs underneath, dorsal decubitus, alteration of 
 ^ Dublin Journal of Medicine, xxiv, 1844. 
 
542 UTERINE DISEASES IN DETAIL 
 
 the features, small coucentrated pulse, bilious vomiting in some cases, 
 just as in simple peritonitis. When these symptoms are alleviated 
 there remains a feeling of fulness, discomfort, pain in the hypogas- 
 trium, especially on one side, exacerbations of pain, slight fever, in- 
 creased in the evening, anorexia, &c. The description of the symptoms 
 of pelvic abscesses following delivery which may be regarded as typical 
 is generally characteristic : rigors, more or less intense pain, quick 
 pulse and acute fever mark the commencement of inflammation. But 
 these initial symptoms may be absent, the patient becoming gradually 
 ill without the appearance of acute symptoms of any kind. It is not 
 uncommon to see a woman who was in good health at the time of her 
 confinement experience symptoms of general indisposition three or four 
 weeks afterwards, become gradually weaker and thinner, and complain 
 of pain down the legs or in the pelvis, lose her appetite and power of 
 digestion and occasionally have shivering fits ; after these symptoms 
 have lasted for a week or two the pelvic symptoms become more 
 marked, such as difficult and painful defsecation and micturition, pain 
 and discomfort in the pelvis, &c. This pain is increased by the 
 slightest movement, and yet the real cause being misunderstood, it is 
 often attributed to weakness. The presence, however, of a pelvic 
 tumour soon discovers to the physician the cause of all these 
 symptoms. 
 
 Chronic peri-uterine inflammation may either be the termination of 
 acute inflammation or it may be chronic from the beginning, which 
 leads to many errors of diagnosis. A subacute condition may exist, 
 an intermediate form, presenting the same phenomena as the acute 
 but less intense, and producing hectic fever in delicate patients. This 
 form is not uncommon after delivery ; the patient rises, but she is 
 weak and complains of pain, indigestion, &c. ; there is slight feverish- 
 ness and the secretion of milk is irregular. In others who are 
 stronger the inflammation only shows itself later, but it originates 
 from labour. This uncertainty as to the origin of chronic perimetritis 
 seems to me a reason for rejecting the distinction of the puerperal and 
 non-puerperal varieties. When chronic inflammation is developed all 
 at once, which is rare, the commencement is insidious. It only 
 attracts attention when the tumour has become large, or when the 
 pains become acute and when functional and digestive disorders occur, 
 which happens especially during menstruation. In fact, chronic peri- 
 uterine inflammation presents few marked local signs, especially if 
 there is any intercurrent malady such as tuberculisation. General 
 symptoms occupy the first place. These are : weariness, paleness, 
 emaciation, sallow face, eyes without expression, dry sometimes hot 
 skin, weak, small, compressed pulse, frequently oppression, palpitation, 
 headache, neuralgia, hysteria, numbness of one side especially of the 
 left, tingling of the extremities, increased or diminished sensibility, 
 painful points along the spine, dyspepsia, acidity, epigastric swelling, 
 occasionally vomiting. 
 
 On interrogating patients we generally find that there have been 
 acute symptoms of some kind to begin with. Since then in spite of 
 
PEEI-UTERINE INFLAMMATION 543 
 
 the comparative calm, a feeling of weight and discomfort has remained 
 in the pelvis, with internal heat and pulsation increased by walking, 
 fatigue or coitus. Menstruation is suppressed or less abundant 
 (metrorrhagia being the exception) ; at the monthly periods the pains 
 are more acute in the abdomen, there is tumefaction of the belly, 
 nausea, vomiting, heat of the skin, shivering, increased leucorrhcea, 
 vulval irritation and desquamation, loaded urine, painful defecation, 
 excretion of mucus by the anus or diarrhoea. Order is re-established 
 till a new crisis ; but there is still weariness, continuance of lumbar 
 and hypogastric pain radiating in one or both limbs to the knee or 
 even to the foot ; leucorrhcea ; constipation or diarrhoea ; vulval itch- 
 ing. On resuming work or coitus, or at the monthly periods, there 
 are exacerbations as in ovaritis, characterised by the redouhlements 
 inflammatoires of Gosselin, and causing a symptomatic manifestation 
 analogous to that of the acute period, with the exception of the general 
 symptoms, which are less marked. These exacerbations last from 
 three to eight days ; they may be repeated every month or at intervals 
 of three months, six months or a year. They aggravate the position 
 of patients but rarely cause death. We must remember that the 
 chronicity and inflammatory attacks depend not only on the impru- 
 dence of patients and on insufficient care, but chiefly on the persistence 
 of inflammation of the ovary and Pallopian tube. At every fresh 
 attack peritonitis appears ; in the end, however, it organises a boun- 
 dary of false membranes which it does not cross. This boundary is on 
 the level of the brim, iliac fossae, or iliac crests (p. 553, fig. 323) : 
 inflammation of the serous membrane never passes beyond the level of 
 the umbilicus. Percussion reveals its exact limits : all the inflamed 
 part gives a dull sound, while the portion which escapes peritonitis 
 gives a tympanitic sound. 
 
 Pain during the development of acute pelvic peritonitis or an 
 exacerbation of the chronic form tends to become generalised whilst 
 preserving a maximum of intensity in its original seat as in ordinary 
 peritonitis. It is acute, darting, incessant and pulsating with exacer- 
 bations every three or four hours, especially when there is internal 
 metritis, leucorrhcea, &c., and with tension of the belly which cannot 
 bear any pressure. It is also felt in the vagina and rectum preventing 
 the introduction of the finger. In chronic peri-uterine inflammation 
 this pain is often confounded with that of ovaritis, metritis and even 
 with the leucorrhcea which co-exists with it. Like the disease it has 
 various seats : generally occupying one side of the belly, especially the 
 left, or a large part of the hypogastrium with a maximum of intensity 
 at the point corresponding to the tumour; it radiates towards the 
 kidneys, loins, pelvis, vulva, thighs and legs, especially on the affected 
 side; it is fixed, deep, pulsating, aggravated by walking, fatigue, 
 standing, or coitus ; sometimes it is acute and darting, at the same 
 time becoming mobile, wandering, intermittent, in which case it is 
 probably due to neuralgia; it is sometimes hardly apparent unless 
 elicited artificially by touch, abdominal pressure, a fall, coughing, 
 vomiting, constipation, eff'orts during micturition or defecation, walk- 
 
544 UTEEINE DISEASES IN DETAIL 
 
 mg, the presence of a foreign body in the vagina, the heat of the bed, 
 uterine congestion, the menstrual period. Sometimes even lying down 
 increases it, so that patients instinctively adopt the decubitus which is 
 least painful to them ; this is generally the dorsal with slight inclina- 
 tion to the opposite side from the tumour. The heat felt by patients 
 in acute perimetritis is considerable ; it is at the bottom of the pelvis, 
 becoming sometimes burning in the vagina. In chronic perimetritis it 
 is hardly observed except at the time of an inflammatory paroxysm. 
 The symptoms of neighbourhood are variable ; there is constipation, 
 discomfort and pain on going to stool with vesical tenesmus. Nonat 
 says that in acute perimetritis menstruation is usually increased : this 
 is not my experience, nor have I often remarked leucorrhoea as a 
 result of inflammatory reaction on the uterine mucous membrane. 
 What is more frequently observed is suppression of the lochiee in the 
 puerperal state and the extension of the inflammation to the uterine 
 parenchyma. 
 
 In chronic inflammation the anatomical and functional disorders of 
 neighbourhood and the general symptoms take quite a different 
 character : the neighbouring organs are displaced, their relationships 
 altered ; the uterus especially is pushed back, deviated or flexed ; 
 there is compression of the bladder, rectum, pelvic vessels and nerves ; 
 there is a permanent state of congestion round the phlegmon or pelvic 
 peritonitis, especially in the uterus, which is hypersemiated, and the 
 chronic congestion of which often accompanies peri-uterine inflamma- 
 tion; hence pain, leucorrhoea, menstrual disorders, the period being 
 usually advanced and prolonged, though the quantity is rarely in- 
 creased, but there is often gradual diminution or suppression; dis- 
 ordered menstruation reacts on the perimetritis itself, causing increase 
 of pain ; sometimes persistence of the peri-uterine inflammation pro- 
 duces hypertrophy of the uterus, especially in multiparae. Marital 
 intercourse is nearly always painful, and should be forbidden. It is 
 less so when the inflammation is in the broad ligaments, and not 
 immediately in contact with the uterus. Chronic peri-uterine inflam- 
 mation is not an absolute obstacle to conception unless there are 
 abnormal adhesions of the Fallopian tubes; but in the few cases in 
 which pregnancy occurs there is undoubtedly a risk of miscarriage 
 from mechanical and physiological causes, therefore treatment should 
 be continued during pregnancy. Micturition is frequent and painful, 
 accompanied by tenesmus and sometimes by retention. There is often 
 constipation, at other times diarrhoea by propagation of the inflamma- 
 tion. At other times defecation is painful and difhcult, the rectum 
 and anus being the seat of spasmodic contractions causing real nervous 
 attacks ; the feces are discharged as if moulded in a tube no larger 
 than a pen, and are covered with mucus, showing the existence of 
 glairy enteritis ; there are hsemorrhoids and even anal fissures. The 
 stomach is affected sympathetically as in metritis and leucorrhoea; 
 there is usually loss of appetite, slow digestion, weight with epigastric 
 swelling after meals, depraved taste, heat, epigastric dragging, gaseous 
 eructations, nausea, vomiting, &c. Respiration is often difficult, and 
 
PEEI-UTEEINE INFLAMMATION 645 
 
 accompanied by a dry nervous cough. Pever appears with every 
 paroxysm ; in many patients the pulse is moderately but continuously 
 quick, or there may be a recurrence of this frequency in the evening 
 after fatigue. In some women disorders of sensibility and motility 
 are added to these general symptoms. Lastly, chloro-ansemia and 
 debility are usually the most marked general symptoms. 
 
 The course of the malady may help in the diagnosis. 
 
 Puerperal peri-uterine inflammation passes rapidly and frequently to 
 suppuration. Non-puerperal perimetritis has a slower course. It 
 may terminate in three ways : by resolution after gradual diminution 
 of the symptoms in two or three weeks or at the normal recurrence of 
 the second monthly period; by transition to the chronic stage, in 
 which case the tumour remains stationary and becomes indurated ; or 
 by suppuration, which is the rarest case. The malady progresses very 
 slowly except in a few cases, when it terminates by sudden generalisa- 
 tion of the peritonitis. Even in the most fortunate cases patients 
 suffer a long time from debility and nervous symptoms, pelvic weight, 
 lumbar pain on standing, and pain in the accomplishment of the sexual 
 functions. The abdomen is painful on pressure ; traces of the tumour 
 exist, either peri-uterine pufiiness, or small tumours of the size of a 
 pea, so well described by Gosselin, tumours which are not perhaps 
 always vestiges of peri-uterine inflammation, but which may often pass 
 for a remnant of this malady; so that resolution of the peri- uterine 
 inflammation perhaps is never complete — at least it is very slow. 
 Usually the malady passes to the chronic state with or without inflam- 
 matory paroxysms. Death may occur in one of these paroxysms by 
 generalisation of the peritonitis, putrid absorption, or even by purulent 
 infection (Aran has seen it twice). 
 
 At other times the neo-membranous peritonitis favoured by these 
 inflammatory paroxysms may be vascularised and hypereemiated to the 
 point of causing hsemorrhages, which again are the sources of new 
 maladies (hematoceles), and which have won the name of hsemorrhagi- 
 parous pachy-peritonitis. At other times, after having passed through 
 several paroxysms and escaped their dangers, patients find their health 
 gradually improved. If, however, they are tuberculous they continue 
 to suffer, now from the chest, now from pelvic peritonitis, till con- 
 sumption at last ends in death. 
 
 Objective signs. — At first it is difficult to perceive the pelvic tumour 
 by abdominal palpation. But when the tumour increases and 
 approaches the surface we discover in the centre of the hard abdomen 
 a tumour, which may or may not be circumscribed, as large as 
 the fist and more painful than the surrounding parts on pressure. 
 In chronic peri-uterine inflammation the belly is always sensitive to 
 pressure and sometimes distended; palpation reveals marked resistance 
 or a real tumour, flattened or rounded, which may reach to the 
 umbilicus, or farther. 
 
 Digital touch is not possible in the commencement of acute peri- 
 metritis, the vagino-uterine pain being too great to allow of it ; but as 
 
 35 
 
546 UTERINE DISEASES IN DETAIL 
 
 soon as the pain is somewhat less intense this examination is indispen- 
 sable in order to prevent the consequences of the phlegmon. 
 
 It is usually easy to discover a globular projection with smooth, 
 regular, resisting surface, hot, painful, and projecting into the vagina, 
 rectum or hypogastrium. There is marked vaginal heat, the vulvo- 
 uterine canal being more or less moistened with mucus. The cervix 
 varies in position, but appears fixed on a solid base; the fundus is 
 immobile ; the utero-vaginal cul-de-sac offers at some points a certain 
 resistance, puffiness or a projection, sometimes in the form of a semi- 
 
 TiG. 318. — Phlegmon of the broad ligament, partially surrounding the cervix 
 
 (after Barnes). 
 
 circle (Fig. 318). Immobility of the uterus and an imperfectly circum- 
 scribed peri-uterine tumour, together with the general phenomena 
 suffice to diagnose the malady. 
 
 In chronic inflammation digital touch shows the uterus to be com- 
 pletely immobile, either in its normal position or inclined, or in a kind 
 of gangue from which the neck alone is free, or closely attacked to a 
 lateral or posterior tumour, or pushed back in an opposite direction 
 from the tumour, from which the cervix is separated by a groove, 
 sometimes with cedema of the neck and upper part of the vagina. 
 Eectal touch enables us better to recognise a shapeless mass, or bands, 
 or a more or less complete ring fixing the uterus. Lastly, the asso- 
 ciation of palpation with digital touch allows the extent of the tumour 
 to be appreciated, its thickness, its consistency, its elasticity announc- 
 ing the formation of pus, &c. The association of vaginal and rectal 
 touch has been successfully employed by Recamier to discover sup- 
 puration, by determining fluctuation in the tumour. As for the ovary 
 and Fallopian tube, they are too much in the centre of this tumour to 
 be accessible to touch. 
 
 Peri-uterine inflammation always leads to the formation of a 
 tumour. This tumour is sometimes apparent above the pubis, 
 through the abdominal walls ; its presence can be verified by manual 
 examination, hypogastric palpation, association of vaginal with rectal 
 touch. It may vary much in form and volume, from the size of an 
 
PERI-UTERINE INFLAMMATION 547 
 
 almond to that of an orange, and may be either circumscribed or 
 diffuse. The surface is generally regular and smooth, \idthout soft 
 depressible projections like those produced by stercoraceous accumula- 
 tions in the rectum ; in consistency it is solid, firm, sometimes hard, 
 generally elastic, like that of the body of the uterus unless there is 
 suppuration. This tumour is sometimes mobile relatively to the 
 uterus, sometimes adherent to this organ, either by one end, or by 
 one surface; it is not on that account necessarily immobile in the 
 pelvis, it may be limited to the folds of the broad ligaments to which 
 it adheres by one surface, whilst the other is free ; in fact it is usually 
 fixed and immobile in the pelvis and round the uterus or at one part 
 of this organ. 
 
 Digital touch shows the parts occupied by the tumour. Nonat 
 says Vndii phlegmon usually begins with one of the broad ligaments and 
 from there spreads inwards towards the uterus or outwards towards 
 the iliac fossae. This writer distinguishes besides this phlegmon of the 
 broad ligaments, latero-uterine phlegmon (the most frequent after the 
 preceding), then antero-uterine, retro -uterine, and lastly, that which 
 makes a belt round the womb meriting the name of peri-uterine, and 
 perhaps the peri-rectal. 
 
 West^s statistics give us an idea of the comparative frequency with 
 which the different parts are affected : out of 52 cases the broad liga- 
 ment was the seat 34 times, the utero-rectal cellular tissue 14 times, 
 the utero-vesical cellular tissue 3 times. 
 
 Pelvic peritonitis is also more common laterally than in the median 
 portion, the ovary or Pallopian tube being the usual starting point. 
 As to frequency, peri-uterine inflammation evidently has a tendency to 
 attack the postero-lateral part to the right or left indifferently, except 
 in puerperal women when, Aran says, the proportion seems rather 
 larger to the right. 
 
 The statistics of Gallard and Aran confirm those of West in this 
 respect. 
 
 In 52 cases, West found 34 on one side, 21 to the left. 
 „ 53 „ Gallard „ 32 ,, ,, 11 „ 
 „ 24 „ Aran „ 17 ,, „ 
 
 Next to the lateral, the posterior part or the utero-rectal eul-de-sac 
 is the most frequent seat of peri-uterine inflammation. Peri-uterine 
 adenitis is also more frequent behind and on one side, usually on the 
 right. 
 
 There is another sign perceptible by digital touch to which Nonat 
 attributes great importance : usually, he says, a tolerably large arterial 
 vessel, as large for instance as the radial, creeps round the base of the 
 tumour giving pulsations perceptible to the touch. It is only to be 
 found in old tumours ; it can be observed in the third month but 
 more clearly in the eighth ; it is never absent from peri-uterine 
 engorgements of a yearns standing, but it may not be accessible to 
 exploration. Its volume is proportioned to the age of the phlegmon, 
 it aggravates the prognosis, the afflux of a larger quantity of blood 
 making the malady more difficult to treat. These remarks of Nonat's 
 
548 UTEEINE DISEASES IN DETAIL 
 
 are mentioned in Martinis ^ thesis. Arterial pulsations may be per- 
 ceived in peri-uterine tumours; but I think this writer exaggerates 
 their importance. 
 
 Differential diagnosis. — Acute but especially chronic peri-uterine 
 inflammations have been long ignored ; they have given rise to many 
 errors of diagnosis ; we may even affirm that such errors continue to 
 be made. We must therefore lay down the basis for a serious diag- 
 nosis. Every unusual phenomenon produced in the abdominal region, 
 especially when accompanied by disturbance of the general health, 
 whether it occur after labour or not, ought to attract the attention of 
 the physician leading him to fear peri-uterine inflammation (for this 
 malady occurs 50 or 70 times out of 100 diseases of the utero-ovarian 
 economy), and induce him to make a minute examination, especially 
 after delivery or abortion, even when this has taken place two months 
 ago (for the disease may have been misunderstood till then) ; or even 
 if there was another malady (for perimetritis may coexist with it. 
 
 1. Special signs of the various peri-uterine inflammations. — They 
 establish a distinction between perimetritis, parametritis, phlegmon of 
 the broad ligaments, peri-uterine adenitis. 
 
 Although Thomas,^ Bernutz,^ and other writers have tjied to 
 enumerate these signs, it is very difficult to find sufficient reasons for 
 deciding whether we have to do with a case of perimetritis, para- 
 metritis, or phlegmon of the broad ligaments, whether it be that they 
 coexist, or that the distinctive signs are not sufficiently pathogno- 
 monic. It is not often that a physician can be sure as to the seat of 
 inflammation, except when he has been called in at the beginning and 
 has seen the malady follow its course, terminating by resolution or 
 suppuration, the abscess having opened at some point or another. 
 There are also cases when we have to do simultaneously with peri- 
 tonitis and pelvic cellulitis. As, however, these diseases may be 
 absolutely independent of each other, each existing separately, I shall 
 endeavour to give the difl'erential diagnosis of peritonitis and simple 
 pelvic cellulitis, after having described the complicated morbid 
 states which most frequently occur under these names, just as 
 I have before endeavoured to bring into relief the characters of 
 simple ovaritis amidst symptoms of complicated ovaritis which is also 
 commoner. 
 
 Teri-uterine cellulitis or pelvic c^^/?<;^i^M, especially when situated on 
 a level with the cervix, is so rare that its existence has been denied; 
 it has, however, been seen after traumatisms and extension of inflam- 
 mation of the broad ligaments : it is a median parametritis, whilst 
 phlegmon of the broad ligament is a lateral parametritis ; it has no 
 direct connection with puerperal fever. There is little or no shivering 
 except at the time of suppuration; dull pain from the abscess, and 
 feverish pulse. The tumour may be felt all round the cervix project- 
 
 ^ Phlegmons des ligaments larges et du Ussu cellulaire peri-uterin. Paiis, 
 1851. 
 
 ^ Diseases of Women, pp. 366, 375. 
 ^ Op. cit., t. ii, p. 397, et seq. 
 
PERr-UTERINE INFLAMMATION 
 
 549 
 
 ing either in front between the bladder and uterus raising the vagina, 
 or behind between the retro-uterine peritoneum and the womb raising 
 
 Fig. 319.— Pelvic cellulitis and pelvic abscess encysted to the right of the 
 uterus, seen from the front, from a case observed at University College 
 Hospital (after Graily Hewitt). 
 
 i m I K mil 7 f/f^^ 
 
 Fig. 320. — Right pelvic cellulitis, same tumour seen in profile. 
 
 the posterior vaginal cul-de-sac, or laterally whence it extends to the 
 broad ligament, forming a hard surface on the side corresponding to 
 the vagina; more frequently it is from the broad ligament that the 
 inflammation extends to the circumference of the cervix; it is slowly 
 developed, not being perceived for some days ; it is very circumscribed 
 hardly rising except when it attacks the broad hgament ; it cannot be 
 perceived above the brim; it is hemispherical and annular, sometimes 
 very hard in the centre, and oedematous externally ; the oedema may 
 extend to the cervix on one side and to the vulva on the other ; later 
 
550 UTERINE DISEASES IN DETAIL 
 
 on it becomes puffy and fluctuation appears; the tumour is immobile. 
 The uterus is not completely immobile, only its mobility is limited in 
 one direction or another according to the seat of the phlegmon; it is 
 the same as to its direction^ which may also be altered. The groove of 
 separation between the uterus and the tumour may not exist or is 
 inappreciable. The pain, which varies with the stage of the disease, is 
 elicited by micturition or defecation according to the seat of the 
 trouble ; dysuria is not uncommon ; pain is also caused by the pressure 
 of the finger in the vagina. There are no signs of peritonitis ; fever is 
 
 Fig. 321. — Pelvic cellulitis or right pelvic phlegmon, which has spi-ead from 
 the broad ligament, on one side round the uterus, on the other side into 
 the iliac fossa. Parnell's case, preserved in TJnivei-sity College Hospital, 
 front view (after Graily Hewitt). 
 
 sometimes high ; there is no tendency to relapses ; duration is limited ; 
 there is marked tendency to suppuration ; termination is by resolution, 
 suppuration or induration, which in all cases diminishes the size of the 
 tumour causing its disappearance, unless some centres of induration 
 persist in its place. Sometimes, on the contrary, the phlegmasia 
 extends towards the periphery of the pelvic cellular tissue, towards the 
 pubic or obturator region, towards one of the iliac fossse, all round the 
 rectum. But the favourite seat of cellulitis is the broad ligament, i. e. 
 the point where the connective tissue is contained between the two 
 folds of peritoneum enclosing in their upper wings the ovary, the ovi- 
 duct and the round ligament. 
 
 Phlegmon of the broad ligaments (utero-pelvic cellulitis) is frequent; 
 it is a common malady in the puerperal state, and may be developed 
 from the second to the twentieth day after labour : it may be seen in 
 nulliparae and even in virgins, but is rare in the state of vacuity. 
 Eigor is not constant, occurring only in about half the cases ; fre- 
 quently it is only produced at the time of the formation of pus. There 
 is dull pain in the abscess, darting at intervals, with a feverish, full 
 pulse. The tumour is lateral and not median as in pelvic peritonitis, 
 extending easily, generally perceived in the broad ligament, and above 
 the margin of the pelvis ; from the first there is the sensation of a 
 cord when abdominal palpation is practised (if when the uterus is 
 
PEEI-UTEEINE INFLAMMATION 
 
 ;5i 
 
 seized with the thumb and middle finger, they are passed along the 
 sides of the organ from above downwards, in place of the soft and 
 supple annexes a cord is encountered, directed from the cornua of the 
 uterus towards the anterior part of the iliac fossae; this cord is hard, 
 tense, and always painful on pressure at the enlarged point); the 
 tumour is sometimes hardly accessible to vaginal touch ; always to be 
 felt at the hypogastrium from the beginning, owing to the tendency 
 of the inflammation to be propagated to the neighbouring areolar 
 tissue, especially in the iliac fossa ; it is sometimes developed indis- 
 tinctly and slowly, the reverse of pelvic peritonitis ; it is generally first 
 perceived on the sides of the pelvis, probably because it commences 
 
 Fig. 322. — Phlegmon of the left broad ligament pushing back the uterus to 
 the right, with diffusion into the pelvis. Formation of an abscess. Open- 
 ing by the inguinal canal (round ligament), below the crural arch, by the 
 obtra'ator foramen on the left side of the vagina (Courty). 
 
 where the cellular tissue is loose ; it is probably also for the same 
 reason that it extends to the internal iliac fossa, the anterior abdominal 
 wall, the crural canal and to the buttock, as well as to the side of the 
 uterus ; tumefaction is perceived later on at the side of the womb on 
 account of the condensation of the cellular tissue at this point, thus it 
 generally progresses from the periphery to the centre and from above 
 downwards ; it may commence or terminate by inflammation of the 
 utero-ovarian veins and pampiniform plexus. Percussion gives a dull 
 sound laterally, a clear sound in the middle of the hypogastrium. By 
 vaginal touch the tumour is felt at the bottom of the lateral cul-de-sac 
 on the sides of the vagina and cervix, under the form of an cedematous 
 plaque, sometimes as hard as wood and regular, often without either 
 indentations or irregularities, not sensitive and almost completely 
 immobile; the internal part embraces the cervix with which it is 
 continuous, or from which it is only separated by a narrow groove ; at 
 the border of the cul-de-sac the induration may double on itself and 
 be prolonged round tlie walls of the vagina, sometimes even the latter 
 is to a great extent enveloped in this kind of lining ; the tumour then 
 becomes soft, pasty and fluctuating. 
 
562 
 
 UTEEINE DISEASES IN DETAIL 
 
 As in internal abscesses, oedema appears in the superficial parts and 
 neighbouring tissues : thus the cervix, vagina and corresponding 
 labium are manifestly (Edematous ; this fact, to which I have often 
 called attention, has not been sufficiently noticed as an element of 
 differential diagnosis. The uterus is only fixed to a limited extent; in 
 place of being completely immobile as in pelvic peritonitis, it preserves 
 a portion of its mobility, its lateral movements only being very 
 restricted; the organ is not displaced if the phlegmon is small; in the 
 contrary case there may be three kinds of displacement, answering to 
 differences of extent and seat in the phlegmon ; if the tumour occupies 
 the whole broad hgament, the uterus is inclined to tbe other side; if 
 it is less developed, it is the fundus or the cervix which is pushed back 
 to the opposite side, according to whether it is the upper or lower 
 part of the broad ligament which is the seat of the tumefaction ; after 
 cure, owing to the retraction of the inodular tissue the uterine dis- 
 placement is the reverse of what it was originally. The groove sepa- 
 rating the uterus from the tumour is absent or hardly apparent. The 
 dull, heavy, strong, continuous pain has nothing in common with that 
 of peritonitis ; it is caused by micturition more than by defecation, is 
 eHcited by pressure on the lateral portion of the vagina and on the 
 hypogastrium above the crural arch. Shortening of the thigh is very 
 common, although not as constant as in sub-aponeurotic abscesses, and 
 especially inflammations of the psoas and internal iliac fossa. There 
 are no general signs of peritonitis ; no nausea, nor excessive vomiting 
 nor tympanitis, nor alteration of the face, nor concentrated pulse. 
 Febrile phenomena predominate over functional alterations of the 
 digestive economy : the latter are more like the symptomatic digestive 
 disorders of pregnancy or those of a malady of the fundus than of 
 peritonitis. There is marked tendency to suppuration and to the 
 formation of abscesses, but no tendency to monthly relapses. The 
 duration of the malady is limited and varies according to whether it 
 terminates by resolution, induration or suppuration. 
 
 Pelvic peritonitis is very common whether puerperal or non-puerperal, 
 acute or chronic. It may occur in the state of vacuity, as a sequence 
 of menstrual disorders, ovaritis, traumatism or abortion. When puer- 
 peral it is developed during the first ten days, generally sooner than 
 phlegmonous inflammation. Shivering is never absent, especially at 
 the outset. la the beginning pain is acute and at one point, recalling 
 that of pleurisy; the pulse is frequent, hard and concentrated. The 
 tumour is usually situated in the utero-rectal cul-de-sac ; but it may 
 be perceived at several other points round the uterus, though it does not 
 project much except in the posterior vaginal cul-de-sac, where the 
 longest prolongation of the peritoneum is found. The efl'ects of it are 
 felt sooner than those of phlegmon, on account of the rapid develop- 
 ment of peritonitis and adhesions ; at first it attacks the lowest parts 
 extending from below upwards and from the centre to the periphery 
 (unless the Eallopian tube or ovary have been the starting-point) ; it 
 does not rise above the brim unless there have been successive attacks 
 of inflammation or extension of the disease to the whole peritoneum ; 
 
PEEI-UTEEINE INFLAMMATION 
 
 553 
 
 it depresses tlie posterior vaginal cul-de-sac to the point of descending 
 below the cervix, but not round the walls of the vagina; it is hemi- 
 spherical, rounded, often indented and irregular ; projecting into the 
 vagina in front, into the rectum behind ; it is resistant and hard, but 
 not woody nor (edematous ; it is immobile. The uterus is also im- 
 
 FiG. 323. — General pelvic peritonitis, rising to below the umbiHcus, seen in 
 front, raising the uterus and annexes. 
 
 Fig. 32'1'. — General pelvic peritonitis and intra-peritoneal pelvic abscess, seen in 
 profile, felt through the vagina and hypogastrium (after Graily Howitt). 
 
 mobile in every direction, fixed by the tumour and always displaced ; 
 the neck is deviated either to the side of the tumour or to the opposite 
 one, according to whether it presses on the body or neck ; usually the 
 whole organ is pushed upwards and forwards towards the pubis. The 
 groove separating the uterus from the tumour is always appreciable. 
 Pain is often very acute ; it is elicited by defecation, digital pressure 
 
554 
 
 UTERINE DISEASES IN DETAIL 
 
 in the vagina and by pressure over the hypogastrium : the tumour 
 is never indolent. 
 
 A vague, diffuse, resistant tumefaction is felt through the abdominal 
 walls when the pain is not extreme ; usually excessive abdominal sen- 
 sitiveness is developed above the pelvis^ towards the median line ; 
 shortening of the thigh never occurs. The general signs of peritonitis 
 are manifested : excessive pain, frequently with paroxysms, prostration, 
 the face drawn and anxious, nausea, green vomiting, distension of the 
 belly, tympanitis, quick and concentrated pulse ; the digestive sym- 
 ptoms predominate over the febrile phenomena. But slight tendency 
 to suppuration, marked tendency to monthly relapses ; duration is 
 
 Pig. 325.— Left lateral pelvic peritonitis, encysted, with pelvic peritoneal 
 abscess surrounding the ovary, tube and uterus with adhesions. 
 
 long, the malady being prolonged by frequent recurrences to the acute 
 state. In short, acute perimetritis is more easily confounded with 
 retro-uterine hematocele than with phlegmon of the broad ligaments. 
 
 Ten-uterine adenitis follows pelvic cellulitis, pelvic peritonitis, or 
 more frequently still chronic endometritis with leucorrhoea and ulcera- 
 tion ; it hardly forms a tumour ; it is perceived by the touch in the 
 form of indentations, nodosities and induration in the connective tissue 
 of the base of one of the broad ligaments and the posterior region of 
 the uterus. It scarcely alters the mobility of the uterus. It is painful 
 on pressure and when the uterus is moved ; it lasts long ; cure is diffi- 
 cult ; there are hardly any relapses or inflammatory paroxysms, but on 
 the other hand there is no tendency to resolution. 
 
 2. Distinctive signs of peri-uterine inflammations and other maladies 
 of the uterus, its annexes and of the pehic cavity.-^— Acute metritis 
 is distinguished by less intensity of the general and local phenomena, 
 by the different seat of pain, which occupies the whole belly, by its 
 expulsive character, by leucorrhoea, more frequent vomiting, the 
 absence of a tumour and especially by the mobility of the uterus, which 
 is recognised as the only tumour occupying the centre of the hypogas- 
 trium. — Simple ovaritis forms a smaller tumour than that of peri- 
 metritis, smooth, mobile, very painful, raised behind the body and one 
 
PEEI-UTERINE INFLAMMATION 555 
 
 of the borders of the uterus ; when complicated, it is the centre of true 
 pelvic peritonitis. — Simple salpingitis forms an elongated tumour, 
 either knotted or globular, perceptible by palpation associated with 
 touch, on one side of the uterus, being continuous with one of the 
 cornua; when complicated, it also is the centre of true pelvic peri- 
 tonitis. — Cystitis is known by examination of the urine and is easily 
 distinguished from perimetritis. 
 
 The diagnosis of chronic perimetritis is the most difficult. Engorge- 
 ment of the uterine walls is less hard than peri-uterine phlegmon, and 
 can be slightly depressed. It is not limited to one side or to one part 
 of the uterus ; there is no border round the neck, nor any groove indicat- 
 ing the boundary between the womb and the peri-uterine engorgement. 
 Pregnancy is distinguished by the uniform development of the body 
 of the uterus, which is globular, without any groove, of normal con- 
 sistency, increasing daily in size. Interstitial fibrous tumours are 
 distinguished by the same characters, by the absence of any groove, by 
 hardness, absence of sensibility, the less frequent existence of arterial 
 pulsations, the mobility which the uterus preserves in spite of its 
 increased size. Fibromata and sub-peritoneal myotnata may occupy the 
 cavity, making diagnosis difficult. We must remember that they are 
 .harder, round, often multiple, more or less mobile, indolent, &c. They 
 sometimes become enormous. Deviations d^udi flexions , which have given 
 rise to frequent errors, are distinguished by the fact that the body of 
 the uterus can be found nowhere apart from the tumour. The uterus 
 must be held simultaneously with the tumour, to be quite certain that 
 the latter exists ; the sound facilitates the diagnosis. 
 
 Amongst extra-uterine tumours, iMegmon of the internal iliac fossa 
 has a recognised seat and boundaries. In order to feel it the abdomen 
 should be depressed behind the ilium, and not behind the crural arch ; 
 no tumour is found in the cavity by vaginal touch ; the cuts- de-sac are 
 free and supple, the uterus quite mobile; the thigh is flexed, the 
 nerves supplying it and the genital organs are the seat of neuralgia. 
 If the peri- uterine cellular tissue is invaded no distinction can be 
 made ; it is the same malady, differing only as to seat and extent. 
 Tumours formed in the rectum by retention of stercoraceous matter 
 have led to mistakes. They are sometimes soft and depressible, some- 
 times hard and indented ; they can be recognised by rectal touch ; an 
 enema given several days running removes all doubt. Sometimes the 
 two maladies are observed simultaneously, for the coexistence of a 
 peri-uterine phlegmon with constipation is not uncommon. Peri- 
 uterine hematocele is perhaps the malady which can most easily be 
 confounded with acute sero-adhesive pelvic peritonitis. There is more 
 resemblance between these two diseases than between pelvic peritonitis 
 and peri-uterine or latero-uterine phlegmons. Nevertheless, hemato- 
 cele does not commence under the same circumstances or in the same 
 way ; the history of the case gives the clue to the differential diagnosis. 
 It frequently follows sudden suppression of the menses. The forma- 
 tion of the tumour is very rapid, and is accompanied by the general 
 symptoms of haemorrhage, acute pains like those of peritonitis, and by 
 
556 UTERINE DISEASES IN DETAIL 
 
 fluctuation from the beginning, which is the reverse of what takes 
 place in pelvic peritonitis. Pain and reaction soon make confusion 
 possible. But the tumour gradually hardens owing to coagulation of 
 the blood, in place of softening; it is not so sensitive to pressure as the 
 inflammatory tumour of pelvic peritonitis ; its usual seat is behind the 
 uterus, which is pushed forwards and upwards against the pubis. An 
 exploratory puncture removes all doubts ; it is not, however, necessary. 
 When hematocele is accompanied by pelvic peritonitis, as happens 
 in the most painful and troublesome cases, it requires the same treat- 
 ment as acute pelvic peritonitis. Peritonitis furnishes the dominant 
 symptoms and afi'ords the chief indication. 
 
 Tuberculisation of the ovaries, broad ligaments and tubes is more 
 difficult to distinguish, for it is but a chronic and diathetic peri- 
 metritis. Ci/sts, especially ovarian cysts, whether serous or purulent, 
 present evident fluctuation unless there is very great distension, thick- 
 ening of their contents, or too great multiplicity. A characteristic 
 globular, mobile form is felt by the vagina and hypogastrium. They 
 are not painful on pressure, nor is there any arterial pulsation. Extra- 
 uterine pregnancy forms a heterogeneous mass, composed of soft and 
 hard parts, mobile, unequal, &c. Perimetritis may coincide with it, 
 or with a serous or purulent cyst. As for sub-aponewotic abscesses, 
 hydatid tumours, cancer, and even aneurisms which may be developed 
 in the pelvic cavity, they give rise to pathognomonic symptoms which 
 allow of their being easily distinguished from peri-uterine inflamma- 
 tion. ^ Lastly, chronic peri-uterine inflammation must not be con- 
 founded with maladies like pulmonary tubercle which are connected 
 with diathetic general affections, and gradually produce consumption. 
 The antecedent circumstances, the general symptoms, the fades 
 uterina, dyspepsia, the symptoms of neighbourhood, viscid leucorrhoea, 
 &c., lead to a direct examination, and consequently to the differentia- 
 tion of two maladies which may indeed coexist in the same patient. 
 The general symptoms may be analogous and increase the confusion, 
 but the local symptoms and^ above all, the presence of the retro-uterine 
 or peri-uterine tumour, remove all doubts. 
 
 Peri-uterine abscess. — The only termination of perimetritis of which 
 I have not yet spoken because it presents special signs, is the termina- 
 tion by suppuration and the formation of pelvic or peri-uterine 
 abscess, called by Puzos ^ and Yan Swieten, depots laitettx. This 
 termination is rare, according to West it occurs fifty-one times in 100 
 cases, but according to Aran, Gallard and Gosselin only from seven to 
 ten times in 100. Under the influence of crowding, weak constitution, 
 lymphatic temperament, a cachectic state, the puerperal condition, or 
 in the absence of special treatment, acute peri-uterine inflammation 
 terminates in suppuration ; or under the influence of external irrita- 
 tion, a blow, a fall, or some menstrual disorder, chronic peri-uterine 
 inflammation passes into the acute stage and may become purulent. 
 
 > See Dictionnaire encyclopedique des sciences medicales, art. Bassin 
 ipathologie) . 
 
 ' Traite d'accouchemenfs, 1743. 
 
PERI-UTEEINE INFLAMMATION 557 
 
 The pus may be infiltrated or collected together according to 
 whether suppuration is rapid or slow. 1. If suppuration of the peri- 
 uterine cellular tissue is rapid^ recent diffuse abscesses are formed, 
 according to Nonat, the relations of which vary according to the seat 
 and extent of the inflammation. There is a retro-uterine or recto- 
 uterine abscess, which must be distinguished from intra- peritoneal 
 purulent collections, an ante-uterine or vesico-uterine abscess which 
 is rare, a lateral abscess which separates the folds of the broad liga- 
 ment and bathes the Fallopian tube and ovary in pus. Usually the 
 pus spreads round the uterus filling the pelvis, and may even reach 
 the iliac fossae or rise to the umbiHcus. There is no doubt it happens 
 much oftener in peritoneal suppuration than in phlegmons. However, 
 according to Nonat, fragments of cellular tissue, vessels, nerves, &c., 
 are found in the centre. 2. When suppuration is slow, the pus is 
 collected in a focus enveloped in a pyogenic membrane, forming one 
 or more circumscribed encysted tumours in relation with the neigh- 
 bouring organs, which may also possibly result from a serous cyst, or 
 suppurating hematocele ; sometimes pus is formed in a latent manner, 
 and is not suspected till evacuated. When there is much of it it may 
 be supposed to come from the peritoneal cavity ; when there is little, 
 it is more likely to be from an ovarian or tubal abscess. From one 
 of these centres which was larger than the uterus at term 15 litres of 
 pus were evacuated. It may be accumulated in a kind of cyst and 
 remain there for a year, becoming very dense, in place of remaining 
 serous, as when recent. These abscesses may open spontaneously into 
 the peritoneum, which is rare and is a cause of rapid death, or they 
 may open into the rectum or vagina, or even into the bladder, on the 
 abdominal wall, or even by various orifices such as the inguinal canal, 
 crural canal, the obturator foramen or the sciatic notch (Fig. 326). 
 In one case which was verified by autopsy, Seux ^ saw the pus 
 discharged through the posterior wall of the uterus. According to 
 Graily Hewitt ^ the most frequent opening is into the intestine ; it is 
 also rather frequent into the vagina and bladder. It is less common 
 along the course of the vessels or nerves leaving the pelvis. With 
 regard to this, a wide distinction must be made between a perimetric 
 and a parametric abscess and one of the broad ligament. They have 
 common points by which they may be discharged, notably the rectum; 
 but there are points of selection by which some open rather than 
 others, for example, the rectum and bladder, for the abscess of pelvic 
 peritonitis ; the abdominal wall or the groin, for abscess of the broad 
 ligament. The former has besides a greater tendency to become 
 encysted and to be tolerated, the latter to ulcerate and discharge the pus. 
 
 As the purulent matter is discharged at certain points determined 
 by exact anatomical connections, the place of opening of the abscess is 
 a last means of completing the difi'erential diagnosis. Suppurative 
 pelvic cellulitis having less tendency to open by the abdominal wall 
 and into the intestine, or even into the bladder and uterus, may be 
 
 1 Bulletin de la Societe iinpdriale de medecine de Marseille, 1862, p. 87. 
 ' Op. cit., p. 228. 
 
558 
 
 UTEEINE DISEASES IN DETAIL 
 
 discharged by the vagina or even by the rectum, all round the anterior 
 part of the brim, by the crural arch, the inguinal canal, the obturator 
 
 Fig. 326. — Points in tlie pelvic cavity by which the pus of phlegmon of the 
 broad ligament may be discharged, a c, above and below the crural arch. 
 s, the great sciatic notch ; o, the small sciatic notch ; t o, the obturator 
 foramen ; 1, 2, 3, the sacral foramina. 
 
 foramen, as vrell as by the sciatic notches ; I have seen some open 
 simultaneously into the vagina (by the lateral wall), below the crural 
 arch, and in the centre of the buttock at the highest part of the sciatic 
 
 Fig. 327. — v, vagina ; it, uterus ; L i, upper border of the broad ligament ; p, 
 peritoneum in which sero-adhesive or sero-purulent peri-uterine inflam- 
 mation is developed ; l s p, sub-peritoneal space of the broad ligament 
 on each side, rising to the upper border L i, in which suppuration of the 
 phlegmon of the broad ligament takes place ; s c, subcutaneous space 
 where abscesses are formed, which only open round the anus and vulva. 
 
 notch, at a point through which an india-rubber bougie might be ])assed 
 
PERI-UTEEINE INFLAMMATION 659 
 
 to the centre of the pelvis where the point could be felt by vaginal 
 touch through the vaginal wall. 
 
 Suppurative pelvic peritonitis then may be discharged by the rectum^ 
 vagina, bladder, or even the uterus, and at various points of the 
 abdominal wall as well as into the intestine, the sigmoid flexure, 
 csecum, or small intestine. I have seen one opening simultaneously 
 into the vagina, into the intestine, and through the abdominal wall at 
 a point more or less distant from the crural arch. Abscesses which 
 are subcutaneous and subaponeurotic, i.e. below the deep perinaeal 
 aponeurosis, open round the vulva and anus. The accompanying 
 figure explains how it is that one abscess should open at one point and 
 another abscess at another point. 
 
 The suppuration which follows puerperal perimetritis has a rapid 
 course, terminating fatally in a few days. In non-puerperal peri- 
 metritis, pus may appear in a fortnight or even sooner. Nonat does 
 not think it possible that pus can be absorbed ; however, I have seen 
 cases of the kind, but the tumours were small. When, however, art 
 does not intervene at an early stage, purulent collections usually make 
 way for themselves to the teguments or to some hollow organ. Some 
 days previously there is exacerbation of the symptoms, then suddenly 
 after a fall, contusion or effort the tumour suddenly gives way bringing 
 relief. Sometimes there is no particular sensation, at other times 
 there is a sensation of internal laceration, and passage of pus into the 
 vagina, which is a favorable termination. I have recently seen a case 
 of this kind in a patient who would not allow vaginal puncture to be 
 attempted, and in struggling the abscess broke into the vagina : cure 
 soon followed, but it was impossible for me to find the vagino-uterine 
 orifice by which the abscess was discharged. 
 
 Evacuation may either be complete or not ; it then takes place 
 several times. At the monthly period the pus becomes sanguinolent. 
 "When the opening is made into the rectum there may be tenesmus, 
 dysentery, and the most serious accidents, as Aran once saw in a 
 virgin. Except in cases where the pus is effused into the peritoneum, 
 death seldom follows rupture of the abscess, though it may result 
 from prolonged suppuration, from the formation of fistulous passages 
 and from the marasmus into which patients finally fall. I have already 
 said what happens when several openings place the abscess in com- 
 munication with the bladder and rectum simultaneously, sometimes 
 even with the abdominal wall as well. Consumption may occur in 
 these cases, as well as in those where the evacuation of pus is incom- 
 plete, where the abscess opens and closes several times, where there is 
 stagnation of pus owing to the existence of only one opening for two 
 or three abscesses.^ If, on the contrary, the opening is large, and the 
 
 ' Nevei-theless, there are cases in which the constitution of patients is able 
 to resist the continued secretion of pus, perforation of the digestive canal, &c. ; 
 I have just seen a case of the kind, where, in spite of the fear of peritoneal 
 adhesions of the tubes hindering the adaptation of the fimbriated extremity to 
 the ovary, and so causing sterility, suppuration had hardly ceased, the patient 
 still being convalescent, when she became pregnant. 
 
560 UTEEINE DISEASES IIS DETAIL 
 
 abscess well emptied, the symptoms disappear : hence the justification 
 for surgical intervention, the right limits of which I shall try to define 
 
 when describing treatment. 
 
 Treatment. — Peri-uterine inflammation, apart from that which is 
 developed in the worst conditions of the puerperal state, is serious, not 
 from the rapidity of the termination, but from the long duration and 
 natural incurability of the chronic form, the constant dangers incurred 
 by the paroxysms^ and the risk of consumption which is all the more 
 serious^ as Aran considers that two thirds of the women attacked by 
 chronic perimetritis are predisposed to tubercle. Besides which, if 
 the malady is allowed to become intense or be prolonged, sterility fol- 
 lows, except very exceptionally, when the peritoneum is not involved 
 in the inflammation, or when the annexes of one side have preserved 
 their integrity; pregnancy is always difiicult, as Madame Boivin^ has 
 shown, but she attaches too little importance to remains of inflamma- 
 tion and exaggerates the mechanical influence of adhesions. It is 
 evident that the treatment of perimetritis ought always to be con- 
 sidered as urgent, and this should be explained to patients as well as 
 the length of time required. 
 
 I shall not speak of prophylactic treatment, which consists in 
 avoiding all fatigue after delivery, rising too soon, marital intercourse, 
 cold injections, cold foot baths, and also the sudden suppression of 
 the milk, but shall now pass on to treatment strictly speaking. 
 The chief indications are the following : 1, to subdue inflammation ; 
 2, to promote resolution of the tumour; 3, to treat the diathetic 
 affection under the influence of which chronic inflammation has a ten- 
 dency to perpetuate itself; 4, to treat complications ; 5, when necessary 
 to promote the evacuation of pus. 
 
 1. Antiphlogistic treatment is so plainly indicated, that all physicians* 
 are agreed as to its occupying the first place in the treatment of the 
 acute form, but opinion is divided with regard to it in the chronic 
 form, especially as to bleeding. 
 
 Experience has taught me the wisdom of limiting myself to local 
 bloodletting, though I do not deny that bleeding may be indicated 
 exceptionally in a strong woman of sanguine temperament. In acute 
 perimetritis leeches or cupping glasses should be apphed to the 
 abdomen even in the puerperal state, and should be repeated at short 
 intervals. The apparent amelioration effected by a first application 
 associated with narcotics must not be trusted to ; fresh applications 
 
 ^ Recherches sur une des coAises les phis frequentes et les moins connues 
 d'avortement. Paris, 1828. 
 
 ^ Behier recommends preventive treatment. Whenever the cord is felt, 
 which, according to him, is the first sign of the development of phlegmons of 
 the broad ligament, continuous refrigeration is applied to the abdomen. An 
 india-mbber bag, two-thirds full of pieces of broken ice, is placed over the 
 painful region, with a wet towel folded in eight under it, to prevent its being 
 in immediate contact with the skin, the whole being kept in place by a large 
 towel which allows the patient to move without any danger of disarranging 
 the ice. The application of cold should be continuous. The success obtained 
 by this treatment has been described by Briand in his thesis and by Joulin in 
 his Traits d'accouchements, p. 1171. 
 
PERT-UTERINE INFLAMMATION 561 
 
 should be made three or four days running, gradually diminishing the 
 number till pelvic pain is no longer elicited by pressure. Leeching is 
 impossible when inflammation is very acute on account of the difficulty 
 and pain caused by the introduction of the speculum; but it should be 
 resorted to as soon as the local symptoms are somewhat alleviated, as 
 well as in chronic perimetritis. Bloodletting produced by leeching 
 is neither revulsive nor derivative; it is really depletive. This deple- 
 tion of the utero-ovarian sanguineous system is necessary to ensure the 
 efficiency of the revulsive and resolvent treatment which is to follow. 
 It has seemed to me insufficient in itself to produce a cure, especially 
 iu the chronic forms of these maladies. 
 
 Further : bloodletting alone, whether local or general, especially in 
 chronic peri-uterine inflammation, as in all other chronic phlegmasias, 
 congestions and engorgements, is followed by a decided aggravation of 
 symptoms, if not immediately, at least subsequently. I have so often 
 had occasion to observe these troublesome results, that I have not the 
 slightest doubt on the matter, and explain the phenomena by the 
 increased instability produced in the organism by the debility of the 
 patient. As a rule the weaker a patient is the greater tendency will 
 there be to fluxionary movements followed by more or less intense 
 congestion, especially in the organs which have become the seats of 
 these fluxionary movements. The equilibrium once broken is lost by 
 increased general debility. Restoration of tone and strength to the 
 economy can alone re-establish it, and facilitate the gradual disappear- 
 ance of local inflammatory phenomena. Therefore depletion of the 
 utero-ovarian vascular system by leeching the cervix ought to be as 
 complete and as rapid as possible, so that it may not be necessary to 
 recur to it unless in cases of chronic inflammation with exacerbations, 
 which can never be removed quickly nor at once. When necessary, 
 therefore, I always make two or three consecutive applications after 
 menstruation. When one application has produced a very abundant 
 flow of blood necessitating plugging, cure follows very rapidly. This 
 depletion of the utero-ovarian vascular system ought to be accom- 
 panied not only by other antiphlogistic means, but by strong revulsives 
 and resolvents as well as bj tonics. 
 
 Absolute rest should be enjoined in acute inflammation; patients 
 instinctively feel the necessity for it, the semi-flexed position being the 
 most favorable to relaxation of the muscles compressing the inflamed 
 parts. Bernutz rightly insists on confinement to bed being prescribed 
 as for men in cases of orchitis. In fact even in the chronic form 
 patients should take as much rest as possible, both mental and physical, 
 and should always keep their bed at the monthly period. Marital 
 intercourse should be absolutely forbidden, for unless the suffering 
 organ has perfect rest treatment is powerless to effect a cure. I agree, 
 however, with Bernutz that in the last stage of the malady there is no 
 occasion to dread the occurrence of conception, which sometimes takes 
 place easily at the end of the menstrual flow. Pregnancy indeed is one 
 of the most efl'ectual means of modifying the diseased organs and of 
 completing the resolution imperfectly produced by the various medi- 
 
 36 
 
562 UTERINE DISEASES IN DETAIL 
 
 cations employed, that is if proper care be taken during gestation and 
 after labour. 
 
 In order to allow patients to rise without interfering with the rela- 
 tive rest required for the abdomen, Bernutz has invented a particular 
 kind of corset, which is useful, not because it fixes the organs as he 
 thinks, but because it supports them and especially prevents the effects 
 of shocks during a period of the disease when the hypogastric belt and 
 cushion (very superior as a means of supporting the abdominal viscera) 
 could not be tolerated on account of the sensitive state of the abdominal 
 region. According to Bernutz this corset plays the same part that the 
 sling does for men affected with orchitis. The idea of supporting the 
 abdomen is good : the best belt is that of Bourjeaurd with or without 
 the air cushion according to the indication. Strict diet should be ob- 
 served during the acute stage, and even in the transition stage great 
 prudence should be exercised. In the chronic form, on the contrary, 
 the diet should be very nourishing, though light and digestible, so 
 that the patient may regain flesh and strength. Emollients should be 
 applied in every form : linseed poultices to the abdomen, fomentations 
 of decoction of marshmallow or poppy-heads, and when these are not 
 tolerated^ embrocations of camphorated oil ; enemata of the decoc- 
 tion of marshmallow, linseed, poppy-heads, starch or oil ; prolonged 
 tepid baths as soon as they can be borne, repeated daily in the 
 acute stage, twice or thrice a week in the chronic form, vaginal 
 injections being made all the time of the bath. Yaginal injections 
 should also be made on the bidet with starch and water, and in 
 some cases poultices in muslin bags should be introduced as far as 
 possible into the vagina ; they may be made of linseed, funis 
 crispus (Lelievre^s instantaneous cataplasm), &c. : such are the dif- 
 ferent ways of employing emollients concurrently with antiphlogistic 
 treatment. 
 
 In acute perimetritis, as in peritonitis, rest should be ensured to the 
 intestines and pain alleviated by the use of narcotics, especially opium. 
 One of the great uses of opium is to put a stop to the stimulation 
 produced by pain which is a continual cause of fluxion (uli stimulus 
 ibijluxus), and thus two elements of the inflammation are subdued 
 simultaneously. It is useful also in suppressing alvine evacuations 
 and of giving absolute rest to the intestine, which is so necessary in 
 alleviating the inflammatory phenomena : when required, laxative 
 enemata should be administered previously, by means of a large rectal 
 or oesophageal sound introduced far enough to pass beyond the tumour 
 (which often projects into the rectum and compresses it), so that the 
 fluid may penetrate into the colon. After an evacuation produced by 
 this simple means rest is often obtained for the intestine. While, 
 however, using narcotics to alleviate pain, the physician should beware 
 of mistaking the insensibility produced for real improvement and con- 
 sequently of omitting to prescribe a fresh application of leeches when 
 required. When leeching followed by the use of other means just 
 enumerated fails to relieve the inflammatory symptoms, or when the 
 weakness of the patient does not allow of bloodletting, recourse may 
 
PERI-UTERINE INFLAMMATION 563 
 
 be had to mercurial and belladonna ointment : from ^v to ^vij of the 
 ointment is spread on a large compress and laid on the abdomen ; this 
 plaster is better than frictions, which aggravate the pain. A thick 
 layer of cotton wool should be laid over it and waterproof over all in 
 order to maintain a moist heat over the abdomen, which helps the 
 absorption of the ointment. The external application of mercury may 
 sometimes be associated with the internal use of calomel. Small doses 
 of calomel may be given combined v^ith jalap. But I do not think 
 that the intestinal fluxion produced is favorable to the resolution of 
 the inflammation nor that salivation is desirable ; for even supposing 
 it efficacious it is attended by so many disadvantages that I have quite 
 given it up. 
 
 II. The second indication is to try to obtain resolution of the tumour 
 and of the liquid and solid matter which has been deposited on the 
 peritoneum. Having explained how useful intestinal rest is during 
 the acute period, it is needless for me to say that purgatives should 
 be proscribed during this period. 
 
 After bloodletting Bernutz recommends that the whole abdomen 
 should be covered with a camphorated blister. This means certainly 
 may be of great use, but should only be applied in very serious cases. 
 Usually blistering is indicated rather at a later period. When resolu- 
 tion commences but progresses slowly a hypogastric blister is an excellent 
 means. We may then follow the example of Piedagnel, Nonat, &c., 
 and powder it with gr. ^ or gr. | of hydrochlorate of morphia to 
 prevent its causing pain. The blister should not be applied at the time 
 of the monthly period, and its effects should always be carefully 
 watched. It is, however, in the transition stage of the disease to the 
 chronic form and in the latter period that blisters are of most use ; 
 they may be said indeed to be the best means of causing the dis- 
 appearance of plastic products. Yelpeau has been the means of their 
 being largely used in such cases. They are applied after bloodletting 
 or substituted for it when there are signs of the formation of pus. One 
 may be applied every month, a few days after menstruation; but if 
 necessary it may be repeated two or three times a month, and should 
 exceed the size of the tumour. They are applied to the hypogastrium, 
 to one or other of the iliac fossse, to the loins, sometimes to the 
 buttock. They should be removed in twenty-four hours and the serum 
 evacuated, care being taken to leave the epidermis in place. A thick 
 layer of cotton- wool should be applied and kept in place by a bandage 
 for several days, as in the case of a burn. Aran boasts of the efficacy 
 of blisters applied to the cervix in chronic perimetritis, but I confess 
 that their use has always seemed to me more suitable in chronic leu- 
 corrhoea than in peri-uterine inflammation. The cauteries, moxas and 
 setons proposed by Huguier and Gosselin are not so useful as in the 
 treatment of ovaritis. The blister acts on a larger surface, it stimulates 
 more suddenly, and its repeated action is more favorable to the elimina- 
 tion of the serum and pus than the continuous but slow and moderate 
 action of these exutories. 
 
 The action of resolvents and alteratives should be associated as soon 
 
564 UTERINE DISEASES IN DETAIL 
 
 as possible with the former means. Preparations of raercurj, iodine, 
 gold and arsenic should be administered internally, whilst externally 
 frictions should be made daily with mercurial or iodine ointment, or the 
 hypogastrium may be painted with tincture of iodine.^ In such cases, 
 as in ovaritis, I have found small enemata of resolvent ointment of great 
 use ; they are better than suppositories because they can be introduced 
 farther, they melt more easily, are tolerated better and are more easily 
 absorbed. The injection of mercurial ointment per rectum may be 
 associated with painting the hypogastrium, cervix and vagina with 
 iodine ; or the application of mercurial ointment on the hypogastrium 
 may be associated with iodide of potassium per rectum and tincture of 
 iodine per vaginam. The action of these merdicaments is increased by 
 tepid and prolonged alkaline or saline baths, by the use of iron, tonics, 
 generous diet and residence in the country, by the use of mineral waters 
 (alkaline and chloride of sodium waters, such as those of Plombieres, 
 Ems, Soden), and at a later period by cold silz-baths, cold abdominal 
 compresses, cold enemata — hydropathy in short — which may be con- 
 tinued for several months till the menses have recurred regularly several 
 times. When the malady is on the decline or when resolution is 
 effected, mineral waters are suitable for the treatment of complica- 
 tions and for restoring the strength ; sea-bathing, hydropathy, sulphur 
 or iron waters, the waters of Luchon, Cauterets, St. Sauveur, Spa, 
 Plombieres, Neris, are indicated. Hydropathic and hydromineral medi- 
 cation is not merely palliative. It is the best adjuvant of resolvents. 
 Purther, these waters have an essentially resolvent action of themselves, 
 in addition to the tonic, restorative or sedative action which they exercise 
 according to their nature or to the manner in which they are adminis- 
 tered. Only this action varies with the patient and the period of the 
 malady ; it varies according to the nature of the diathetic aflPection 
 which complicates the peri-uterine inflammation ; it varies also with the 
 mineral water and with its mode of administration. Hence another 
 action beyond that of simple absorption of plastic products, which 
 leads to these medicaments being classed among those which fulfil the 
 third indication in the treatment of perimetritis. 
 
 III. The third indication is to treat the diathetic affection under the 
 influence of which chronic perimetritis has a tendency to be per- 
 petuated, and at the same time restore the weakened and deteriorated 
 organism. Pelvic peritonitis being according to Bernutz a malady 
 symptomatic of very different affections, presents very various thera- 
 peutical indications, not only according to its acute or chronic form, 
 its sero-adhesive or purulent nature, but according to the indications 
 furnished by the diathesis of which the inflammation of the serous 
 membrane is a remote manifestation. Bernutz therefore recommends 
 mercury when there is reason to believe that the diathesis is syphilitic, 
 turpentine when there is blennorhagia, &c. 
 
 ^ Joannowsky of Prague {Prager Vierteljahrsclio-i'ft, 1878) lias proved that 
 iodine is absorbed and is found in the urine. Out of 30 women treated by- 
 painting the hj'pogastrium, cervix and vagina with iodine, 11 were cured, It 
 improved. 
 
PEEI-UTERINE INELAMMATION 565 
 
 It is in chronic pelvic peritonitis that the principles of Beruutz may 
 be applied. He recommends the alkaline waters of Vichj if dyspepsia 
 predominates, hydropathy if the symptoms are nervous, sulphurous 
 baths if scrofula has previously existed, arsenical baths if there is any 
 cutaneous affection the result of scrofula, arthritis or rheumatism. The 
 determination of the diathesis, to which the chronicity of the inflam- 
 matory action is to be attributed, deserves the careful attention of the 
 physician. Bernutz usually associates hemlock with this antidiathetic 
 medication. He considers it the specific narcotic of the genital oro-ans, 
 and increases the dose till disorders of vision and hallucinations are 
 produced. He is not, however, sure of its efficacy. As to iodide of 
 potassium, I do not see that its administration is contra-indicated, as 
 he says, by the necessity of feeding up patients. 
 
 IV. The complications which coexist with perimetritis or which 
 persist after its cure must also be treated. Vomiting is one of the first 
 complications which may require treatment, for it is symptomatic of 
 peritonitis. It appears at the most acute period of the disease and 
 returns with every exacerbation. In order to stop it nothing should be 
 taken but fragments of ice from time to time or a little iced cham- 
 pagne, lemonade or soda water ; sedatives should be given externally 
 and internally, opium, belladonna, chloroform, a blister powdered with 
 hydrochlorate of morphia on the epigastrium, nux vomica or strychnia 
 in small doses or subnitrate of bismuth. One of the best preparations 
 is the following: Pulv. Eadic. Caiumb., Calc. Carb. prep, aa gr. 1^ to 
 gr. 3; Pulv. Bellad. Eadic. gr. -^V to gr. i mixed and given in a 
 spoonful of iced water, and repeated every four hours or oftener if 
 necessary. The distension of the belly which often occurs with 
 vomiting should be treated with poultices sprinkled with camphor- 
 ated oil or with iced compresses. Constipation necessitates the 
 administration of simple or laxative enemata introduced by a thick 
 and long cannula ; mild laxatives may be given by the mouth in the 
 chronic period, and in the absence of acute pain in the belly. When 
 it does not yield to these means, cold ascending douches should 
 be prescribed or pills containing from gr. | each of the extract 
 and powder of bellad. and gr. ^^^ of strychnia, a little sulphate 
 of zinc, or even a little aloes with great prudence. If diarrhoea 
 occurs, it should be treated with bismuth or opium, giving from 
 gr. 3 to gr. 4-^ in the day, care being taken to give it in small 
 doses at a time. Small enemata may also be given containing a 
 little laudanum or nitrate of silver in the proportion of gr. 3 to gr. 6 
 in ^iij of water. 
 
 Pain and neuralgia are the most frequent complications during and 
 after the malady. I have already explained how the pains of acute 
 perimetritis should be subdued by large doses of opium which also 
 ensure the rest so necessary to the viscera. Anodyne fomentations 
 should be applied simultaneously with the same object. Bernutz 
 recommends a bath every three or four days, and from 5 to 7 grains 
 of powdered hemlock every day. Wlien pain occurs suddenly in the 
 loins or belly during chronic perimetritis, it is usually the sign of aa 
 
566 UTEEINE DISEASES IN DETAIL 
 
 exacerbation : one of the best means of dissipating it is to leech the 
 cervix and then apply a blister to the abdomen or rub with croton oil, 
 care being taken to cover the part afterwards with adhesive plaster to 
 prevent pain being produced by contact with the clothes. When pain 
 continues and uterine or peri-uterine hyperaesthesia also exist, Aran's 
 application of laudanum may be tried, which consists in pouring a 
 little into the vagina by means of a speculum and then applying a 
 tampon. In place of simple pain, there is often neuralgia, even at the 
 commencement of the disease in hysterical patients, but generally at 
 the end. This neuralgia is best subdued by the application of a 
 small ammoniated blister to the painful part, which must be after- 
 wards dressed every day with hydrochlorate of morphia, or by sub- 
 cutaneous injections of this salt. Lastly, as the final treatment of 
 the nervous symptoms which persist after pelvic peritonitis, recourse 
 should be had to hydropathy and to residence in the country, 
 as the best adjuvants of narcotics, faradisation, the continuous cur- 
 rent, &c. 
 
 There may be haemorrhage in chronic perimetritis though this 
 seldom occurs ; when it does, hemostatics should be administered, 
 such as lemonade, mineral acids, rhatany, cold or acid applications to 
 the hypogastrium, or on the contrary very hot injections; sometimes a 
 blister on the iliac fossa stops the flow. Ergot should never be 
 employed in such cases. As for the other comphcations, metritis, 
 nterine catarrh, leucorrhcea, vulval pruritus, deviations, &c., they are 
 ameliorated by the treatment of perimetritis, but should not be 
 attacked directly till after the peri-uterine inflammation has been 
 cured. ^ 
 
 Y. The opening of the purulent collection. In the case of acute 
 pelvic peritonitis puncture may be made through the vagina. This 
 often simplifies the malady and hastens cure as in cases of acute 
 pleurisy with effusion; but as it is attended with some risk it is 
 usually preferable to wait the formation of pus. Even when pus is 
 formed, opinions are divided as to whether the abscess should be 
 opened. Bourdon ^ is in favour of the artificial opening of pelvic as 
 of all other abscesses ; he says " the presence of pus facilitates its 
 formation ; the tumour may be very large and the pus may travel a 
 long way producing irreparable mischief; the abscess finding no 
 external outlet may be discharged into the peritoneum ; and if the 
 opening occurs spontaneously or is made late, patients are condemned 
 to sufferings which they might have been spared ; it may also open at 
 an unfavorable point for the discharge of pus; and lastly, in many 
 cases the patient being greatly enfeebled by a long malady is no 
 longer in a favorable condition for recovery after the opening of the 
 abscess, even in the absence of interminable fistulas and suppurations.'" 
 Nonat also insists on the necessity of opening abscesses : the presence 
 of pus may cause peritonitis, even phlebitis with general disorders and 
 
 ^ Piotowsky {Bu catarrhe iderin d^xns la pelvi-peritonite et de son traite- 
 ment) places beyond doubt the dangei-s attending too hasty intervention. 
 ' Tumeurs jiuctuantes du petit hassin {Revue medicale, 1841). 
 
PEEI-UTERINE INFLAMMATION 567 
 
 perforations which may be fatal. Bernutz also recommends artificial 
 opening as soon as symptoms of hectic fever have succeeded the acci- 
 dents of acute pelvic peritonitis. 
 
 Aran on the contrary thinks that pelvic abscesses should seldom be 
 opened artificially : he says that the pus being imprisoned in a kind of 
 cyst formed by false membranes does not spread; an artificial opening 
 does not prevent a natural opening occurring at an unfavorable point 
 for the evacuation of pus ; hectic fever may follow the one as well as 
 the other ; lastly^ the pus may possibly be absorbed and the malady be 
 cured without any opening either natural or artificial as occurred in 
 cases described by Aran and Marchal de Calvi. It is therefore 
 prudent he thinks to abandon the opening of pelvic abscesses to 
 nature. I think, however, that these reasons are exaggerated. On 
 the one hand, the origin of abscesses should be taken into account ; 
 expectation is more indicated in those produced by pelvic peritonitis 
 (which is usually encysted), artificial opening for those resulting from 
 a phlegmon of the broad ligaments, as it has a tendency to spread. 
 On the other hand, whatever be the origin, though pelvic abscesses 
 may not always be in conditions to be opened early, as happens in 
 other purulent collections, I think it is dangerous to wait too long. 
 If the abscess reacts on the economy, if the presence of pus causes 
 hectic fever, if the tumour raising the abdomen seems to adhere to it 
 or to project towards the vagina or rectum, if the walls have become 
 thin announcing imminent rupture, if the abscess has opened at an 
 unfavorable point for the complete evacuation of the pus, if the urine 
 or fsecal matter accumulates in the sac the abscess should be opened 
 artificially. 
 
 When the abscess is subtegumentary it should be opened through 
 the abdominal wall. When it is very superficial and points to the 
 surface of the abdomen, and when there is reason to hope that adhe- 
 sions are established between the visceral and parietal peritoneum the 
 bistoury may be used ; in doubtful cases the bistoury should only be 
 used according to the method of Graves, who reaches the peritoneum 
 without opening it, or according to that of Begin, who incises the 
 parietal peritoneum without touching the tumour. As a rule, how- 
 ever, the use of caustics is preferable, all the more so that by arousing 
 the vitality of the tissues and producing a salutary derivation they may 
 exceptionally bring about the absorption of pus. In employing them 
 the rules laid down by Recamier for the opening of liquid tumours of 
 the liver should be observed, or those of Martin^ for the opening of 
 deposits of the annexes occurring after delivery, that is to say, succes- 
 sive applications of caustic potash should be made at the same point 
 from without inwards. Vienna paste is better still : the scar should 
 be incised and excised daily and a fresh appHcation of the caustic 
 made so that adhesions may be established all round the opening after 
 the abscess is reached. If the opening remains fistulous too long 
 there is no danger in cautiously trying antiseptic and iodine injections. 
 
 1 Memoires de med. et de chir. prat., p. 312. Paris, 1835. 
 
568 UTERINE DISEASES IN DETAIL 
 
 Bertrand^ cured an abscess in this way, tlie pus from whicli was eva- 
 cuated by the navel after puerperal metro-peritonitis lasting for six 
 months. We know of cases of definite cure due to pregnancy, proba- 
 bly owing to the compression and adhesion of the walls of the abscess. 
 Why then not imitate nature, taking care to exercise methodic com- 
 pression of the hypogastrium, after the pus has been evacuated, with 
 Bourjeaurd's belt? I have seen methodic compression do so much 
 good in cases of iliac abscess and of enormous abscesses in the hips 
 that I have no doubt as to the efficacy of this means when applied to 
 the cure of pelvic abscesses. Lister^s antiseptic treatment should also 
 be carefully carried out. 
 
 When the abscess points towards the vagina or rectum it should be 
 opened there. Openiag by the vagina is easier and more favorable, 
 and therefore should always be preferred when possible. According 
 to Bernutz, a curved trocar can when necessary be introduced by one 
 of the iliac fossae passing thence into the vagina. This method has 
 been employed by Koeberle after ovariotomies giving rise to an accu- 
 mulation of pus in the vagino-rectal cul-de-sac, and by Pean,^ who has 
 invented a curved trocar for perforating the posterior vaginal cul-de-sac 
 from above downwards; it is introduced by a small incision in the 
 abdominal wall above the crural arch near the border of the uterus. 
 In such cases I have introduced a long curved trocar (such as is used 
 in puncturing the bladder by the rectum in men) behind the uterus, 
 by means of which I have perforated the retro-uterine cul-de-sac and 
 passed a drainage tube into the wound. In such cases caustics cannot 
 be used ; the bistoury is introduced, with or without the speculum to 
 the dependent part, or to the most projecting portion of the tumour. 
 When Eergusson's speculum cannot be used Sims's should be tried, or 
 the labia and vaginal walls may be kept apart by the fingers of assis- 
 tants or by the instruments invented by Jobert for the operation of 
 vesico-vaginal fistula. Eecamier used a pharyngotome or a silver bis- 
 toury.^ Blandin^s or any other concealed bistoury can be employed. , 
 However an ordinary straight bistoury will serve the purpose; its 
 blade should be covered with linen or diachylon plaster to within half 
 an inch of the point and introduced flat on the index finger till the 
 most projecting and resistant portion of the tumour is reached and 
 pierced, moderate pressure being used till we feel that resistance has 
 been overcome and that pus is being discharged. Large openings 
 should not be made for fear of hsemorrhage, for the flow of blood is 
 often considerable even when a vertical direction has been given to the 
 incision according to Recamier's advice. The best instrument of all 
 is the fine aspirator trocar ; it is introduced like the bistoury on the 
 index finger of the left hand ; we make sure that it has entered the 
 cavity of the abscess by withdrawing the stylet, and if the pus is not 
 discharged easily the opening is enlarged. Usually there is not much 
 
 * Bulletin de la 8ocietedemed.de Besangon, 1858. — Gazette med. de Paris, 
 1860, p. 430. 
 ^ Ovariotomie et splenotomie, p. 21. Paris, 1869. 
 ^ H. Bourdon, Mem. cit., p. 71. 
 
LEUOOEIiHCEA AND UTEEINE CATAKRH 569 
 
 pus, and it is quite exceptional for the sac to fill again and again and to 
 persist in the fistulous state. Hence the uselessness of a second punc- 
 ture ; it would be better to discover the purulent collections of the 
 ovary and Fallopian tube, which are situated frequently in the centre 
 of the abscess, and evacuate their contents ; unfortunately it is very 
 difiicult. After puncture it is unnecessary to leave the cannula of the 
 trocar in the opening ; or even to introduce a gum-elastic sound as 
 Laugier did after puncturing a peri-uterine hematocele, or a tent, 
 because there is not always pus to be discharged, and all these foreign 
 bodies touch the peritoneum and consequently may become very 
 dangerous. 
 
 After puncture perfect rest should be enjoined and emollient 
 enemata and cataplasms prescribed. That improvement may be lasting- 
 inflammation must be entirely extinguished : many cures are then ob- 
 tained, as mentioned by Bourdon in his paper. A strict diet, how- 
 ever, should not be enforced for long. On the contrary, tonics, bitters, 
 quinine and iron should be given. Lastly, we hold ourselves in 
 readiness for the approaching monthly period when there will be a 
 recurrence of pelvic pain and inflammation. 
 
 Of Leucorrhcea in General and Uterine Catarrh in 
 Particular 
 
 Leucorrhcea is a pathological discharge produced by the increase 
 and alteration of the normal secretions of the genital economy. This 
 name, which literally means white discharge [XevKog white, puv to 
 flow), is commonly used to denote all discharges except that of 
 blood, depending on diseases of various nature, excreted by different 
 organs, being less a special malady than a symptom common to several 
 diseases. The progress of medicine with regard to this has been 
 checked for long by a feeling of modesty on the part of women ; for a 
 great number refrain from telling their physician of these discharges, 
 whilst others inform him of the fact, but refuse to submit to an 
 examination. Now there is as much difference between the various 
 kinds of white discharges as there is between various kinds of expecto- 
 ration. 
 
 We shall give the name of false leucorrkoea to fluid discharges of 
 various kinds issuing from the genital organs, reserving that of leucor- 
 rhcea to those produced directly by these organs under the influence of 
 a very characteristic pathological condition. 
 
 I. False leucorrhcea. — This may be occasioned by the presence of 
 foreign bodies or by the development of more or less serious organic 
 lesions. A foreign body, such as a pessary, remaining in the vagina 
 or in the uterus produces inflammation, hypersecretion and suppura- 
 tion, retaining purulent fluids which in decomposing exhale a pene- 
 trating odour of acid fermentation. Hydatidiform or fleshy moles, 
 polypi, fibroid tumours, produce discharges resulting from the irrita- 
 
570 UTEEINE DISEASES IN DETAIL 
 
 tion produced by their presence on the uterine mucous membrane and 
 especially on its glands. Abscesses of the uterus or extensive sup- 
 puration of the whole internal surface of the organ may determine the 
 intermittent or continuous discharge of quantities of pus, which are 
 seen in such cases to issue from the uterine cavity itself. Ashwell 
 has seen half a pint of pus discharged from this cavity, and Saflbrd- 
 Lee once saw an abundant purulent discharge produced by the presence 
 of a polypus (referred to by Graily Hewitt, p. 86). Matthews Duncan^ 
 describes the case of an old woman who had ceased to menstruate, 
 and who had a considerable discharge of pus from the uterine cavity ; 
 I have seen a similar case j and another in which an interstitial abscess 
 opened on the anterior lip of the cervix. Uterine tuberculisation, 
 which however is rare, may also determine an aqueous, dirty yellow or 
 pale brown discharge. Cancer produces a serous or sero-sanguineous 
 discharge like reddish water, sometimes acrid and irritating to the sub- 
 jacent tissues, seldom inodorous, usually foetid. Lastly, the evacuation 
 of an ovarian cyst by the Fallopian tube may cause a discharge which 
 may be confounded with leucorrhoea. 
 
 II. Leucorrhoea properly so called. — Leucorrhoea, like the white 
 discharges just enumerated, is usually symptomatic ; indeed it is only 
 by an abuse of language that leucorrhoea can be called idiopathic. 
 Nevertheless I think it is well to keep the name and give the patho- 
 logical description of leucorrhoea for several reasons. The first is the 
 interest presented by leucorrhoea in uterine semeiology. The second 
 is the importance of this sjmptom with regard to indications. In order 
 to judge of the existence, intensity, seat and nature of leucorrhoea, we 
 must first of all learn to recognise the leucorrhmal products. 
 
 The normal secretions of the vulva, vagina and uterus differ from 
 each other just as do the membranes from which they are produced. 
 
 Vulval mucus is viscous, slightly adherent to the fingers when 
 touched, becoming thready when the latter are slightly separated. 
 That of the vulvo-vaginal glands resembles greatly that of Cowper's 
 glands in man. It gives an acid reaction. The mucus of the ves- 
 tibular and peri-urethral follicles has always seemed to me more acid 
 than that of the vulvo-vaginal glands. When mixed with the seba- 
 ceous secretion it often forms a kind of magma with a cheesy smell or 
 rather a smell of sour and fermented cheese. Sometimes, although in 
 immediate contact, the two products do not mix. 
 
 The vaginal fluid, to which the name of mucus should perhaps 
 not be given, cannot apparently be produced in such abundance as the 
 mucus of the vulva and uterus, at least not in the normal condition. 
 It is a clear, transparent, serous fluid, having no viscosity, but seldom 
 seen alone, for apparently it is only the vehicle of innumerable broad, 
 lamelliform corpuscles which are detached continuously by exfoliation 
 and in more or less considerable quantity from the surface of the 
 mucous membrane, giving to the excretion the white, opaque, cheesy 
 aspect which characterises it. The vaginal excretion therefore is in 
 
 1 Edin. Med. Journal, March, 1868. 
 
LEUCOEEH(EA AND UTERINE CATARRH 
 
 571 
 
 factj as described by Donne/ a thick creamy fluid, never glutinous like 
 that from the uterus, acid and containing cells of pavement epithelium 
 four or five hundredths of a millimetre in diameter. This mucus is 
 acid, whilst that from the uterus is alkaline ; both contain globules 
 of pus in proportion as the mucus is diseased ; their colour is more 
 or less modified according to the quantity of these anatomical 
 elements. 
 
 The uterine mucus is quite different from the vaginal fluid. It is 
 more like vulval mucus, although distinguished from the latter by its 
 physical characters and by its mode of excretion. We must, however, 
 remember that the name uterine mucus includes two very different 
 kinds of mucus : that of the cervix and that of the fundus. Both are 
 limpid normally, and the secretion is so scanty when the organ is at 
 
 Fig. 329. — Vaginal pavement epithelium covering the mucous membrane of 
 the cervix. 240 diameters (Tyler Smith). 
 
 rest that when examining with the speculum a woman whose uterus is 
 normal not only is there no discharge to be seen, but not even a single 
 drop can be forced to exude by pressing the cervix with the instru- 
 ment. Both may appear at the uterine orifice in the form of a drop of 
 thin transparent fluid spreading from the orifice to the lower lip of 
 the cervix, increasing in quantity by pressure, but remaining adherent 
 to the organ, from which there is usually some difficulty in detaching 
 it entirely even by wiping with cotton-wool. In this mixed fluid there 
 is usually more mucus from the cervix than from the fundus ; but the 
 mixture may be so equal that it is difficult to distinguish them. Some- 
 times their different characteristics are recognised at once by the 
 absence of one or other secretion ; sometimes the cervix is obstructed 
 by its own secretion; sometimes it does not apparently secrete mucus, 
 but after the sound has been used a fluid is seen to exude which really 
 comes from the body, or the hollow sound brings with it a portion of 
 this fluid, the special characters of which may then be distinguished. 
 Both are transparent and limpid, and if, as some observers aflirm, that 
 of the cervix is yellowish and that of the body semi-transparent and 
 greyish, it is owing I think to some slight disorder of the secretion. I 
 
 * Cours de microscojne complcmentaire des etudes medicales, p. 155. Paris 
 1844. 
 
572 
 
 UTERINE DISEASES IN DETAIL 
 
 have never observed such differences in the normal state. Both have 
 a peculiar stale odour, which may be strong in different diseases and 
 after delivery or puerperal fever, but which is never acid; both, on 
 
 
 
 
 nwr^'i^ 
 
 4.1 
 
 Fig. 331,— Cylindrical epithe- 
 lium with vibratile cilia 
 from the cavity of the body 
 of the uterus. 220 diame- 
 ters (Tyler Smith). 
 
 Fig. 330. — Normal mucous secretion from 
 the cervix, extracted from its mucous 
 follicles. The mucous corpuscles ai'e 
 ranged in longitudinal series owing 
 to the viscosity of the fluid in which 
 they are entangled. 220 diameters 
 (Tyler Smith). 
 
 the contrary, are always alkaline. As to their distinguishing charac- 
 teristics, that of the cervix is gluey, tenacious, half solid rather than 
 liquid ; hypersecretion of it is frequent ; mucous corpuscles, cells of 
 nucleated epithelium, are more or less abundant in the transparent and 
 granular fluid. During pregnancy it is produced in considerable 
 quantity, and is then more glutinous, more tenacious still than in the 
 state of vacuity, and it plugs the cervix {houchon gelatineux) . It does 
 not hold any other anatomical element in suspension except the nucleated 
 cells ; it is entirely homogeneous. That from the body is viscous, less 
 tenacious than that from the cervix; it contains numerous epithelial 
 globules, ovoid nuclei, coming from the flexuous follicles of the mucous 
 membrane, prismatic epithelial cells or cylindrical and vibratile cells 
 from the surface of this mucous membrane, sometimes granular bodies 
 of inflammation. The relatively large number of these solid elements 
 mixed with the secreted fluid sometimes alters its transparency, giving 
 it the grey tint of which I have just spoken. This distinction is all 
 the more important as uterine leucorrhcea is often limited to the 
 cervical mucous membrane. 
 
 To sum up, this.mucous surface, which was long regarded as iden- 
 tical in all its parts, secretes mucus, the physical and chemical 
 
LEUOOREHCEA AND UTERINE CATARRH 573 
 
 characters of which are very different. If these differences have not 
 been observed sooner, it is because the speculum has only been used 
 during the last fifty years, because the utero-vaginal secretions were 
 often altered or mixed in cases where the introduction of the speculum 
 would have allowed them to be distinguished, because the attention of 
 the physician was not directed to searching for differences between 
 fluids coming from mucous membranes the anatomical structure of 
 which was supposed to be similar, and lastly, because in other cases in 
 which it was a question of diseases not accompanied by discharges, 
 or in which the genital organs, the uterus especially, were in normal 
 health, secretions were not observed. 
 
 III. Idiojmtkic leitcorrkixa is an abnormal discharge from the 
 mucous membranes of the genitals, more especially from the uterus ; 
 it is mucous or muco-purulent, favoured by general atony and by a 
 local predisposition, and filially determined by a slight irritation of the 
 secreting membrane or by a functional imperfection, such as chlorosis. 
 It constitutes a special morbid condition or an essential malady, the 
 same as any other fluxion such as diarrhoea, bronchorrhoea, urethral 
 blennorrhoea, sialorrlicea, profuse sweating, &c. Amongst other condi- 
 tions of general atony which predispose to leucorrhcea, we may men- 
 tion age, temperament, constitution, climate, food, &c. It is difficult, 
 however, to appreciate the influence of these various causes. It is 
 said that feeble constitutions and lymphatic temperaments are subject 
 to leucorrhoea, which I think is true in spite of the contrary assertion 
 made by some pathologists who have probably observed cases of 
 simultaneous blennorrhagia, vaginitis and leucorrhcea in prostitutes, 
 and who have made these the basis of their statistics. I think it is 
 more commonly met with in young women than in old ; I have seen 
 it in girls after the appearance of the catamenia. Cold and damp 
 climates also predispose to it. It has been said that warm climates 
 relax the vessels and prepare the way for fluxions and hsemorrhages, 
 but as a matter of fact it has been proved that damp countries, such 
 as Belgium, Holland, and the marshy districts of England do so much 
 more.-^ According to statistics made in Paris by Marc-Despine, and 
 in Marseilles by Girard, two thirds of the women in Paris suffer from 
 leucorrhoea, whilst only one fourth of the Marseilles women do.^ 
 Residence in towns is generally considered as favorable to leucor- 
 rhoea, and this opinion is confirmed by the researches made by Brierre 
 de Boismont.^ Lastly, a poor diet is one of the most powerfully pre- 
 disposing causes ; it is on this account that the use of coffee has been 
 blamed, but wrongly so, for when pure it is very wholesome. To 
 these causes of general debility we may add the more special ones 
 which act in the same direction : prolonged lactation in weak nurses, 
 cardiac disease, chronic pulmonary disease, emphysema, tendency to 
 
 ^ Graily Hewitt, op. cit., p. 89. 
 
 ^ Marc Despine, Recherches anatomiques sur quelques points de Vhlstoire 
 de la Heucorrhee, in Archives generales de medecine, 2* sei-ies, t. x, p. 105. 
 Paris, 1836. 
 
 ^ De la menstruation consider ee dans ses rapports pi bysiologiques ct patliolo- 
 giques, ch. xiii, Desjlueurs blanches, p. 259. Paris, 18X2. 
 
574 UTERINE DISEASES IN DETAIL 
 
 phthisis and phthisis itself^ lastly the various diatheses of which leu- 
 corrhoea is not always symptomatic but which prepare the organism 
 for it by the debility into which they throw it. To this I think we 
 may add a local predisposition, consisting in a special atony of the 
 genital economy or of one of its organs. I have often observed that 
 leucorrhceic women were pale, flabby, the vulvo-vaginal mucous mem- 
 brane being very extensible, the follicular or glandular orifices open, 
 that there were symptoms of passive hypersemia, prolapsus or flexion 
 of the uterus, relaxation of its ligaments, frequent involuntary excre- 
 tion of urine caused by laughter or some other effort, sometimes even 
 nocturnal incontinence of urine. In women who have these predispo- 
 sitions, leucorrhoea may be determined by two causes of different kinds 
 which it is important to diagnose in order to seize the indications of 
 treatment. Sometimes a slight local irritation suffices to produce the 
 discharge which is afterwards kept up all the more easily because the 
 patient is in a sense prepared for it. Venereal excitement, excessive 
 coitus, menstruation, pregnancy, abortion, delivery are the most com- 
 mon causes. These same causes acting energetically and continuously 
 may produce inflammation of the vulva, vagina or uterus ; but usually 
 their action is limited to the production of leucorrhoea. The approach 
 of puberty, the slight excitement which precedes and follows every 
 monthly period, are often marked by the whites. Pregnancy, under 
 the influence of the fluxion and congestion which it keeps up in the 
 genital mucous membrane often develops vaginal leucorrhoea. The 
 simple congestion which it may leave in the organs, the slow retro- 
 grade evolution of the uterus, are often the starting-point of a leucor- 
 rhoeic fluxion which may be prolonged indefinitely. 
 
 Sometimes a functional imperfection of the uterus or the reaction on 
 this organ of the functional disorder of another organ may be the origin 
 of leucorrhoea. In chlorotic and amenorrhoeic girls it seems that from 
 some alteration of the blood such as general debility or atony of the san- 
 guineous vessels of the uterus, the periodical fluxion of this organ is 
 insufficient to produce haemorrhage ; it terminates in a simple mucous, 
 sero-mucous, muco- sanguineous or muco-purulent fluxion. This dis- 
 charge sometimes only appears at the monthly period, sometimes it is 
 repeated in the interval. At other times it is continuous but usually 
 increases at the time corresponding to the monthly period, decreasing 
 afterwards. I have often seen all these varieties. This discharge some- 
 times undoubtedly contains globules of pus, indicative of a slight irrita- 
 tion of the surface of the mucous membrane or its follicles ; at other 
 times it contains globules of blood which seem to signify a tendency to 
 the accomplishment of the natural hsemorrhage, or to the recurrence of 
 the normal conditions of the function; frequently it is sero-mucous as 
 if serum exuded from the vessels was mixed with mucus hyper-secreted 
 under the influence of the fluxion of which the follicles with all the 
 rest of the uterine system are the termination. The reaction exercised 
 on the uterus by the functional disorder of another organ may also 
 cause uterine leucorrhoea. The suppression of a physiological or 
 pathological function such as lactation, perspiration, expectoration, 
 
LEUCORRHCEA AND UTERINE CATARRH 575 
 
 diarrhoea, hsemorrhoids, an exutory, &c,, may originate it, or the sup- 
 pression of menstruation itself. This kind of leucorrhoea has been 
 designated by the terms metastatic or supplementari/ ; but in these 
 cases it is still more difficult than in those of amenorrhoea to discover 
 the true pathogeny of leucorrhoea and to decide whether it is really 
 supplementary of the fluxion the suppression of which coincides with 
 its appearance, or if it is, like these fluxes themselves, symptomatic of 
 a common general condition which causes both. 
 
 Lastly, leucorrhoea often exists in women who do not menstruate. 
 Now, when the menses are absent leucorrhoea may be produced in two 
 ways : like amenorrhoea it may either be symptomatic of a general state 
 which dominates both, or it appears or is increased at the time cor- 
 responding with that of the menses by the fluxion and congestion 
 which characterise this period : menstruation commences ; its ter- 
 mination by the ordinary crisis is impossible ; it terminates by a 
 mucous discharge instead of a sanguineous one. When the first 
 monthly period has been delayed, when the menses do not reappear 
 after an acute malady, or when they begin to disappear in the course 
 of chronic maladies, e. g. in phthisical patients, the appearance and 
 return of menstruation are often announced for some months by a 
 periodical leucorrhoeic discharge, which lasts like the menses for a few 
 days, and which is the indication of a real uterine congestion insufficient 
 to lacerate the vessels and produce haemorrhage ; this menstrual leu- 
 corrhoea, analogous to that which accompanies ovulation in some mam- 
 malia, has been exceptionally seen for several years in women who are 
 apparently in good health, occasionally even in some who have become 
 pregnant. 
 
 IV. Symptomatic leucorrTicP.a. — Usually leucorrhoea is only a symptom. 
 The diseases which produce it are of various kinds and occupy different 
 seats. These diseases may be either acute or chronic, general or local, 
 diathetic or non-diathetic. Amongst the diathetic causes we may 
 mention herpetic, rheumatic or scrofulous affections ; amongst the 
 local causes, sexual excitement, inflammation of the genital organs and 
 especially of their mucous membranes, uterine catarrh, or blennorrhagia, 
 which may affect the vulva, vagina and uterus, extending even to the 
 ovary, and which is distinguished by its essentially contagious 
 character. 
 
 With regard to the seat, leucorrhoea may be limited to the vulva, 
 more frequently to the vagina or to the uterus. It may invade 
 simultaneously the mucous membranes of these three organs; it may 
 even extend to the Fallopian tubes and to the ovaries and produce 
 inflammation {see Ovaritis). It can be distinguished on micro- 
 scopic examination by the characters that I have just assigned to the 
 various leucorrhoeic products of the vulva, vagina or uterus. 
 
 Some maladies have a greater tendency than others to determine the 
 appearance of leucorrhoea simultaneously or successively on all the 
 mucous membranes of the genital economy, in place of limiting it to 
 one of them. Eor instance herpetic leucorrhoea has a tendency to 
 invade alternately, or successively, various points of the utero-vulval 
 
576 UTEEINE DISEASES IN DETAIL 
 
 raucous membrane and even of the neighbouring organs. Sometimes 
 the uterine leucorrhrea diminishes and the vaginal increases ; sometimes 
 the latter is ameliorated, and the vulva is affected; the labia, the in- 
 ternal surface of the thighs and the anus are covered with eczematous 
 or herpetic vesicles, with pustules of impetigo, or at least they are 
 attacked by erythema; and then when these organs begin to improve 
 the vaginal or uterine mucous membrane is affected anew. I have 
 seen similar cases in men ; herpetic diseases successively and alter- 
 nately invading the scrotum, foreskin, glans, urethra, neck of the 
 bladder, bladder, urethra and kidney. The same remarks are appli- 
 cable to virulent or contagious hlennorrliagic leucorrliaa, to catarrhal 
 leucorrlio&a, to rheumatic leucorrhcea and to scrofulous leucorrhcea. 
 
 A. Vulval leucorrhoea. — This is common in children, especially in 
 scrofulous or herpetic girls ; it coexists or alternates with crusts on the 
 head, with impetigo, eczema, herpes. It is sometimes complicated with 
 superficial ulceration, engorgement of the inguinal ganglia, inflamma- 
 tion and suppuration of these organs. It is evidently due to excessive 
 secretion, to a herpetic eruption, to superficial ulceration caused and 
 kept up by scrofula, as suppurative maladies of other mucous mem- 
 branes usually are at this age, especially maladies of the mucous 
 membrane of the orifices, the mucous membrane of the lips, the Schneide- 
 rian membrane, the conjunctiva, the external ear, &c. It extends 
 rapidly to the vagina ; I have seen it, however, go further ; in making 
 a post-mortem examination of a child of 13, I remember having seen 
 the uterus and the external half of the Fallopian tubes filled and dis- 
 tended with epithelial debris forming a mass of cheesy matter. 
 
 B. Vaginal leucorrhcea. — -This is rarely seen in children. It is very 
 common in married women, being caused by venereal excitement, blennor- 
 rhagia, vaginitis even, or by pregnancy. Usually there is neither swelling 
 nor heat at the vulva, but it may occur, the fluid in issuing may irritate 
 the mucous membrane of the labia and produce erythema, or at least 
 an inconvenient and sometimes a painful pruritus is excited. The 
 discharge of the fluid is almost continuous, especially in pregnant 
 women. When the hymen exists or when the vulval ring has not been 
 dilated by frequent marital intercourse, the leucorrhoeic fluid may be 
 accumulated for some time in the vagina before being discharged, 
 and then its issue may appear intermittent. Frequently it is milky, 
 justifying the name of whites. Sometimes it is very liquid, at other 
 times rather consistent, on account of the epithelial elements which 
 it holds in suspension, but it is never viscous, strictly speaking, nor 
 S'^ey. 
 
 c. Uterine leucorrhcea is very rare in children, but common m 
 chlorotic girls and in married women before or after pregnancy; in 
 many it is abundant before and after menstruation. It may be pro- 
 voked by venereal excesses, but usually is caused and kept up by 
 uterine disease, often by catarrh, sometimes even by inflammation or 
 by a rheumatic, herpetic, blennorrhagic or syphilitic affection localised 
 on the womb, or by the presence of a polypus, fibroid tumour, simple 
 granulations, an ulcer, &c. Generally there is neither heat, nor pain 
 
LEUCORRHCEA AND UTERINE CATAKRH 
 
 577 
 
 nor any other symptom of disease of the vulva^ vagina or neighbouring 
 parts. But there is frequently a feeling of weight in the pelvis, lumbar 
 and hypogastric pains almost as commonly, with colics, especially in 
 young girls, corresponding to the contractions by which the uterus 
 expels the fluid ; therefore the discharge is intermittent in place of 
 being continuous. Even when the uterine orifice is large and the fluid 
 runs out witliout a uterine contraction accompanied by pains, the 
 mucus or the muco-pus is retained by its viscosity, and is only detached 
 from the mucous membrane to which it adheres when the mass is large 
 enough to be dragged away by its own weight. A flow of liquid then 
 escapes from the uterus, and finally from the vagina, from time to 
 time, of which the patient is conscious even when she has not felt any 
 pain previously. 
 
 Differential diagnosis of the various kinds of infantile leucorrhcea. — 
 The importance of this diagnosis from a medico-legal point of view 
 induces me to devote a few lines to it.^ The leucorrhcea of children 
 may, as I have already said, attack the uterus itself; but it is more 
 common in the vagina, and especially in the vulva, when the urethra 
 may be affected simultaneously. 
 
 The chief symptoms which distinguish infantile leucorrhcea caused 
 by an indecent assault (especially when blennorrhagic) from other forms 
 
 Fig. 332.— Pavement epithelium Fig. 333. — Mucous corpuscles with 
 
 in every degree of development, some epithelial cells and oily 
 
 in epithelial or vaginal leucor- granulations in mucous or cervi- 
 
 rhoea. 220 diameters (Tyler cal leucorrhcea. 220 diameters. 
 Smith). 
 
 of leucorrhcea are the following : traces of contusion, swelling, ecchy- 
 mosis, turgescence of the vessels of the vulva and vagina, the rapid 
 and intense development of the malady, purulent discharge of a green- 
 yellow hue, and abundant enough to cover the external parts and soil 
 the linen in many places, thick enough to glue the vulval lips together 
 
 ' See Tardieu, Etude .'.ur les attentats am: moeurs, 4,^ edit. Paris, 1862, 
 p. 20 and following. 
 
 37 
 
578 UTERINE DISEASES IN DETAIL 
 
 when dry, simultaneous discharge from the vagina and urethra. This 
 last sign is important, as being peculiar to virulent and contagious 
 leucorrhosa; for according to Tardieu, the violence exercised on the 
 genital organs of a child by the healthiest man may produce as acute 
 and as violent an inflammation, as well as a discharge as abundant and 
 thick as that caused by the approach of a man affected with blennor- 
 rhagia or any other contagious disease. 
 
 V. Uterine catarrh is the malady which most frequently produces 
 uterine leucorrhoea. It is sometimes confounded with inflammation of 
 the uterine mucous membrane, and described as internal metritis, 
 mucous metritis^ endometritis. It sometimes assumes the acute form, 
 frequently the chronic; it may be complicated with inflammation, 
 erosion, ulceration of the mucous membrane, as occurs in old bronchial 
 or intestinal catarrhs. It must not, however, be confounded with these 
 various morbid states, or regarded as being only symptomatic of them, 
 for it has distinctive characters which allow a differential diagnosis to 
 be established. What characterises it is the peculiarity of its manifes- 
 tation, the causes which produce it, its mode of development, the 
 analogy of the complications, the speciality of the treatment. The 
 speciality of its manifestation is the discharge itself. How often the 
 uterine mucous membrane is inflamed, red, painful, even suppurating 
 like that of the vagina without producing any discharge ! How often, 
 on the contrary, this discharge exists alone, abundant, seldom purulent, 
 but often muco-purulent or merely mucous, the glandular hyper- 
 secretion increased, fatiguing patients by its quantity and persistence, 
 ending by producing swelling of the mucous membrane and pain in the 
 organ by hypertrophy of the follicles, but not accompanied by really 
 inflammatory symptoms except in the acute state caused by a sudden 
 attack or after a long duration from the effect of organic alterations 
 produced by prolonged functional alteration ! The external causes 
 producing it are the same as those which usually determine localised 
 catarrhal affections on other mucous membranes : coryza, bronchial 
 catarrh, intestinal catarrh, &c. I have often seen leucorrhoea follow a 
 sudden chill of the genital organs and abdomen occurring in women 
 while perspiring, either from sitting down on the cold grass or on a 
 damp stone, or from taking inopportunely a cold sitz-bath followed by 
 no reaction, or from having the genitals exposed to a current of cold 
 air. I have seen men contract vesical and prostatic catarrh from the 
 same causes. The influence of these causes is still more marked when 
 a number of women are affected as by an epidemic. TrousseU says 
 that when the Font des Arts was finished at Paris it became a fashion- 
 able promenade. Ladies sat there after sunset as in the public gardens, 
 and owing to the cool, damp air from the river were attacked with 
 leucorrhoea. We find proofs of the epidemic character of uterine 
 catarrh in Blatin's work, and in the article Leucorrhee in the Biction- 
 naire des Sciences medicales, in which are recorded the facts observed 
 by the Breslau physicians in 1702, by Morgagni in Italy in 1710, by 
 
 ' Des ecoiolemeiits particuliers amcfemmes. Paris, 1842. 
 
LEDOORRHGEA AND UTERINE CATAREH 579 
 
 Bassius of Magdebourg at Halle in 1730, by Raulin' at Paris in 1765, 
 by Leake in England, concurrently with catarrh and diarrhoea ; the 
 observations made at Berlin in 1713 are also given, and those in 
 Prance by Eoux in 1769. Its mode of development presents this 
 peculiarity, that it often depends on a feeble constitution, on a 
 lymphatic temperament, a susceptibility of the mucous membranes, 
 and an impressionability to the action of damp cold and to sudden 
 varieties of temperature, or to the hygrometric state of the air, being 
 determined by the action of the external causes just mentioned — that 
 is, by circumstances which beget the catarrhal affection and which 
 produce localisation on the nasal, bronchial, vesical, intestinal mucous 
 membranes. 
 
 Acute uterine catarrh may be complicated by a certain degree of 
 inflammation. The mucous membrane affected by the morbid cause is 
 first painful and the secretion is diminished. In proportion as reaction 
 takes place hypersecretion commences, being more or less intense and 
 more or less altered. Hypogastric pain is accompanied by heat, pelvic 
 discomfort, pain during defecation and micturition, assuming occasion- 
 ally the character of colics. 
 
 Chronic uterine catarrh follows, or this form may be assumed from 
 the commencement j sometimes also it follows metritis, which develops 
 in the uterine glands a tendency to hypersecretion which is favoured 
 or prepared by a general tendency. 
 
 Subjective signs. — Hypersecretion, this discharge being apparently 
 more weakening than that from the vagina, and sometimes, when it is 
 abundant, coinciding with an irritation which extends from the 
 uterine mucous membrane to that of the vagina, vulva, the internal 
 surface of the thighs, where it produces irritation, a kind of erythema, 
 and even slight epithelial desquamation. Menstrual disorders, usually 
 dysmenorrhoea, occasionally metrorrhagia ; in the latter case, it is 
 seldom that there is not some alteration of the mucous membrane 
 symptomatic of a concomitant morbid state such as ulceration, granu- 
 lations, fungosities. Pains beginning at the sacrum and terminating 
 in the groins and pubis, accompanied by colics preceding the expul- 
 sion of the muco-pus accumulated in the uterine cavity, and compli- 
 cated with a feeling of discomfort, weight and pelvic fulness. Very 
 often an impression on some other part of the body, such as the 
 sudden sensation produced by laying the hand on marble, reacts on the 
 uterus awakening a slumbering pain and determining hypersecretion 
 with expulsion of mucus. Gastralgia is soon added to these pains, a 
 sensation of weariness and dragging extending from the epigastrium 
 to the dorsal region between the shoulders, resulting from derange- 
 ment of the digestive functions, from the general debiHty which 
 follows, from the chlorosis and chloro-ansetnia which are its conse- 
 quences. Dyspeptic symptoms are developed : heartburn, acidity, 
 vomiting, abdominal distension are often followed by constipation or 
 catarrh in the lower portion of the intestine, painful defecation, 
 tenesmus, mucus passed with the feeces ; the urine becomes muddy, 
 
 ' Tralte desjiueurs blanches avec la methode de les gucrir. Paris, 17G6. 
 
580 UTERINE DISEASES IN DETAIL 
 
 loaded, muco-purulent, and micturition is painful. Emaciation, 
 languor, sadness complete the picture. 
 
 Objective signs. — Tension and resistance in the hypogastrium, sensi- 
 bility of the cervix ; digital touch discovers a characteristic glairy or 
 purulent mucus ; there is often flaccidity of the uterine walls, some- 
 times increased size of the neck or body ; the latter becomes globular, 
 especially when by occlusion of the orifices from the swelling of the 
 mucous membrane or by their obliteration from the formation of 
 bands or the adhesion of ulcerated surfaces, the products of secretion 
 are accumulated and retained in the uterine cavity. The hollow 
 uterine sound penetrates with some difficulty ; but when once it has 
 done so, it is mobile in every direction, showing an increased capacity 
 of the cavity of the womb ; sometimes mucus is discharged from its 
 canal. Frequent exuberations are observed on the cervix, even on the 
 border of the orifice and particularly on the inferior lip, a pheno- 
 menon which may depend on maceration of the epithelium by the 
 raucous secretion as Gosselin has remarked,^ but which may also 
 exist as a complication, as in more serious alterations such as 
 granulations, fungosities, and follicular cysts. I agree with Scan- 
 zoni^ that persistent leucorrhosa, like uterine congestion which 
 often accompanies it, may, by the irritation and hypersemia which 
 it keeps up in the organ, favour the development of chronic me- 
 tritis, ulcerations, granulations, uterine fungosities, follicular cysts, 
 fibroid bodies, &c. Catarrhal leucorrhoea is rarer in the vagina 
 than in the uterus ; but may manifest itself in the former organ, 
 succeeding vaginitis ; it may, especially in the acute form, exist 
 simultaneously in both. It is the same with rheumatic leucorrhoea 
 which scarcely differs from catarrhal leucorrhoea : but usually rheu- 
 matism affects the muscular tissue rather than the mucous membrane 
 of the uterus. 
 
 VI . Hydrorrhcea. Hydrometria. Physometria? — This is the occa- 
 sion to say a few words on these rare morbid states, the existence of 
 v\'hich has often been doubted. Hydrorrhoea is the abundant discharge 
 of an aqueous fluid from the uterine os; hydrometria, the tumour 
 formed by the retention of this fluid in the uterus ; physometria, the 
 distension of the uterus by gases. 
 
 Apart from amniotic dropsy, the results of abnormal pregnancy, 
 
 1 De la valeur symptomatique des ulcerations du col uterin {Archiv. gener. 
 de med., 4^ serie, t, ii, p. 129, 1815). 
 
 2 Op. cit., p. 175. 
 
 3 Lafosse, Theses de Strasbourg, 1816, No. 39. — Tessier of Lyons, De I'Hy- 
 dropisie et de la Tympanite uterines Tiors de I' Stat de gestation {Gaz. med. de 
 Paris, p. 8, 1844). — Jobert, De I'Hydropisie du col uterin {Journ. de Chir., 
 t. i, p. 265. Paris, 1843). — P. Franck, Traite de med. prat., t. ii, p. 20. Paris, 
 1842. — Bonet, Sepulcliretwm, L. iii, sect, xxi, obs. 55. 
 
 Consult also for Hydrometria: Dard, Gazette medicale de Paris, 1855, p. 
 44 ; Shanks, Id., 1855, p. 178 ; and a case in the Gazette hehdomadaire, 1855, 
 p. 411 ; Malicheis, Gazette des Hopitaux, 1866, p. 323. 
 
 For Physometria : Roy {Gazette inedicale de Paris, 1833, p. 629) ; Batten 
 (Id., 1834, p. 505) ; PoUet (Id., 1850, p. 114) ; and Canstatt's Jahreshericht, 
 1849, p. 333. 
 
LEUCORRHCEA AND UTERINE CATARRH 581 
 
 moles, alterations in the dead body of a foetus, its membranes, or the 
 placenta, the intra-uterine opening of a tubal or ovarian cyst, and the 
 other causes of false leucorrhsea already enumerated, hydrorrhcea and 
 hydrometria can only occur from hypersecretion of the uterine mucous 
 membrane.^ The fluid secreted may be altered in its quantity and 
 quality, be discharged continuously or intermittently, be completely 
 retained in the uterine cavity and even produce gases ; these are the 
 only direct causes to which hydrorrhoea, hydrometria and physometria 
 can be attributed. The serous, sero-sanguinolent, sanious, ichorous 
 discharges produced by the serious organic alterations of the mucous 
 membrane, are sometimes considerable, but they hardly exceed the 
 limits of the symptomatic discharges included under the name of false 
 leucorrhoea. Idiopathic hydrometria only originates from the secretion 
 of the uterus. 
 
 Hydrorrhoea therefore supposes an increase of the uterine secretion, 
 accompanied usually by a diminution in the density of the secreted 
 fluid. This diminution in density, which is common to dropsies of 
 other organs, is caused by the precipitation of the solid elements or by 
 an alteration in the secretion of the organ which is brought about by 
 the distension and attenuation of the latter to the condition of a kind 
 of fibro-serous capsule.^ Hydrometria supposes the imperforation of 
 the neck, more frequently its obliteration or its obstruction by the 
 presence of a polypus, by a well-marked flexion or an abnormal tume- 
 faction of the columns of the isthmus which, fitting closely into each 
 other, close the os internum, or even by an interstitial uterine tumour 
 or an extra-uterine one such as an ovarian cyst,^ in short, by the same 
 causes to which we have already attributed (p. 270) retention of the 
 menses (hematometria). It is evident that these two conditions (abun- 
 dant secretion and retention of the fluid secreted) are alone favorable 
 to the formation of a fluid collection in the uterus and to the consecu- 
 tive distension of the walls of this organ. It is also evident that it is 
 after the menopause or prolonged amenorrhoea that hydrometria must 
 be produced ; for in other conditions there would be retention of blood 
 instead of mucus. 
 
 1. Hydrometria \ki.vcs> defined is the uterine ascites or uterine dropsy 
 of the ancients. — The diagnosis may present some difficulty, especially 
 when the uterus is very thin and much distended ; the question is then 
 of a differential diagnosis between hydrometria, hematometria, and preg- 
 nancy (p. 281). In every case there is amenorrhoea or at least reten- 
 tion of the menses. In most cases the size of the uterus does not 
 exceed that of the same organ in the sixth month of gestation, and it 
 only reaches these dimensions slowly. Exceptionally the fluid may 
 pass into the Fallopian tubes, distend them gradually and find an issue 
 into the peritoneal cavity, or it may distend the uterus to the ])oint of 
 causing rupture. 
 
 ' The existence of idiopathic liydrometria has been proved by autopsies made 
 by Cruveilliier {Anat. i)atholo(j.,i. ii, p. Sl'J) and by Tliompson {Medic. -chir. 
 Transactions, xiii, part i, p. 170). 
 
 " Scauzoni, op. cit., p. I'Jfi. 
 
582 UTERINE DISEASES IN DETAIL 
 
 Pancture of the uterus through the hypogastriuni^ may be necessi- 
 tated, or better still puncture of the cervix from the vagina^^ dilatation 
 of the cervico-uterine canal, suppression of the obstacle preventing the 
 discharge of the accumulated fluid, all these methods being followed 
 up with great care to keep the uterus open by means of a sound or 
 tents, to make detersive and afterwards caustic injections, to exercise 
 methodic compression on the hypogastrium, to provoke contractions of 
 the muscular fibres of the uterus and the gradual return of this organ 
 to its normal dimensions.^ Cases have been described in which the 
 fluid was discharged from the uterus by perforation due to ulceration : 
 this evacuation may be very dangerous.^ 
 
 "When the isthmus, in place of being obliterated, is only obstructed 
 by a temporary tumefaction, this mechanical obstacle may temporarily 
 hinder the exit of a single drop of mucus from the uterine cavity, as 
 the swelling of the median or one of the lateral lobes of the prostate 
 prevents the discharge of a single drop of urine from the bladder. If 
 this obstacle yields to the variations which menstruation, various 
 movements and muscular contractions produce in the position or in 
 the form of the uterus, there may be alternative retention and evacua- 
 tion of serous or viscous fluids, sometimes in great quantity. I have 
 seen five cases of this disease.^ 
 
 2. Fhysometria, pneumatosis or uterine tympanitis when not merely 
 the result of the introduction of air by the injection syringe, or when 
 not dependent on the formation of gas produced by the decomposition 
 of the foetus or placenta, a polypus, or a menstrual clot, may be due 
 to the alteration of the sero-mucous fluid of hydrometria, but this is 
 rare. It is evident that the gas always occupies the upper part of the 
 uterus^ in the region of the navel or hypogastrium^ according to 
 whether the patient is standing or lying. Percussion and succussion 
 usually enable us to perceive the peculiar sensation as well as to hear 
 the sound characteristic of air mixed with fluid in the uterine cavity. 
 Lastly, the discharge of this gas may take place simultaneously with 
 the fluid in a noisy manner.^ The treatment is the same as tliat of 
 hydrometria. 
 
 Treatment. — Leucorrhoea, especially when acute, may, like every 
 catarrh, be cured spontaneously. Treatment ought not, however, 
 to be neglected on that account, for it has often a great tendency 
 to pass into the chronic form, and chronic leucorrhcea is one of the 
 
 * Wirer has extracted in this way 32 lbs. of a thick fluid from the uterus of 
 a woman of 53 years of age, who recovered {Ann. litt. med. etr., ii, 290). 
 
 ^ Cruveilhier has mentioned a case in which this puncture was followed by 
 death {Anat. path., i, 281). — See also Clements of Frankfort {Gazette medicale 
 de Str'asboiorg, 1813, p. 371). 
 
 ^ Fantonelli, Hydrometrie guerie par le seigle ergote {Gazette medicale de 
 Paris, 1837, p. 234). 
 
 * Luigi {Annali universali di rtiedicina. Milano, March, 1861). 
 
 •'' Browne has described a case, quoted by Duges and Boivin (Op. cit., t. i, 
 p. 259). 
 
 ® Gooch has seen a case of this kind {Diseases of Women, p. 241) ; and 
 Scanzoni two (op. cit., p. 198). 
 
LEUOOERHCEA AND UTERINE CATARRH 583 
 
 most obstinate diseases. It gradually produces disorders of the diges- 
 tion, impoverishment of blood, emaciation and consumption mani- 
 fested by languor, paleness of the face, alterations of the features and 
 complexion, the whole being designated by the term fades uterina. 
 The physician ought therefore to explain to the patient the necessity 
 for prolonged treatment, not only on account of the difficulty of 
 obtaining cure but of the frequent relapses. 
 
 Vulval leucorrhcea in children requires more immediate attention 
 still; it ought to be cured at once to prevent the little patients from 
 acquiring the habit of touching the genital organs with their hands, 
 which keeps up and increases the evil and sometimes leads to mastur- 
 bation. On the other hand, leucorrhcea in phthisical patients should 
 not be treated except in the way of paying great attention to cleanli- 
 ness which alleviates the pain and irritation. It plays the part of an 
 anal fistula or artificial exutory, and its suppression sometimes aggra- 
 vates the pulmonary symptoms and hastens death. Most practitioners 
 are agreed as to this. Lagneau was strongly of this opinion, and 
 Lisfranc also [Cliniqiie cJdrurgicale, t. ii, p. 300), who says, " I have 
 observed a great number of women in whom leucorrhoea diminished or 
 suspended the progress of pulmonary phthisis, sometimes even check- 
 ing it ; hence the necessity for respecting leucorrhoea when there is a 
 morbid visceral affection.^^ 
 
 A. Treatment of acute leucorrhcea ouglit almost always to be general 
 as well as local. 
 
 1. General treatment is much more important than one would be 
 inclined to think : it is almost impossible to cure leucorrhoea without 
 resorting to it, and in some cases it alone is sufficient. It is so in 
 chlorotic patients when the leucorrhcea is dependent on functional 
 disorder. In such cases injections, local applications and cauterisation 
 may be dispensed with. What is required are sedatives, antispasmo- 
 dics, tonics, iron, mineral waters and hydropathy. General treatment 
 is usually sufficient in acute catarrhal leucorrhoea. We should remove 
 the causes, subdue the complications, especially inflammation when it 
 exists, by rest and emollients if not by antiphlogistics, e. g. by general 
 baths, sitz-baths, tepid and sedative irrigations, enemata ; avoiding chills, 
 especially sudden changes of temperature, by wearing flannel and 
 making dry frictions over the whole surface of the skin ; and keeping up 
 the strength by tonic but unstimulating diet. These means, however, 
 are not always enough : sometimes we should try to bring on a crisis 
 as in the treatment of bronchial catarrh. The skin from its great 
 extent and the influence which it may have had in the development of 
 the catarrh from exposure to a chill, appears the most favorable organ 
 for the establishment of this crisis. With this aim in view diaphoretics 
 are employed to promote perspiration. When leucorrhoea persists and 
 threatens to pass into the chronic form, this diaphoretic action is 
 transformed into revulsion by sioeating, or irritating or serous revul- 
 sion by the use of dry or stimulating frictions over the whole surface 
 of the body, rubefacients, epispastics, blisters, or at least frictions with 
 croton oil, so as to obtain a mihary eruption which is covered by au 
 
584 UTERINE DISEASES IN DETAIL 
 
 adhesive paper to spare the patient too great pain. If cutaneous 
 revulsion is insufficient^ intestinal revulsion may be added by repeated 
 purgatives. The cure which is quickly obtained in this way should 
 be kept up by overcoming the debility which predisposes to relapses 
 and chronicity by administering iron, cold baths followed by frictions, 
 residence in the country, &c. 
 
 2. Local treatment. — Lastly, passage to the chronic state should be 
 prevented by the use of local astringents : tepid vaginal injections 
 (tannin, coal tar, sulphate of zinc or copper, alum) ; inert or astringent 
 powders like subnitrate of bismuth, alum alone or mixed with 
 starch, applied to the vagina by insufflation or on a tampon; and by 
 painting the vagina with a weak solution of nitrate of silver or 
 tincture of iodine. These means, however, though heroic in chronic 
 leucorrhoea, should be cautiously employed in the acute form. 
 
 B. Treatment of chronic leucorrhoea. — 1. Prom the beginning it 
 often affects this diathetic character, which shows the necessity of 
 attacking it by general treatment. It does not necessarily follow that 
 it has been originated by a diathesis : defective and disordered men- 
 struation, pregnancy, abortion, delivery, physiological excitement, 
 excesses, mechanical irritation, the sudden invasion of an acute catar- 
 rhal affection have often been its starting-point ; but a diathesis, the 
 latent existence of which had passed unobserved till then, finding in 
 this morbid state an opportunity to become localised, is not long in 
 replacing the occasional cause the action of which is soon exhausted ; 
 it imprints its character on the leucorrhcea and soon becomes with the 
 alteration of tissue which is dependent on the duration of the disorder, 
 the principal if not the only cause of its persistence. Whatever point 
 may have been invaded by a pathological action, however limited the 
 space on which its evolution is effected, however slight the symptoms 
 of its presence may be, a pre-existing affection almost always takes this 
 opportunity of ceasing to be latent ; it manifests itself externally, and 
 forms, if not the very nature of the morbid state, at least one of its 
 most serious complications. Therefore even when not diathetic origin- 
 ally, leucorrhoea soon becomes so. What takes place in women in the 
 case of leucorrhoea is similar to what occurs in men in the case of 
 chronic discharges from the urethra and prostate. Nothing is more 
 easily or quickly cured in a healthy man of good constitution : nothing 
 more difficult in a catarrhal, rheumatic, gouty, herpetic or scrofulous 
 subject, I have seen so many examples in both sexes of the difficulty 
 of effecting a cure in such circumstances, and of the necessity of 
 resorting to antidiathetics and restoratives, of the insufficiency of local 
 treatment employed alone, of the success of the same treatment when 
 preceded by general treatment, that I have no hesitation in saying 
 that this is the true secret of the treatment and cure of these maladies. 
 The affections which exercise most influence on the duration of leucor- 
 rhoea may be arranged as to their frequency almost in the following 
 order : chlorosis, chloro-ansemia, catarrh and rheumatism, herpetic, 
 scrofulous or syphilitic diathesis. Each of these is the source of a 
 special indication, sometimes specific; in this way iron, alteratives. 
 
LEUCORRHCEA AND UTERINE CATAEEH 585 
 
 iodine, mercury, arsenic, iodide of iron and cod-liver oil may be admi- 
 nistered successfully in the treatment of leucorrhoea in children, 
 according to the nature of the affection which keeps up this morbid 
 condition. At the head of these means we must place restoratives, 
 tonics, quinine, iron, residence in the country, change in the mode of 
 of life, and especially climate. I have seen striking examples of the 
 influence of the change to a dry and warm climate from a cold and 
 damp one. 
 
 The balsams, tar water, pills of turpentine, in leucorrhoea as in all 
 other catarrhal diseases, act simultaneously on the base or affection and 
 on the form or hypersecretion. I find tar water of great use and it is 
 not repugnant to patients when mixed with seltzer water. Ergot has a 
 more direct action on the uterus and has been employed with success. 
 Marshall Hall,^ Bazzoni,- recommend it in chronic leucorrhoea, one 
 drachm boiled in eight ounces of water, half to be taken one day, the 
 other half the next; they say that very rarely more is required. It 
 may also be taken in powder every six hours in varying doses. It is 
 evident that it may render great service in cases where the cavity of 
 the uterus is the seat of the excretion, by stimulating the weakened 
 contractility of the walls of the organ. Mineral waters are often 
 recommended but are not always efficacious. Natural or artificial 
 iron baths, so highly thought of by some physicians, are useful in 
 cases of chlorotic leucorrhoea ; but if another diathesis is added to the 
 chlorotic they may be more hurtful than useful. I have even seen 
 some chlorotic patients to whom they have done no good, whilst 
 alkaline waters, but especially sulphur and sea bathing, have been very 
 beneficial. In doubtful cases therefore we should try different means 
 in place of obstinately persevering with one which, however valuable, 
 has its limits. Sulphur baths and sea bathing are efficacious in 
 scrofulous children. Hydropathy, however, is much more generally 
 useful. In chronic uterine catarrh cold water employed in various 
 ways with the graduated and energetic reactions provoked by its 
 methodic application produces wonderful results. It is the best 
 revulsive and the best tonic and cannot be too much used in the 
 treatment of this disease. When necessary, the douche may be pre- 
 ceded by a vapour bath which determines revulsion on a large surface 
 and by abundant sweating helps to restore the functions of the skin, 
 substituting cutaneous perspiration for the morbid flux of leucorrhoja. 
 Only w^e must beware of weakening patients, and take care to follow 
 up this medication by tonic treatment. 
 
 When vapour baths, dry frictions and hydropathy are contra-indi- 
 cated, we may resort to the revulsion produced on the digestive tube 
 by purgatives, or on the skin by epispastics. I cannot, however, 
 recoii)niei\d this kind of revulsion : patients affected with chronic 
 leucorrha3a being generally weak and dyspeptic, the only result is 
 increased debility and irritation. Cutaneous epispastics also sometimes 
 
 ^ London Medic, and Phys. Journal, vol. Ixi, p. 399, 1829. 
 - Oinodei, Annali di medicina. May, 1831. — Lazowski, Revue therapeiitique 
 dn MidiA. v, p. 211, 1853. 
 
586 UTERINE DISEASES IN DETAIL 
 
 irritate greatly by the pain whicti they cause and the rest they neces- 
 sitate, especially when applied to the abdomen. Therefore I seldom 
 use purgatives and then only at the end of acute leucorrhoea to 
 prevent its passage to the chronic form, or during the treatment of 
 the latter as laxatives to keep the bowels regular, increase the appetite 
 and stimulate digestion, rather than as a revulsive on an organ which 
 ought to be spared. Schcenbein and Aran^ have recommended 
 enemata containing aloes suspended in a kind of mucilage of soap and 
 water. The results are successful in proportion to the time they are 
 retained. One may be taken every night or every two nights till 
 there is irritation of the rectum or anus ; they should then be sus- 
 pended for a few days and resumed if found useful. They are only 
 suitable when all the congestive or inflammatory symptoms have dis- 
 appeared : after all, they are very uncertain, and the same may be 
 said of enemata of colocynth. The application of blisters to the 
 cervix is very useful in cases of uterine leucorrhcea especially when 
 it is the body of the uterus that is affected, when there is no 
 discharge from the vulva and vagina and when the cervix is almost 
 healthy, merely engorged or at least when it is not the principal seat 
 of the discharge. The blister is applied according to the rules pre- 
 viously laid down. 
 
 One blister is not enough, it is almost always necessary to apply a 
 second, third, and sometimes even a fourth at intervals of a fort- 
 night, taking care to prevent iDf3ammation by rest, the use of 
 baths and emollients, continuing general treatment as much as 
 possible. It is needless to say that blisters should not be applied 
 at the monthly period. I have found them very useful when circum- 
 stances prevented the use of hydropathy and mineral waters. Simul- 
 taneously, I recommend the abdomen to be wrapped in cotton wool 
 with an india-rubber bandage over it so as to keep up constant moist 
 heat. 
 
 2. We have now come to the local treatment of chronic leucor- 
 rhcea. This should frequently be associated with general treat- 
 ment; but with the exception of simple irrigations or emollient and 
 detersive injections to promote cleanliness and alleviate pain, topical 
 applications should generally be confined to the last stage, when the 
 constitution is sufficiently modified to give us reason to hope that 
 energetic local action may put a stop to the discharge. 
 
 For vulval and vaginal leucorrhcea these local applications are : 
 injections, powders and various applications. Their object is to 
 modify directly the surface of the mucous membrane and the cavity 
 of the follicles which are the seat of leucorrhoeal discharge, in fact 
 the local morbid state, which seems to keep up the discharge as if by 
 habit of hypersecretion. 
 
 The injections or rather vaginal irrigations made on the bidet with 
 
 ' Bulletin de therapeutique, t. liv, p. 193. Maladies de I'uterus, p. 464. The 
 prescription is : Aloes gr. Ixxv ; Saponis gr. Ixxv ; Aq. ferventis 3iij ; to be 
 injected at bedtime when cold, after having emptied the intestine by a tepid 
 enema. 
 
LEUCOERHCEA AND UTEEINE CATAERH 587 
 
 the hydroclyse should usually be tonic, astringent and caustic. They 
 are sometimes made with the mineral water itself during the bath, 
 whether emollient, alkaline, iron or sulphur. After having injected 
 pure water into the vagina for a few minutes, a solution of coal tar 
 may be used, or a decoction of walnut-leaves, tannin, or oak bark, or 
 a solution of alum (5j to a quart of water), sulphate of zinc (same 
 strength), sulphate of copper (30 grains to a quart), or a very weak solu- 
 tion of salicylate of soda. Instead of injections it has been proposed 
 to apply astringents or slight caustics in the form of ointments or 
 powders. The action of ointments is uncertain, and the presence of 
 grease in the vagina is not favorable to the cure of leucorrhoea. It 
 is different with powders : they absorb the fluid or are gradually dis- 
 solved, and so the tissues in contact with the solution are affected 
 continuously. The subnitrate of bismuth is the best, and the way to 
 apply it is to powder the diseased surfaces with it through the specu- 
 lum. Sometimes bags filled with inert and astringent powders are 
 introduced, or they may be placed on a tampon of cotton wool. The 
 latter is one of the best ways, I prefer it to soaking the pledget in an 
 astringent or caustic solution because it acts simultaneously as an 
 absorbent and modificator : I confess, however, that I do not much 
 hke leaving any foreign body in the vagina; but I except tampons 
 saturated in a glycerole of tannin (gr. 30 to 5ij of tannin to glycerine 
 5j)- The solubility of tannin in glycerine, and the absorption of the 
 glycerine by the vaginal mucous membrane render this application, 
 which was first suggested by Demarquay,^ very efficacious. After 
 cleansing the vagina thoroughly introduce a large tampon wrung 
 out of hot water and then saturated with the glycerole and repeat 
 every two or three days. It is better still to pour one or two 
 spoonfuls of this glycerole into the vagina through a Pergusson's 
 speculum and afterwards introduce a tampon of dry cotton wool which 
 the patient can remove the next morning and then make a vaginal in- 
 jection. It is still easier to modify the mucous membrane by painting 
 with a brush. A solution of tincture of iodine (1 in 5, 10 or 20) may 
 be used, or tannin or glycerole of tannin of the same strength, or 
 peroxychloride of iron or a solution of nitrate of silver ( 1 in 30, 20 
 or 15) applied every two days. 
 
 The same medication is applicable to uterine leucorrJioea ; only it is 
 more difiicult to apply caustic to this mucous membrane and to make 
 it penetrate into the follicles. The following method is the best : in 
 the first place the mucus must be expelled from the uterine cavity. 
 To do this I compress the cervix with the speculum, and sometimes 
 the body simultaneously by abdominal pal|)ation; or I direct a small 
 douche on the cervix ; or after having used the sound to ascertain the 
 direction of the cervico-uterine canal, I introduce a fine brush or inject 
 tepid water by means of a hollow sound, continuing to do so suffi- 
 ciently long to let the cavity be thoroughly cleansed, i. e. if the orifice 
 is large enough to allow the water to pass back into the vagina. If 
 
 ' De la Glycerine et de ses applications a la medecine et a la chirurgie. 
 Paris, 1863. 
 
588 UTERINE DISEASES IN DETAIL 
 
 the OS is not large enough it must first of all be enlarged. The os and 
 cervical canal should be suificiently enlarged to expose the mucous 
 membrane of the cervix. We are then sure of reaching the sources of 
 the leucorrhoeic secretion vrith the caustic. After these preliminary 
 preparations I introduce a brush covered with caustic into the cavity 
 of the organ turning it in various directions so as to reach the whole 
 surface. 
 
 When the leucorrhcea is situated in the cervical portion and is of 
 sufficiently long standing to have produced hypertrophy of the cervical 
 glands more must be done : in such circumstances we cannot dilate 
 the raucous membrane sufficiently nor cleanse it thoroughly, nor yet 
 reach the follicles and excretory canals of the rugged surface 
 (Fig. 334) with the caustic. I therefore have recourse to a small 
 preliminary operation which I often employ in the treatment of fol- 
 licular granulations of the tonsils, palate and pharynx : I make 
 numerous scarifications in various directions over the whole of this 
 rough surface, either with an ordinary scarificator, a narrow convex 
 or concave tenotome knife, or with a small lancet. I wait till 
 the slight hsemorrhage is arrested : I then wash the cervix with 
 very hot water to stop the hsemorrhage and to cleanse the surface 
 of the cavity, after which I apply a caustic solution. If these 
 caustic solutions are insufficient, or if the leucorrhcea is compli- 
 cated by ulcerations, granulations or an engorgement of the neck, 
 I substitute the solid caustic or even the actual cautery (a fine 
 cautery like the bill of a bird or a knife), which T apply in various 
 directions in the most tumefied portion of the cervical mucous mem- 
 brane, taking care to protect the other portions by Recamier^s large 
 curette, to prevent vicious cicatrices which contract and obliterate the 
 cervix when the cauterisation has affected the whole periphery of the 
 cervical cavity (lamentable cases of which I have seen). 
 
 Huguier^ was the first to recommend making scarifications before 
 cauterising, in order to ensure the action of the caustic on the mucous 
 membrane of the cervix : and I can certify that it is one of the best 
 means of curing this membrane. 
 
 The difficulty of painting the uterine cavity when the leucorrhcea is 
 from the mucous membrane of the hocly has led to the use of caustic 
 injections. 
 
 Fine vulcanite uterine sounds are used^ or india-rubber sounds into 
 which the small cannula of a syringe is fitted (Fig. 199, page 319). 
 We must make sure of two things : 1, that the sound moves freely in 
 the cervico-uterine orifice, and that the fluid when gently injected 
 returns easily by the neck and falls into the vagina ; 2, that there is 
 no trace, I do not say of metritis, but of inflammation of the annexes, 
 perimetritis or pelvic peritonitis. I often prefer cauterising with the 
 solid caustic, with a brush moistened and rolled in powdered nitrate 
 of silver applied several times to the fundus. This cauterisation when 
 well applied is very successful. No leucorrhcea, however abundant, 
 purulent, or chronic withstands this treatment. To sum up : the os 
 ' Gazette des Hopitaux, 1819. 
 
LEUCOEEHCEA AND UTERINE CATARRH 
 
 589 
 
 must be large or well dilated and quite free, there must be no flexion 
 of the body on the cervix preventing the passage of the mucus from 
 
 Fig. 334. — Ti-ansverse ramifications of the arhor vita in the cervical cavity, to 
 show the uneven surfaces of this cavity and the difficulty there is in reach- 
 ing the diseased follicles in cases of leucorrhoea. 
 
 the one into the other, nor must there be any inflammation either 
 uterine or peri-uterine^ or even strong congestion of the organ ; the 
 menses should have ceased a week previously, so that the monthly 
 congestion may have quite disappeared ; lastly, a general treatment 
 should have been followed and simple intra-utcrinc injections made 
 with applications of less energetic medicaments such as tincture of 
 iodine, iodoform or tannin, to test the sensitiveness of the mucous 
 membrane, or to see whether these milder topics are not sufficient. 
 Usually I apply powdered nitrate of silver to the fundus. Unless 
 
590. UTERINE DISEASES IN DETAIL 
 
 the OS is unusually large I first dilate it with a sponge tent (Fig. 136, 
 p. 149); then I wash it with very hot water and carbolic acid, or 
 salicylate of soda; and then holding the cervix with tenaculum hook 
 forceps I apply successively three or four brushes moistened in water 
 and rolled in powdered nitrate of silver to the uterine fundus, so as to 
 be sure that the whole surface of the mucous membrane has been 
 reached (Fig. 201, p. 221). — Immediately afterwards the patient takes 
 an emollient bath, making injections all the time, or she makes injec- 
 tions on the bidet. She should be confined to bed for a fortnight, con- 
 tinuing the baths and injections. When the leucorrhoea is of long 
 standing and so abundant that this mode of cauterisation seems insuffi- 
 cient, 1 use the crayon. After having used the sound to ascertain the 
 direction of its cavities, I introduce the crayon by means of forceps, 
 or a porte-crayon furnished with a piston (Figs. 202, 203), leaving it 
 in the uterine cavity by opening the forceps, or pushing the piston 
 and then withdrawing the instrument gently. 
 
 It is needless to say that the fragment of nitrate of silver left is 
 sometimes extremely small, and that its size should vary with the in- 
 tensity of the malady and the more or less favorable conditions for 
 applying it. A tampon saturated with salt water should be introduced 
 into the vaginal cul-de-sac close to the cervix, and care be taken to 
 prevent the development of inflammation. Immediately after the 
 operation the pain is alleviated by general and local antispasmodics, 
 enemata, baths and vaginal irrigations, which when necessary may be 
 prolonged for several hours and continued till the next monthly 
 period. 
 
 I have never seen a case of leucorrhoea withstand this treatment 
 combined with the other means already mentioned, and 1 have proved 
 by experience that it is unattended with any danger for reasons 
 already explained (p. 224) ; that menstruation has become normal, 
 that conception has taken place and has been followed by normal 
 pregnancy and delivery. 
 
 Other gynecologists have acknowledged the usefulness of this mode 
 of cauterisation and its innocuity when applied according to the rules 
 I have laid down. Braun of Vienna has invented a small instrument 
 consisting of a cannula of vulcanite furnished with a piston to precipi- 
 tate the nitrate of silver into the cavity in the way 1 first suggested. 
 I have also received letters from a great number of physicians telling 
 me of the success they have obtained from the use of this means in 
 the treatment of obstinate leucorrhoea.^ 
 
 Hypeetrophy and Atrophy 
 
 In the first place, common hypertrophy must be distinguished from 
 special hypertrophy. 
 
 1. Common hypertrophy afi'ects all the elements at once, it is true 
 
 ' Laroyenne of Lyons has also adopted this means ; he uses a crayon 
 composed of equal parts of nitrate of silver and nitrate of potash. Bianchard 
 {Theses de Paris, 1873). 
 
HYPERTROPHY AND ATROPHY 591 
 
 uterine hypertrophy. It may be total, i.e. extending over the whole 
 organ (body and neck) ; or partial (hypertrophy of the body, hyper- 
 trophy of the neck) ; or even be limited to one portion of the body or 
 neck ; when the body is affected, it may be limited to the anterior or 
 posterior segment or one of the cornua^ and in the neck it may be 
 confined to the supra- or sub-vaginal portion, or to the anterior or 
 posterior segment, and even in each of these segments, the hyper- 
 trophy may be limited to the vaginal or to the uterine portion of the 
 one or other, to one of the cervical lips, or to one of the columns of 
 the cervico-uterine isthmus. 
 
 2. Special hypertrophy or hypertrophy of the tissue affects only one 
 or more of the histological elements of the organ. It may be general, 
 i.e. extending over all the portions of the affected tissue [e.g. hyper- 
 trophy of the tissue proper, hypertrophy of the mucous membrane, 
 hypertrophy of the vascular economy, &c.) ; or local, i.e. limited as to 
 seat as well as to tissue (giving rise to fibromata, follicular polypi, 
 vascular tumours, fungosities, granulations). Nevertheless, although 
 this division is the exact expression of the diversity of the anatomical 
 alterations, I think it is sufficient in practice to distinguish total from 
 partial hypertrophy, and for the latter specially to study hypertrophy 
 of the neck. Partial hypertrophy is more common than total hyper- 
 trophy, that of the cervix is more common than that of the whole 
 uterus, that of the mucous membrane or of some special element of 
 that membrane is more frequent still. Special or histological hyper- 
 trophy is more frequent than common hypertrophy. When the 
 elements of the mucous membrane are affected, excrescences are pro- 
 duced known under the names of granulations, fungosities, follicular 
 cysts, mucous polypi, vascular tumours ; when the elements of the 
 tissue proper are affected, polypi, fibroids, &c., are produced. The 
 former having common symptoms requiring analogous treatment will 
 be described in another chapter. The latter, which are very much 
 localised and also often very much developed, assume the character of 
 true organic alterations, and in this way become the source of special 
 indications and will be studied in another section. 
 
 Here therefore I shall only describe common hypertrophy or hyper- 
 trophy properly so called, that which affects all the elements of the 
 organ and which attacks the whole uterus or one of its two principal 
 segments. The first is total hypertrophy of the womb, the second 
 pjartial hypertrophy of the cervix. 
 
 I. — General Hypertrophy of the Womb 
 
 1. Hypertrophy proper. — In my lectures I have taught for a long 
 time that general hypertrophy of the uterus should be admitted, and I 
 have shown preparations in support of the opinion. I have distin- 
 guished hypertrophy not only from inflammation, congestion and 
 fluxion which are accompanied by pain, redness, infiltration, vascular 
 injection and general phenomena ; but also from engorgement which 
 is less consistent, from oedema which is soft, and from the irregular 
 and hard tumefactions of commencing cancer. In general hypertrophy 
 
592 UTERINE DISEASES IN DETAIL 
 
 the uterus preserves its normal aspect, but is more voluminous ; one 
 would say a womb beloDging to a woman of colossal dimensions. 
 Simpson has given a perfect description of this state. Hypertrophy- 
 is always an acquired condition resulting from morbid action, from an 
 exaggeration of normal nutrition. It is a morbid increase in the size 
 of the uterus and of the elements of its normal tissues. Eeal hyper- 
 trophy is essential or idiopathic, that which Scanzoni designates by the 
 name of primary, which is a disease in itself requiring special treat- 
 ment, the basis of which is resolvent medication. Essential hyper- 
 trophy is seldom primary, i. e. it is rarely developed unless a pre-exist- 
 ing morbid state of the uterus has brought the organ into a condition 
 in which hypertrophy may be developed. 
 
 The two most favorable conditions for the development of hyper- 
 trophy are congestion and defective involution. When congestion is 
 repeated or prolonged it introduces into the material conditions of the 
 organ the inevitable changes always produced by hyperemia in the organs 
 aflf cted by it, and in particular hypertrophy. It is in the nature of long 
 continued hypersemia to stimulate nutrition in the tissues which are the 
 seat of it. Chronic inflammation may produce the same result ; but it 
 is more apt to induce engorgement or induration : something more is 
 required to bring about hypertrophy. As to defective involution, it 
 leaves the organ hypertrophied rather than produces hypertrophy : if 
 absorption is interrupted while the normal work of nutrition continues 
 in a uterus the retrograde evolution of which is suspended, the size of 
 the uterus will not decrease, the thickness of its walls will be pre- 
 served, the density of its tissue and the mass of its textular elements 
 will persist, and it will continue in this condition, i. e. it will be 
 hypertrophied. In the former mode of production the hypertrophy is 
 active, in the second it is passive.-^ 
 
 It is very seldom that the whole uterus is equally hypertrophied, 
 sometimes the mucous membrane, at other times the tissue proper is 
 chiefly hypertrophied. Sometimes it is accompanied by enlargement 
 of the cavity of the organ, like excentric cardiac hypertrophy ; this is 
 especially the case when a foreign body occupies this cavity. Some- 
 times it coincides with a relative diminution of this cavity, as in con- 
 centric hypertrophy of the heart; there is then often partial hyper- 
 trophy of the tissue proper at one or more points, e. g. the formation 
 of fibroids. I have recently seen a lady who presented a case of this 
 kind, and in whom the uterine cavity measured from 6 to 7 inches 
 in length. 
 
 Diagnosis, — Individual differences of size and excessive congenital 
 development must be taken into account. When the uterus is really 
 hypertrophied the patient experiences a feeling of discomfort in the 
 
 ^ West describes one cause of uterine hypertrophy to which he attributes 
 great importance, but which seems to me only dependent on congestion or on 
 repeated fluxions produced by immoderate sexual excitement. The cause is not 
 so much excessive coitus, as a voluntar}^ imperfection in the accomplishment of 
 this act, that is to say, copulations repeated too frequently but which are always 
 incomplete and congest the uterus uselessly, and in which conception cannot 
 take place. 
 
HYPERTROPHY AND ATROPHY 593 
 
 pelvis and weight on the perinseum, without either heat or pain ; there 
 is little or no leucorrhceaj sometimes metrorrhagia^ at other times 
 amenorrhoea. Digital touch combined with palpation shows an in- 
 crease in size and weight with prolapsus or deviation ; examination of 
 the cervix by speculum confirms these facts; the sound discloses an 
 increase in the length and breadth of the uterine cavity and yet no 
 indication of tumour either sessile or pediculated. The principal 
 symptoms are : on the one hand those which indicate an increase of 
 size, and on the other hand negative characters. For the organ has 
 increased in mass and volume, the number and dimension of its con- 
 stitutive elements are increased, it may even have changed its form ; 
 but its structure has not become modified, nor have its physiological 
 or pathological properties fundamentally altered. Tillaux read a paper 
 before the Societe de Ckirurgie} describing a very interesting case of a 
 nullipara who suffered for fifteen years from prolonged and acute 
 menorrhagia to which she succumbed at the age of 47, and which was 
 due to essential varicose hypertrophy of the uterus associated with 
 fibromata. The case is very interesting from the double point of view 
 of the size that the organ had acquired and the vascular character of 
 the hypertrophy, and affords me an opportunity of here describing the 
 differential diagnosis of symptomatic and essential hypertrophy : 
 
 1. Symptomatic hypertrophy (especially from a fibroma) is produced 
 by a double influence. As a foreign body the fibroid provokes con- 
 tractions for its expulsion from the uterine cavity which are unsuc- 
 cessfully repeated till the womb becomes hypertrophied. The fibroid 
 by obstructing the orifice or incompletely determining its occlusion 
 may cause considerable menstrual retention ; a portion of the con- 
 tents may at first escape by overflow, but enough always remains 
 to distend the organ or to provoke contractions ; clots are expelled, 
 but every expulsive effort is an additional cause of hypertrophy : 
 
 2. Hypertrophy proper does not require for its development the 
 presence of a foreign body in the uterus. It is not so uncommon as 
 is believed ; cases of special hypertrophy, of fibromata especially, occur 
 frequently in girls and nulliparae. Common and total hypertrophy, 
 although not so general, is sometimes seen. It is known by the 
 absence of any foreign body, or any cause which could have determined 
 frequent contractions of the uterus. In Tillaux's case the hypertrophy 
 was idiopathic : it was common and total, having affected all the ele- 
 ments and the whole organ ; only it was localised more strongly on 
 three points of the tissue proper, where it gave birth to three fibro- 
 mata. One of the most interesting circumstances in Tillaux's case 
 was that of considerable periodical variations in the volume of the 
 tumour : the enormous increase of the uterus before menstruation and 
 the sensibly diminished size of the organ afterwards. The uterus was 
 congested at every monthly period as if it were really pregnant. I 
 have seen this very often though in a less degree. This great varia- 
 tion in size probably depends on hypertrophy of the sinuses and their 
 enormous dilatation. It might also probably serve as an clement of 
 
 1 Meeting? of the 18th November, 1868. 
 
 38 
 
594 UTEEINE DISEASES IN DETAIL 
 
 differential diagnosis between the hypertrophy which affects simulta- 
 neously all the organic systems of the uterus and the vascular economy 
 exceptionally, and that of the tissue proper in particular. — Lastly, 
 these periodical variations of size, due to the enormous congestion of 
 the uterine vessels, ought to be distinguished from those which depend 
 on incomplete menstrual retention. The essentially distinctive sign 
 between these two morbid states seems to me to be the absence of 
 muscular contractions in the former, the frequent appearance of ex- 
 pulsive efforts in the latter ; the acute pains, the uterine colics expe- 
 rienced by patients in the latter case, will be distinguished easily from 
 the continuous dull pain caused by slow and persistent congestion of 
 the uterus. 
 
 As to the definite results of menstrual retention on uterine hyper- 
 trophy, what occurs in complete retention must be distinguished 
 from what takes place when retention is incomplete. In the former 
 the uterus is sometimes considerably distended, and the thickness of 
 its walls is not developed in proportion to the capacity of its cavity ; 
 the continuous accumulation of blood which induces hsematometria 
 distends the organic tissue, which gradually loses its powers of con- 
 traction at the same time that its walls become attenuated. In the 
 latter, on the contrary, the uterus, especially the muscular tissue, is 
 always hypertrophied. The coagulated blood, the expulsion of which 
 is difficult though not impossible, acts on the uterus as a foreign body, 
 a fibroma, a polypus, a mole ; it provokes incessant contractions, de- 
 termining hypertrophy, particularly hypertrophy of the muscular 
 tissue, and consequently considerable thickening of the uterine walls. 
 
 Treatment. — Hypertrophy is best treated by resolvent medication, 
 including local resolvents, strictly so called, as well as caustics poten- 
 tial or actual ; and all general means, cutaneous and intestinal revul- 
 sives, alteratives (iodine, mercury, arsenic), vapour baths, hydropathy, 
 and cura famis. It must, however, be remembered that a malady 
 like hypertrophy takes a long time to cure. The treatment is long 
 and does not always succeed completely. Portunately health may be 
 restored without complete resolution of the hypertrophy. When reso- 
 lution cannot be obtained we must be satisfied with palliatives, e.g. a 
 pessary or perinseal pad kept in place by straps under the thighs and 
 a belt with braces such as is used in cases of prolapsus. 
 
 3. Arrested Involution 
 I have reserved a special description for a form of hypertrophy not 
 uncommon according to Simpson •} I mean hypertrophy due to the 
 arrest of the retrograde evolution of the uterus after delivery. I have 
 said that it is very important to recognise these two phenomena in 
 interpreting uterine diseases. The retrograde evolution of the uterus, 
 which has been well studied in Germany and especially in England, is 
 effected by gradual absorption of the hypertrophied elements. This 
 process comprises two others : a primary modification, the fatty infil- 
 tration of the hyperplastic or hypertrophic muscular fibres, or rather 
 " Op. cit., p. 585. 
 
HYPEETEOPHY AND ATEOPHY 
 
 595 
 
 the substitution of fat for the elements of muscular fibre, which brings 
 back this fibre to an elementary form more favorable to its absorption 
 and to its definite disappearance ; and a second act of decomposition, 
 the successive absorption of the fibres which have undergone this fatty 
 
 Fig. 335. Fig. 336. Fig. 337. 
 
 Fig. 335. — Fibres of the pregnant uterus. 
 Fig. 336. — Fatty infiltration of muscular fibres and gradual absoi-ption of their 
 
 elements during the period of involution, i.e. recurrence to the state of 
 
 vacuity after gestation. 
 Fig. 337. — Eetum of the muscular fibres to the size they present when the 
 
 uterus is in a state of vacuity. 
 
 infiltration, and the gradual return of the organ to its histological 
 composition and to its normal dimensions. This process, which is 
 regressive, resorbent and retractive, is designated in England by the 
 term involution. Simpson applied the term subinvolution to defective 
 and superinvolution to excessive involution. In the former case the 
 uterus remains partly what it was during pregnancy or after delivery : 
 now, in the unimpregnated condition this state is one of real hyper- 
 trophy. In the latter case the uterus exceeds the hmits of the normal 
 diminution in size, becoming quite small and atrophied. The hyper- 
 trophy proceeding from defective retrograde evolution is pathological 
 in its permanence, but physiological in its origin. 
 
 We know nothing of the causes strictly so-called which arrest 
 regressive transformation, absorption and involution of the uterine 
 walls. The occasional circumstances which are most favorable to the 
 action of these essential causes are : metritis, fatigue experienced by 
 the uterus in women who rise too soon after delivery, especially 
 repeated pregnancies and abortions. 
 
 Diagnosis. — This malady is not very uncommon. Simpson men- 
 tions three cases, and I have seen several others that were very 
 characteristic. It may be suspected then if, in the absence of signs of 
 inflammation or congestion, the patient experiences after the birth of 
 
596 
 
 UTEEINE DISEASES IN DETAIL 
 
 her last child menstrual disorders, a feeling of weight and fulness in 
 the pelvis, in short most of the rational symptoms of uterine hyper- 
 trophy. We ascertain by direct examination the absence of a distinct 
 tumour while the volume of the uterus is increased in every direction 
 equally, recalling the size of the uterus at the third month of gesta- 
 tion, the sound showing the cavity to be 9 or 10 centimetres or more. 
 
 Fig. 338. — Uterus of a woman who died immediately after delivery. This 
 figure shows the volume which the organ may preserve when involution is 
 arrested. It is anteflesed ; in other women it is sometimes retroflexed 
 (fig. 291, p. 435). 
 
 Defective involution always coincides with softening and may be com- 
 plicated by flexion, prolapsus, permanent congestion and even chronic 
 inflammation. 
 
 There are two principal characteristics which will especially help us 
 in making a diagnosis and in distinguishing the arrest of involution from 
 other kinds of hypertrophy : the first is the uniform softness of the 
 uterine tissue, combined with the wine-red colour and other character- 
 istics of gestative congestion ; the second is the extreme laxity of the 
 ligaments and consequent tendency to prolapsus, or at least the indif- 
 ference of position or direction of the uterus. This distinction is 
 important, since the treatment of this kind of hypertrophy consists 
 less in the use of resolvents strictly speaking than in the application of 
 means capable of stimulating muscular contractions, and inducing 
 involution ; I have frequently seen this lead to cure in cases in which 
 the disease (for long misunderstood) had been treated as simple con- 
 gestion or chronic hypertrophic metritis. 
 
 Trealmeul.—S[m])son recommends the use of local antiphlogistics 
 in the acute form of arrested retrograde evolution, asserting that such 
 treatment effects absorption ; but I think he confounds hypertrophy 
 resulting from defective evolution with the cause itself which pro- 
 
HYPERTEOPHY AND ATROPHY 597 
 
 duces it and which temporarily suspends the contraction of the organ; 
 in fact he adds that all traces of inflammation disappear with the use 
 of these means and that their disappearance is followed by rapid 
 improvement. 
 
 Therefore, he adds, even if all inflammation seems to be extin- 
 guished, and when the results only remain, we often find, without 
 knowing why, that local antiphlogistic treatment has the effect of 
 determining absorption of the hypertrophied organ, and of finally 
 restoring it to its normal condition. Consequently if the patient is 
 not too weak we begin by the application of ten or twelve leeches to 
 the vaginal portion of the cervix, or the perinseum, or round the anus. 
 But in these cases and in the most chronic form the same effects are 
 obtained from the application of counter-irritants to the external 
 surface of the abdomen or sacrum, such as antimonial ointment, 
 croton oil, tincture of iodine; but cantharides is the best stimulator 
 of absorption especially in the chronic form of the disease and when 
 the bladder is not irritable. A series of small blisters may be applied 
 to the lower portion of the abdomen every two or three days till the 
 volume of the uterus is visibly diminished. Simpson used to make 
 them the size of a five-shilling piece and apply one every few days. 
 Whilst absorption is stimulated by the application of counter-irritants 
 to the cutaneous surface, the same action may be promoted by the 
 application of mercurial ointment to the vagina, or iodide of lead, or 
 bromide of potassium, in the form of pessaries. Local applications, 
 however, are not sufficient j resolvents should also be administered 
 internally. Amongst these the most efficacious are the iodide and 
 bromide of potassium. Simpson preferred the bromide : it has this 
 advantage over the iodide that it can be administered for a much 
 longer time without causing marasmus ; it is tonic and perhaps the 
 best resolvent in the whole pharmacopoeia ; it is also a sedative to the 
 genital organs. In such cases from 3 to 7 grains may be given three 
 times a day, indeed the dose may be raised to 90 grains a day. 
 Sometimes patients suffering from this kind of hypertrophy are 
 anaemic and feeble. When this is so recourse should be had to 
 resolvents of iron, manganese and other tonic metals, either alone or 
 associated with more specific remedies in order to improve the general 
 health of patients by hygienic measures. Lastly, when the uterus 
 does not respond to any indirect stimulus we may try Simpson's plan 
 of introducing small sponge tents into the uterus or an intra-uterine 
 pessary. We may provoke a tendency to hypertrophy in the uterus 
 and then take advantage of the tendency of the organ to undergo 
 molecular fatty substitution and retrograde evolution, as soon as the 
 artificial stimulus is withdrawn, and by the use of the various resol- 
 vents already mentioned, rest, counter irritants, and bromide deter- 
 mine such absorption so actively, that the uterus is at last reduced to 
 its normal dimensions. I have also found the use of ergot and elec- 
 tricity beneficial, as well as iron baths, sea bathing, stimulating fric- 
 tions, hydropathy, &c. Simpson says that in some obstinate cases he 
 has been obliged to repeat this treatment by irritation and artificial 
 
598 UTERINE DISEASES IN DETAIL 
 
 hypertrophy of the organ from time to time before obtaining a com- 
 plete cure. 
 
 II. Partial Hypertrophy of the Cervix 
 
 The hypertrophy which is limited to the cervix is characterised 
 especially by the elongation of this portion of the organ. It has often 
 been mistaken for prolapsus. It must not^ however, be thought that 
 this uterine displacement is always simulated by hypertrophic elonga- 
 tion of the cervix. Huguier^ who deserves the credit of showing the 
 mistake which had for long been made with regard to supposed proci- 
 dentia^ has given examples of complete prolapsus uteri without elon- 
 gation of the cervix, and has published woodcuts of them.^ On the 
 other hand we cannot believe with Veit [Zeitschrift f. Geburts&.,'Bd.i, 
 S. 144), that primary hypertrophic elongation is very rare and that this 
 kind of hypertrophy is usually consecutive to prolapsus ; it is on the 
 contrary the hypertrophy which simulates prolapsus ; hypertrophy 
 subsequent to descent may occur, but it is very rare. Hypertrophy 
 may affect the whole of the cervix ; but usually it is limited to one or 
 other of the two portions of this organ, sometimes to the vaginal or 
 intra-vaginal portion situated below the insertion of the vagina, some- 
 times to the supra- or utero-vaginal portion, situated above this inser- 
 tion and ending in the isthmus separating the cervix from the body ; 
 sometimes even it is insensibly extended to the latter. The former 
 might be designated by the name of cervico-vaginal hypertrophy, the 
 latter by that of cervico-uterine hypertrophy. At other times the 
 hypertrophy is confined to one of the segments, anterior or posterior, 
 or to one portion of this segment. These three maladies should be 
 studied separately. 
 
 These difi'erent kinds of hypertrophy should never be confounded with 
 cedematous elongation and prolapsus of the cervix during pregnancy, 
 described by Gueniot,^ Scarlau,^ &c. 
 
 1. Suhvaginal Hypertrophy of the Cervix 
 The relative length of the two portions of the cervix (vaginal and 
 supra-vaginal) depends in some women on the height of the vaginal 
 insertion ; but in addition to this cause, which is foreign to the cervix, 
 there is another which exceptionally increases the projection of the 
 cervix, so as to give it considerable length. The proof of this is that 
 in virgins we often see the cervix (usually conical) several centimetres 
 long. Bennet* has also seen the cervix in virgins nearly 9 centi- 
 metres long, resting on the vulval orifice or even projecting below it, 
 and asserts that the elongation may exist congenitally notwith- 
 standing Huguier's opinion, and in spite of the great tendency 
 of the uterus and cervix to become hypertrophied under the influence 
 of inflammation or even of simple congestive irritation. He has seen 
 
 ' Memoire siir les allongements hypertrojMques. See the plate taken from 
 Dupuytren's museum. Case xii, and figure 3. 
 
 2 Archives de viedecine, April, 1872. 
 
 3 Beitrdge zur Geburtsk. u. Gryndh., Bd. ii, Heft 1. Berlin, 1872. 
 * Op. cit., p. 10. 
 
HYPERTROPHY AND ATROPHY 
 
 599 
 
 several cases in unmarried women when no inflammatory action of any 
 kind could be discovered. They consulted him for prolapsus, the 
 appearance of the cervix at the vulva having frightened them and in- 
 duced them or their parents to seek medical advice. The congenital 
 elongations which I have met with have never seemed to me to reach 
 9 centimetres in length. West says also that hypertrophy of the 
 vaginal portion of the cervix is met with not only in sterile married 
 women, but in virgins, that it may be so serious as to be mistaken 
 for prolapsus, the cervix appearing at the vulva, and that it forms an 
 obstacle to marital intercourse causing sterility. 
 
 More frequently hypertrophy of the cervix follows the swelling 
 produced in the tissue of the organ by the persistence of the modifica- 
 tions accompanying pregnancy, and is the result of defective involu- 
 tion of the uterus after delivery. The hypertrophy may even be 
 limited, in this case, to one of the cervical lips, usually to the anterior ; ' 
 
 Fig. .339. — Conical hypertrophy of the sub-vaginal portion (Huguier). 
 
 as a rule also elongation and hypertrophy of the cervix follow the 
 swelling produced in the tissue of the organ by the persistence of con- 
 gestion, inflammation and frequently ulceration of the mucous mem- 
 brane, which is itself the cause of the long duration of these morbid 
 states. 
 
 Another cause requires to be added to the ulceration, congestion and 
 
 * Evory Kennedy, in Dublin Medical Jonrnal, 1838. — Simon of Rostock has 
 also published a remarkable example, with three drawings {Monafsschrift fiir 
 Geburtsh. u. Frauenkranhheiten, 1864, Bd. xxiii, S. 241). 
 
600 
 
 UTEEINE DISEASES IN DETAIL 
 
 inflammation and to the swelling which accompanies them, in order to 
 produce hypertrophy : the special tendency of the uterus to hyper- 
 
 FlG. 340. — Pyriform hypertropliy of the sub-vaginal portion (Huguier). 
 
 trophy requires to be stimulated ; for a congested and swollen cervix 
 equal in size to that of a hypertrophied cervix may remain after several 
 years soft and simply engorged. There is, however, so great a ten- 
 dency towards hypertrophy in the uterus that the eff'usion of plastic 
 lymph produced by inflammation in the deep tissues becomes organised ; 
 the elements of the tissue proper, stimulated by the persistence of the 
 fluxionary movement, increase in size and multiply ; in fact, real hyper- 
 trophy supervenes, which may survive the extinction of inflamma- 
 tory phenomena. 
 
 It is very easy to distinguish congenital from morbid hypertrophic 
 elongation of the vaginal portion of the cervix. Congenital hyper- 
 trophy is rare, the elongated cervix is regularly cylindrical or conoid ; 
 its consistency is relatively soft; in appearance it is normal, presenting no 
 lesion, or only superficial alterations, unless it has really become diseased. 
 Morbid hypertrophy is common, the elongated cervix is irregular, 
 not only conoid but globular, the lower portion sometimes spreading 
 out when the latter is particularly affected by the hypertrophy ; it is 
 congested, inflamed or even ulcerated, and consequently it is hard, 
 painful, sometimes bleeding and requires energetic treatment. 
 
HYPERTEOPHY AND ATEOPHY 
 
 601 
 
 With regard to cervical hypertrophy consecutive to inflammation as 
 well as hypertrophy of the whole organ due to defective retrograde 
 
 Fig. 341. Fig. 342. 
 
 Fig. 341. — Hypertrophy of the sub-vaginal poi-tion affecting the two lips un- 
 equally, with e version of the lips and ectropion of the arbor vitiS (Huguier). 
 
 Fig. 342. — Hypertrophy and procidentia of the vaginal portion affecting both 
 lips, which converge towards the cervical cavity ; the anterior lip is more 
 hypertrophied in its centre, the posterior in its whole extent and at its 
 extreme points ; hypertrophic polypi coming from the central column of 
 the anterior lip (Barnes, p. 638). 
 
 evolution, we must take into account one important circumstance, viz. 
 the time which has elapsed between a delivery or abortion and the 
 development of inflammation; for the hypertrophic character of the 
 malady is frequently due to this circumstance. The nearer the in- 
 flammation is to the period of delivery or abortion the more con- 
 siderable the consecutive hypertrophy wnll be, because the organ has 
 been seized at the time when regressive absorption had not been able 
 to produce any efl'ect on it. Whether hypertrophy of the cervix may 
 or may not be dependent, like that of the whole organ, on arrested 
 retrograde evolution consecutive to delivery, the limitation of this 
 hypertrophy to the cervix is a favorable circumstance in the prognosis : 
 it is always easier to dissipate cervical hypertrophy, whatever its origin 
 be, than to bring back the hypertrophied fundus to its physiological 
 state and to its normal dimensions. 
 
 Whether congenital or morbid, hypertrophy gives to the cervix 
 varied and occasionally singular forms. Sometimes it is pointed and 
 
602 
 
 UTEEINE DISEASES IN DETAIL 
 
 conical below (Fig. 339), the os being at the extremity of the cone or 
 on one of its surfaces ; sometimes it is cylindrical, globular or enlarged 
 
 at the base in the form of a club 
 (Figs. 342, 345). Sometimes 
 the two lips are equally hyper- 
 trophied and the utero- vaginal 
 OS is in the centre (Figs. 343, 
 345); sometimes they are une- 
 qually hypertrophied (Fig. 341), 
 the OS being on one or other of 
 the surfaces, and occasionally 
 completely hidden by the more 
 hypertrophied lip. Lastly, when 
 the hypertrophy has chiefly af- 
 fected the external layers of the 
 organ the borders of the orifice 
 incline towards the cervical ca- 
 vity (Figs. 340, 343) ; when, on 
 the contrary, the hypertrophy 
 has most affected the internal 
 layers eversion of the lips takes 
 place (Figs. 341, 343) and a 
 kind of eversion of the os, which 
 spreads out like a flower, allow- 
 ing the mucous membrane of 
 the cervical cavity to be seen on 
 the two lips, either equally or 
 unequally, according to whether 
 the hypertrophy has attacked 
 these two portions of the organ 
 equally or not.^ 
 
 It is to these anomalies of 
 form already known that we 
 must add that prolongation of 
 the cervical lips described by 
 Virchow under the name of 
 polypus of the lips of the os.^ I shall, however, have occasion to recur 
 again to partial hypertrophy of the segments of the cervix, which 
 deserves the serious attention of the physician on account of its con- 
 nection with sterility. 
 
 Diagnosis — subjective signs. — Patients often experience a painful 
 sensation of dragging in the loins, the iliac regions, even the abdomen, 
 a more painful sensation still of weight in the pelvis, produced by tension 
 of the ligaments and pressure of the cervix on the rectum, perinEeum 
 and vulva. When standing they feel as if the uterus were going to escape 
 from the vulval opening ; when lying down they feel the pressure of 
 
 ' See the Atlas belonging to Boivin and Duges's work and Huguier's paper. 
 ^ Vircliow's Archiv, Bd. ^^i, S. 164 ; and Verliandl. der GeseUsch. f. Ge- 
 bnrtsTc. Berlin, Bd ii, S. 205, 1847. 
 
 Fig. 343. — Advanced hypertrophic elon- 
 gation of the sub-vaginal portion, 
 affecting both lips equally, which di- 
 verge in escaping from the vulva 
 (Barnes, p. 640). 
 
HYPEETEOPHY AND ATEOPHY 
 
 603 
 
 the organ to the right or left and a dragging when the position is 
 changed ; when sitting another sensation is felt, that of compression 
 
 Fig. 344. — Conical congenital 
 hypertrophy, more common 
 than the preceding. 
 
 Fig. 345. — Acquired hypertrophy, club-shaped, 
 also more common than the preceding. 
 
 of the tumour or of the organs situated above it by the chair on which 
 they are seated. And if they sit down quickly in a chair they expe- 
 rience a shock which is felt not only in the hypertrophied organ but in 
 the abdominal viscera; therefore they instinctively sit down wdth 
 great care. 
 
 As for the objective signs an idea will readily be formed of the varie- 
 ties of size and form of the organ by looking over the different wood- 
 cuts representing the various kinds of cervical hypertrophy. Bennet ^ 
 gives a characteristic sign distinguishing scirrhous indurations of the 
 cervix from inequalities due to simple hypertrophic induration. When 
 division of the cervix into knotty and irregular lobes results from 
 laceration in a previous confinement and is simply inflammatory or 
 hypertrophic, the fissures which separate the lobes radiate towards the 
 centre of the os, which does not occur in the case of cancerous 
 tumour. 
 
 Treatment. — I have already laid down the principal indications for 
 the treatment of general hypertrophy of the uterus. They are the 
 same in hypertrophic elongation of the cervix ; effect depletion of the 
 organ when necessary, especially when there are traces of inflammation 
 or congestion; stimulate absorption by resolvents administered inter- 
 nally and externally, by mercurial preparations, iodides, bromides, &c., 
 and by more general means still, addressed more directly to the general 
 
 I Op. cit., p. 90. 
 
604 
 
 UTERINE DISEASES IN DETAIL 
 
 niitrition, such as strict diet and regime, sweating, hydropathy, cwa 
 famis. 
 
 With these general means I combine energetic local treatment, with 
 the object of giving a new direction to the vitality of the organ, and 
 of bringing into action the faculty of absorption which has been in 
 some degree stifled by hypertrophy. The use of these last means is 
 doubly indicated because cervical hypertrophy is often due to local 
 pathological conditions consecutive to morbid states which, although 
 they may have been general, have yet only left a limited result on the 
 diseased part. Sometimes I make more or less deep scarifications^ 
 introducing into them perchloride of iron, or I apply the actual 
 cautery to them ; at other times I make ignipunctures at the most 
 hypertrophied points of the organ. Paquelin's thermo-cautery and 
 my small cauteries are the most suitable instruments for this opera- 
 tion (pp. 211, 216). 
 
 Unfortunately medicinal means and the various modes of cauterisa- 
 tion are insufficient for the treatment of serious hypertrophic elonga- 
 tion. Recourse must be had to excision. Congenital conoid hyper- 
 trophy does not always necessitate amputation of the cervix. Cases 
 requiring incision must be distinguished from those requiring section. 
 Sims (Kg. 346) has represented very exactly a normal type of rounded 
 and truncated cervix. Let us suppose the cervix extended in the 
 direction of the dotted line a, we shall then get a very common form 
 of conical cervix which is almost always associated with constriction of 
 the OS, and almost as constantly with induration. Division of the os 
 extending to the circular fibres will suffice to separate the lips, bring 
 the cervix back to the form of a rounded cone, and cure dysmenor- 
 rhoea and sterility ; but if the cervix extends in the direction of the 
 dotted line b, simple division is not sufficient. A portion of the cervix 
 
 Fig. 346. — Normal cervix : 
 a, cervix slightly coni- 
 cal ; h, cervix very coni- 
 cal (Sims). 
 
 Pig. 347.— Dotted line 
 indicating the point 
 for section of a coni- 
 cal cervix (Sims). 
 
HYPERTROPHY AND ATROPHY 
 
 605 
 
 will require to be amputated, following the transverse direction of the 
 dotted line in fig. 347. 
 
 Acquired hypertrophy, especially club-shaped hypertrophy (T^igs. 
 342, 345) or hypertrophy with elongation simulating procidentia, is 
 not only a cause of dysmenorrhoea and sterility, but it cannot be cured 
 by either simple incision or by cauterisation 
 applied in the way I have just described. When 
 hypertrophic elongation of the cervix gives rise 
 to serious symptoms, and has withstood the 
 means described, when it is of long standing, 
 and when it has reached from 5 to 7 centimetres 
 in length, I agree with Huguier ^ that there is 
 only one means of effectual cure, viz. amputation 
 of the cervix \ of an inch from the vaginal 
 insertion. 
 
 Bennet,^ although not in favour of this ope- 
 ration, acknowledges that it should be performed 
 when elongation of the cervix resists all means 
 of treatment, when it produces permanent dis- 
 comfort, and is an obstacle to marital inter- 
 course or a cause of sterility. West,^ after 
 exaggerating the dangers from haemorrhage and 
 peritonitis, judging from an unfortunate case 
 performed by Paget with the ecraseur, admits 
 that he knows of no other treatment for this 
 malady except ablation of the hypertrophied 
 portion. Scanzoni* goes further in his approval 
 of the operation ; he says : "I have so often seen 
 the inefficiency of all therapeutical means, local as 
 well as general, that now I always perform am- 
 putation of the cervix." I also have seen sterility 
 yield to amputation of the hypertrophied cervix. 
 This operation is doubly desirable when elonga- 
 tion is complicated with a cyst, a fibrous tumour 
 or epithelioma commencing at the lower ex- 
 tremity of the cervix. Huguier says, "We 
 should have all the less hesitation in performing 
 it in that it is an operation at once quick, easy, 
 almost painless and generally unattended with 
 danger,^ and that it relieves patients so quickly 
 
 Fig. 348. — Museux's 
 forceps for seizing the 
 hypertrophied cervix : 
 A, with two hooks ; B, 
 with three hooks. 
 
 and surely of their malady." I agree with this 
 opinion all the more willingly that I know of no 
 other means that can be substituted for ablation 
 of the cervix, and that there are cases in which 
 the malady not only proves uncomfortable but 
 
 ' Op. cit., p. 23. 
 
 ■^ Op. cit., pp. 11, 324. 
 
 3 Op. cit., p. 100. 
 
 '' Lchrhucli der Kranlilieiten der Weiblichcn Sexnalorgane. Wicn. S. 76. 
 
 ^ This operation however, like simple cauterisation, is not without danger 
 
606 
 
 UJEEINE DISEASES IN DETAIL 
 
 painful, reacting on the whole economy and necessitating prompt and 
 decisive intervention. The patient should lie on her back so that 
 plenty of light is thrown on the pelvis. Sometimes the cervix pro- 
 jects at the vulva, in which case the labia and vaginal walls may be 
 separated with dilators or the fingers of an assistant, to reach the 
 point at which the amputation is to be performed. Sometimes it is 
 hidden in the pelvic cavity : in which case it must be brought to view 
 by means of a large bivalve speculum, or two dilators. In any case, 
 it is best to follow Huguier's advice to amputate the cervix without 
 using efforts to try to bring it to the vulva and without dragging on 
 the uterine ligaments. 
 
 The cervix is then seized with a strong tenaculum hook or with 
 Museux's forceps. It is at first drawn upwards, and then with a long- 
 handled curved bistoury a semicircular incision is made at its lower 
 portion, half a centimetre below the vaginal insertion. It is then 
 drawn downwards, and the upper half of it is divided in the same 
 
 Fig. 349. 
 
 -Amputation o£ the vaginal portion of the hypeiirophied cervix 
 with Chassaignac's linear ecraseur. 
 
 manner. The hardness of the tissue and the difficulty of managing the 
 bistoury, sometimes make long curved scissors preferable. I have 
 often used them if not to commence with, at least to finish the section, 
 so as to give it the proper regularity. In fact I prefer using the 
 thermo-cautery or a small cautery at red-heat, to avoid hsemorrhage in 
 
 Apart from opening the peritoneum, examples of which I shall give later on, I 
 may just refer to the case published by Greenhalgh of ablation of the cervix 
 by the ecraseur, followed by peritonitis and death {Obstetrical Transactions, 
 vol. V, pp. 75 and 102). We should therefore be sure that there is no inflam- 
 mation of the annexes or pelvic peritoneum. 
 
HYPEETROPHY AND ATROPHY 607 
 
 forming the posterior and anterior flaps. Even when the haemor- 
 rhage does not seem alarming at first we should pay attention to it, 
 and not leave the patient till it has entirely ceased. Plugging the 
 vagina is sufficient, but it should be done methodically : after having 
 washed the cervix with cold vinegar and water or with iced water 
 (provided that ice can be continuously applied for several days to the 
 hypogastrium, rectum or vagina), small tampons of cotton- wool 
 powdered with alum or saturated with tincture of perchloride of iron 
 should be laid against the bleeding surface, then compressed and kept 
 in place with a number of other tampons till the whole vaginal cavity 
 is filled, when if necessary they can be retained by a T bandage. 
 This dressing is removed the next day or the day following, care being 
 taken to remove only the superficial tampons at first, leaving those 
 that are in contact with the amputated portion for some time longer, 
 and facilitating their removal by making injections to prevent any 
 laceration which would inevitably cause a return of the hsemorrhage. 
 All these inconveniences, however, are avoided by the use of the actual 
 cautery. 
 
 When the base of the tumour is large and traversed by arteries the 
 pulsations of which can be felt, when the patient is chlorotic and can- 
 not be exposed without danger to haemorrhage, the ecraseur should be 
 used. This instrument, however, has two disadvantages : the first is, 
 that it makes the operation not only long but painful when chloroform 
 is not used, on account of the symptoms of strangulation determined 
 by the constriction of the chain ; the second is the difficulty of placing 
 the ecraseur properly on the cervix alone without including a portion 
 of the vaginal walls, and even without touching the bladder or without 
 opening the peritoneum. Huguier mentions a case that occurred in 
 LangenbecFs clinique, in which these two accidents both happened ; 
 the patient died the third day ; a perforation of the bladder and peri- 
 toneum was discovered.^ Therefore I have replaced the ecraseur by 
 the elastic ligature, which has all the advantages of the extemporaneous 
 ligature and is more conveniently applied. If it is desirable to operate 
 more quickly the galvano-canstic wire may be applied, which was used 
 so successfully by Lehmann [Nederl. Tidjschrift voor Geneesk., 1877, 
 No. 7) in a case of prolapsus with elongation, in which the total 
 length of the uterus was 16 centimetres; but Paquelin^s thermo- 
 cautery is better. We must take precautions against consecutive 
 obliteration. I have collected six cases. In order to prevent it I 
 commence by dissecting (with the cautery) two large flaps of mucous 
 membrane, either antero-posterior or lateral, and apply the clastic 
 ligature to the tissue proper at the base, where the flap is adherent, or 
 I finish this section with Paquelin's thermo-cautery. The flaps of 
 mucous membrane are then united to the tissue by a metallic suture, and 
 
 ^ This accident has occmTed several times, after removal of the cervix by 
 the linear ecrascvir, eitlier on account of hypertrophy or cancer. Besides Lan- 
 genheck's patient, in whom the peritoneum was injured, according to the report 
 made by Mayer to the Obstetrical Society of Berlin, five cases at least of this 
 serious accident arc recorded. 
 
608 
 
 UTERINE DISEASES IN DETAIL 
 
 are sufficient afterwards to procure autoplastic restoration of the orifice. 
 This is, I consider, at present the best method of performing partial 
 section of the cervix. 
 
 When there is no danger of haemorrhage and no special indication 
 for the use of the ecraseur, the thermo-cautery or the elastic ligature, 
 it is better to make a clean, transverse section of the cervix which 
 allows of union by first intention. It is to Marion Sims that we owe 
 this idea. In 1859 this surgeon, being about to perform section of a 
 hypertrophied cervix, and not having an ecraseur by him, slit the organ 
 on both sides with scissors as far as the insertion of the vagina, excised 
 both halves,^ and covered the bleeding surface with the vaginal mucous 
 membrane, as the stump of a leg is covered with the skin after circular 
 amputation. The borders of the wound were united from before 
 backwards with four metallic sutures, two on each side of the cervical 
 canal. The wound healed by first intention ; the sutures were removed 
 nine or ten days afterwards. There was no other opening than the 
 oval orifice of the cervical canal in the centre of the line of union. 
 Since then Sims has adopted this method in his practice.^ I have 
 also employed it with success; but I prefer autoplasty of the cervix by 
 excision of two portions of the uterine tissue, after previous dissection 
 
 Tig. 350. — Amputation of the cer- 
 vix, four metallic threads passed 
 though the lips of the wound. 
 
 Fig. 351. — Twisted sutures, union by 
 first intention (Sims). 
 
 of two flaps either antero-posterior or lateral according to my method, 
 or semicircular to allow of excision of a conical portion of the tissue, 
 according to Max Markwald^s method. 
 
 ' Later on, he adopted a kind of small guillotine for excision of the cervix 
 (op. cit., pp. 211, 224). 
 
 ■^ Spiegelberg has published a paper in AreMv filr GynaeJeol., Bd. v. Heft 3. 
 Berlin, 1873 {Ueber die Amputation des Scheidentheils der Gebdrmutter), 
 containing unpublished cases on various modes o£ amputating the cervix in 
 cases of carcinoma, hypertrophy, elongation, &c. The author prefers the 
 method of Sims for hypertrophic elongation (Hayem, Revue des sciences medi- 
 cales, iii, 205). 
 
HYPERTROPHY AND ATROPHY 609 
 
 After amputation of the cervix, whether simple or by the method of 
 Sims, even when followed by immediate union, if there is consecutive 
 contraction of the external orifice it is better to let things take their 
 course than prevent union of the wound by premature and inopportune 
 dilatations. Two or three months afterwards the orifice can be enlarged 
 by incision and dilatation, as in cases of congenital narrowness in which 
 autoplasty is practised. 
 
 2. Supra-vaginal Hypertrophy of the Cervix 
 Hypertrophic elongation of the supra-vaginal portion of the cervix 
 (cervico- uterine elongation) was discovered by Huguier^ in 1849. 
 Before the appearance of his work this elongation had been mistaken 
 for procidentia, and although measurements had been taken both on 
 the living and dead body by Saviard, Morgagni, Hoin, Levret, Dance, 
 Cloquet and Cruveilhier, which proved excessive length of the supra- 
 vaginal portion of the cervix and the presence in the pelvis of the 
 supposed prolapsed uterus, no conclusions had been drawn from them 
 as to the existence of cervico-uterine hypertrophy, its diagnosis or 
 treatment. 
 
 West^ refers in a few words to the existence of supra- vaginal hyper- 
 trophy. He mentions the case quoted by Morgagni^ and the descrip- 
 tion given of it by some German writers, especially by Virchow,^ under 
 the name oi prolapsus of the womb without descent of the fundus. He 
 mentions a specimen of this kind of alteration which is in the Museum 
 of St. Bartholomew's Hospital, series xxxii, 30. He justly remarks 
 that the mechanical means of support and reduction, which are useful 
 in true prolapsus, are useless here and only aggravate the sufferings 
 of the patient. 
 
 Diagnosis — subjective signs. — The principal are the following : 
 abnormal heat and sensibility, pain, muco-purulent hypersecretion 
 from the uterus. Menstruation usually longer and more abundant, 
 prolonged after the age of the menopause, sometimes accompanied by 
 metrorrhagia. Marital intercourse often difficult or impossible, and 
 generally sterility. Micturition frequent, painful, difficult and even 
 impossible, unless the patient pushes the tumour backwards and up- 
 wards with her hand ; for the bladder partly escapes from abdominal 
 pressure, its walls are relaxed and weakened, and the urethra is strongly 
 flexed at the point where it crosses the subpubic ligament and Wilson's 
 muscle. Sometimes there is incontinence of urine, at other times re- 
 tention. The clothes, the abdomen and the tumour are soiled by con- 
 tact with the urine, which cannot be voided in a jet ; hence itching, 
 irritation, frequently even excoriation and ulceration of the vaginal 
 mucous membrane, especially of that which covers the anterior surface 
 1 Memoire sur les allongements hypertrophiques dii col de I'uterus dans les 
 affections designees sous le nom de descente, de precipitation de cet organe, et 
 sur leur traitement par la resection ou V amputation de la totalite du col, 
 suivant la variete de la maladie. Paris, 1860. 
 ^ Op. cit., pp. 144-45. 
 
 ^ Morgagni, De sedibus et Causis Morborum, folio. Venetiis, 1761, 2nd vol., 
 epist. 45, art. 11, p. 204. 
 
 '' Verhandl. der Gesellschaft f. GeburtsJmlfe in Berlin, vol. ii, p. 205, 1847. 
 
 •^9 
 
610 
 
 UTERINE DISEASES IN DETAIL 
 
 of the tumour. There is constipation and difficulty of defecation from the 
 retention of fsecal matters at the point where the tumour projects into 
 the rectum, patients being sometimes obliged to lift the tumour upwards 
 and forwards, to favour the accomplishment of this act. When the 
 
 Fig. 352. — Considerable hypertropliic elongation of the supra- vaginal portion 
 especially, but also of the sub-vaginal portion. From a preparation in St. 
 Bartholomew's Museum. The Fallopian tubes are also diseased. The 
 vagina contains the globular portion of the elongated cervix (Barnes). 
 
 perinseum is lacerated there is at the same time incontinence of faecal 
 matter ; in such cases there is irritation and frequently ulceration of 
 the posterior half of the tumour. 
 
 Lastly, when the patient is obliged to walk or work, in addition to 
 the general feeling of discomfort, there is a dread of the viscera 
 escaping through the vulva, there being no longer any resistance from 
 
HYPERTROPHY AND ATROPHY 
 
 611 
 
 the perinseum, and she also experiences constant pain, dragging in the 
 lumbo-sacral region, sometimes in the hypogastrium and groins, at other 
 
 Fig. 353. — Hypertrophic elongation, principally of the supra-vaginal portion 
 of the neck, simulating prolapsus : /, fundus ; i, isthmus ; c, cervix (from 
 nature, after Farre). 
 
 times in the epigastrium. Every position, especially the vertical one, 
 becomes difficult. Lastly, digestion and nutrition are disturbed. 
 
 Objective sights. — In procidentia the sound penetrates to a depth of 
 from 6 to 7 centimetres, in elongation from 9 to 15 centimetres and 
 exceptionally to 20. The sound also allows us to ascertain the direc- 
 tion of the cervico-uterine canal, the situation of the fundus, &c. 
 Other means also allow a differential diagnosis to be established and 
 completed by the discovery of other elements which may exist in the 
 tumour. For instance, in hypertrophic elongation, rectal touch dis- 
 covers the cervix and above that the body of the uterus ; in procidentia 
 it reveals a vacuum in the middle, and laterally two painful cords, ex- 
 tending from the angles of the womb and formed by the round liga- 
 ments, the ovaries and the Pallopian tubes. A sound passed into the 
 bladder and directed towards the rectum is arrested in the middle by 
 the hypertrophied cervix ; on the contrary it may be felt by the finger 
 placed in the rectum above and behind the uterus when the latter is 
 merely prolapsed. Palpation of the tumour in cases of elongation 
 discovers the presence in its centre and throughout its whole length of 
 a hard and rather broad cylinder ; while in procidentia it reveals a 
 vacuum in the centre of its base, and below this a firm elastic body, 
 of the form and consistency of the uterus, and continuous with the sub- 
 vaginal portion of the cervix, which is visible externally. Lastly, 
 attempted reduction of the tumour gives quite different results in both 
 cases : in procidentia, the first part of reduction, that of making the 
 body of the uterus pass through the vulva, may be painful, difficult or 
 
612 
 
 UTEEINE DISEASES IN DETAIL 
 
 impossible, especially during the menstrual period ; the second part is 
 easy, the parts seeming to go up of themselves, the patient is soothed 
 and the uterus may be maintained by a pessary ; in hypertrophic 
 
 Pig. 354. — Complete procidentia, from a preparation in St. George's Museum 
 (Barnes), pa, anterior peritoneal fossa; pp, posterior peritoneal fossa; 
 T, cystocele ; E, rectum ; p, pubis ; u, urethra ; A, anus ; o, ovaiy ; v, 
 bladder ; M, womb. 
 
 elongation reduction is easy at any time, either before or after men- 
 struation, the entrance of the tumour is effected without any resist- 
 ance from the vulval orifice, it takes place gradually, without pain till 
 the cervix is on a level with the lower extremity of the vagina ; flat, 
 oval, annular pessaries may then be borne with benefit ; but if we wish 
 to raise this part higher, to its normal position, we usually feel resist- 
 ance, the uterus becomes curved on itself, and more or less acute pain 
 is produced, or the body of the uterus is raised out of the pelvic into 
 the abdominal cavity, where it causes great discomfort and even un 
 bearable pain by its pressure on the neighbouring parts and by the 
 tension exercised on its own ligaments. These considerations are very 
 useful in establishing a differential diagnosis. 
 
 Treatment. — The impossibility of reducing the tumour and of main- 
 taining it reduced in confirmed hypertrophic elongation explains how 
 this malady, reputed to be incurable, becomes a real infirmity which 
 only rest combined with the use of vulval bandages of various kinds 
 
HYPERTROPHY AND ATROPHY 613 
 
 makes bearable. The discomfort attendant on micturition of which I 
 have spoken, the contact of the urine with the tumour, the friction of 
 the latter against the clothes, and the ulceration which follows cause 
 such constant discomfort that the intervention of art becomes neces- 
 sary. Unfortunatelj the means at our disposal are very incomplete, 
 and are only successful when the malady is slight. 
 
 As for medical means, those which I have enumerated in speaking 
 of general hypertrophy may be used ; the horizontal posture with the 
 pelvis raised, iodide of potassium, ergot, cold enemata, frictions with 
 resolvent ointment, &c. 
 
 When the elongation is not very extensive (about 2 or 3 centi- 
 metres), when the upper extremity of the vagina only is inverted and 
 when the whole of the tumour does not protrude more than from 4 to 
 5 centimetres beyond the vulva when the patient strains in a standing 
 position, the cervix and vagina can usually be kept reduced by one 
 of the numerous varieties of pessaries (especially Hodge^s lever 
 pessary). Unfortunately reduction cannot always be maintained for 
 want of apoini d'appui owing to the considerable enlargement of the 
 transverse diameter of the vaginal opening. Their diameter must 
 therefore be proportioned to that of the vaginal opening. I know a 
 woman aged sixty affected with hypertrophic elongation measuring 
 nearly 12 centimetres, mistaken till lately for a simple prolapsus ; she 
 was accustomed to reduce it by means of a large ball of linen which 
 served as a pessary, and although suffering discomfort she is able to 
 do a great deal of hard work in a maternity hospital. When the pro- 
 lapsed parts can be raised above the vulval opening and when patients 
 cannot tolerate any kind of pessary, we must be content with main- 
 taining the tumour in this position by means of an oval plate sup- 
 ported by elastic bands, or mounted on a steel spring fixed to a belt. 
 Unfortunately the presence and pressure of this plate can hardly be 
 borne by women who have hard work to do ; sometimes too the uterus 
 escapes at one side of the instrument, and the contact of the latter 
 irritates the organs and provokes secretions so that patients are 
 obliged to lay it aside. 
 
 When these means are found insufficient, an operation should be 
 tried.^ This operation, which consists in removing a part or the 
 whole of the cervix with the upper extremity of the vagina, by scoop- 
 ing it out from without inwards, after having previously detached the 
 bladder from the part which is to be removed, has been suggested by 
 Huguier under the name of conoid amputation of the cervix. It has 
 been successfully performed by this surgeon and by others ; I have 
 performed it several times with equal success ; and although not 
 exempt from danger, it seems to me that it ought to be accejjted as 
 the only means of curing an infirmity which though not endangering 
 life yet produces very great discomfort. We must not, however, 
 
 ^ I ao;ree with Marion Sims who, while approving of Huguier's operation, 
 says, that as a rule conoid amputation should only be made when there is 
 hypertrophic elongation of the infra- vaginal portion of the cervix as well a& 
 procidentia and supra-vaginal hypertrophy. 
 
61*4 UTERINE DISEASES IN DETAIL 
 
 forget that the most serious accidents may be developed, for they 
 occur on the occasion of much less serious operations. Metritis or 
 peritonitis may cause the death of patients. Peter/ the translator of 
 the last edition of Bennet's Treatise on Uterine Inflammation, mentions 
 an unfortunate case of the kind which he saw. The surgeon must 
 judge of each case individually, taking into account all the indications 
 and contra-indications. 
 
 The object of the operation is not merely to amputate the sub- 
 vaginal portion of the cervix, but also to remove that extending 
 between the insertions of the vagina and the body of the organ, which 
 is the principal seat of hypertrophy. It should be performed a few 
 days after the menstrual period, the patient having since then made 
 very hot injections and kept the horizontal posture. The first part of 
 the operation consists in section of the posterior walls of the vagina 
 and cervix. The danger incurred is that of lesion of the peritoneum. 
 To avoid it the surgeon introduces the index finger of the left hand 
 into the rectum, pressing against the anterior wall of the intestine ; 
 this finger indicates to the eye the limit of the recto-vaginal fold of the 
 peritoneum, and serves as a guide during the whole operation. The 
 portion of the vagina which is inserted on the cervix is incised above 
 this finger, whilst an assistant pushes the whole tumour upwards and 
 forwards by means of a pair of Museux's forceps fixed in the posterior 
 lip of the cervix. This incision is carried at first towards the cervical 
 cavity to avoid the peritoneum, then into the uterine tissue obliquely, 
 from below upwards, and from without inwards till the cervical cavity 
 is reached. The second part of the operation consists in section of the 
 anterior walls of the vagina and cervix. The chief danger incurred is 
 injury to the bladder. To avoid it, a sound is introduced into this 
 organ and directed downwards into the lower portion of the vesical 
 cicl de- sac "^hich invariably forms the anterior part of the tumour; 
 this part is raised and rendered prominent, and the assistant to whom 
 the sound is entrusted is told to make it perceptible to both finger and 
 eye. The anterior lip of the cervix is seized with Museux^s forceps 
 and drawn down by an assistant ; the surgeon then makes a horizon- 
 tal and semi-lunar incision, convex above, at about one centimetre 
 from the projection formed by the sound, which embraces the anterior 
 portion of the cervix, its extremities joining those of the first incision. 
 The anterior surface of the cervix below the bladder must only be 
 reached by small incisions; when the operation has arrived at this 
 point the sound is taken away ; the bladder is separated by a careful 
 dissection from the anterior portion of the cervix to an extent of from 
 2 to 4 centimetres in the centre, and from 40 to 50 millimetres on 
 the sides, for fear of injuring the ureters; after which the anterior 
 wall is divided from the cervix obliquely from below upwards and 
 from before backwards^ till the cervical cavity has been reached, as 
 has been done for the posterior wall. The portion taken from the 
 uterus ought to be cone-shaped, the base corresponding with the 
 cervix, and the vagino-uterine wound funnel-shaped, the most con- 
 
 1 Op. cit., p. 463. 
 
HYPERTROPHY AND ATROPHY 615 
 
 tracted portion corresponding to the uterine cavity. In order to pre- 
 vent hsemorrhage; especially after the operation, the arteries should be 
 ligatured as they are opened. The uterine tissue is so dense and 
 friable that it is very difficult for the ligatures to keep a hold of them. 
 Huguier has invented an ingenious method of ensuring constriction : 
 the use of hooked pins. In place of seizing the uterus with forceps 
 or with an ordinary tenaculum hook, he uses a good strong pin in the 
 form of a fish-hook to the head of which a long thread is attached. A 
 ligature is made on the parts fixed by the pin, the point of -which is 
 cut at 1 millimetre from the knot, so as to prevent it from pricking 
 and hurting the neighbouring parts. The whole is left in place and 
 falls from the third to the fifth day. In applying the ligatures in this 
 way as the arteries are opened time is gained, the loss of a quantity of 
 blood is avoided, and the patient spared a subsequent hsemorrhage. 
 When hsemorrhage continues in spite of the use of the ecraseur and in 
 spite of the appHcation of tenaculum ligatures, the vagina must be 
 plugged as after amputation of the subvaginal portion of the cervix. 
 I have left this description unaltered because there are cases in which 
 it is necessary to have recourse to the bistoury in order to avoid the 
 formation of cicatricial tissue and preserve the flexibility and supple- 
 ness of the uterus, but I should add that latterly when performing this 
 operation, especially in old women, I have used very small cauteries or 
 Paquehn's thermo-cautery in place of the bistoury. I have also pre- 
 scribed very hot injections previously as a preventive haemostatic means, 
 and I think the gravity of the operation is greatly diminished by their 
 use. After section of the cervix has been performed, I push the rest 
 of the uterus and vagina back into the pelvis, and make no other 
 ap])lication than simple detersive vaginal injections. Cicatrisation is 
 usually completed towards the twentieth day. The upper extremity of 
 the vagina is then retracted and punctured; it presents a reddish 
 cicatrix nearly 2 centimetres long, at the base of which is felt a small 
 mammillated eminence the size of a finger-tip, pierced in the centre by 
 a small transverse opening : it is the lower part of the uterus. The 
 womb at the end of two or three months is less voluminous and shorter 
 than after the operation: it diminishes from 1 to 1| centimetres. 
 This diminution is to be attributed to the resolution and suppuration 
 which have followed the solution of continuity, as well as to the 
 retraction of the cicatrix. The procidentia is then radically cured, 
 except in cases in which there is a very wide pelvis and vulval open- 
 ing, a more or less lacerated perinsaum, and considerable weakening of 
 all the soft parts which form the floor of the pelvis, and when the 
 body of the uterus is completely prolapsed from the pelvis and in 
 retroflexion, so that the fundus of the organ is lower than the cervix. 
 These various circumstances contra-indicate operation, or at least give 
 no hope for complete success. 
 
 Lastly, when the malady is preceded by a voluminous rectocele or 
 cystocele, or by both, it may be necessary, after removal of the cervix, 
 to operate for the herniffi of the rectum and bladder separately. The 
 best way of operating consists in destroying on each side a circular 
 
616 UTERINE DISEASES IN DETAIL 
 
 portion of the vaginal wall which covers them^ in order to determine 
 strong cicatricial retraction. It is important in dissecting the vaginal 
 wall to avoid injuring the bladder and rectum. Huguier has con- 
 trived for this end an ingenious method, which he applies one or two 
 months after conoid section of the cervix, i. e. when the first wound is 
 cicatrised, the patient out of bed, and the result of the operation can be 
 judged of. Por cystocele, after having previously dilated the urethra 
 with prepared sponge, he introduces the little finger by this canal, and 
 if possible, the index finger of the left hand into the bladder. He 
 seizes the tubercle and the anterior wall of the vagina with a small 
 pair of Museux^s forceps, making an assistant draw them downwards 
 and forwards, so as to stretch them and separate them, if possible, 
 from the corresponding wall of the bladder. Then he passes, at the 
 base of the fold formed by the part of the vaginal wall which he wishes 
 to remove, a long pin, or several pins crossed, for example four, form- 
 ing two crosses, taking care that the pins traverse the cellular tissue 
 lying between the vagina and bladder without touching the walls of 
 this organ, of which he is warned by the finger introduced into the 
 vesical cavity. He throws a loop of thread behind each cross formed 
 by the pins, forms a pedicle of the whole with a triple thread and 
 applies the ecraseur. The same operation may be performed simulta- 
 neously on the posterior wall of the vagina covering the rectum, care 
 being taken to introduce the index finger into the intestine to serve as 
 a guide, and to preserve the wall of the organ, remembering that the 
 upper portion of the rectocele is not only in proximity to the anterior 
 wall of the rectum, but also with the vagino-rectal cul-de-sac of the 
 peritoneum. 
 
 3. Hypertrophy of the Cervix limited to one Segment or to one Lip} 
 I have already said (p. 602) that the two lips of the cervix may be 
 
 * I cannot better sum up my opinion on partial hypertrophy of the cervix 
 than by quoting the conclusions of the paper on this subject presented to the 
 Academy of Medicine, 22 May, 1877. 
 
 1. Partial hypertrophy of the cervix is an increase of volume limited to one 
 point of this organ. 
 
 2. It must not be confounded with tumours properly so-called of this organ. 
 
 3. It exists in the peripheric parts or in the parts which form the walls of 
 the cervical cavity. 
 
 4. This partial hypertrophy of the walls of the cervical cavity is the least 
 known and the most important to recognise. 
 
 5. It exists most frequently in the median line. It is often congenital, 
 depending on arrested absorption of the partition which separates primitively 
 the two uteri, and of which the columns of the arbor viteg are the vestiges. 
 
 6. The irritation caused by excessive coitus and inflammation of the cervix 
 after abortion or delivery, also cause or increase it. 
 
 7. It is often situated on a level with the vaginal orifice, lies frequently on 
 a level with the isthmus, more rarely in the central portion. 
 
 8. The subjective signs are sometimes those of metritis or dysmenorrhcea 
 (for deep-seated hypertrophy), always sterility. Usually there is the contrast 
 of persistent sterility with the absence of dysmenorrhoeic symptoms. 
 
 9. The most marked objective sign is the semi-lunar form of the os ; in 
 hypertrophy of the upper part of the cervix there is difficulty in passing the 
 
HYPERTROPHY AND ATROPHY 617 
 
 unequally hypertrophied so as to place the orifice on the one or the 
 other surface^ and even to hide it behind the most hypertrophied lip. 
 I have given examples of sterility due to this cause^ in vt^hich aptitude 
 for conception has been restored by the cure of the hypertrophy [see 
 chapter on Sterility). Here I wish to give a brief but more complete 
 explanation of the various kinds of partial hypertrophy which may aflect 
 one of the segments of the cervix. 
 
 In this kind of partial hypertrophy it is not one of the transverse 
 segments of the cervix which is affected, but one of its two longitudinal 
 segments, the anterior or the posterior. The anterior has seemed to 
 me more frequently affected than the posterior. I have reason to 
 believe it is the same with the body, and that partial hypertrophy may 
 exclusively affect either the anterior or posterior segment, and, if I 
 may judge by my own observations, it is more commonly the posterior. 
 These partial hypertrophies of the body, however, besides being more 
 difficult to verify than those of the cervix, do not produce such marked 
 symptoms, and are not so easily curable. Hypertrophy of one of the 
 segments of the cervix is often observed at the lower part of this organ, 
 i. e. on one of the cervical lips; but it may exist also at its upper ex- 
 tremity, as well as at its median part, and even in its whole extent. 
 
 Sometimes we can only gain an exact idea of the existence and seat 
 of this partial hypertrophy after dilating the cervix with sponge tents. 
 We then see clearly that the obstacle to the free penetration of the 
 sound is a partial hypertrophy of one lip (in this case the anterior one) 
 a little above the orifice, and therefore we cauterise at the seat of the 
 hypertrophy or the cervix itself, penetrating, however, deeply into the 
 hypertrophied lip. 
 
 Hypertrophy of one lip not only is more frequently observed than 
 other forms of hypertrophy, but it is more frequent; for whilst some- 
 times congenital, as the others generally are, it is much more commonly 
 than these the consequence of chronic congestion or inflammation. 
 Now the causes of these morbid states are much more numerous for 
 the cervico-vaginal than for the cervico-uterine portion of the neck, 
 more numerous also for the anterior lip (which is more commonly 
 hypertrophied) than for the posterior. The hypertrophied lip may 
 assume various forms : sometimes it is very voluminous, especially ex- 
 ternally, entirely hiding the opposite one by projecting beyond it; 
 sometimes, on the contrary, it is more developed internally, and then 
 it distends the opposite lip and becomes covered by it;^ sometimes it 
 
 sound ; dilatation by sponge tents and subsequent use of the sound allow of 
 its being distinguished from anteflexion. 
 
 10. Treatment consists in general and local resolvents (baths, injections, 
 medicated pessaries, hydroi^athy) . 
 
 11. The special means are dilatation by sponge tents, scarifications or caus- 
 tics for hypertrophy situated at the cervico-uterine isthmus, ignipuncture foi* 
 hypertrophy situated at the vaginal orifice. 
 
 12. The cure of partial hypertrophy of the cervix leads to the cure of the 
 sterility. 
 
 ' Figs. 355, 356, give an exact idea of this arrangement. The cervix, as 
 seen through the speculum (Fig. 355), shows a marked increase in the size of 
 the anterior lip. The orifice assumes the form of a crescent, convex posteriorly, 
 
618 
 
 UTERINE DISEASES IN DETAIL 
 
 is broad and thin, exceeding the other lip^ over which it falls like an 
 apron ; at other times it is narrow and long and_, projecting beyond the 
 opposite lip, assumes the form of a beak or snout. ^ Even when the 
 
 Fig. 355. 
 
 Fig. 356. 
 
 uterus is conical, and when the os is reduced to a pin-point, not un- 
 frequently this pin-point instead of being at the summit of the cone is 
 on its posterior surface, constituting true hypertrophy of the anterior 
 lip ; sometimes the hypertrophy seems connected with flexion of the 
 cervix, and in this case the lip corresponding to the convexity without 
 being thicker is much longer than the other (anteflexion being most 
 common, it is the posterior lip which is usually the seat of this elonga- 
 tion, of this hypertrophic extension). 
 
 These various kinds of hypertrophy are met with in women who have 
 never conceived, and are either congenital (in which case they chiefly 
 affect the conical form) or acquired in consequence of venereal excesses 
 or local disease neglected for a long time. They are observed more 
 frequently in multiparse; then they are always acquired, and are due 
 to chronic inflammation which has hypertrophied the organic tissue or 
 the mucous membrane. They are a common cause of sterility, though 
 not generally recognised as such, for though presenting an obstacle to 
 the penetration of the semen, they permit the easy discharge of the 
 menses, and consequently do not attract the attention of patients. I 
 have seen in several sterile women a partial hypertrophy, the remains 
 of the union of the two uteri, more common before than behind, and 
 exaggerated by the natural anteflexion of the organ. This tubercle, 
 which may be called the uterine uvula, is similar as regards position 
 and symptomatological consequences to hypertrophy of the median lobe 
 of the prostate. It does not always prevent the escape of the menses, 
 
 sure sign of hypertrophy of the anterior lip. The sound only penetrates into 
 the uterus by following the curve formed by the cervical cavity, as is indicated 
 in the section of the uterus, shown in Fig. 356. The posterior lip covers the 
 anterior lip partly. Sims also refers to this semi-lunar form of the orifice 
 (op. cit., p. 223). 
 
 1 Beigel has made similar observations {Berlin. Klin. Wochensch., 1867, 
 Nos. 47, 48). 
 
HYPERTROPHY AND ATROPHY 619 
 
 but even when it offers no obstacle to any discbarge from the interior 
 it opposes an impassable barrier to the entrance of any fluid from 
 without. 
 
 Hypertrophy of the median portion of the cervix is less frequent 
 than that of its extremities. In this the cervix follows the law of every 
 hollow organ, the orifices of which are the seat of hypertrophy or of 
 the development of tumours and of degeneration more frequently than 
 the walls. But it exists all the same, especially in the columns of the 
 arhor vitce, sometimes on both simultaneously, but more commonly on 
 one only, the other being depressed by the progressive development of 
 the former. Usually it is consecutive to hypertrophy of the internal 
 orifice or of the lips of the vaginal orifice, and gradually disappears 
 towards the median portion of the cervix. It may, however, be inde- 
 pendent of it, existing alone. 
 
 Diagnosis, — This is easily made when we are aware of the possi- 
 bility of the existence of such a disease. I am sure that I often 
 ignored it in the beginning of my gynaecological practice. Besides 
 the subjective signs, sterility, dysmenorrhoea and the other symptoms 
 of hypertrophy, sight, touch, and the sound especially leave no doubt 
 on the subject. Sight and touch only discover the excessive size of 
 one of the lips, or the alteration in the form of the orifice. The in- 
 ternal seat of the hypertrophy of the tumefied lip is disclosed by the 
 sound, which alone permits of the verification of partial hypertrophy 
 of the median portion and of the os internum. 
 
 Treatment. — I shall add nothing to what I have already said as to 
 resolvent treatment, general and local, solvents, tampons of glycerine, 
 and glycerole of iodide of potassium, which may be applied here as in 
 other kinds of hypertrophy. There are, however, two points upon 
 which I ought to insist, because they may lead to cure without neces- 
 sitating recourse to operation : I refer to puncture with the actual 
 cautery, and the application of dilating bodies. It is especially in 
 hypertrophy limited to one of the cervical lips that I have been able 
 to observe the marked resolvent action of the actual cautery ; but it 
 is principally in this case that the tissue must be pierced with pointed 
 cauteries at red or white heat according to the size of the tumefaction, 
 taking care to spare the circumference of the orifice ; although the 
 cautery may be introduced into the cervical cavity, this is not usually 
 indispensable (^see Fig. 194, p. 213, representing ignipuncture of the 
 hypertrophied anterior lip). 
 
 As for laminaria or sponge tents, they produce the most remarkable 
 efi'ects ; it is sometimes necessary to slit the cervix or to incise the 
 portion of the prominent lip slightly in its thickness, then to dilate the 
 cervix with tents of increasing size, and lastly to profit by the dila- 
 tation to incise, excise, or abrade the exuberant tissues. But dilata- 
 tion alone sufiices to produce great modification of the hypertrophy ; 
 it softens the tissue, determining hypersecretion, a discharge which 
 may be increased by the addition of a tampon of glycerine, facilitates 
 resolution, and by the excentric compression which it exercises on the 
 tissue, it stimulates the resolvent action. Resolvents may then be 
 
620 UTERINE DISEASES IN DETAIL 
 
 applied directly to the tumefied parts to complete the mechanical and 
 vital action of dilatation. 
 
 Recourse must sometimes be had, notwithstanding, to extreme 
 measures, which are not dangerous if applied intelligently ; these are 
 excision, incision, or abrasion of the hypertrophied part. In per- 
 forming incision and excision the flaps of mucous membrane should be 
 preserved so as to allow the full size of the orifice to be retained. In 
 amputation of the cervix there is still more reason for preserving 
 fragments of mucous membrane when the os is involved. It is 
 different when the malady is in the cervical cavity, or even at the os 
 internum. 
 
 When the hypertrophy is situated in the cervical cavity or at the 
 cervieo-uterine orifice we should commence by dilating the isthmus 
 before thinking of section. Yery often repeated dilatation is sufficient 
 to procure a satisfactory result. When insufficient, section, abrasion, 
 or even amputation may be tried, according to the size of the tubercle 
 or valvular barrier. Having dilated the uterine canal, I introduce one 
 of Recamier's large curettes, which serves me for a guide, and prevents 
 the uterus from bending. Then with a short probe-pointed bistoury 
 or curved tenotome, guarded by the curette till the obstacle is reached, 
 I make a median incision, or two converging incisions, which must 
 not be deep ; or I try to excise the tubercle, dividing it from left to 
 right. To facilitate this amputation, or rather this abrasion, when 
 the hypertrophied portion is soft, I have used one of Eecamier's 
 curettes, broad and sharp at the end, or better still one with a trian- 
 gular fenestrated and sharp extremity, like that of Marion Sims, with 
 which the excrescence, or its fragments if it has been previously di- 
 vided, can be removed by trapping each successively in the fenestrum 
 and withdrawing the instrument ; or I sometimes use a kind of little 
 hooked knife, the stem of which is flexible enough for it to be inclined 
 in various directions. 
 
 When the hypertrophy is situated in the median part of the cervical 
 segment it may be first treated with sponge or laminaria tents, scari- 
 fications, ignipunctures, or the same methods of abrasion and 
 section may be employed as in cases of partial hypertrophy of the 
 isthmus. 
 
 III. Atrophy of the Uterus 
 
 Atrophy of the uterus constitutes a morbid state in which this organ, 
 after having been normally developed, loses, from various causes, its 
 normal dimensions and shape, and is reduced to a smaller size. 
 Scanzoni,^ from whom I borrow this definition, divides atrophy into 
 excentric and concentric. Excentric atrophy, a thinning of the walls 
 with dilatation of the cavity, is usually symptomatic, either of hydro- 
 metria produced by the accumulation of mucus and the obliteration of 
 the cervieo-uterine orifice in the period of decrepitude, or of a rapid 
 and considerable effusion of blood, with atresia, in young women, or 
 of the formation and persistence of a fatty state after puerperal 
 
 diseases. 
 
 1 Op. cit., p. 71. 
 
HYPERTROPHY AND ATROPHY 621 
 
 Concentric atrophy, thinning of the walls with contraction of the 
 cavity, may be general or partial. When general, it is often accom- 
 panied by softening and small apoplectic centres. When partial, it 
 may affect the cervico-uterine isthmus and produce flexions of the 
 fundus on the cervix, or contractions and obliterations of the os 
 internum. 
 
 Sometimes it depends on a purely local cause, compression exercised 
 on the womb by tumours situated outside this organ, by sub-peri- 
 toneal fibroids, peritoneal exudations, organised plastic deposits round 
 the uterus, solid ovarian tumours, or by large tumours arising from 
 the pelvic walls. At other times it is due to simple senile altera- 
 tions, or alterations of nutrition produced in the uterus by chronic 
 maladies : to this last category belong cases of uterine atrophy brought 
 on by a state of paralysis, a result which appears possible from some 
 curious cases observed by Scanzoni in young paraplegic women, in 
 whom the fact was demonstrated by autopsy. Jacquet {Beitrdge z. 
 Geburtsk., Bd. ii, S. 2) mentions two cases of atrophy of the uterus : 
 in one ovarian molimen persisted, in the other it was wanting. Ac- 
 cording to Chiari ^ atrophy may be observed in chlorotic patients and 
 may be dependent on menstrual disorders. I have seen a case of uterine 
 atrophy due to amenorrhoea dependent on general as well as local 
 causes ; and I have met with another which occurred after eight abor- 
 tions. There is, however, a special kind of atrophy, due to an excess 
 of the retrograde evolution which the uterus undergoes after delivery, 
 to which Simpson has referred under the name of atrophy from exces- 
 sive involution or siiperinvolution. It is the inverse of hypertrophy 
 from subinvolution. It occurs when the progress of absorption is 
 effected, after delivery, to an excessive degree, the organ being reduced 
 to a size smaller than that of the uterus in the state of vacuity. It is 
 comparatively rare, but occurs occasionally. Simpson ^ saw several 
 cases in his practice^ one of which was confirmed by autopsy.^ 
 
 Diagnosis — subjective signs. — Suppressed or imperfect menstrua- 
 tion, which is not established normally after lactation. The breasts 
 shrivel, the subcutaneous adipose tissue covering them is absorbed, 
 the skin becomes wrinkled, the patient although young having all the 
 appearance of premature old age. The whole economy participates in 
 the change that has taken place in the uterus, just as in women at the 
 climacteric when the functional activity of this organ terminates. 
 Sterility results as a matter of course. The health is aflected, the 
 patient suffering from anaemia, dyspepsia, frequent headaches, and 
 general debility of body and mind. 
 
 Objective signs. — Vaginal touch reveals an unusually small cervix, 
 projecting so slightly beyond the vaginal cul-de-sac that it is hardly 
 
 1 Klinilc der Geburtsk. in Gyndcol. Erlangen, 1852, S. 271. 
 
 2 Op. cit., p. 597. 
 
 ^ Mickschik {Wiener Zeitschr., 1856, Bd. xii, Heft 3) has published the 
 autopsy on a woman 24 years of age, who died five months aftei* two deliveries. 
 The ovaries and the uterus were atrophied. Tlie latter was 30 mm. in length, 
 40 in width. The walls were i inch thick. Microscopic examination showed 
 fatty degeneration of the uterus and ovaries. 
 
622 UTEEINE DISEASES IN DETAIL 
 
 perceptible; the womb is small, light and mobile; it is difficult to 
 seize it by abdominal palpation notwithstanding the thin and relaxed 
 abdominal wall. The os is small, only admitting the entrance of an 
 extremely fine sound, in the introduction of which great care must be 
 taken not to use any force, for the walls are hardly any thicker than a 
 sheet of paper. Kiob ^ mentions a case of the kind, Simpson saw a 
 similar case, where a sound carelessly introduced pierced the uterine 
 walls and penetrated the peritoneal cavity. This accident has happened 
 more than once ; fortunately it is not followed by such serious conse- 
 quences as might be supposed. When the sound is used with all 
 necessary precaution, it only penetrates to a depth of 3 to 4 centi- 
 metres, which proves that the organ is abnormally small. 
 
 Treatment. — Is there any means of bringing the uterus back to its 
 normal condition and of restoring the patient to her former health ? 
 When the uterus is completely atrophied, this is hardly possible, but 
 when only slightly affected there is some chance of cure. In atrophy 
 of the uterus due either to congenital imperfection of development at 
 puberty, or to excessive retrograde evolution during the puerperal 
 state, the best treatment consists in the use of the galvanic stem. In 
 order to understand the way in which this treatment acts, we must 
 remember this general law: in uterine therapeutics as well as in 
 uterine physiology and pathology, all continuous and increasing irrita- 
 tion, all dilatation of the walls of the uterine cavity by a foreign body, 
 promotes the development and hypertrophy of the organ. When the 
 uterus is atrophied, a short and acute irritation like that produced by 
 the introduction of a sponge tent for one or two days is not enough, a 
 more continuous irritation is required, like that produced by the pro- 
 longed use of a series of small galvanic stems of gradually increasing 
 length and thickness. Simpson ^ often saw menstruation restored 
 temporarily or even permanently by the use of this means. Among 
 other cases he mentions a very remarkable one, in which the galvanic 
 pessary was left several months or even years in the uterus and in 
 the end effected the restoration of regular menstruation, the return of 
 the organ to normal dimensions and the disappearance of all the 
 serious accidents which had for long disordered the general health. 
 Marriage may be the means of curing atrophy. Therefore Yannoni ^ 
 has recommended coitus in atrophy of the cervix as useful in hasten- 
 ing the development of this organ. Intra-uterine injections may be 
 beneficial, as well as stem pessaries, laminaria tents, or other foreign 
 bodies. Electricity is especially likely to be successful : it would act 
 probably on the uterus as it does on atrophied muscles. 
 
 ^ Pathologische Anatomie der weihlichen sexual Organe. Wieii, 1864, p. 206. 
 
 2 Op. cit., p. 637. 
 
 3 Journal des connaissances med.-chir., 1850, p. 19. 
 
GRANULATIONS AND FUNGOSITIES 623 
 
 Geanulations and Pungosities 
 
 Uterine granulations are small fibro-vascular excrescences, usually 
 multiple and confluent, variable in number and size, seen most com- 
 monly about the cervical orifice, although they may be developed over 
 the whole external and internal surface of this organ and even in the 
 uterine cavity, either from a simple disturbance of its local life, or 
 under the influence of a general morbid condition whether diathetic 
 or not. 
 
 Fmigosiiies are only granulations in a further stage of development, 
 softer, more vascular, bleeding more, situated on the cervix or at 
 different depths in the uterine cavity. ChomeP says : "Granulations 
 constitute a malady proper of the cervix uteri." He adds, however, 
 that a tendency to similar granulation is sometimes observed in the 
 mucous membrane of the pharynx, and more frequently in men than in 
 women. 
 
 Etiology. — Predisposing causes. — Local predisposing causes. — The 
 vitality of the uterus with its remarkably plastic tendency, its struc- 
 ture in harmony with this tendency, showing an instability of organisa- 
 tion, or rather a continual tendency to hypertrophy and atrophy, the 
 character of its functions, favouring by the frequency, periodicity and 
 nature of its fluxions this tendency to plasticity, are evidently three 
 circumstances which predispose the uterus, and particularly its mucous 
 membrane, to hypertrophy, and more especially to granular hyper- 
 trophy. The fibro-plastic tissue, which is chiefly found in the dermis 
 of the mucous membrane, is by its nature more predisposed to hyper- 
 trophy than any other ; for it constitutes in itself a state of transition 
 between the blastema and the fibrous tissue, and manifests anatomically, 
 in the most evident way, the incessant tendency of the uterus to 
 organisation or hypertrophy. It is to this structure that the internal 
 membrane of the uterus owes the power of undergoing an enormous 
 tumefaction from the moment of conception, of forming the decidua 
 and of finding the elements of its regeneration ready to hand at the 
 given moment. 
 
 It is impossible not to attribute to these anatomical conditions a 
 great influence over the hypertrophic tendency which characterises all 
 uterine maladies, particularly those of its mucous membrane; and 
 further, it is difficult not to attribute to the existence of \h& fibro- 
 plastic tissue the part which it takes in the formation of the papillse 
 of the dermis, and to its interposition between the mucous follicles the 
 special tendency to granular hypertrophy. Thus it is that uterine 
 fungosities, i. e. more or less fungous granulations of the cervical 
 cavity are frequent ; and that granulations of the cervix especially, as 
 the part most exposed to external agents and to all the morbid acci- 
 dents capable of producing them are more frequent still ; there is no 
 diathesis under the influence of which they cannot be developed or 
 
 • Diction, de med., en 30 vol., art. Utertts, M^iteite GRANrLEE. Paris, 1846. 
 
624 UTERINE DISEASES IN DETAIL 
 
 perpetuated : judging from my own experience, out of nearly 3000 
 cases of uterine maladies I have had 450 cases of granular cervix. 
 
 Oeneral predisposing causes. — Diathetic affections of all kinds 
 have a large share in the production and chronicity of uterine maladies. 
 Almost all writers on uterine diseases in the last few years have attri- 
 buted these granulations to inflammation of the cervix. Since Bennet^ 
 published his admirable book on this disease, metritis has taken too 
 large a place in the domain of uterine maladies. Por Aran, Becquerel, 
 Nonat, granulations as well as redness, erosions, ulcers, leucorrhoea, 
 &c., are but symptoms of metritis. I am not, however, alone in trying 
 to prove that inflammation is not everything in uterine diseases in 
 general, and in the production of uterine granulations in particular. 
 Timbart,^ although he admits, contrary to my opinion, that granula- 
 tions do not of themselves form special and distinct maladies, demon- 
 strates in the conclusion of his work that these lesions may occur as 
 symptoms or complications in the majority of uterine affections : those 
 affections with which he specially connects them are uterine catarrh 
 and scrofulous engorgement of the cervix. Fontan, Durand-Fardel 
 and Gueneau de Miissy, being struck with the coexistence of pharyn- 
 geal and uterine granulations with skin diseases, think that they may 
 often be dependent on herpetism. Tillot,^ like Pidoux, connects them 
 as well as all other uterine diseases with the existence of some 
 diathesis. 
 
 Among the diathetic states which, in fixing themselves on the 
 cervix, may produce uterine granulations, syphilis and catarrh seem 
 to play the chief part. — In the lock wards of the General Hospital of 
 Montpellier I have had occasion to see a number of women affected 
 with uterine granulations coexisting with various syphilitic symptoms, 
 and although it is difficult to decide in all cases whether there is simple 
 coincidence or community of origin and nature between these granula- 
 tions and the various manifestations of the syphilitic affection, I 
 am inclined to believe (especially after the cures which have followed 
 the specific treatment employed) that the syphilitic diathesis had a 
 share in the development of the granulations. It is seldom, however, 
 that anti-syphilitic treatment is sufficient of itself to overcome this 
 malady ; this is doubtless owing to the hypertrophic tendency of the 
 uterine tissue under the influence of which it is produced and has a 
 tendency to become perpetuated. — Catarrh which attacks the uterus 
 so frequently, not only in multiparse but in newly married women, and 
 even in girls, is not only manifested by a mucous discharge, but by 
 the fluxion which it keeps up towards the mucous membrane, bring- 
 ing its hypertrophic tendencies into play and producing granulations. 
 Timbart justly remarks that cervical erosions and granulations dia- 
 gnosed constantly as lesions of blennorrhagia and uterine catarrh 
 
 1 A Practical Treatise on Infiammation of the Uterus, its Cervix and Ap- 
 pendages. 
 
 2 Des erosions et des granulations du col de Vuterus, de leur valeur nosolo- 
 gique. Theses de Paris, 1849. 
 
 3 De la lesion et de la vialadie dans les affections chroniques du systcme 
 uterin. Theses de Paris, 1860. 
 
GRANULATIONS AND FUNGOSITIES 625 
 
 ouglit to be included as special characters in the history of these dis- 
 eases : simple erosion for the acute and non-malignant form^ and 
 granulations for the chronic and serious form. I could myself men- 
 tion cases of catarrhal granulations, and have no doubt that granula- 
 tions of this kind are at least as frequent as others. — The diathesis 
 which exercises most influence on the development of granulations 
 according to Chomel, Robert, Huguier, Scanzoni, Gueneau de Mussy, 
 Durand-Fardel, Pontan, &c., is the herpetic, the external manifestations 
 of which these writers have often seen coincide with the existence of 
 granulations. I have also met with several cases in which these two 
 maladies coexisted (herpetism and granulations), especially in women 
 affected with pityriasis, eczema, herpes, ciliary blepharitis, simulta- 
 neously with uterine granulations, and who had no symptoms of any 
 other aff'ection, such as catarrh, scrofula, inflammation, &c., or who 
 could not attribute the development of this disease to any local cause, 
 such as excessive intercourse, pregnancy, &c. 
 
 Tillot, in reviewing the various diatheses which play the chief part 
 in the etiology of chronic uterine afl^ections (granulations amongst the 
 rest), enumerates them in the following order of frequency : the 
 strumous, syphilitic, herpetic, cancerous, &c. In the production of 
 these granulations I do not think that the scrofulous should have a 
 more prominent place assigned to it than the other diatheses just 
 named. — The part taken by rheumatism and more rarely by gout, 
 although less marked, is not the less certain, and I think the prac- 
 titioner cannot afford to ignore it. 
 
 Betermining causes. — Any cause which produces a certain degree of 
 irritation in the organ, which stimulates its vital activity, and excites 
 its plastic or hypertrophic tendency, may occasion the formation of 
 these granulations. In this way dysmenorrlicea and other menstnial 
 disorders suffice to develop them, and may be the only causes to which 
 they can be attributed in girls. Marital intercourse in newly married 
 women is undoubtedly a determining cause. Owing to the novelty 
 of the act, and in some measure to the traumatism to which the 
 cervix is exposed, or it may be to the frequency of coitus and the 
 attendant excitement, the cervix undergoes, as a consequence of this 
 anatomical and physiological shock, a modification in its vitahty which 
 brings into play its tendency to hypertrophy, probably at the most 
 sensitive parts, or at the orifices, whence it results that the urethral 
 meatus is usually the starting-point of the granular formation. In 
 such cases especially these granulations seem to me to coincide with 
 inflammation of the follicles and uterine discharges. Excitement of 
 the sexual organs by venereal excesses, especially the frequent contact 
 of the penis with the cervix, may have a share in the development 
 of granulations, but not more, it appears to me, than it has in the 
 development of other uterine diseases. Pregnancy, by bringing into 
 play the hypertrophic tendency, should be the most common of all 
 determining causes. Pregnancy of itself modifies the life of women 
 so greatly, producing so many pains and morbid symptoms due to the 
 development of the uterus and abdomen, that the majority of women, 
 
 40 
 
626 UTEEINE DISEASES IN DETAIL 
 
 even when they suffer much, do not think of consulting a physician, 
 and still less of undergoing an examination; therefore it is difficult 
 to establish any conclusions with regard to this matter. It may, 
 however, safely be affirmed that it is rare to examine a pregnant 
 woman without finding a granular cervix. Delivery, and especially 
 the after effects of labour, bringing in their train engorgement, con- 
 gestion and even inflammation or hypertrophy, may be regarded next 
 to pregnancy as the most powerful determining causes. Lastly, uterine 
 inflammation, when left to itself, or if some condition of its develop- 
 ment have fixed it on the cervix, may play the double part of occa- 
 sional and essential cause. 
 
 Course. — Usually these granulations first appear at the os, on one 
 of the lips or else all round the orifice. This is seen especially in 
 women who have not conceived, in whom the cervix is more or less 
 conical, with a narrow circular orifice. They afterwards spread either 
 externally or into the cavity, so that when examined they already form 
 a red mammillated patch from 1 to 2 centimetres in diameter, the 
 centre of which corresponds very nearly with the os, the borders being 
 very irregular on both lips, owing to the unequal development of the 
 granulations on the neighbouring points of the uterine tissue. At the 
 same time that the granulations spread over the surface, whether ex- 
 ternally or in the depth of the cervical cavity, they also extend in all 
 their dimensions — that is to say, that having increased in number they 
 increase in size, acquiring sometimes a considerable volume, and taking 
 the name of fungosities. This course is essentially chronic, offering 
 no natural retrograde tendency — that is to say, no tendency to spon- 
 taneous cure. The intervention of art is all the more necessary that 
 the course of these granulations is not always limited to the symptoms 
 I have just sketched. Although they sometimes exist without com- 
 plications, they more generally cause concomitant symptoms, functional 
 alterations or pathological processes, either concentrated in their 
 own sphere or further removed from it. Thus follicles, the orifices 
 of which are usually at the bottom of the grooves which separate the 
 granulations, become irritated and secrete an abundant, opaline, 
 whitish mucus. Sometimes they become inflamed as well as the 
 granulations themselves ; they secrete pus, ulceration may attack the 
 granulated surface, and the purulent secretion of this surface is then 
 added to the muco -purulent secretion of the follicles. This secretion 
 may be the only apparent trace of organic lesion when the granulations 
 or fungosities are situated in the interior of the cervix, and when the 
 conditions are not such as to allow of the gaping of this organ. The 
 development of granulations, which are an obstacle to free communi- 
 cation between the uterine and vaginal cavities, prevents conception 
 and may become a more or less painful obstacle to the expulsion of 
 uterine mucosities, menstrual blood, &c., even when it does not cause 
 the still more serious symptoms of uterine fluxion, tumefaction of the 
 womb, or obstinate menorrhagia or metrorrhagia. This, however, 
 hardly occurs except in the case of fungosities developed in the cavity 
 of the body of the uterus, and known as uterine fungosities. Since 
 
GEAXDLATIOXS AND FUNGOSITIES 627 
 
 Eecamier's^ investigations these latter alterations have been the object 
 of special study.- Although infinitely less frequent than granulations, 
 they seem to form an analogous malady, and several times the gradual 
 extension from the one to the other has been observed. 
 
 Granulations, in certain cases, cannot long continue without causing 
 engorgement, and more frequently partial or total hypertrophy of the 
 cervix, and what is more serious, inflammation of this organ and even 
 of the whole uterus. They are, therefore, a constant source of danger 
 for the women who are affected by them, especially in cases of preg- 
 nancy. Most writers agree in considering granulations and fungosities, 
 as well as ulcerations, as possible causes of abortion in pregnant 
 women. 
 
 Varieties. — The seat is at the os uteri, especially in virgins and in 
 nuUiparse : usually on the cervical lips in pregnant women and in 
 multiparse ; very often extending farther on one lip than on the other 
 (the anterior has seemed to me more frequently affected than the 
 posterior), but seldom on one only; often limited to the external 
 surface of the cervix (especially in pregnant women) ; often also ex- 
 tending to a more or less considerable height into the interior of the 
 cavity (when they occur after delivery); sometimes even reaching to the 
 cervico-uterine isthmus, in fact they may be situated exclusively in the 
 neck whilst there is no external trace ; this is especially the case when 
 they are catarrhal in nature. 
 
 The number of the granulations is usually considerable. Some idea 
 can be formed as to the variation in number from their differences of 
 disposition and volume. 
 
 The d'ujwsition may differ much according to whether the granula- 
 tions are discrete or confluent. They are very seldom discrete : the 
 only examples perhaps being the hypertrophic inflammatory pimples 
 round the follicular orifices, which, as I have said, may be seen on the 
 cervix. On the contrary, they are almost always confluent, spreading 
 more or less on the surface of the cer^dx, or rising more and more 
 from the point where they have taken birth so as somewhat to resemble 
 a strawberry or raspberry. Lastly, granulations are seldom seen dis- 
 seminated singly or in little groups outside the principal granulated 
 surface. This surface is rounded or elliptical, sometimes irregular, 
 with jagged edges. It seldom extends over the whole cervix, although 
 it may greatly exceed the average extent of from 1 to 2 centimetres, 
 especially in cases of hypertrophy. In colour and relief it contrasts 
 strikingly with the pale colour and smooth aspect of the rest of the 
 cervix when the latter is neither congested nor inflamed. 
 
 The size of the granulations is usually very small, about that of a 
 millet seed, seldom equalling that of a smaU lentil. The agglomera- 
 tion and confluence of these little pimples often give to a number of 
 them the appearance of one large one. However, there is no doubt 
 that the granulations which are formed on ulcers, those which become 
 fungous, those which are of scrofulous nature and those which are 
 
 ' Union medicale, 1850. 
 
 ^ Rouyer, Des fongosiies uUrines. These de Paris, 1858. 
 
628 UTERINE DISEASES IN DETAIL 
 
 found on an engorged or oedematous cervix, sometimes present very 
 considerable dimensions. 
 
 The colour of the granulations is always more or less red. This red- 
 ness varies little in successive examinations in the same woman. It 
 may, however, increase or diminish in intensity, according to whether 
 menstruation is near or not. Usually this redness is very marked, but 
 sometimes it is pale pink, at other times it is more or less purple ; in 
 this respect inflammatory granulations, for example, may differ much 
 from granulations of a scrofulous nature. The colour of the granula- 
 tions although coutrasting strongly with that of the cervix in the 
 normal condition, is not so different as Chomel has asserted. For in- 
 stance, during pregnancy they assume the wine-red aspect which is 
 characteristic of the cervix at that time, and which spreads, as we 
 know, to the surface of the vagina and to the nymphse. It is remark- 
 able that after death they lose much of their colour and even of their 
 volume, especially those which are fungous. 
 
 The structure of these granulations may vary like the other charac- 
 teristics of which I have just spoken. It is such as to impart a soft 
 consistency generally to the granulations ; therefore in practising 
 digital touch they may be torn with the nail or be made to bleed by 
 wiping the surface with cotton-wool. Sometimes, owing to the pre- 
 dominance of fibrous or fibro-plastic elements, they acquire a hardness 
 which enables them to resist these attempts and prevents their being 
 removed by scraping. At other times from the predominance of the 
 vascular elements, they become fungous on the contrary, bleeding 
 easily, the slightest contact, coitus especially, in such cases causing slight 
 hsemorrhage, or at least the flow of a few drops of blood. Between 
 these two extremes there may be a number of degrees and even varie- 
 ties of structure, according to whether the fibrous element, the epithe- 
 lium, the amorphous matter, the lymph, &c., have more or less share 
 in their composition. 
 
 As to the differences in nature, herpetic granulations are generally 
 external, bright red and only slightly projecting ; scrofulous granula- 
 tions more frequently than others occupy only one lip, they are more 
 voluminous and paler ; catarrhal granulations are often more developed 
 internally than externally, and are always covered by a more or less 
 opaline consistent mucous discharge. Fungous granulations frequently 
 developed on a pre-existing ulcer often occupy the cervical cavity also; 
 they are voluminous, red and bleeding. Granulations are not con- 
 tagious unless syphilitic. 
 
 Diagnosis. — They often exist without giving rise to any characteris- 
 tic symptom, or to any local phenomena; therefore we must take 
 sympathetic disorders into account ; however slight they may be they 
 should never be neglected ; leucorrhoea especially ought to be taken 
 into serious consideration as well as lumbar pain. 
 
 Subjective signs. — Uterine granulations sometimes cause disordered 
 menstruation. When fungous they may determine menorrhagia, the ex- 
 pulsion of clots, &c. ; when they are hard, hysteralgia uterine colics, and 
 excited doubtless by the difficulty which the uterine contractions have 
 
GRANULATIONS AND FUNGOSITIES 629 
 
 in overcoming the spasm or mechanical obstacle caused by induration 
 of the cervix. The pains are sometimes absent or are the same as in 
 all uterine maladies ; they seem to be seated in the vagina or deve- 
 loped on the cervix, especially during coitus. The remote pains are in 
 the renal region or in the thighs, seldom in the hypogastrium or in 
 the iliac regions, as in metritis, peri-uterine inflammations, engorge- 
 ments, deviations, &c. When there are no pains, or when they are 
 concealed, for example by pregnancy, the trouble may be ignored, 
 manifested only by general discomfort, want of appetite, paleness, 
 emaciation and all the consequences of the sympathetic disturbance of 
 the digestive and nervous functions. 
 
 There is one general symptom which is not pathognomonic but 
 which is frequently the consequence of granulations, viz. sterility. It 
 is owing to the mechanical and physiological difficulties in the way of 
 fecundation formed by the granulations fitting into each other, the 
 viscosity and adhesiveness of the mucus which covers the surface and 
 forms a gelatinous stopper and by the irritability and spasm pro- 
 duced in the cervico-uterine sphincter. 
 
 Objective signs. — A red, granular surface, commencing at the os 
 uteri and radiating over a more or less considerable extent of the 
 cervix, formed of small granulations usually confluent, seldom discrete, 
 rarely attacking the whole cervix, but forming a kind of patch or 
 mammillated elevation somewhat like a raspberry, surrounded on all 
 sides by a healthy annular surface of the cervix. A more or less 
 abundant glairy, muco-purulent or purulent discharge almost always 
 covers it, and must be removed before the granular surface can be 
 seen. This discharge which is seldom pus, but which may be opaque, 
 semi-transparent or opaline, is often clear like white of egg. In the 
 latter case it is seldom that it is not sufficiently abundant to be dis- 
 charged from the vulva moistening the inner surface of the thighs, 
 and leading the patient to think she must have some uterine disease. 
 The finger with difficulty determines the circumference of the granula- 
 tions, but can easily discover the elevations round the cervix or in its 
 orifice ; the sensation felt by the tip of the finger, and which has been 
 compared to that produced by shagreen leather, is more like that 
 communicated by Utrecht velvet (Chomel) ; the finger almost inevit- 
 ably brings away a few drops of blood from the nail slightly scraping 
 the diseased surface : it is easy by sight and touch to distinguish 
 granulations of the cervical cavity from simple leucorrhoea. 
 
 Differential diagnosis. — Granulations must be distinguished from 
 vegetations, ulcers, erosions and the various eruptions which may have 
 their seat on the mucous membrane of the cervix, such as pemphigus,, 
 eczema and especially herpes. 
 
 Vegetations are only vascular epithelial excrescences. When the 
 epithelial development is not accompanied by a rich vascular develop- 
 ment there results a hard production of a dull leathery white, some- 
 thing like a flattened wart, developed on one of the lips or on one of 
 the sides of the cervix rather than at the orifice. In the rare cases 
 when great vascularity is added to epithelial exuberance, vegetations of 
 
630 UTEEINE DISEASES IN DETAIL 
 
 the cervix have the familiar appearance of vegetations of the vulva and 
 prepuce, and consequently are distinguished by their projection, their 
 subdivisions, by real granulations and even by uterine fungosities. As 
 for the other vegetating excrescences which do not depend on syphilis, 
 like the majority of the vegetations of which we have spoken, and 
 which under the names of fungosities, cauliflower excrescences, &c.^ are 
 only manifestations of the more or less rapid increase of uterine cancer, 
 it is still more difficult to confound them with granulations of the 
 cervix. 
 
 Polypi are pediculated tumours of a more or less considerable size, 
 resulting usually from the hypertrophy of one of the anatomical ele- 
 ments of the uterus, and developing gradually without any diathesis or 
 morbid state other than hypertrophy pure and simple. It is the 
 same with ihe, follicular cysts described by Huguier. 
 
 Various vesicular and pustular eruptions, such as herpes, eczema, 
 pemphigus, &c., may appear on the cervix leaving a red surface, which 
 bleeds easily, and which is sometimes confounded with granulations 
 strictly so called and classed with these latter by some writers, and more 
 or less distinguished from them by other authors under the name of 
 erosions, exuberations, &c. It is always easy to verify the charac- 
 teristic course of these maladies, the gradual development of vesicles, 
 pustules, follicular eruptions, however small and confluent they may 
 be, the flat bleeding surface which results, the distinct borders of the 
 erosion, the absence of more or less thick mucous secretion, the epi- 
 dermic denudation ; lastly, the absence of exuberances due to the de- 
 velopment of the anatomical elements, the existence of which is verified 
 in the granulations. 
 
 Ulcers may attack a more or less extensive portion of the cervix, in 
 some circumstances presenting at first sight so much apparent analogy 
 with uterine granulations, that several writers have not distinguished 
 granulations strictly so called from granular ulcers. Now, at the com- 
 mencement of their development, ulcers may present the appearance of 
 some of the eruptions first named, but with the progress of the patho- 
 logical process which produces and keeps them up they soon assume 
 a characteristic form, an inspection of which is usually suflicient to 
 distinguish them. — There is, however, a period when ulcers may 
 assume characters which make them resemble granulations : it is 
 when they become really granular, either from being covered by true 
 cicatricial granulations, which will soon produce a real cicatrix, or 
 because they become the seat of a more or less luxuriant vegetation, 
 which makes the healthy granulations persistent, extensive, bleeding, 
 sometimes considerably exceeding the limits of the ulcer. 
 
 Healthy granulations, to borrow the description given by my friend 
 and colleague M. Charles Eobin, " are conical and reddish eleva- 
 tions developed on the surface of suppurating wounds where they 
 determine cicatrisation. They are formed all the more quickly when the 
 tissue is cellular and vascular ; at first broad, soft and only slightly 
 projecting, they soon constitute by their union a kind of membrane 
 provided with blood-vessels. They are composed : 1, of a large pro- 
 
GRANULATIONS AND FUNGOSITIES 631 
 
 portion of amorphous granular matter ; S, of fibrillse of cellular tissue 
 of new formation interlaced ; 3, of fibro-plastic elements with rather 
 large and pale nuclei ; 4<, of capillaries. They increase in size by the 
 production of new elements added to those of the same kind throughout 
 the whole thickness of their mass. The surface of these rudiments of 
 cicatricial tissue is covered with pus and gradually with epithelial 
 cells, which soon exceeding the pus in quantity form a thin and 
 whitish pellicle of epidermis continuous with that of the skin : this is 
 called cicatrisation. As this epidermic pellicle is formed the granula- 
 tions disappear, owing to the slow but energetic disappearance of the 
 molecules of the amorphous matter by absorption, and the consequent 
 bringing together of the fibrous elements ; this is what determines 
 retraction of the borders of the wound, leading to the belief in the 
 contractility of cicatricial tissue.'' Absorption, continuing after cica- 
 trisation is concluded, determines, as I think I was the first to teach,^ 
 contraction of the cicatrix. Uterine granulations which are developed 
 on the cervix are composed, like true cicatricial granulations, of the 
 elements of fibrous tissue which enter into the composition of the 
 cervix, of fibro-plastic elements whether pre-existing or of new forma- 
 tion, of fibrillse of cellular tissue newly developed, and of granular 
 amorphous matter. These elements, constituting a kind of hyper- 
 trophy of the dermis of the mucous membrane, are traversed by capil- 
 laries, the variable number of which renders cicatricial tissue more or 
 less prone to bleed at the slightest contact. It is covered by epithe- 
 lium, in which cells of new formation often strengthen the layer of the 
 old cells ; the thickness of the epithelium which results does not pre- 
 vent the granulations from bleeding when rubbed with the tip of the 
 finger or when wiped with cotton wool, because the cells of new forma- 
 tion are always so soft and delicate as to ofier but little resistance ; 
 sometimes even the subjacent connective tissue is laid bare by a super- 
 ficial erosion. — There is therefore a great resemblance between uterine 
 granulations and the granulations of cicatricial tissue. Uterine granu- 
 lations, however, besides being real tissue developed at the expense of 
 the fibro-plastic or embryonic elements, are hypertrophied papillae of 
 the dermis, either simple epithelial elements, like those entering into 
 the structure of vegetations, or hypertrophied vascular elements of the 
 papillae or capillaries interposed between the follicles or surrounding 
 them, or else real hypertrophied follicles always characterised by a point 
 at the summit of the granulation, the point being only the orifice of 
 the follicle. 
 
 Prog7iosis. — Uterine granulations do not involve any serious danger ; 
 but they have a tendency to increase, they last a long time, often with- 
 standing rest and treatment ; they are inconvenient from the mucous 
 and sometimes sanguineous discharges which accompany them ; they 
 cause more or less marked general debility, and prevent conception 
 taking place. This prognosis makes it the duty of the physician to 
 persuade patients to undergo necessary treatment. 
 
 ^ Clinique chirurgicale. — Be la formation des cicatrices, de lev/r retractilite 
 et des difformites qui en rhultent, p. 291. Montpellier, 1851. 
 
632 UTEEINE DISEASES IN DETAIL 
 
 Treatment — the indications. — According to 1, the nature of these 
 granulations or the diversity of the affections or morbid processes by 
 which they are kept up; 2, the analogy and variations of structure 
 which they present in various cases ; and 3^ the hypertrophic tendency 
 which characterises them, it is evident that each of these three terms 
 becomes the source of indications in proportion to the share which 
 inflammation has in its development. 
 
 I. I shall not speak of the treatment to be used in subduing the 
 nature of the malady, except to mention that my opinion is contrary 
 to that of those gynaecologists who regard uterine granulations as 
 granular metritis to be treated by antiphlogistics local and general 
 which usually produce no effect. Nevertheless when metritis exists, 
 the inflammation should be treated by leeching the cervix, emollient 
 baths, with prolonged irrigations, the application of mercurial oint- 
 ment to the abdomen, groins and thighs, and by revulsive purgatives. 
 After the cure of the metritis it will, however, be necessary to treat 
 these granulations by suitable local means. In other cases we must 
 treat the catarrhal affection or the constitutional diathesis whether 
 scrofulous, rheumatic, herpetic or syphilitic before using local means 
 or at least simultaneously with them. I could mention many cases in 
 which patients have only been definitely cured after having undergone 
 general treatment by mercury, iodide of potassium, cod-liver oil, iron, 
 sea bathing, mineral waters, hydropathy, &c. It is the same with the 
 chronic form, which may exist without being dependent on any dia- 
 thesis and without presenting any inflammatory character which would 
 allow of its being considered with chronic metritis as some writers 
 have done. In such cases the organ may no longer be inflamed, even 
 if it has previously been so, but it retains the habit of fluxionary 
 movements, congestion, engorgement, hypertrophy, which are all the 
 more difficult to eradicate because favoured by a condition of anaemia, 
 chloro-auEemia and general debility. When this is the case restorative 
 medication, tonics, a generous diet, iron, hydropathy, hot vaginal 
 injections, blisters on the cervix, astringent and resolvent applications, 
 with inert powders, and igni-punctures to destroy the granular surface 
 produce the best results. 
 
 II. As to the second indication, the state of hypertrophy which 
 characterises uterine granulations and the hypertrophic tendency of 
 the cervix which their existence increases, necessarily indicate the 
 application of means the resolvent properties of which have the faculty 
 of determining a tendency to absorption or atrophy. Therefore 
 astringents of all kinds are employed in injections, e.g. the decoction 
 of red roses, oak bark, rhatany, solutions of tannin, alum, nitrate of 
 silver, &c., sulphur and iron waters whether natural or artificial have 
 often been tried, although perhaps no case of cure can be attributed to 
 them. Astringent powders, such as tannin and alum ; solvents, such 
 as mercurial and iodide ointments, have also been applied unsuccess- 
 fully to the seat of disease. They have the drawback not only of 
 acting very superficially on a lesion of considerable depth, but of 
 necessitating the presence of a tampon in the vagina, the contact of 
 
GEANDLATIONS AND FUNGOSITIES 633 
 
 which only irritates the cervix and the neighbouring parts, while it 
 prevents other means of treatment (injections and irrigations) from 
 which the patient would derive more benefit. Vaginal injections made 
 on the bidet morning and evening with very hot water and a little 
 carbolic acid is an excellent way of combating the congestion of the 
 cervix and removing purulent liquids, the contact of which helps to 
 keep up the granulations : but this is often insufficient to obtain a 
 cure. 
 
 III. The third indication, to subdue the hypertrophic tendency of 
 the granulations, leads to the necessity of cauterisation, the most 
 powerfully destructive as well as alterative local means that can be 
 used. I have given up the use of liquid caustics with the exception of 
 Tinct. Ferri Perchlor., Tinct. lodi, the concentrated solution of nitrate 
 of silver, and a few others which only act slightly on the healthy sur- 
 faces covered with epithelium. Solid caustics are either insufficient, 
 like melted nitrate of silver, or too active like the Vienna paste or 
 chloride of zinc. These latter caustics as well as arsenic and crystal- 
 lised chromic acid, may be of great service in the treatment of cervical 
 ulcerations; but in the treatment of granulations, the actual cautery 
 seems to me very superior. 
 
 The actual cautery is in fact that which requires least precaution, 
 the action of which is the most easily limited throughout its whole 
 extent, and that in which the consequences seem most favorable to 
 speedy and complete cure on account of the nature of the cicatrix and 
 of the good results experienced by the neighbouring tissues, nor do I 
 know any drawback that it has. It is usually sufficient to use it once, 
 in order to destroy the granulations and to modify the underlying 
 tissues sufficiently. On the other hand I have often seen less energetic 
 but frequently repeated cauterisation cause fluxionary and inflamma- 
 tory symptoms which never follow the use of the red iron. Cure is 
 very rapid. Taking the average of several hundreds of cases it follows 
 in six weeks, i.e. in the simplest cases and it may be obtained in three 
 weeks ; in complicated cases requiring general treatment and a second 
 cauterisation it may be delayed for three months. The surgeon is 
 complete master of the caustic ; by varying the form of the cautery, 
 the degree of heat applied, the duration of the application, &c. he 
 can make the application as superficial or as chief, as limited or as 
 extensive as he wishes. When made nothing is left in the vagina and 
 uterus but the scar, so we have neither to consider how to get rid of 
 the rest of the caustic, nor to contrive means for retaining it. 
 
 The actual cautery may even be applied exceptionally in cases of 
 pregnancy when formidable symptoms such as obstinate vomiting 
 seems produced or kept up by granulations. I have long ago proved 
 not only the innocuity and utility of the actual cautery applied to the 
 cervix even during pregnancy,^ but also the consecutive accomplish- 
 ment of the normal phenomena of parturition in pregnant women in 
 whom granulations had been treated by cauterisation.^ 
 
 ' Annales cliniques de Montpellier, Aug. 25, 1853. 
 » Ibid., April 10, 1854. 
 
634 UTEEINE DISEASES IN DETAIL 
 
 Lastly, when it is a question of uterine fungosities situated in the 
 cavity of the body and causing haemorrhage, cauterisation is too pain- 
 ful and difficult to be applied so deeply. In such cases we should 
 commence by removing these fungosities with Eecamier's or Sims^s 
 curette, and afterwards modify the surface of the mucous membrane 
 by a caustic injection. 
 
 Ulceration and Ulcers oe the Uterine Cervix 
 
 An ulcer is a morbid state characterised by a loss of substance of 
 variable extent as regards both width and depth, kept up if not pro- 
 duced by some internal cause or by local morbid action, and usually 
 excreting a more or less purulent fluid. 
 
 Ulceration is the pathological action which produces the ulcer. It 
 is an alteration in the nutritive process as when decomposition is iu 
 excess of composition, disassimilation of assimilation. I may say of 
 ulceration what I have already said of leucorrhoea, engorgement, in- 
 flammation, that this malady may be developed at the close of another 
 malady of which it seems to be the result or termination ; but it may 
 also be developed all at once under the influence of general causes and 
 a local tendency. Sometimes it remains simple, pursuing its natural 
 course, and passing through the various phases of its development 
 without necessarily leading to new disturbances in the organ ; some- 
 times on the contrary it is accompanied by other morbid states either 
 as consequences or simple complications. It therefore happens that 
 ulceration usually coincides with other diseases, and that if not the 
 result of them it cannot last long without producing them. 
 
 But it would be wrong to conclude from these coincidences that 
 ulceration is the primary cause of these maladies as the ancients did, 
 or as some gynaecologists in our own time have done ; nor would it be 
 correct to conclude with Bennet, Aran and Nonat that it is the result 
 of inflammation, nor with Lisfranc and Duparcque that it is the con- 
 sequence of engorgement, or with Gosselin, Tyler-Smith and others, 
 that it is produced by leucorrhcea; while West's opinion, that ulcers 
 of the cervix are of no importance, ought to be refuted coming as it 
 does from a writer so justly entitled to respect. 
 
 If we investigate facts we shall admit with West that ulceration of 
 the cervix is very common ; but we shall not like him deduce from 
 this fact of frequency that it is unimportant. I do not mean to say 
 that its frequency necessarily involves its importance. Its importance 
 depends on several causes : in the first place undoubtedly on the 
 frequency of the lesion (we should always pay attention to a malady 
 which occurs often) ; then on its varieties of aspect, on the difl'erent 
 causes which produce it, on its incurability when left to itself; lastly, 
 on the necessity of applying a suitable local treatment. I have often 
 endeavoured to measure the degree of importance which should be 
 attached to ulceration of the cervix; I have frequently treated the 
 engorgement, inflammation, leucorrhcea, without treating the ulcer; I 
 
ULOBEATION AND ULCERS OF THE UTERINE CERVIX 635 
 
 have often employed the most powerful alterative general treatment, 
 injections even, and I may say that I have hardly ever succeeded in 
 curing the ulcer by these means alone. Local treatment, cauterisation 
 and dressings have seemed to me indispensable in the great majority 
 of cases. 
 
 1. Erujotions on the Cervix 
 
 Eruptions of various kinds may be developed on the cervix. When 
 we are fortunate enough to see their first appearance we can form an 
 idea of the variety of forms which they assume, and when we compare 
 them with those which are seen on the skin or on other mucous mem- 
 branes, we are disposed to admit the difi'erence of causes which influ- 
 ence their development. These eruptions and other modifications in 
 the structure of the cervix are conditions which prepare the way for 
 ulceration. 
 
 The most simple of these modifications of the cervix is redness or 
 erythema, whether due to hyperemia, real erythema or to a large 
 ecchymosis, or to a special congestive condition with softening of the 
 tissue and a tendency to bleed. In addition to these morbid condi- 
 tions there may also be leucorrhoea ; under the influence of which an 
 abrasion of the epithelium of the mucous membrane is sometimes pro- 
 duced vehich gives rise to the superficial exulceration designated by the 
 name of erosion. Herpes, which is one of the forms of the vesicular 
 variety, is very common on the cervix : it is constituted by a heap of 
 small vesicles, all confluent, or some of which are discrete, grouped 
 irregularly, forming a surface covered with small hollow eminences 
 filled with transparent, citrine, whitish or slightly purulent serosity. 
 It is limited by sinuous or jagged borders, rather redder than the 
 neighbouring parts but gradually blending with the natural colour of 
 the rest of the cervix. It is situated on one of the lips, in the central 
 and most convex part, or near the orifice more frequently than on the 
 external border. It resembles the herpetic eruption on the prepuce, 
 and though it sometimes becomes the starting-point of an ulcer it is 
 often cured spontaneously, disappearing in a few days, which is un- 
 doubtedly the reason why it has not been seen more frequently. 
 
 Eczema, whether simple or impetiginous, is also developed on the 
 cervix. It is hardly ever seen in its first stage; but is known by its 
 extent, secretion, and the denudation of the dermis. In place of being 
 confined like herpes to a small surface or to one of the lips, it usually 
 extends over the whole of one of the lips or over both. The surface 
 is often covered by a fluid or semi-fluid secretion, which must be wiped 
 off before the dermis can be seen. 
 
 Pemphigns, of which I have seen some cases, has been described by 
 Joulin.^ It is constituted by one large and transparent vesicle, formed 
 by an elevation of the epithelium, containing a serous fluid like water. 
 It has a globular or rather elliptical form, with irregular borders, re- 
 sembling somewhat a large and thick drop of transparent and thready 
 
 ' Academie de medecine, April 2, 18G1. 
 
636 
 
 UTEEINE DISEASES IN DETAIL 
 
 mucus secreted by the cervix. It is sometimes surrounded at its base 
 by a very narrow bright-red border, which appears to consist of pure 
 blood. The surface of the cervix on which it rests is perfectly normal, 
 preserving its usual hue, and may show absolutely no alteration. The 
 portion of epithelium which serves as a wall to the vesicle is so re- 
 sistant that rubbing with cotton wool will not always rupture it ; if 
 rubbed with the crayon of nitrate of silver the bulla is destroyed im- 
 mediately, and the fragments of epithelium which are observed after 
 this rupture form the only appreciable alteration. The fluid dis- 
 charged does not appear to be viscous ; it seems to possess the proper- 
 ties of ordinary serum. — Uterine pemphigus is a rare disease. Nelaton, 
 Castelnau and Braun^ have observed a few cases. — It seems always 
 to terminate spontaneously in three or four days without leaving any 
 traces ; it is accompanied by no symptom perceptible to the patient. 
 It is therefore only accidentally observed on applying the speculum for 
 some other cause. 
 
 Folliculitis, true acne of the cervix, may assume various forms, from 
 the most simple, that of punctated acne, to that of hypertrophic acne, 
 depending on the share which inflammation and the secretion of the 
 
 Fig. 357. — Indurated acne of the cervix in a woman 42 years of age. Slight 
 retroflexion and induration of the uterus. Eound the os externum 
 there is considerable tumefaction, almost like a mushroom, extending to 
 the vaginal portion as well as to the cervical cavity, and dotted over with 
 a number of Naboth's eggs, some containing mucus, others pus (Virchow). 
 
 follicles take in the malady.— Sometimes the follicles are tumefied, 
 prominent, and secrete more abundantly than usual ; we then see rising 
 
 1 Medical Jahrhucher, S. 182. Vienna, 1861. 
 
ULCERATION AND ULCERS OF THE UTERINE CERVIX 637 
 
 from the cervix discrete or confluent eminences formed by these organs, 
 and small drops of a thick, viscous^ transparent fluid oozing from their 
 orifices ; the colour of these little eminences or their orifices is often 
 slightly redder than that of the neighbouring parts of the mucous 
 membrane, but frequently it does not greatly differ from it. Some- 
 times the follicles, and especially their mouths, are very red as well as 
 prominent : this bright redness contrasts so much with that of the 
 mucous membrane surrounding them, that they might be taken for 
 granulations or papillary eminences analogous to those of granular 
 vaginitis. These eminences may be confluent, like granulations of the 
 cervix ; greatly hypertrophied, of a light red or violet colour, complex 
 like acne of the nose with considerable dilatations of the capillary net- 
 work, or of the superficial venous network ; but usually they are dis- 
 crete and scattered, and by this character, which attracts the attention 
 of the physician, the differential diagnosis between these two diseases 
 is facilitated. On pressure purulent mucus is seen to escape, in 
 the form of a small yellow drop ; each small eminence then forms a 
 well-marked red border round each little drop that escapes from its 
 summit, i. e. from its centre. 
 
 This malady is quite distinct from the uterine granulations already 
 described. 
 
 The other pustular diseases of the cervix are very numerous, and are 
 the most common origin of ulcers properly so called. Usually they con- 
 sist in the development of a great number of small, contiguous, con- 
 fluent pustules, easily torn, and exuding pus as in impetigo, and 
 becoming the starting-point of a purulent secretion renewed incessantly 
 on a base which is ulcerated and complicated by granulations, follicu- 
 litis, mucous hypersecretion, &c. At other times they present the 
 appearance of isolated pustules, broad and flat, resembling those of 
 ecthyma, and terminating at times like the preceding ; but this form 
 is much rarer than the other. It is probable that, independently of 
 eruptions due to disordered local vitality, various eruptive forms are 
 developed on the cervix under the influence of a diathetic affection. 
 The mucous membrane of the cervix resembles the skin as regards her- 
 petism and scrofula. As for venereal affections I may say that I have 
 seen every kind of syphilide on the cervix, from erythema, small cir- 
 cular patches, red and like ruheola, macula, spots, &c., to pityriasis, 
 psoriasis, flat pustules and tuhercles. In examining women in whom 
 the uterus is supposed to be healthy, as well as those in whom it is 
 diseased, we cannot fail to meet with these various eruptive forms, 
 sometimes isolated, sometimes coexisting with a uterine malady, or 
 partly assuming another form, or complicated with granulations or 
 ulcers. 
 
 2. Ulcers of the Cervix 
 
 Ulceration of the cervix is one of the most common diseases of this 
 organ, in spite of what has been said by Robert Lee, whose statistics 
 are opposed to those of West. I may say that my own experience has 
 
638 UTERINE DISEASES IN DETAIL 
 
 confirmed the results arrived at by West, and has justified the opinion 
 that ulceration of the cervix is a morbid condition of great importance 
 in uterine pathology. The following are the results of some statistics 
 on the frequency of ulcerations of the cervix, relatively to uterine and 
 other diseases. 
 
 Compared with uterine diseases we find : 
 
 According to my experience . 425 ulcerations out of 1563 uterine diseases. 
 „ H. Benneti . . 222 „ „ 300 
 
 „ West2. ... 17 „ „ 29 
 
 Compared with other diseases we find : 
 
 According to West ... 17 cervical ulcerations in 65 autopsies. 
 „ D. S. Stewart' 15 „ „ 60 
 
 „ „ Aran^ ... 1 „ „ 10 „ 
 
 Diagnosis — subjective signs. — Superficial ulcerations or erosions, 
 exulcerations and fissures generally pass unperceived, like the erup- 
 tions which have given rise to them. Ulcers properly so-called may 
 exist for a long time without having determined leucorrhoea, men- 
 strual disorders, local pain, or general disturbance of the health which 
 would have attracted attention to them. This usual, though not 
 constant, tolerance of the organism with regard to recent uterine 
 ulceration makes the description of the symptoms which characterise 
 it difficult. The frequency of complications is another cause which 
 increases the difficulty. It is seldom indeed that ulceration exists 
 alone for any length of time. When it has lasted for some time and 
 is at all extensive, there is at least leucorrhoea. All the follicles con- 
 tained in the ulcerated tissue and those of the neighbourhood are 
 attacked by a morbid irritation, which determines on their part a 
 hypersecretion the products of which are added to the pus secreted 
 by the surface of the ulcer. I do not speak of congestion, fungos- 
 ities, softening, hypertrophy of the organ, metritis, nor of other 
 complications or concomitant morbid states giving rise to special 
 symptoms previously enumerated. I try to distinguish the special 
 symptoms of the ulcer from those which, although they may have first 
 attracted attention to the uterine malady, may depend only on com- 
 plications. Now in those cases in which I have not had to separate 
 the ulcer from any other concomitant morbid state, but have treated it 
 directly without being first obliged to resort to leeching or other 
 medication, I have almost always found that patients had few local 
 symptoms. These appear to be limited to lumbar and inguinal, or 
 rather femoral pain shooting down the thighs to the knees ; as a rule, 
 there is no hypogastric pain ; sometimes there is pain in coitus or for 
 
 1 Op. cit., p. 37. 
 
 2 Op. cit., 1st edition, p. 119, omitted in 4tli edition. 
 
 ' H. Bennet, Op. cit., Appendix, Uterine Pathology in India, by D. S. 
 Stewart, p. 587. 
 * Op. cit., p. 485. 
 
ULCERATION AND ULCERS OF THE UTERINE CERVIX 639 
 
 a daj or two afterwards ; sometimes after sexual intercourse there is a 
 slight discharge of blood mixed with the leucorrhoea, and if the ulcer 
 is fungous, there may even be haemorrhage, more or less abundant but 
 always limited in duration. The general symptoms are usually more 
 marked. Without presenting anything very special, they almost always 
 attract attention to the uterus, even when there are no local symptoms. 
 Amongst those which are common to all uterine diseases, disorders of the 
 digestive functions I think occupy the first place in cases of obstinate 
 ulceration. Patients almost always complain of dyspepsia; they are 
 languid and their suffering is increased by emaciation, ansemia, pale- 
 ness, and the peculiar alteration of the features which has been desig- 
 nated by the name oi fades uterina. These symptoms, however, it 
 will be seen, merely attract attention to the uterus and to the neces- 
 sity of examination by speculum, which is indispensable in order to 
 determine the existence and character of the lesion. The objective 
 signs alone allow of a diagnosis being made. 
 
 Objective signs — I. Diversity in the form of cervical ulcers. — Cer- 
 vical ulceration is seldom deep. Its existence is manifested by the 
 condition of the surface rather than by the loss of substance. The 
 ulcers which least alter the aspect, form or structure of the cervical 
 mucous membrane are erosions, exuberations, fissures. Next in 
 order come ulcerations proper, some of which are distinguished by an 
 exuberance of tissue, others by a more or less sensible loss of sub- 
 stance. In the former category are granular, vegetating, fungous, 
 varicose ulcers and generally those depending on chronic metritis, 
 uterine catarrh, or merely on pregnancy ; in the latter, excavated 
 ulcers, those with greyish base, indurated ulcers, ulcers with callous 
 borders perpendicular to the surface or detached from it, corroding 
 ulcers and generally those which are kept up by a diathetic affection. 
 
 Fissures are chiefly found where the cervix has been lacerated by 
 previous labours, and they are situated at the base of these old lacera- 
 tions. Thence they may extend, forming, on a more or less consider- 
 able portion of the cervix, exuberations which have a continual 
 tendency to increase. When erosion of the cervix is left to itself for 
 some time, or exposed for several months to the deleterious influence 
 of external causes, e.g. want of cleanliness, venereal excesses, abor- 
 tions, or repeated deliveries, it becomes transformed into an ulcera- 
 tion, at first deep and accompanied by loss of substance, later on filled 
 up by the development of granulations produced either from papillary 
 hypertrophy, or rather from true cicatricial granulations which rise 
 from the base and soon project beyond the smooth and healthy surface 
 of the cervix. The hypertrophic tendency of these granulations is 
 sometimes so considerable, that the ulcer may pass from the granular 
 to the vegetating form, presenting excrescences of from 3 to 5 millime- 
 tres in height of dark red colour similar to that of uterine granula- 
 tions, formed like them and like true granulations of a very delicate 
 and very vascular fibro-plastic tissue, often very near together, separ- 
 ated by hollows, protruding more or less over the irregular border of 
 the ulcer, sometimes projecting into the cervical cavity, giving rise to 
 
640 UTEEINE DISEASES IN DETAIL 
 
 a very abundant purulent secretion requiring immediate treatment. 
 As soon as discovered they should be treated energetically. 
 
 Scanzoni ^ says that varicose ulceration is one of the forms least 
 frequently seen. It is only developed after a chronic stasis of blood, 
 within the uterine walls. The ulceration is consecutive to congestion 
 of the organ ; not only is its colour bluish red, like that of the 
 genital organs when gestation is advanced^ but its surface is traversed 
 by varicose veins. " In one case," adds this writer, " such an erosion 
 was traversed by a vein about half an inch in length and dilated to the 
 thickness of a crow's quill, from which there was discharged about two 
 ounces of blood when we opened it." 
 
 The ulcers kept up by diathetic disorders usually present different 
 forms. The hypertrophic tendency of the uterine tissue may some- 
 times render them granular or fungous like the preceding ; but fre- 
 quently, in place of being exuberant {excedens) the diathetic ulcer is 
 distinguished by loss of substance, by its colour, its consistency and 
 its limits. Thus the base, instead of being granular and exuberant, is 
 depressed, irregular, more or less hard, covered with a thick yellow or 
 greyish secretion, which is sometimes adhesive and pseudo -membranous, 
 at other times, on the contrary, transparent, ichorous, sanious and san- 
 guinolent. The borders, in place of being irregular, ill defined, and 
 concealing the limits of the ulcer more or less, are, on the contrary, 
 well marked, of a bright red, contrasting with the base of the ulcer as 
 well as with the neighbouring tissues, following a regular curve, or 
 ragged and spreading unequally in various directions, now detached, 
 soft and pale, now adhesive, perpendicular and hard. 
 
 II. Diversity/ in the nature of cervical ulcers. — With regard to 
 their nature, cervical ulcers depending on disordered local vitality, 
 whether physiological or pathological, are easily distinguished from 
 ulcers depending on general diathetic disorders. 
 
 1. Amongst the former, depending on an alteration of local vitality, 
 one of the most remarkable is the ulcer produced or kept up by preg- 
 nancy. It is difficult to know whether pregnancy is the only cause of 
 these ulcerations. It is probable that many of them are really due to 
 the existence of some general undetermined aQ"ection or to a special 
 tendency of the uterine tissue to become ulcerated as an effect of the 
 special irritation or the epithelial maceration caused by the leucorrhoea 
 produced by pregnancy. Pregnancy, however, by congesting the 
 cervix with the rest of the organ, and especially by softening it and 
 modifying its nutrition, has determined ulceration, even if it has not 
 predisposed to it. 
 
 However that may be, it is all the more important to pay attention 
 to these ulcerations, as they seem actually to have produced abortion 
 in some cases. 
 
 The ulcer produced or kept up by uterine catarrh is recognised by 
 the existence of a concomitant uterine leucorrhoea and by the presence 
 in the midst of the granulations of inflamed hypertrophied follicles, 
 
 ' Scanzoni, op. cit., p. 212. 
 
ULCERATION AND ULCEIiS OF THE UTERINE CERVIX 641 
 
 producing an abundant hypersecretion. It is usually granular, some- 
 times even fungous, and except at the commencement, when it is only 
 shghtly raised and has a velvety or strawberry aspect, the surface 
 becomes irregular and broken, owing to the inequality in the size of 
 the granulations ; the fluid pellicle which covers it is not only purulent, 
 but viscous, more or less tenacious and adherent ; usually the ulcer 
 cannot be laid bare nor made to bleed without wiping it well. Never- 
 theless we cannot cure the ulcer by merely curing the leucorrhcea ; 
 unless the means of treatment, such as the introduction of nitrate of 
 silver, be sufficient to modify profoundly the surface of the ulcer as 
 well as the uterine cavity. 
 
 Ulceration determined by the persistence of chronic metritis, 
 especially of parenchymatous metritis, whilst occupying an important 
 place in the production of cervical ulcers, is far from being as frequent 
 as is represented by modern gynaecologists who describe cervical ulce- 
 rations as the termination of metritis. Sometimes indeed their parts 
 seem to me to be reversed, and especially in cases where the metritis 
 is confined to the cervix, we may regard it as being as often the effect 
 as the cause of ulceration. 
 
 2. Amongst ulcers depending on general diathetic alterations we 
 may first of all distinguish herpetic ulcers, which may be recognised at 
 the outset by the appearance of one of the eruptive forms which I have 
 described as originating them ; later on, by the formation on the bor- 
 ders or in the neighbourhood of the ulcer of vesicles, phlyctenes and 
 pustules analogous to those from which they sprang. Scorbutic ulcers, 
 which occur but seldom, are violet in colour, fungous, soft and bleed 
 easily ; they are also engorged and oedematous at the base or at the 
 part surrounding the cervix. Scrofulous ulcers have their edges de- 
 tached and slimy, often spreading considerably over both cervical lips. 
 Like most of the others, with the single exception perhaps of leucor- 
 rhoeic ulcers, they are not confined to the posterior lip of the cervix, 
 and they seem to be as common on the anterior as on the posterior 
 lip. They secrete pus abundantly, which is often unhealthy, serous or 
 sero-caseous. It would seem as if from their borders and from the 
 anfractuosities hollowed out below them there flowed a thick pus, con- 
 densed by its prolonged sojourn in these crevices and from which 
 the serous part has already been discharged. I think it is this 
 thickened pus, mixed with fragments of tissue separated by the 
 progress of ulceration, which has sometimes been taken for tuberculous 
 matter. 
 
 Si/philitic ulcers are rare on the cervix when compared with their 
 frequency on the vulva and other parts ; they are not, however, rare 
 absolutely. I have frequently seen chancre of the anterior lip deter- 
 mine by contagion, after the lapse of a few days, the appearance of a 
 chancre on the corresponding part of the posterior vaginal wall which 
 is constantly in contact with this portion of the anterior lip and on no 
 other part. I have seen women who were accused of having infected 
 men with whom they had had intercourse, and in whom I could not 
 
 41 
 
642 UTERINE DISEASES IN DETAIL 
 
 discover any ulcerated or chancrous surface, any syphilitic symptom 
 or even any morbid symptom, with the exception of a leucorrhoeic 
 drop escaping at intervals from the os uteri. 
 
 After a few days I have seen the circumference of this orifice 
 gradually attacked from within outwards by a chancrous ulceration 
 commencing evidently in the cervical cavity and gradually extending 
 to one of the lips ; I have collected six well-authenticated cases of this 
 development of iutra-cervico-uterine chancre. Chancres of the cervix 
 have the same appearance that they present on other parts of the 
 genital mucous membrane ; they are seldom indurated ; they have 
 perpendicular edges, on a greyish base, are sometimes diphtheritic, or 
 at least covered with a thick, hard, adhesive pseudo-membrane, and 
 have apparently a phagedenic tendency. Lastly, the cancerous ulcer, 
 variable in form with edges usually hard, unequal, friable and 
 bleeding, with an ichorous rather than a muco-purulent secretion, 
 presents characteristics so well marked that I cannot dwell on 
 them here ; they will be described when we come to Cancer of the 
 Uterus. 
 
 III. Diversity of the ulcerative or destructive tendency of ulcers of the 
 Cervix. — Superficial ulcers, slightly granular exulcerations, erosions pro- 
 duced by the various eruptions previously described, have frequently a 
 natural tendency towards cicatrisation and may be called non-malignant. 
 Simple granular or even fungous ulcers, those due to pregnancy, leu- 
 corrhcBa or chronic metritis, frequently also diathetic ulcers, although 
 not naturally tending towards cicatrisation but on the contrary to 
 further development, may also be ranked as non-malignant because 
 prompt and energetic rational treatment succeeds in curing them. 
 There are, however, ulcers which, on the contrary, have a destructive, 
 fatal tendency, and which may be characterised as malignant. Can- 
 cerous abscess may be placed in the front rank ; they are easily distin- 
 guished from others. Are these the ulcers described by Clarke and 
 Levers as the conoding ulcer of the os uteri? I am inclined to think 
 with Kiwisch and Scanzoni^ that it is so; Jlokitansky,^ however, de- 
 scribes a corroding ulcer of the uterine orifice which is similar to the 
 phagedenic ulcer of the skin. "Although it has no neoplasm for a 
 starting point," he says, " yet it gradually destroys the vaginal portion 
 or even the greater part of the uterus, destroying at the same time the 
 adjacent tissues as far as the rectum and bladder. It is an irregular 
 ulcer with sinuous, indented outline, at the borders and base of which, 
 from slow inflammation, the tissues are thickened, hypertrophied and 
 hardened. The base is of a dirty green or brownish-green colour, 
 secreting sometimes a small quantity of a viscous purulent fluid, at 
 other times a more abundant and aqueous fluid ; it presents no granu- 
 lations, but a gelatinous exudation, in which the various tissues of the 
 ulcerated surface hquefy.''^ This description evidently refers, if not to 
 encephaloid or scirrhous cancer, at least to epithelioma of the cervix, 
 and these ulcers may produce considerable destruction of the uterus. 
 
 ' Op. cit., p. 214. 
 
 2 ^^a^. imtli., 1861, t. iii, p. 538. 
 
ULCERATION AND ULCERS OF THE UTERINE CERVIX 643 
 
 I have seen several cases of the kind, and they may be found in the 
 admirable works of Cruveilhier and Lebert. But apart from this ten- 
 dency, which is due to a diathetic affection, may not a similar tendency 
 be developed in a cervical ulcer, especially if syphilitic ? I have seen 
 one case so marked that I think the cervix would have been destroyed 
 if I had not arrested the progress of the ulcer by repeated cauterisa- 
 tions and frequent dressings. I willingly reserve the name of corroding 
 or phagedenic to this form of ulceration. 
 
 At other times without having so marked a destructive tendency, 
 the ulceration pursues its course in one direction whilst cicatrisation 
 is obtained in the other, and its existence is thus prolonged indefi- 
 nitely. In such cases the ulcer may be called serpiginoiis, and should 
 be carefully and energetically treated. 
 
 But a well-marked destructive tendency is manifested in the ulcer 
 when it becomes diphtheritic. Fortunately this case is very rare, and 
 judging from the description which Boys de Loury and Costilhes^ 
 give of it they do not seem to have observed it accurately. I think I 
 have seen it as well as the phagedenic ulcer once. However, even 
 when not truly diphtheritic, cervical ulcers may frequently be covered 
 with pseudo-membranes of variable nature, like those on the tonsils, 
 in the mouth and on the pharynx. I share the opinion^ of Laboulbene 
 and other practitioners who have studied diphtheritic and pseudo- 
 membranous products, that there are great differences in the nature 
 and degree of maladies presenting this complication. I am convinced 
 from frequent observation that cervical ulcers are also liable to be 
 covered with membranous, pseudo-membranous and even diphtheritic 
 ])roducts from the effects of an adynamic and cachectic condition. 
 Without having the extreme gravity of true diphtheria, especially 
 when left to itself, these products always indicate an unfavorable ten- 
 dency and necessitate active and energetic treatment. They may be 
 distinguished by the difficulty there is m getting rid of the yellowish 
 or greenish layer covering the ulcer. The membrane has to be taken 
 away in fragments with forceps before the base of the hollow bleeding 
 ulcer is seen, which has extended in breadth as well as in depth under 
 the shelter of this false membrane. The neighbouring parts are 
 tumefied, violet red, sometimes livid and the neighbouring ganglia 
 inflamed. 
 
 Treatment. — Granular ulcerations of the cervix are never cured 
 spontaneously, and they have a continual tendency to extend and to 
 become fungous when left to themselves ; therefore they should be 
 treated, care being taken to fulfil the indications in the order in which 
 they present themselves. 
 
 1. The first indication is to treat the general or local cause which 
 produces the ulcer, or which keeps it up. The patient should follow 
 an antidiathetic treatment, the means of which will vary, not only 
 according to the nature of the affection on which the ulcer depends, 
 
 ' Gazette medicale de Paris, 1845, p. 374. 
 
 ' Recherches sur les conditions mctcorologiques dti developpentaU du croup 
 et de la diphtherie, p. 35. Montpellier, 1862. 
 
614 UTBEINE DISEASES IN DETAIL 
 
 but also according to the condition of the various functions ; for the 
 form in which the remedy is administered must vary according to 
 whether the condition of the digestive functions is normal or not. As 
 to the local state, we must not forget that fluxion, congestion, 
 inflammation, hypertrophy or leucorrhcea may complicate the ulcer 
 as cause, effect or simple coincidence. But whatever part these 
 morbid states may play, they should be treated by bloodletting, 
 rest, baths, prolonged irrigations, associated with general and local 
 resolvents. 
 
 2. The second indication is to maintain great cleanliness of the 
 ulcer and neighbouring tissues, sometimes isolating the ulcer from 
 the contiguous surfaces. The necessary attentions to cleanliness con- 
 sist in irrigations with tepid water repeated at least twice a day in 
 order to prevent the fluids which are secreted from remaining in the 
 vagina ; sometimes they require to be made every four hours. These 
 sometimes suf&ce for the cure of erosions and exulcerations. They 
 serve two purposes : by ridding the vagina of the abundant and irri- 
 tating secretions which accumulate there, they prevent the contact of 
 these fluids from keeping up and increasing the ulceration ; by clean- 
 ing the ulcer itself, which is irritated and positively infected by its 
 own secretion, they prevent its extension and also the transmission by 
 contagion of the malady to the contiguous mucous surfaces. As a 
 rule, simple irrigations should be made with tepid water in winter and 
 at the temperature of the room in summer. Cold water should be 
 used when the ulcer is fungous or bleeding. These irrigations may 
 be rendered disinfecting by the addition of a little carbolic acid, vine- 
 gar, permanganate of iron or chloride of lime. When there is conges- 
 tion or a tendency to hsemorrhage I prescribe injections to be made 
 three times a day with water as hot as can be borne (112° E.) with 
 one or two tablespoonfuls of a solution of carbolic acid (75 gr. crys- 
 tallised carbolic acid to a quart of water). These injections often 
 sufiice to cure certain kinds of ulcers. 
 
 3. The third indication is to modify the surface of the ulcer in 
 such a way as to stimulate its vitality and to produce a tendency 
 towards cicatrisation, a more or less marked resolvent action. A 
 tampon applied every day to the cleansed cervix for a few hours is 
 sometimes sufficient to give a favorable impulse to cicatrisation. At 
 other times an inert powder, such as starch, will produce the same 
 effect ; in both cases unless there is no discharge the vagina should be 
 syringed several times a day. The injections may be medicated, but 
 previously to using them a simple or purely detersive lotion should be 
 made. 
 
 After having washed and wiped the cervix we may apply a little 
 subnitrate of bismuth, calomel, alum, sulphate of zinc or acetate of 
 lead to the ulcer, and then a spoonful of starch in powder to keep the 
 drug in place, or a tampon will do as well. I generally place the 
 powder on the tampon and then apply it to the cervix, pushing it close 
 against the uterus while I withdraw the speculum, taking care not to 
 allow the powder or fluid to come in contact with the vaginal wall. A 
 
ULCERATION AND ULCERS OF THE UTERINE CERVIX 645 
 
 number of drugs are employed in this way. I shall content myself 
 with mentioning alum, tannin, sulphate of zinc, sulphate of copper, 
 nitrate of silver, tincture of iodine, perchloride of iron. Each of these 
 medicaments may answer to a special indication, which may be gra- 
 duated according to the nature of the lesions. Thus it is sufficient to 
 touch simple erosions with a weak solution of alum or nitrate of silver. 
 When the ulceration is more extensive or deeper, these solutions may 
 be made stronger, and when there is leucorrhoea or excoriation of the 
 vaginal cids-de-sac, as frequently happens, these drugs should be left 
 for a few seconds in contact with the diseased surfaces in order to give 
 them time to penetrate sufficiently. After having embraced the cervix 
 with a wooden, porcelain, or glass speculum, and having wiped not 
 only the whole surface of this organ, but the neighbouring portion of 
 the vagina, we pour into the inclined speculum one or two teaspoou- 
 fuls of a solution of nitrate of silver (30, 20 or 10 per cent, according 
 to whether we wish to use it as an alterative, a catheretic, or a mild 
 caustic). It is left for a few seconds in contact with the diseased 
 surfaces, then poured out of the speculum by depressing the instru- 
 ment, what is left being removed with a little cotton wool to prevent 
 any injury to the vagina or vulva. When only the surface of the ulcer 
 requires treatment we simply touch it with the crayon, perchloride of 
 iron or laudanum. These are the agents I use most frequently and 
 find successful. When the neck is engorged, (Edematous, or when the 
 ulcer is callous, the tincture of iodine has the advantage of being 
 resolvent as well as catheretic. When the ulcer is fungous, varicose, 
 bleeding, the perchloride of iron (30 per cent.), which acts not only as 
 a caustic but as a powerful hemostatic, is of great use. In such cases 
 I sometimes touch the ulcer with iodoform, creosote or crystallised 
 chromic acid ; but these medicaments should be reserved for cases in 
 which destructive action is desirable. When a specific action is 
 required solutions of corrosive sublimate should be used. 
 
 We may also have recourse to ointments, though I think they are 
 less efficacious than other applications. If there is pain and hyperses- 
 thesia I use laudanum, as recommended by Aran, only instead of 
 keeping it in place by powdered starch, after pouring in from 15 to 
 60 drops I introduce a tampon, which I push against the cervix, which 
 the patient removes a few hours afterwards in order to make an injec- 
 tion. In other cases I spread a thick layer of opiate ointment on the 
 tampon and apply it to the ulcer. When I wish to excite a resolvent 
 action I apply in the same way an ointment of iodide of lead and 
 potassium or a glycerole of bromide or iodide of potassium. If specific 
 action is needed as well I use mercurial and belladonna ointment, or 
 ointment of red oxide of mercury, which is extremely resolvent, and in 
 some cases hastens cicatrisation. In cases of acne or of ulcer kept up 
 by folliculitis I apply an ointment of the double iodide and chloride of 
 mercury, taking care to protect the vaginal walls, and I treat acne 
 rosacea of the cervix like that of the face. 
 
 Medicated pessaries are not so good, having the double drawback 
 of not being always pushed as far as the cervix or of not remaining 
 
646 UTEEINE DISEASES IN DETAIL 
 
 there, and of acting on the vaginal mucous membrane as well as on 
 the uterus. 
 
 4. The fourth indication is to destroy by cauterisation granula- 
 tions, fungosities, callosities, in fact all pathological tissues." The 
 sulphate of copper and the nitrate of silver are quite insufficient for 
 this purpose, being only applicable to small ulcers, and only curing 
 after a considerable number of cauterisations, and modifying the tissue 
 so slightly that whilst they favour dessication of the ulcer and repro- 
 duction of the epithelial covering of its surface, they leave the deeper 
 alterations untouched, or may even increase them by the repeated 
 irritation which their too frequent contact determines in the tissue. 
 What I have just said of nitrate of silver may also be said of more 
 energetic caustics, especially of the various acids, and in particular of 
 the acid nitrate of mercury so much used at present. Their liquid 
 form is also a drawback ; in the case of the acid nitrate of mercury 
 there is the additional risk of salivation. The potential cautery, such 
 as Vienna paste, is preferable to the means just enumerated, and would 
 be indispensable in cases in which the size of the granulations necessi- 
 tates deep destruction, were not the same effect produced with less 
 danger with the actual cautery. Actual cauterisation may be either 
 superficial or deep as required. It should be sufficiently energetic not 
 to make a second application necessary, remembering that the depth of 
 the scar produced is really less than it seems to be. In such cases we 
 must not fear to use more than one cautery to the portion of the cervix 
 to be destroyed, especially if the fungosities of the ulcer are voluminous 
 and bleeding, if the cervix is engorged and hypertrophied, if we require, 
 in short, by suppurative action of some duration and by the cicatricial 
 process which follows to produce absorption of the tissues or inter- 
 stitial fluids and resolution of the tumour formed by the ulcerated 
 cervix. I have seen ulcers of this kind resist cicatrisation so long as 
 to force me to have recourse to the actual cautery every four or five 
 weeks during general and local treatment; but I have never had a case 
 that I could not cure. Actual cauterisation is also applicable to ulcers 
 during pregnancy; double care, however, is required to prevent any 
 subsequent fluxionary movement towards the uterus. When rest, 
 baths and cold fomentations are insufficient the best means of avoiding 
 abortion is to subdue sanguineous fluxion of the uterus by revulsive 
 bleedings of the arm, which may be repeated when necessary, but 
 should not be copious. 
 
 Lastly, we must not imagine that all local treatment is finished when 
 we have burned the ulcer. As soon as elimination of the scar com- 
 mences the physician should direct the cicatricial tendencies of the 
 bleeding surface. In many cases this period is critical, and if a favor- 
 able impulse is not given to the cure of this new wound it may relapse 
 under the unfavorable influence which kept up the ulcer, and in a (ew 
 days become as fungous as before owing to the hypertrophic tendencies 
 of the uterine tissue. The wound should therefore be stimulated to 
 form a good cicatrix in a few days. Lastly, we must be wilhng to wait 
 for a considerable time after cauterisation before obtaining all the 
 
TJLCEEATION AND ULCERS OP THE UTEEINE CERVIX 647 
 
 results that we have a right to expect from itj and we should use the 
 general and local means of which I have so often spoken (especially 
 hydropathy and mineral waters) to forward resolution and to prevent 
 the renewal of ulceration or the development of some other affection 
 on an organ too recently cured not to be liable to a relapse. 
 
CHAPTEE lY 
 
 OEGANIC ALTEEATIOXS — FIBEOUS TUIIOTES — POLYPI A^'D MOLES — TrBEECLE — 
 
 CAXCEE 
 
 Organic alterations differ from morbid states without neoplasm in 
 the production of new elements appearing in the form of more or less 
 voluminous tumours^ and constituting the most important character of 
 these diseases as regards diagnosis and treatment. These new 
 elements may be the very elements of the uterine tissue or their 
 analogues (homeomorphous tumours), or they may appear to have only 
 a distant analogy with these elements and be developed in the uterus 
 with the same characters which distinguish them in the parenchyma of 
 any other organ (heteromorphous tumours). To the first category 
 hAong fibroids, fibromata^ myomata and polypi ; to the second tubercle 
 and cancer. 
 
 PiBROus Tumours 
 
 The names fibrous tumours, fibrous bodies, myomata, leio-myomata, 
 fibroids, hysteromata, &c., are used to designate tumours of a fibrous 
 appearance which are frequently developed in the uterine parenchyma. 
 They are excrescences from the uterine walls similar in structure to the 
 uterine tissue. They are also the most common of all organic diseases 
 of the womb. 
 
 The name fibrous body given by Cruveilhier indicates the nature, the 
 isolation and the independence of these productions, as well as the 
 absence of pediculisation which distinguishes them from polypi. 
 
 The expression interstitial filrous tumours is often employed to call 
 attention to their development in the midst of the uterine tissue. The 
 recent names of fibroids ^ and fibromata designate the principal aspects 
 under which they are usually seen; that of myomata" defines their 
 muscular or fleshy texture ; whilst that of hysteromata (Broca) recalls 
 their nature, which is no other than that of the uterus itself, their 
 development appearing to be due, according to my own observations 
 as well as that of Lebert and Eobin, to hypertrophy of the fibro- 
 muscular element, of all the anatomical elements that which best 
 characterises the uterine tissue. They are rounded tumours, slightly 
 irregular or nodulated on the surface, formed of greyish fibres or 
 fibrillse of considerable consistency, closely approximated, encircling a 
 fictitious centre, or it may be several centres closely interlaced, inter- 
 sected with dull white bands, distinct from the uterine wall in colour, 
 
 ^ M. H. Currey, On Fibroids of the Uterus {Philadelphia Med. and Surg. 
 Bepoi-t, March, 1874). 
 
 ^ Virchow, Die Kranlchaften Geschwillste. Berlin, 1863. He calls them 
 leio-myomata, or tumours formed of smooth muscular fibres. 
 
FIBROUS TUMOURS 
 
 649 
 
 consistency and in the absence of blood-vessels of any size. — They 
 occur at all ages^ before 20 and after 80.^ 
 
 The site is in relation with the thickness of the uterine wall and the 
 region of the uterus that they occupy. 
 
 1. As regards the wall, they may be developed in the central por- 
 tion, in which case they remain sessile for a long time; or towards the 
 free surfaces, in which case they are generally pediculated. The first 
 class are interstitial. Those of the second class have been called sub- 
 mucous or sub-peritoneal, according to whether they push before thf m 
 in the direction of least resistance the mucous membrane or the 
 peritoneum ; but these expressions are incorrect, for the fact which they 
 seem to imply does not occur : whether covered with uterine mucous 
 membrane or peritoneum fibromata have always a thin layer of uterine 
 tissue over them.^ Even the interstitial tumours may become enor- 
 
 FiG. 358. — Interstitial fibroid {ad nat., Farre). 
 
 mous without being pediculated, although they are only separated from 
 the uterine cavity by a thin layer of tissue proper. The uterus neces- 
 sarily participates in this development, as if it contained a product of 
 conception, a fact which to some extent justifies the expression of 
 fibrous pregnancy''^ given to it. 
 
 2. As regards the region of the uterus, fibromata may arise from 
 any point ; they are, however, produced more frequently in the body 
 than in the cervix, almost in the proportion of 110 to 21.* The latter 
 segment may remain intact, whilst the body is loaded with them so 
 as to resemble a bag filled with nuts.^ 
 
 1 Engehnann {Zeitschrift f. Geburtsk, 1877, Bd. i, Heft 1.) 
 
 ^ Cruveilhier, Anatomic pathologique, t. iii, p. 067. Paris, 1865. Baylc, 
 Diet, des sciences medicales, vii, 72. Paris, 1813. 
 
 ^ P. Guyon, Des tumeurs fibreuses do L'uterus, p. 13. Paris, 1860. 
 
 * Safford Lee, On Tumours of the Utcnts. London, 1817. 
 
 ^ As in an anatomical preparation of Huguier's, quoted by Guyon, op. fit., 
 p. 15. 
 
650 
 
 UTERINE DISEASES IN DETAIL 
 
 In fibromata of the body those of the posterior wall are the most 
 frequent^ those of the anterior wall come next, and those of the fundus 
 last.i Those of the cervix are developed like the latter, and are 
 usually pediculated towards the cervical cavity ; they escape from the 
 uterine orifice much more easily than do those of the body. 
 
 The size of uterine fibroids varies greatly, according to the stage of 
 development and the arrest which the development may undergo ; they 
 may be seen from the size of a pin's head to that of the head of an 
 
 Fig. 359. — Fibroid tumour of enormous size, rising to the hypochondriac 
 region (Graily Hewitt, op. cit., p. 498, fig. 102). 
 
 adult. I have seen a patient who had one which could not have 
 weighed less than 50 Ibs.^ Binz^ examined one which weighed 62 lbs.; 
 Walter one of 74 lbs. It is the same as regards number ; they may 
 be single or multiple. In the latter case they are usually of various 
 sizes, and they may also be found in the annexes.* They do not occur 
 singly as often as Cruveilhier thinks. 
 
 Sub-peritoneal fibromata are sometimes very numerous, while the 
 sub-mucous are usually single, probably from want of room, for abla- 
 tion is commonly followed by the development of a fresh tumour. 
 
 Interstitial tumours are sometimes multiple, one of them generally 
 
 1 Houel, Manuel d' anatoinie pathologique, p. 596. 
 
 ^ Courty, Excursion chirurgicale en Angleterre, p. 58. Montpellier, 1863. 
 
 ' Gazette med. de Paris, 1858, p. 807. 
 
 ■• Neugehauer {Prager Vierteljahrschrift, Bd. ii, S. 59, 1877). 
 
FIBROUS TUMOURS 651 
 
 being larger than the others. Lastly, we may observe fibromata 
 belonging to all these three categories in the same uterus. 
 
 The/bnw is usually spherical ; it may, however, assume various and 
 curious shapes, e.g. pointed, bilobed, owing to the entrance of the 
 tumour into the neck, or irregularly nodulated when a number of 
 tumours are fused together. 
 
 The texttire is very dense; the dull white or mother-of-pearl tissue 
 is one of the most resisting that is known. The tumour is chiefly 
 composed of amorphous matter finely granulated, fibrous or fibro- 
 plastic elements and muscular elements, or smooth muscular fibre-cells 
 which are larger than in the empty uterus but smaller than in preg- 
 nancy,^ and which form a quarter or a half of the mass of the tumour. 
 This composition, however, may vary according to the starting point 
 of the hyperplasia and the predominance of any particular element : 
 hence fibromata properly so-called, fibroids (in which the embryonic 
 element predominates), fibro-myomata, or hard myomata (the most 
 common), soft myomata (in which the muscular fibres and sometimes 
 the vessels predominate, the connective tissue being thin and loose), 
 vascular or telangiectatic myomata, cystic myomata, myo-sarcomata,^ 
 &c. 
 
 Evolution. — We must distinguish in fibromata a primary state of 
 development and a secondary state in which they live their own life. 
 
 a. Owing to our ignorance as to the commencement of the evil 
 (from knowing only large tumours), it was believed that there was a 
 want of primordial continuity between the myoma and the uterine 
 tissue (Bayle, Cruveilhier). But after histological researches had 
 proved the identity of the fibres of the myoma proper with the 
 muscles of the uterus,^ these tumours, which at first were thought to 
 be developed in an interposed blastema were then regarded as result- 
 ing from local hypertrophy,^ and at a later period as being all special 
 hypertrophic forms of the uterine parenchyma.^ This connection is so 
 close that sometimes it is impossible to limit even large tumours, 
 especially if they are soft. Fibromata therefore seldom appear to be 
 formed by the interstitial development of elements similar to those in 
 the midst of which the fibro-plastic tissue is produced or their forma- 
 tive blastema deposited, but more frequently by the proliferation of a 
 limited group of uterine fibres, which become isolated from all the 
 others just as adenoid tumours are developed in the glands, heter- 
 adenomata in their neighbourhood, pigment in the choroid,^ &c. 
 
 ' Vogel, Erlautenmgstafeln zilr pathologischen Histologie. Leipsic, 1843. — 
 Oldham, Guy's Hospital Reports, 1844. — Lebert, Societe de biologie, 1852, 
 p. 68. Anat. pathol. gen., pi. 157, 32« liv., 1859. — Eobin, These de Ferrier, 
 1854, p. 41. 
 
 * Virchow, Die JcranTchaften Geschwiilste. Berlin, 1863, Bd. iii, S. 810, et seq. 
 ' Vogel, Icones histol. pathol. Leipsic, 1843. 
 
 ^ Simpson, Obstetric. Mem. Edinburgh, 1855, vol. i, p. 115. 
 
 * Virchow, Wiener med. Wochenschrift, 1856, No. 7. 
 
 ® An example of the law of homology or analogy of formation. — Vogel, 
 Anat. path, gen., p. 100. Paris, 1847.— Courty, Substitutions organiques, p. 33. 
 Paris, 1847, and Gazette med. de Paris, 1847. 
 
652 
 
 UTERINE DISEASES IN DETAIL 
 
 Their origin seems to be a swelling of certain bundles of muscular 
 fibres at a given point analogous to the tumefaction of nerves in 
 neuroma, 
 
 h. The life of fibromata may be said to be a parasitic one as 
 soon as they are isolated from the tissue from which they have taken 
 birth. The anatomical independence which they then acquire as 
 regards the uterine fibres, the feeble vascularity which they enjoy, 
 the capillarity of the vessels by which their periphery commu- 
 nicates with the rest of the womb, all concur to prove their physiolo- 
 gical independence. It is easily ascertained that, with the exception 
 of some adhesions abnormally established, they have no continuity 
 with the tissue of the womb, but are separated from it by a loose cel- 
 lular tissue as if by a cyst, sometimes by accidental serous bursse.^ 
 Sometimes even the nutrition of fibromata takes place by imbibition ; 
 it is probable that it is so when they seem to be contained in an 
 envelope or a kind of sac which isolates them in every direction ; it 
 cannot be otherwise when they are perfectly free in the abdomen with- 
 
 FiG. 360. — Large fibrous interstitial tumour of the uterus, making the size of 
 this organ equal to that which it acquires at full term (Sims). 
 
 out on that account experiencing any alteration, and even without 
 ceasing to grow, which is accounted for by their being protected from 
 contact with the air and from the obscurity of their life. The growth 
 of fibromata is unlimited ; it is very variable according to whether 
 their development is rapid, slow, stationary or even retrograde. It is 
 not rare to meet with an interstitial fibroma the size of which is equal 
 to that of a foetus of seven or even nine months. Occasionally they 
 are seen still larger (see p. 650, and Pigs. 359 and 360). 
 
 Amongst the alterations which they may undergo the most uncommon 
 is atrophy by retrograde evolution. Soft myomata may become in- 
 durated in consequence of inflammation ; their muscular fibres disap- 
 
 ^ Verneuil, Fenerly ; Bulletin de la Societe anatomique, xxxix, 346. 
 
FIBROUS TUMODES 658 
 
 pear, they become fibrous and may even assume a cartilaginous aspect. 
 The density of the tumour increases much more when the fibres com- 
 posing it become encrusted with calcareous matter and when the fibroid 
 undergoes petrification. This petrification, to which the name of ossi- 
 fication has been given, may occur in two ways, either by a simple 
 ])eripheric encrustation forming a kind of shelP for the fibroma, or more 
 frequently by a general calcareous infiltration, by the formation of 
 multiple concretions in the interior of the tumour," and the petrifica- 
 tion of the whole of the fibrous body. The stony hardness of the 
 whole mass may be great enough to allow of its being polished, as was 
 done with one in the Middlesex Hospital Museum. The uterus some- 
 times contains such stones of considerable size and enormous weight. 
 I have seen one that weighed 22lbs. Arnott^ mentions another of 
 50lbs. weight, which caused death in an old woman by tearing the in- 
 testine in a fall. Cruveilhier regards the petrification of fibrous bodies 
 as a kind of atrophy, an opinion which seems shared by Louis,'* who 
 says that the calcareous transformations of fibromata occur chiefly 
 after the menopause. — Another kind of atrophy is the regressive fatty 
 transformation of the muscular fibres, which modifies in an opposite 
 manner the consistency of fibrous tumours, softening them, and giving 
 them a yellowish coloration and determining their partial liquefaction 
 and the formation of cavities. This transformation (which bears some 
 analogy to the retrograde evolution which brings back the uterine 
 fibres from the state of pregnancy to that of vacuity) may promote 
 the gradual diminution in size and even the disappearance of myomata, 
 either spontaneously or under the influence of rational resolvent treat- 
 ment. West draws attention to the analogies which may be estab- 
 lished, from this point of view, between a myoma and a tuberculous 
 bronchial ganglion, both being capable of undergoing softening as well 
 as calcareous induration. West also thinks, and I share his opinion, 
 that absorption of a myoma without notable alteration of the tissue is 
 not impossible, but might take place by regressive evolution as opposed 
 to the progressive evolution which has given it birth. 
 
 Fibromata may be attacked by softening, liquefaction and suppura- 
 tion. Sometimes they are red, the whole tumour appearing inflamed; 
 they become oedematous, fluctuating, giving rise to a collection of 
 serosity, blood and pus, very difiicult to diagnose and threatening to 
 terminate by dangerous peritoneal rupture, or they may become sepa- 
 rated towards the uterine cavity by a kind of maceration in the san- 
 
 ' Bourdillet presented a specimen to the Socicte anatomique ; the patient 
 had been in M. Mauriac's wai'd in the Hospice cles Menagcs. 
 
 - Michel Morus counted thirty-two calcareous nuclei in a fibrous tumour. 
 Louis, R. Lee and Velpeau have also mentioned remarkable cases of the same 
 alteration (Truraet, These sur les tumeurs de Vuterus, p. 76. Paris, 1851). 
 Ashwell mentions four cases in the Gazette hebdomad., 1854, p, 410. — Louis 
 Mayer and Lehnerdt each describe a new case (Monatsclirift fiir Gehurtsh, 
 18G9, Bd. xxxiii, S. 241). — Also Lumpe [Gazette hebdomad., 18()(), p. 71(5). — • 
 And Mordret [Annales de f/ynecologie, t. xi, p. 135). 
 
 ^ Medic. -Chirurg. Tr(in.?actions, xxiii, 1810. 
 
 '' Concretiona calcnleuses de la viatrice. — Acad, de cliir., v, 1. 
 
654 
 
 UTERINE DISEASES IN DETAIL 
 
 guineous fluids which bathe them. — Sometimes they are only partially 
 attacked by inflammation, softening, suppuration or gangrene, either 
 on the surface or in the centre, where a cavity is hollowed out, com- 
 pared by Cruveilhier^ to an eagle-stone. — When clustered together, 
 cysts, either single or multiple, may be developed in the tissue between 
 the fibromata, which may acquire a great size and become the seat of 
 hsemorrhage or suppuration and even be taken for ovarian cysts. — 
 
 Fig. 361. — Uterus, containing an ovum with an embryo of about two months, 
 compressed between two fibi'omata, a large posterior pelvic one and a 
 smaller anterior hypogastric one. The_ patient was operated upon : she 
 died thirty hours afterwards (Barnes, Etudes cliniques sur les tumeurs 
 retro-uterines, in Annales de gynecologie, t. ix, p. 443. Paris, 1878). 
 
 Cancerous degeneration has not been observed in fibroma. It may be 
 propagated from the neighbourhood, but is never developed there in 
 the first instance ; and fibroma and cancer very seldom coincide. 
 
 What influence do fibromata exercise (ya. fecundation, pregyiancy and 
 delivery?"" — There is no doubt that the presence of myomata diminishes 
 the number of conceptions and increases that of abortions and miscar- 
 riages. Out of 605 patients (of whom 500 were married and sterile 
 or had become sterile) seen by Marion Sims, 119 had fibrous tumours 
 (not including cases of polypi). — Pregnancy is not impossible, but it 
 seldom follows its normal course : whether the presence of the fibrous 
 tumour prevents the free development of the uterus or whether it de- 
 termines hsemorrhage it often causes abortion. — Delivery may be 
 impossible; it is always difficult, dangerous, complicated, and it 
 exposes to troublesome consequences. According to Tarnier,^ out of 
 
 ' Anai. path., liv. 13, pi. 6. 
 
 2 Yoch, Des hysteromes au point de vue de la generation. These de Paris, 
 1874. — Lefour, Des fibromes uterins au point de vue de la grossesse et de 
 V accouchement. These de concours pour I'agregation. Paris, 1880. 
 
 ^ Societe de chirurgie, Feb. 10, 1869. 
 
FIBROUS TUMOTJES 65 
 
 42 cases, delivery only terminated spontaneously 8 times ; it required 
 the use of forceps 6 times, version 6 times, induction of premature 
 labour once, embryotomy once, enucleation of the tumour once, 
 Csesarean operation 14 times ; the malady caused death 5 times before 
 delivery (of these 42 patients only 13 were cured) ; sessile fibromata are 
 displaced with the uterus ; their ascension at the time of delivery is 
 produced by the contraction or shortening of the longitudinal fibres ; 
 they are therefore less dangerous at this time than pediculated tumours ; 
 but they expose more to hsemorrhage afterwards ; patients who escape 
 may succumb to metro-peritonitis, to softening, to suppuration de- 
 veloped not only in the uterus but in the fibromata themselves (Bayle, 
 Lisfranc, Barnetche). 
 
 What influence does pregnancy in its turn exercise on the development 
 of fibrous tumours ?^ In spite of the interest which Gueniot imparted 
 to this question by showing that, apart from the influence of preg- 
 nancy, a fibroma may be attacked by hypertrophy, softening and sup- 
 puration, we must admit with Ashwell, West, Yirchow and all 
 pathologists, that pregnancy is one of the conditions which most pro- 
 mote the development of these tumours. My experience accords with 
 that of Guyon, Bailly and others, that there is no doubt that the 
 increase in the size of myomata takes place at the menstrual period 
 and during pregnancy ; it is the same with their softening and change 
 of position ; but it is more doubtful whether they resume their former 
 size and still more whether they become atrophied in following the 
 retrograde evolution of the organ after parturition. In speaking of 
 the termination of these tumours I shall, however, mention cases in 
 which they have disappeared after delivery, and even during pregnancy, 
 according to some writers. 
 
 Diagnosis — signs common to fibromata — subjective signs. — The first 
 symptom which the patient notices is metrorrhagia, sometimes neither 
 preceded by local pains nor by fatigue. The loss of blood usually 
 coincides with the menstrual period, in the beginning at least, and is 
 therefore menorrhagic; at other times, or at a later period, metror- 
 rhagia occurs. Excessive menstruation and hsemorrhages in the inter- 
 calary period are, in half of the cases at least, the first symptoms which 
 betray the presence of a fibroma.^ In women who have ceased to 
 menstruate haemorrhage is also frequently the first symptom. It some- 
 times alleviates the acute lumbar pains from which patients suffered 
 and gives a false confidence by misleading them as to the real cause of 
 this loss of blood. The haemorrhage depends on the fluxion which the 
 
 ' See Forget, BecJierches sur les corps fibreux et les polypes de I'uterus con. 
 sideres pendant la grossesse et apres I' accouchement, in Bulletin gen. de 
 therap., 1846. — Forget, Gueniot, Tamier, &c., Discussion on the same subject 
 in Bulletin de la Societe de chirurg., 1868, 1869. — Em. J. Lambert, Essai 
 sur les grossesses compliquees de myomes uterins. Paris, 1870. 
 
 " In 88 women suffering from myoma before the menopause, West (op. cit., 
 p. 272) observed 45 cases of disordered menstniation, either as to frequency 
 or abundance, or both simultaneously ; 15 cases of dysmenorrha'a, 4 of diminu- 
 tion in the quantity of menstrual blood, and 44 cases of hajmorrhage occurring 
 in the intercalary period. 
 
656 UTERINE DISEASES IN DETAIL 
 
 increase of the fibroma keeps up in the womb and on the alteration of 
 the uterine raucous membrane owing to the presence of this organic 
 lesion. It increases when the fibrous body, in place of remaining 
 interstitial, has become pediculated, being a still more prominent 
 symptom in the history of polypi than in that of fibroids. Expulsive 
 hypogastric pains accompany the menses. They sometimes extend to 
 the hips and thighs, and especially along the sciatic nerve. There is 
 also dull mechanical pain, pelvic fulness, weight, painful pressure on 
 the sacrum, dragging in the groins and loins. Earlier or later leucor- 
 rhoea supervenes, being sometimes a mucous, glairy, transparent or 
 opaque discharge, sometimes sanguinolent or purulent, its viscosity in- 
 dicating that it comes from the uterine cavity. This glairy discharge 
 is very abundant in some patients. 
 
 Dysuria, vesical tenesmus or complete retention of urine, produced 
 by the pressure, elevation or dragging of the bladder by the uterus, 
 may occur in the beginning or when the fibroids have attained a certain 
 size or are situated in the periphery. These symptoms are very 
 common, as West has noticed them in 21 patients out of 40 ; accord- 
 ing to Hervez deChegoin, they may even be the first that are observed. 
 They are often remarked before constipation. The difficulties of de- 
 fecation, especially when marked, may be said to be less common than 
 those of micturition. Constipation may not even exist: is this the 
 result of the normal anteversion of the uterus or is it, as Clarke-^ 
 thought, because the tumour does not correspond in its form to the 
 shape of the pelvis, and being prevented by its size from entering the 
 cavity, rests on the pubis and on the promontory, without either com- 
 pressing the rectum or the sigmoid flexure which is to the left ? Con- 
 stipation may, however, become so complete as entirely to prevent the 
 normal passage of fecal matter, determining symptoms of strangula- 
 tion. This occurs especially when the fibroid has become stony. 
 Nelaton," in a case of absolute constipation in which the rectum was 
 so flattened that no sound would pass, performed the operation for 
 artificial anus as the only means of prolonging the life of the patient, 
 who lived for eight days. I have seen analogous cases. Alterations of 
 the neighbouring organs may extend much farther. Strange displace- 
 ments have been described, e.g. the rectum pushed to the right, the 
 bladder on one side or the other, or extending upwards as far as the 
 navel ; gradual wearing away and perforation of the bladder and rectum 
 have been seen. Soir^ has seen a fibrous tumour the size of the fist 
 perforate the uterus and linea alba, and escape through the gangre- 
 nous skin of the hypogastrium in the form of a black and fungous 
 mass. 
 
 Objective signs. — The speculum is of no use in the diagnosis of a 
 fibroma. Palpation permits the assumption of the existence of these 
 organic alterations, especially when much developed, multiple or pro- 
 jecting towards the peritoneum, when they give a nodulated form to 
 
 ' Observ. on Diseases of Females, i, 279. London, 1821. 
 
 ^ Gnyon, op. cit., p. 49. 
 
 ^ Mem,, de hi Sac. de cliirurcj. de Paris, 1851. 
 
FIBROUS TUMOUES 657 
 
 the uterus or are distinctly perceived round this organ. Vaginal 
 touchj however, is infinitely superior to the two preceding means of 
 exploration ; associated with palpation, rectal touch and the use of the 
 sound, which serve as complementary or auxiliary means, it alone can 
 lead to a certain diagnosis. 
 
 The association of touch and palpation with the use of the sound 
 not only allows the difference in thickness of the two uterine walls to 
 be appreciated ; the mobility of the catheter and the direction in which 
 it is carried, the reverse of the natural or apparent situation of the 
 organ, show that the uterine cavity is both enlarged and deformed. 
 Vaginal touch should be practised in different attitudes and at various 
 times, especially during menstruation and metrorrhagia, when the 
 cervix is open ; for fibrous bodies and polypi present themselves at the 
 orifice at these times, returning into the uterine cavity afterwards. In 
 order to facilitate digital touch we may, like Simpson, dilate the cervix 
 with sponge tents, only we must be prepared to act immediately in 
 case of haemorrhage, either injecting iodine, giving ergot, and plugging 
 if we have to do with an interstitial fibroma, or operating if the fibroma 
 is pediculated. 
 
 When a fibroma by its size and weight can overcome the natural 
 means of fixity of the uterus, it forces this organ to incline towards 
 the side which it occupies, more frequently in lateroversion than in 
 anteversion and especially than in retroversion. 
 
 When of considerable size the influence of volume is greater than 
 that of weight : instead of bending the uterus to its own side it pushes 
 it to the opposite side, taking its point d'appiii on some portion of the 
 pelvic cavity, the sacrum, the cotyloid surface or the margin of the 
 coccyx. If it becomes so large as no longer to be contained in the 
 pelvis it is forced to rise into the abdominal cavity, dragging the uterus 
 with it, thus producing the opposite condition to the prolapsus which 
 the presence of the fibroma had produced in the beginning. 
 
 II. Distinctive signs of interstitial, sub-mucous, and sub-peritoneal 
 fibromata. — Interstitial fibromata present different symptoms, accord- 
 ing to whether they are situated in the fundus of the uterus, enlarging 
 its dimensions transversely, or occupying the walls and increasing its 
 cavity longitudinally. Those of the fundus may completely reverse 
 the position of the uterus, making the exact limit between the tumour 
 and the uterus very difficult to define; sometimes the fundus of the 
 uterus remains thick, whilst the layer which covers the fibroma on the 
 side of the uterine cavity is so attenuated as to make spontaneous 
 enucleation possible, of which Barth,^ Bernutz,^ and several other 
 writers have given examples ; at other times the fundus of the organ 
 is so equally divided, that the uterine cavity is preserved and may 
 become the seat of a pregnancy, as in the cases mentioned by Cruveil- 
 hier,^ and by others.* Those of the walls are less favorable to the 
 
 ' Bulletin de la Societe anatomique, 1850, p. 82. 
 2 Gazette hebdomad., 1866, p. 763. 
 ^ Anat. pa,thol., ii"^ liv., p. 45. 
 
 ■♦ Ingleby, Gaz. mcd., 1839, p. 73— Pillore, Gaz. des hnpit, 1854, p. 547.— 
 
 42 
 
658 UTERINE DISEASES IN DETAIL 
 
 accomplishment of the uterine functions ; they may be prolonged into 
 the cervix where they can be reached by operation_, they may efface 
 the cavity of the body by pressing together the mucous membranes of 
 the two uterine walls in their whole extent, or these membranes may 
 even become inflamed, ulcerate and adhere together at several points.^ 
 The continuity of the myoma with the fibrous bundles, the muscular 
 trabeculse and the vessels persisting longer here than in sub-mucous 
 and sub-serous myomata, it is not surprising that these interstitial 
 tumours attain a larger size than the others, sometimes simulating 
 pregnancy. The entire wall of the uterus is in a condition analogous 
 to that of pregnancy, the muscular fibres are hypertrophied, the 
 vessels dilated, the mucous membrane hypersemiated.^ Sometimes on 
 the contrary, the uterus is atrophied ; then the myomata are small, 
 they become indurated and calcareous ; occasionally they become very 
 large; in these cases the atrophy of the uterus seems to be produced 
 secondarily.^ Interstitial fibromata whether simple or compound, 
 most frequently occupy the posterior wall of the uterus which is 
 normally the thickest. They produce in the womb changes of size, 
 form, situation and capacity presenting the greatest varieties. 
 
 Sub-mucous fibromata. — Though seldom multiple, they may coincide 
 with intra-parietal and sub-serous myomata ; but when at all large, 
 they are seldom accompanied by important intra-parietal tumours. 
 When voluminous, they may adhere to the uterus by a broad base, it 
 being impossible for them to become pediculated or to descend into 
 the uterine cavity without dragging after them the fundus of the 
 uterus. Usually, however, before appearing at the orifice, they are 
 sufficiently separated from the uterine wall to be only adherent by a 
 pedicle hke a cord of variable resistancy, very distinct from the 
 tumour and apparently holding it suspended from the womb and 
 liable to spontaneous rupture. One of the most important points to 
 be decided with regard to treatment is whether there is a broad base 
 or a pedicle. Scanzoni used to seize the portion of the tumour visible 
 at the orifice with Museux's forceps and try to impart movements of 
 rotation to it, which could only be possible in the case of a narrow 
 pedicle. The migration of sub-mucous fibroids provokes very charac- 
 teristic changes in the uterus. It excites in the mucous membrane an 
 irritation producing softening, injection, haemorrhages, cedema, a muco- 
 sanguinolent or muco-purulent secretion; the uterine cavity is in- 
 creased in its vertical diameter, whilst the two opposite surfaces are 
 placed more or less in contact with each other ; in the end the cervix 
 
 Leguerie, Gaz. rtied., 1854, p. 412. — "Weber, Monatschrift fur Gehurtsk., 1864, 
 Bd. XXV, S. 157. — Ostertag, id., id., Bd. xxv, S. 317. — Spiegelberg, id., id., Bd. 
 xxviii, S. 426. — Lorimer, id., id., Bd. xxix, S. 394. — Gueniot, Des tumeurs 
 fibreuses deV uterus pendant la grossesse et I' accouchement. Paris, 1868. 
 
 1 Chassaignac, Btdletin de la Societe anatomique, t. xviii, p. 10. 
 
 - Carl Venzel, Die KranJihciten des Uterus. Mayence, 1816, Taf. xi, a, b. — • 
 Hooper, Morhid Anatomy of the Human Uterus, pi. v, a, h. — Eobert Lee, 
 Medico. -Chirurg. Transact., vol. xix, p. 122, pi. ii. — Lebert, Traite d'anat. 
 paihol, Atlas, pi. clvii, fig. 2. 
 
 3 Walther, Ueber fibrose Korper, S. 16. 
 
FIBROUS TUMOURS 659 
 
 becomes softened, shortened and reduced to a simple ring, as in the 
 last months of pregnancy, the os being enlarged to allow the fibroid to 
 pass. 
 
 Sub-peritoneal fibromata. — In place of presenting the characters of 
 uterine tumours like the two preceding, they have those of abdominal 
 tumours as regards situation and symptoms. The symptoms vary 
 according to the part of the uterus from which they have originated, the 
 portion of the abdomen where they are situated, the volume wliich 
 they acquire, the transformations which they undergo. They may 
 cause errors of diagnosis and real danger from these various points of 
 view. The origin of subperitoneal fibromata is near the peritoneum or 
 just below this membrane. These tumours remain attached to the 
 uterus, and if largely developed, the womb appears to be only an 
 appendage to them {see fig. 362) ; they project more or less consider- 
 
 FiG. 362. — Uterus siuTounded and suiToonnted by pediculated sub-peritoneal 
 fibroids {ad. nat. Farre). 
 
 ably towards the pelvis or abdomen, even the largest being seldom 
 completely freed from the uterine tissue. Some, however, end by 
 being only connected with the uterus by a long and narrow pedicle ; 
 Martini has seen one weighing 6 lbs. connected with the uterus by a 
 pedicle two inches long and one wide; Gaubric^ found in the right 
 iliac fossa a tumour reaching to the gall bladder, attached by a thin 
 pedicle to the right half of the cervix ; Cruveilhier^ saw a fibroid 
 11 lbs. in weight connected by a long pedicle of the diameter of a quill 
 pen with the right superior angle of the uterus. They seldom appear 
 singly, they coexist with intra-parietal or with internal myomata. 
 They are usually hard, having a tendency to become calcareous, proba- 
 bly by muscular atrophy and arrested nutrition. These fibroids may 
 even be detached spontaneously from the uterus and continue to live 
 either completely free in the abdomen, or fixed by accidental adhe- 
 sions; in such cases there was necessarily rupture of the pedicle. 
 They often give rise to no symptom, and do not even affect the regu- 
 
 ' Memoires de medecine et de chirurgie pratique, p. 271. Lyons, 1835. 
 ^ bulletin de la Societe anatoiniqiie, 1841, p. 235. 
 2 Anatomie pathologique, t. iii, p. G67. 
 
660 UTERINE DISEASES IN DETAIL 
 
 larity of menstruatioTi. Bayle^ has mentioned a remarkable case of 
 this iniiocuity. Like interstitial or submucous fibromata they are, 
 however, often accompanied by considerable hsemorrhage. Some by 
 their weight and displacement have been seen to produce torsion of the 
 uterus on its axis (Kg. 363), or the spontaneous separation of the 
 body and cervix, others have caused symptoms of intestinal strangula- 
 tion by pressure on the intestine,^ or even laceration of the intestine 
 owing to a fall on the belly in the case of an osseous tumour;^ lastly, 
 general compression and difficulty of respiration and circulation, 
 asphyxia in fact, may be produced owing to their size.* Subperitoneal 
 fibromata are those which are most easily recognised by })alpation and 
 touch combined. There is no uncertainty except with regard to those 
 which arise from the upper portion of the posterior wall, which must 
 not be confounded with uterine flexions or peri-uterine tumours (the 
 sound associated with vaginal and rectal touch enables a diagnosis to 
 be made), or with hard pelvic or abdominal tumours, such as ovarian 
 cysts and solid tumours (the general health is much more affected in 
 these latter cases than in cases of subperitoneal tumours). 
 
 III. Distinctive signs of fibromata and other uterine and peri- 
 uterine maladies. — Pregnancy is distinguished from them by the 
 menses being suspended ; but there are abnormal pregnancies, either 
 in aged women, or with continuation of the catamenia or haemorrhage, 
 hence the error made by Bayle^ in a case of this kind. In order to 
 avoid such a mistake the patient should be examined frequently at 
 regular intervals. Balottement should be tried after the fourth month, 
 and the physician should endeavour to determine the absence of 
 nodulations, and observe whether there is the wine-red colour, the 
 softening of the cervix and the oedematous sensation which the poste- 
 rior wall of the gravid uterus sometimes presents ; he must remember 
 also that voluntary movements and fcetal heart sounds observed in the 
 fifth month are certain signs of pregnancy. The existence of a fibrous 
 tumour may not prevent conception although not allowing of uterine 
 pregnancy : there may then be a tubal pregnancy, as in the case seen 
 by Stoltz.^ Extra-uterine pregnancy alone may also be taken for a 
 fibrous tumour.''' Lastly, as a distinctive sign, we should notice in 
 cases of fibroids whether expulsive pains are developed; they are 
 frequently present, and would produce abortion if the uterus contained 
 
 ' Op. cit., p. 79. 
 
 ^ It is the only mode of strangulation by fibromata that is known. Three 
 cases are recorded : one by jSTelaton, one by Duchaussoy, both mentioned by 
 Guyon (op. cit., p. 77), and another by Holdouse : flattening o£ the rectum, 
 lumbar anus, death the tenth day {Transact, of Path. Soc. of London, vol. iii, 
 p. 371). 
 
 ^ Arnott, Med.-Chir. Transact., vol. xxiii, 1840. 
 
 * Cruveilhier : two tumoui-s in the same patient, one of 11 lbs. with a long 
 thin pedicle, situated in the right hypochondrium ; the other of 22 lbs., filling 
 the pelvis and abdomen. Op. cit., p. 668. 
 
 '" Op. cit., p. 80. — Fredet, Annales de la Societe de medecine de St.-Etienne, 
 1865, p. 205. 
 
 ^ Mentioned by Aran, op. cit., p. 850. 
 
 ' Jobei-t (de Lamballe), Gaz. des hopit., July 5, 1845. 
 
FIBROUS TUMOUES 
 
 661 
 
 a product of conception in place of a fibroid. — We should remember 
 that after delivery the presence of a fibroma in the uterus may expose 
 
 /^5P^»f»r-. 
 
 Fig. 363. — a, enormous sub-peritoneal pediculated fibroid, accompanied by 
 intra-muscular myomata and complicated with pregnancy, in a woman of 
 42, who had a miscarriage sixteen years previously ; transverse diameter, 
 32 in., vertical diameter 14 in. B, left kidney ; c, Wolifiau cyst ; 
 D, interstitial fibroid contained in the right cornu of the uterus ; E, inser- 
 tion of tlie peduncle of the large tumour on a level with the left cornu 
 (the uterus is twisted on .its axis) ; F, left ovary and round ligament ; g, 
 right ovary and round ligament ; H, cervix (Leon Labbe, Legons de 
 clinique chirurgicale, pp. 447, 452. Paris, 1876). 
 
 us to an error in diagnosis leading us to think there is a second child. 
 Abortion is distinguished by the coincidence of pains and hneraor- 
 rhage, the pains ceasing with the hajmorrhage. Prolapsus of the 
 uterus inverts the vaginal walls, which does not happen when a pedi- 
 culated fibroid passes through the cervix. The mistake is more easily 
 made if the fibroid has a cavity and a transverse fissure imitating the 
 cervix into which tlie finger can penetrate. In such cases the fibroid 
 has sometimes been removed under the impression that it was the 
 uterus. Levret, Richeraud^ Cloquet^ Bosredon, Velpeau, Maree and 
 
662 UTERINE DISEASES IN DETAIL 
 
 Dolbeau^ have mentioned cases of the kind. The key to the problem 
 is in the diagnosis of the uterus by determination of the cervix^ vaginal 
 cul-de-sac, the relations of the fundus, the direction of the ureter^, the 
 displacement of the bladder. Inversion of the uterus may be still 
 more easily mistaken for a fibroid. The error has been committed by 
 W. Hunter and Denman and followed by death ;^ at other times 
 patients have survived the mistake.^ In these cases, which are rather 
 numerous, sometimes simple inversion has been taken for a fibroid, at 
 other times the fibroid has been rightly diagnosed but not the inver- 
 sion which complicated it. In order to distinguish the one from the 
 other two facts should be remembered : 1, in inversion, above the ring 
 which encircles the tumour, a furrow or closed sinus exists all round, a 
 cul-de-sac of moderate depth which cannot be prolonged into a uterine 
 cavity which no longer exists ; 2, the fundus no longer occupies its 
 usual place in the pelvis ; by means of vesical catheterism and rectal 
 touch, or by means of a male catheter introduced into the bladder, the 
 point of which is directed towards the uterine infundibulum (Mal- 
 gaigne), this characteristic displacement of inversion can easily be 
 ascertained^ at least in most cases ; 3, acupuncture may be utilised, as 
 I have already said apropos of inversion. 
 
 Cancer may be taken for a fibroma and vice versa, especially when, 
 owing to the gangrene of several fibrous tumours, an abundant fcetid 
 discharge escapes from the uterus ; but the odour of the discharge 
 accompanying the presence and even the softening of the fibroid in the 
 uterine • cavity differs from that which characterises cancer : the 
 former is acid, being the result of fermentation and heat ; that of 
 cancer is not only fcetid but nauseous and putrid, having the smell of 
 decomposition. The general symptoms differ also ; in cancer they 
 are very serious, characterised by cachexia and hectic fever, the course 
 of the disease also is relatively rapid ; while in the case of fibroid they 
 are almost limited to impoverishment of blood and to ansemia. The 
 other uterine diseases are more easily distinguished from fibromata 
 than the preceding. Hypertrophic elongation differs from it by its 
 regularity of form and the cervical elongation ; uterine cysts by fluc- 
 tuation, softening, or the cavities which they contain ;* anteflexion and 
 retroflexion (Fig. 364) by the curve which has to be described by the 
 catheter in penetrating the uterine cavity ; engorgement by an in- 
 feriority of size and weight, a less considerable displacement, a less 
 irregular tumefaction, a previous delivery or abortion ; metritis, by the 
 equal tumefaction of the two walls, the ease with which the sound 
 passes, the elevation of temperature, the acuteness of the pains caused 
 by pressure, redness, muco-purulent or purulent leucorrhoea, ulcera- 
 tion, granulations, &c., as well as by the relative rarity of hsemor- 
 
 ^ Guyon, op. cit., p. 80. 
 
 - Robert Lee, Med.-Chirurg. Trans., xx, 144. 
 
 ^ American Journal of Med. Sciences, April, 1849. — Bloxam, Gaz. med. de 
 Paris, 1837, p. 122. 
 
 '' We may, like Huguier, complete the difFerential diagnosis between a hard 
 fibroma and a iitero-follicular polypiis, with its cavity distended by a fluid, by 
 making an exploratory puncture. 
 
FIBROUS TUMOURS 
 
 663 
 
 rhage. Some tumours situated outside the uterus may easily be 
 confounded with fibromata, especially with pediculated subperitoneal 
 fibromata, if in diagnosing them we have not recourse to the most 
 exact means of investigation, — The first of these in frequency is retro- 
 uterine hematocele : the error has been made.^ However, the history, 
 the frequent suddenness in the formation of the tumour, the acuteness 
 of the first symptoms, the persistence of peri-uterine adhesions, the 
 absence of a pedicle, the site in the retro-uterine cul-de-sac of the san- 
 guineous effusion which is at last absorbed, the absence of hsemor- 
 rhage and of complication of the uterine cavity, the almost invariable 
 
 Fig. 364. — Fibroma projecting trom the posterior wall of the uterus, com- 
 pressing the rectum and simulating uterine retroflexion (Barnes, Annales 
 de Gynecologie, t. ix, p. 441). 
 
 position of the uterus immediately behind the pubic symphyses and 
 almost on the median line, are sufiiciently distinctive signs. Eecta- 
 vaginal and vesico-vaginal ^ fibrous tumours are more easily distin- 
 guished. They do not deform the cervix, but they displace it, raising 
 the vaginal cul-de-sac, becoming enveloped in it in place of depressing 
 it, always having between their convexity and the corresponding por- 
 tion of the uterus a cul-de-sac the presence or absence of which decides 
 the question. It is less easy to distinguish hard, osseous or osteo- 
 cartilaginous tumours,^ especially those of the anterior wall of the 
 pelvis. 
 
 Ovarian tumours, provided they are not too voluminous, pre- 
 serve an evident mobility, the existence of which is undoubted 
 when the patient is made to change her position or when movements 
 
 * Voisin, De V hematocele retro-uterine, p. 193. Paris, I860. 
 ^ Dupuytren, Cliniqtie, iii, 326. 
 
 ^ Dolbeau, Mem. sur l' enchonclrome du hassin (Journ. du Progres), 1860. — 
 Nekton, Clinique, par W. Atlee, p, 707, quoted by Guyon, Tum.fihr., p. 49. 
 
664 UTERINE DISEASES IN DETAIL 
 
 are communicated to the tumour. If, however, it is difficult to con- 
 found them with interstitial or submucous fibroids, it is not less so to 
 distinguish them from subperitoneal fibrous tumours (especially when 
 the latter have become free or abdominal). 
 
 It is well to remark, with regard to all extra-uterine tumours, that 
 they push the womb up or down, according to whether they arise from 
 the abdomen or the pelvis, in place of dragging it directly with them 
 as uterine fibromata do. We may also remark that difficulties of 
 differential diagnosis increase when fibromata become inflamed, sup- 
 purate or perforate the uterine wall. 
 
 Treatment. — The frequency of fibromata ought to call attention to 
 the treatment which these tumours require. Loir, in examining the 
 uterus in 40 old women met with fibrous bodies 15 times. — Statistics 
 prove that they are most frequent during the period of uterine activity. 
 Dupuytren, out of 57 patients affected with fibroma, met with 52 in those 
 from 20 to 50 years of age; Malgaigne, out of 51 patients, found 40 
 from 30 to 50 years old; VVest, out of 76, mentions 67 between 20 
 and 50 years; Braun and Chiari have made analogous observations. 
 We may, however, find them in young girls and in old women. Hardy^ 
 operated on a girl of 17. One was observed in a child of 9. Trsezl^ 
 saw a vaginal polypus in a child of 16 months. — They are not only 
 developed in the uterus, but also in the appendages, in consequence 
 of the identity of nature of the muscular envelope common to these 
 organs : this frequency is proved as regards the ovaries, Tallopian 
 tubes, broad ligaments, utero- rectal ligaments and the vagina; I have 
 seen them in these various organs, with their characteristic aspect, 
 rounded, firm, hard, elastic, white and fibrous, with fibres encircling 
 several centres.^ 
 
 The prognosis from the reproductive point of view is unfavorable : 
 the presence of myomata in the uterus diminishes the chances of con- 
 ception, increases those of abortion and leads to great dangers at de- 
 livery ; it mechanically opposes the passage of the child, it prevents 
 the uterus from contracting after the expulsion of the placenta and 
 exposes to hsemorrhages, it prevents retrograde evolution of the organ 
 and becomes the source of inflammation, softening, peritonitis and 
 septiceemia. From the point of view of danger to life in a non-pregnant 
 woman it is much less serious : undoubtedly the presence of myomata 
 affects the general health seriously and permanently, owing to haemor- 
 rhage and to the development of the parasitic tumour at the expense 
 of nutrition : but though the malady is often incurable it is seldom 
 fatal. 
 
 The termination of the malady may be unfavorable or favorable. 
 In the former case, it may threaten life in several ways : by haemor- 
 rhage, by its rapid development which is sometimes arrested by the 
 
 ^ Monatschr . filr Gehurtsk., Bd. xxv, S. 358. 
 
 8 Ibid., Bd. xxii, S. 227. 
 
 3 According to Virchow, if tlie usual seat of myoma is the body, i.e. the 
 art of the uterus which is richest in muscular tissue, it is also frequently 
 ound in the ovary, rather less often in tlie uterine ligaments, less frequently 
 still in the cervix, and most seldom of all in the vagina. 
 
 I 
 
FIBROUS TUMOUES 665 
 
 menopause, by compression of the rectum, by suppuration, by gan- 
 grene (a termination in which cure may be bought too dearly), lastly, 
 by perforation of the uterus and organs covering it, the vesico- vaginal 
 or vagino-rectal mucous membrane, the abdominal wall and the peri- 
 toneum in various directions. 
 
 In the latter case, there is spontaneous retrocession, diminution, or 
 expulsion. There may be simple tolerance of even large tumours 
 sometimes covered with calcareous incrustations : this is what happens 
 in old women, for in them fibrous bodies seem to become pediculated 
 less frequently than in the young. Retrocession may take place spon- 
 taneously either under the influence of iodine or after pregaancy and 
 parturition. Theoretically pregnancy seems to promote the develop- 
 ment as well as the absorption of fibromata ; but the physician ought 
 to take advantage of the period following delivery to prescribe resol- 
 vent treatment, as at that time there is a very energetic regressive 
 tendency. Spontaneous expulsion is very rare; it is probable that the 
 expulsion of polypi has often been confounded with that of true inter- 
 stitial tumours ; it coincides with the expulsion of the foetus or follows 
 it closely, or it may take place independently of gestation and delivery, 
 by enucleation and with laceration of the uterine tissue, usually with 
 colics as acute as those of labour ; it may require surgical assistance, 
 and is sometimes followed by profuse haemorrhage. Therefore though 
 fibroids are not malignant, they become serious owing to the hsemor- 
 rhage which they provoke, to their becoming jammed into the pelvic 
 cavity and to the enormous size which they may attain. Haemorrhage, 
 however, may diminish under suitable treatment which brings into 
 play the curative processes of nature (the tendency to enucleation and 
 to the expulsion of the fibroma). It is the same with other sym- 
 ptoms : the tumour may soften, decrease, shrivel, become encrusted, 
 and even disappear at the menopause. It is therefore important to 
 treat the symptoms, moderate the development of the tumour and 
 keep up the general health of the patient till the climacteric age is 
 reached; the danger is much less afterwards. West thinks that 
 patients should be reassured, as out of 96 cases he has only had one 
 death from haemorrhage and two from utero- peritoneal inflammation 
 after delivery. However, that is no reason for neglecting to promote 
 atrophy of the myoma, to assist the uterus to expel the tumour or to 
 interfere directly when advisable. 
 
 Medical treatment is more efficacious than might be supposed : no 
 other should be used at first in cases of sub-peritoneal tumours ; as to 
 other fibroids, it may at least be palliative and preparatory to surgical 
 treatment. It includes many means rightly designated by Cruveilhier 
 as atrophic treatment, the action of which may have a favorable result, 
 especially when patients are near the menopause. It consists in sub- 
 duing pain sometimes, haemorrhages frequently, in promoting the 
 spontaneous enucleation of the fibroid, avoiding all causes which 
 stimulate uterine circulation, in bracing the constitution and promot- 
 ing the natural resolution of the tumour. 
 
 Pain seldom requires treatment by opium or belladonna. Some- 
 
666 UTEEINE DISEASES IN DETAIL 
 
 times we may follow Clarke's advice to push the uterus and the 
 fibroid it contains above the brim, so that it can be developed without 
 hindering the functions of the pelvic organs by painful pressure. 
 At other times the patient may be eased by the use of Bourjeaurd's 
 abdominal belt, which prevents the concussion of sub-peritoneal 
 or abdominal tumours, at the same time that it promotes their 
 resolution. 
 
 Heemostasis is obtained by abdominal applications, cold irriga- 
 tions, long continued applications of ice, or better still very hot injec- 
 tions morning and evening for ten minutes at a time, the general and 
 local use of perchloride of iron, alum, acids, tincture of cinnamon, 
 tannin, rhatany, and vaginal plugging. Savage, of the Samaritan Hos- 
 pital in London, dilates the cervix with a sponge tent and then injects 
 tincture of iodine (iodine thirty grains, iodide of potassium one 
 drachm, rectified spirit two drachms, water three ounces), or pure ofii- 
 cinal tincture of iodine into the uterus ; the injection not only arrests 
 the hsemorrhage but diminishes the size of the tumour, according to 
 this surgeon, when repeated on each recurrence of the hsemorrhage for 
 five or SIX months.-^ 
 
 In order to remove all causes of disordered uterine circulation, the 
 patient should be told to keep her bowels regular by enemata or mild 
 laxatives; to lie on her back with the knees drawn up, especially 
 during menstruation and metrorrhagia ; lastly, complete rest should be 
 prescribed for the diseased organ, i.e. patients should be dissuaded 
 from marriage, while those who are married should be advised to dis- 
 continue intercourse, with the double object of saving the uterus from 
 excitement tending to produce hsemorrhage and the hypernutrition of 
 the fibroids, and of preventing the possibility of pregnancy. Ergot is 
 the hemostatic which I prescribe most frequently with the double 
 object of arresting hsemorrhage and of producing the spontaneous 
 enucleation of the tumour. I usually prescribe four grains of freshly 
 powdered ergot to be taken from one to six times a day ; I sometimes 
 substitute pills of ergotine and continue the use of it for five or six 
 days after every monthly period for some time." I know of few cases 
 of fibroids which have not been improved if not cured by the use of 
 this drug associated with other means of treatment which I shall 
 describe. 
 
 In cases of formidable hsemorrhage (where an operation is contra- 
 indicated), McClintock and West assert that free incisions of the 
 cervix almost always diminish the flow of blood. Does this 
 act by depleting the uterus, facilitating the escape of blood and 
 thereby preventing the distension of the organ, or by producing a 
 
 ^ Sims, op. cit., p. 121. 
 
 - Hildebrand of Kajnigsterg has tried subcutaneous injections of a solution 
 of extract of ergot (15 gr.) in water and glycerine (aa 105 gi'.). Inject 
 from 15 to 30 drops. Berlin Klin. Wochensch., June 17, 1872.— Baker 
 Brown {American Journal of Obstetrics, 1877, p. 38) has seen eclampsia occur 
 after injections of ergotine for a large fibroma, but this is the only case re- 
 corded. They are now largely used. 
 
FIBROUS TUMOURS 667 
 
 certain amount of indurating and cicatrising metritis ? ^ It is not 
 enough to subdue the hsemorrhage without dissipating its bad effects 
 by tonics. 
 
 As for the spontaneous absorption of the tumour, although this 
 result cannot be counted on, remarkable cases of it have been known 
 (I have myself seen such); therefore we must not hesitate to prescribe 
 resolvents. Amongst other means we may try pills of hemlock, mer- 
 cury, preparations of gold, bromine, iodine, the alkalis and the cura 
 /amis. I prefer the following : the long-continued use of bromide or 
 iodide of potassium, which may be increased from 15 gr. to 45 gr. 
 a day, diuretics, milk, nitre, squills, daily friction of the abdomen and 
 upper and inner parts of the thighs with mercurial and belladonna 
 ointment ; pessaries and suppositories, or rather enemata, of this oint- 
 ment ; a large abdominal compress, or painting the hypogastrium with 
 iodine, Yichy water or an alkaline solution taken before or during 
 meals, alkaline baths and mineral waters (Vichy, Andabre, Yals, 
 Boulou, Plombieres), associated with hydropathy. The medical treat- 
 ment which I prescribe for fibro-myomata is the following : a diet of 
 meat and fish, fresh vegetables, ripe fruit, stale bread, wine diluted 
 with Bussacg or Orezza water ; alteratives in the various forms just 
 mentioned) ; I also specially recommend my patients : 1, to make 
 vaginal injections on the bidet for ten minutes with water as hot as 
 can be borne, and to which has been added one or two dessert-spoon- 
 fuls of a solution of carbolic acid (from ^ to 1 oz. of crystallised car- 
 bolic acid to a quart of water) ; 2, three times a week a subcutaneous 
 injection of 15 drops of a solution of ergotine (15 gr. of ergotine 
 dissolved in 105 minims of water and 105 minims of glycerine) ; 3, three 
 times a week the application for ten minutes of a rather strong con- 
 tinuous current, rendered intermittent by means of a metronome, the 
 positive pole being applied to the cervix and the negative pole to the 
 abdomen. Although we cannot hope to cure all fibromata we may by 
 these means keep them in check. 
 
 Surgical treatment is very effectual. In the numerous cases in which 
 it can be applied it is curative. It varies according to whether the 
 fibrous body is interstitial or detached from the uterine wall and only 
 connected with the peritoneum or mucous membrane by a more or 
 less broad pedicle. In this latter case if the fibroma is subperitoneal 
 or abdominal, and if operation is not contra-indicated, it may be 
 removed by abdominal section performed in the same manner as for ex- 
 tirpation of an ovarian cyst," an operation which will be described when 
 we come to ovariotomy. If the jjediciilated fibroma is submucous, and 
 especially if it has escaped from the cervix, surgical intervention is 
 indispensable : it consists in the extirpation or destruction of the 
 tumour by one of the numerous methods apjjhcable to the treatment 
 of polypi. 
 
 ^ Amilcar Riconli, Traitement des fihrumes par la methode des incisions 
 multiples (Comment, di. medic, et chirurg. Milan, 1st year, No. 1). 
 
 2 W. Atlee, two cases : American Journ. of Med. Science, Aj)i'il, 1845, 
 April, 1855. 
 
668 UTERINE DISEASES IN DETAIL 
 
 In the former case, i. e. of interstitial fibroma, surgical intervention 
 is debateable; it is surrounded with difficulties and often with danger. 
 Its aim is to extirpate the tumour, but this can only be effected by 
 enucleation. 
 
 The methods differ as does the facility of operation according to 
 the depth at which the fibroid is seated (in the cervix or in the body), 
 the projection which it makes under the mucous membrane, the thick- 
 ness of the layer of uterine tissue covering it, tlie adhesions which it 
 has contracted in the kind of cyst in which it is contained, and lastly, 
 the size it has attained. With regard to depth, if the fibroma is con- 
 tained in the thichiess of one of the two cervical lips it is easy, after 
 having slightly drawn down this organ, or having separated the 
 vaginal walls by means of dilators, to incise the mucous membrane 
 and uterine tissue in the median line, to reach the tumour, to rupture 
 with the finger or handle of the scalpel the connections which loosely 
 unite it to the neighbouring parts, to seize it when necessary at the 
 sides with tenaculum hook forceps or in the centre with a corkscrew 
 driven into the tissue itself, and to enucleate it completely. In such 
 cases, unless the tumour has acquired an enormous size, there is no 
 contra-indication to operation. If the fibroma is contained in the 
 cavity of the body the orifice must be previously dilated. Ergot often 
 produces the double effect of pediculating the tumour and forcing it 
 powerfully and continuously towards the orifice, by the contractions 
 which it excites in the uterine tissue ; gradual dilatation of the cervix 
 is produced by pressure of the tumour, a dilatation similar to that 
 determined by pressure of the bag of waters during labour. 
 
 When the dilatation of the cervix produced by the expulsive efforts 
 is insufficient, it should be facilitated by the introduction of instru- 
 ments into the uterine cavity to dilate or divide it. I prefer prepared 
 sponge to more violent means because its slow but continuous action 
 produces in the end complete dilatation almost without causing any 
 pain. Dilatation is facilitated and the pain of it diminished by cover- 
 ing the dilator with a little extract of belladonna. In 1 814 Bonnie,i 
 having diagnosed a polypus in a woman subject to repeated haemor- 
 rhages, by forcing his finger into the os, dilated this orifice with 
 sponge tents till he was able to introduce several fingers into the 
 uterus, and having discovered the insertion of the pedicle applied a 
 ligature. Dupuytren^ considers simple or multiple division of the 
 cervix better than dilatation. This eminent surgeon divided it in one 
 stroke from without inwards, whereby he avoided injuring everything 
 except the tumour, whilst Velpeau performed the same operation iu 
 several little incisions from within outwards. The incisions should be 
 made obliquely when possible, and should be multiple rather than 
 single. Whilst recognising the utility of this method when there is 
 danger of fatal haemorrhage and urgent necessity for the removal of 
 the fibrous body, I think it is usually unnecessary, and that gentle 
 mechanical dilatation associated with the use of ergot is sufficient in 
 
 ' Bulletin de la FacuUe, t iv. 
 ^ Clinique chir., in, 360. 
 
FIBROUS TUMOUKS 669 
 
 submucous fibroids, as in polypi, to allow of the introduction of the 
 fingers and instruments into the uterus. When the cervix is suffi- 
 ciently dilated to admit of operation the uterus is drawn down if neces- 
 sary, the index finger of the left hand is then introduced into the 
 uterine cavity, the form of the tumour diagnosed, and the uterine 
 tissue covering the central and most prominent portion incised from 
 above downwards with a probe-pointed bistoury ; then with the fingers 
 or the handle of the scalpel the fibroid is separated from its envelope 
 and extracted. Amussat used to detach the tumour by beginning at 
 the upper part and working downwards. The remaining fragments of 
 mucous membrane or uterine tissue contract, cicatrise, or are partially 
 destroyed by suppuration. 
 
 This operation is not very difficult, and I think unattended with 
 much danger when the tumour is not very large, when it is free from 
 adhesions, when it projects towards the uterine cavity and when from 
 the long-continued use of ergot it has a tendency to become pedicu- 
 lated. I have performed it several times successfully. Hsemorrhage 
 resulting from division of the vessels of the uterine wall need not be 
 feared any more than spontaneous hsemorrhage. It is true that the 
 uterine wall has been dragged away, that it has been divided and the 
 peritoneal cavity penetrated ^ in this operation, but if under the influ- 
 ence of the long-continued use of ergot the tumour has become suffi- 
 ciently prominent to authorise the surgeon to decide on extraction, it 
 is to be presumed that the subperitoneal portion of the uterine wall in 
 the interstices of which the fibroma is contained, is thicker than the 
 submucous portion, and consequently protected from the danger of 
 these accidents. The important point is not to operate in a hurry or 
 before enucleation has been facilitated. The adhesions which Berard " 
 found between the fibroma and the cavity containing it are almost the 
 only obstacles that cannot be foreseen, and which it is difficult to remove. 
 
 But the chief difficulty is the size of the tumour. To this cause 
 must be attributed the great mortality attending such operations.^ 
 Amussat^ first performed ablation of these large fibroids ; since then 
 different methods have been adopted, varying with the site of the 
 fibroids according as they are seated in the walls or fundus. — In cases 
 of Jibroids of the walls the tumour may be divided by two incisions, 
 separated below but touching above, and enclosing a triangular seg- 
 ment or the third of the fibroma, the ablation of which will greatly 
 facilitate the extraction of the two remaining thirds. Or, like Maisson- 
 neuve,'^ after dividing the tumour longitudinally into halves and 
 enucleating all the lower portion of one of these halves we may divide 
 the latter from below upwards in a direction parallel to its surface and 
 
 ' Le Piez, Journal de chir. de Malgaigne, 1845, p. 90. 
 
 * Bulletin de la Societe anatomique, 1849, p. 82. 
 
 ^ Hutcliinson {Med. Times and Gazette, August, 1857) has collected .39 
 cases of similar operations ; out of 18 enucleations with the hot iron there 
 were 12 cures, 6 deaths ; out of 15 enucleations with caustics 9 cures, 6 
 deaths ; out of 6 unfinished operations 4 cures, 2 deaths. — Guyon (op. cit., p. 
 114) counts not less than lU deaths out of 17 operations. 
 
 ■• Bulletin de la Societe de chir., 1849. 
 
670 
 
 UTEEINE DISEASES IN DETAIL 
 
 thus, by the extraction of a superficial slice, facilitate the enucleation 
 of the deep portion; the other half is easily extracted afterwards. — 
 
 Fig. 365. — Sub-mucous fibroma, pi'ojecting into the vagina through the dilated 
 cervix. Attempted extraction by the vagina lasting two and a half hours. 
 Death from haemorrhage and exhaustion nine and a half hours afterwards. 
 (Emmet, op. cit., p. 582, fig. 100). I have seen a similar case, except that 
 the patient died of septicaemia. 
 
 With regard to interstitial fibromata of the fundus, it is difficult to reach 
 them if they cannot be drawn through the cervix ; but even when this 
 is the case two difficulties present themselves ; the thinness of the 
 uterine wall which separates them from the peritoneum, and the 
 difficulty of distinguishing the exact limit of the fibroid on the fundus 
 of the womb, which is necessarily inverted by the descent of the 
 tumour. 
 
 When obliged to perform such operations we should adopt Jarja- 
 vay's method. Instead of cutting the tumour transversely it should 
 be divided longitudinally by a vertical section with great care, so that 
 each hemisphere may be separated right and left and the upper boun- 
 dary between the tumour and the uterine tissue easily defined. After 
 operation the inversion is reduced. 
 
 Whatever method be adopted we must endeavour to effect extraction. 
 Such an operation is fatal if left unfinished. The denuded or divided 
 fibrous body becomes softened and tumefied, causing ineffectual ex- 
 pulsive efforts and infectious suppuration which always terminates 
 
 fatally. 
 
 To sum up, it is very difficult to estimate the dangers of the operation 
 beforehand. Apart from haemorrhage, death is too often caused by 
 peritonitis, phlebitis, pyaemia, resulting from traumatism of the uterus in 
 
FIBROUS TUMOURS 671 
 
 women exhausted by loss of blood. Therefore we should not under- 
 take the extirpation of fibromata of any considerable size unless it is 
 decidedly indicated, the life of the patient being in continual danger 
 from haemorrhage.^ It should never be undertaken, moreover, until 
 resolvent treatment has first been tried ; the continuous current, sub- 
 cutaneous injections of ergotine, very hot vaginal injections, perchloride 
 of iron and bromide or iodide of potassium being the means most 
 likely to succeed. When, however, operation is successful it may efi'ect 
 a radical cure and be followed by conception, normal pregnancy and 
 delivery.^ When the fibromata are voluminous, multiple and do not 
 project towards the uterine cavity, extirpation of the whole uterus with 
 its appendages has been attempted by abdominal section, as in ova- 
 riotomy. Clay^ ties the vessels of the broad ligaments and then 
 secures the cervix by a ligature of circular thread. Kceberle,* by a 
 single puncture from before backwards, passes two metallic ligatures 
 through the uterine mass, and tying one on each side removes each 
 half of the organ with the corresponding broad ligament successively 
 by constriction. This method has been adopted by the majority of 
 surgeons. I shall revert to this operation when describing that of 
 ovariotomy, merely mentioning now in passing that this daring sur- 
 gical operation has been successfully performed; as, however, the 
 mortality has hitherto been considerable,^ it is best to reserve our 
 opinion upon the future of an undertaking which but a short time ago 
 would have been condemned as unwarrantably rash. 
 
 During pregnancy the indications presented by fibromata vary 
 according to the symptoms produced ; it may be necessary to subdue 
 uterine contractions, to induce abortion or to remove a tumour of the 
 cervix when it causes serious hsemorrhage.^ During labour'^ an inter- 
 stitial fibrous tumour may force the surgeon to have recourse to 
 forceps, version, embryotomy, Csesarean section, puncture^ or ablation^ 
 
 ^ Jarjavay, Des operations applicables aux corps fibreux de V uterus. 
 These de concours. Paris, 1852. 
 
 ^ Grimsdale, A Case of Artificial Enucleation of a Large Fibroid Tumour 
 of the Uterus, ivith some Remarks on the Surgical Treatment of these 
 Tumours; in Liverpool Medico-Chirurg . Journal, Jan., 1857. 
 
 2 Observations on Ovariotomy, Statistical and Practical. Also a Successful 
 Case of Entire Removal of the Uterus {Transact, of the Obstet. Soc. of 
 London, vol. v, 1864). 
 
 ■• Documents pour servir a I'histoire de I'extirpation des tumeurs fibreuses 
 de la matrice, pur la methode sus-pubienne [Qaz. med. de Strasbourg, 1864). — 
 Operations d'ovariotomie, pp. 79, 98, 105. Paris, 1865. 
 
 ^ Routh, On some Points connected with the Pathology, Differential Diag- 
 nosis and Treatment of Fibrous Tumours of the Uterus (The Lancet, 1863, 
 1864). — Kceberlc, Operations d'ovariotomie, p. 98. Paris, 1865. He lost three 
 patients out of six. — Caternault, Essai sur la gastrotomie dans les cas de 
 tumeurs fibreuses peri-uterines. Paris, 1866. List of 76 cases. Nearly two- 
 thirds of the patients died from lucmorrhage. 
 
 •^ Merrimann, polyjius ligatured during pregnancy. Cure. Delivery one 
 month afterwards. See also the remarkable work already mentioned of R. 
 Lefour. 
 
 7 Puchelt, De tumoribus in pelvid. partum impedientibus. Heidelbero-, 1840. 
 
 ^ Cazeaux, Bulletin de la Soc. de chir., 94. 
 
 ^ Danyau, Bulletin de I'Acad. de med., 1851. — Bevv£ medico.-chirurg., 1861. 
 
672 UTEEINE DISEASES IN DETAIL 
 
 of the tumour itself. We should, however, know when to wait ; for 
 we know by experience that delivery may exceptionally take place 
 spontaneously and almost without accidents. To sum up the indica- 
 tions to be followed in such cases they may be arranged in the following 
 order : 1, expectation ; 2, attempted reduction or retropulsion of the 
 tumour above the brim (Stoltz places this foremost) ; 3, ordinary forceps 
 with or without continuous traction (preferred by Depaul and Gueniot 
 to version) ; 4>, version (preferred by West and Tarnier to forceps), 
 it may help in the reduction of the tumour;^ 5, embryotomy; 6, enu- 
 cleation of the tumour (unfortunately the boundaries and connections 
 of it are very uncertain and hsemorrhage is to be feared) ; 7, Csesarean 
 section ;^ 8, induction of premature labour (a doubtful point, for the 
 tumour may rise, even in the third month, as Blot's case shows) ; 9, 
 induced abortion (to be reserved for cases in which the life of the 
 mother is in serious danger). After delivery, if accidents occur which 
 do not allow of our waiting till the fibroid, which hypertrophied during 
 gestation, resumes its original size or atrophies, examples of which 
 have been given by Chaill}/^ and Cazeaux,''' the tumour may be 
 extracted immediately, as in the cases recorded by Guyot,^ Danyau,^ 
 Langenbeck'^ and Keating,^ or only after the uterus had resumed its 
 usual size, as Ramsbotham^ advised, in order to take advantage of the 
 regressive tendency which the uterine tissue possesses at that time to 
 institute energetic resolvent treatment, which, while it might cause the 
 disappearance of the tumour, would at the same time exercise a favor- 
 able action on the involution of the uterus. 
 
 Polypi and Moles 
 
 Polt/pi and moles are excrescences of various kinds having their 
 origin in one or other of the uterine tissues or in certain elements of a 
 fertilised ovum. The hypertrophy of these tissues, or rather the pro- 
 perty which the uterine tissues and the embryonic envelopes possess of 
 becoming hypertrophied, is the immediate cause of the development of 
 both structures. Folypi are kinds of hypertrophic vegetations of a 
 portion or of one of the elements of the uterine tissue proper, of its 
 mucous membrane or of its vascular system. Moles are organised 
 bodies arising from the envelopes of aproductof conception, implanted 
 
 ' Too few cases have been recorded to allow o£ our deciding between these 
 two methods (forceps or version). 
 
 2 Etlinger, Obseroationes obstetricice. Bonnse, 1854. 
 
 ^ Traits de I'art des accouchements, p. 572. Paris, 1861. 
 
 4 Ibid., p. 620. Paris, 1862. 
 
 * Levret, op. cit., p. 220. 
 
 ^ Beclierches sur les polypes fibreux de I'uterus {Journ. de cJiir. de Mal- 
 gaigne, 1846). 
 
 ' Schinidt's Jahrbuch, August, 1851. Operation followed by death. 
 
 ^ American Journal of Med. Sciences, May, 1858. Operation followed by 
 death. 
 
 ^ Obstetric. Med. and Surg., p. 224. London, 1856. A woman of 30 years, 
 delivered three weeks previously. Cure. 
 
POLYPI AND MOLES 673 
 
 in the uterine tissue^ deriving from it a morbid hypertrophic growth 
 and presenting themselves under the two very different forms of grape- 
 like clusters and fleshy bodies. 
 
 1. Uterine Poli/pi 
 
 Polypi 1 are tumours which differ from all others by the existence, 
 if not of several feet as the etymology seems to indicate, at least of one 
 foot or pedicle or contracted portion, by which they are attached to 
 the uterus. Whether this pedicle is broad or narrow, short or long, 
 whether the tumour is contained in the womb or expelled by muscular 
 contractions, the polypus is always characterised by the existence of a 
 pedicle. These tumours are classed together because the presence of 
 a pedicle suffices to produce a group of special symptoms and special 
 indications common to ail tumours of this kind. They are all due to 
 the hypergenesis and hypertrophy of one or more of the elements 
 which enter into the composition of the uterine substance. There are 
 therefore only three principal kinds of uterine polypi : the fibrous or 
 muscular, much the most common ; the mucous less common ; the 
 vascular the rarest of all. Hypergenesis may affect several of the 
 uterine elements simultaneously so as to produce composite polypi, m 
 which these various elements enter in various proportions ; lastly, the 
 polypi themselves are subject to various alterations which more or less 
 modify their structure. 
 
 1. Fibrous polypi are nothing but interstitial fibromata or myomata 
 which have become submucous and pediculated. They are sometimes 
 enormous, sometimes multiple, at other times degenerated, fibro- 
 cystic, softened in their centre, or, on the contrary, indurated, cartila- 
 ginous, encrusted on their surface and stony throughout. 
 
 2. Mucous polypi are formed by the hypergenesis of the elements of 
 the mucous membrane and especially of the follicles of this membrane. 
 Sometimes they are very small, very transparent, more sub-epidermic 
 than mucous, meriting the name of vesicular or epithelial." At other 
 times they are produced by the accumulation of mucus in a cervical 
 gland the orifice of which is obliterated, in one of Naboth's eggs 
 which acquires a size varying from that of a pea to that of a large 
 nut, and which, instead of remaining sessile or buried in the uterine 
 tissue, is gradually detached from it, becoming pediculated ; at other 
 times they are formed by the development of analogous phenomena in 
 several follicles of the body or cervix in such proportions that they 
 may form considerable tumours, cysts, cystic or hollow polypi, to 
 which the name of follicular or utero-follicular ^ has rightly been 
 given, producing sometimes simultaneously the hypertrophy of the 
 
 ^ The name polypus, applied to certain tumours of the uterus, seems to date 
 as far back as Moschion ; but it is only since the time o£ Ruysch {Obsero. 
 Anat., 6) that this word, which till then was confined to polypi oE the nose, has 
 been generally employed to designate the analogous excrescences of the uterus. 
 
 ^ Montfumat, Etudes sur les polypes de VuUrus, 1867. 
 
 ^ Huguier, Des kystes de la matrice et du vagin. Mem. de la Soc. de 
 chirurg., t. i. — Luna, Des kystes folliculaires de la matrice et des polypes 
 utero-folliculaires. Theses de Paris, 1852. 
 
 43 
 
674 UTEEINE DISEASES IN DETAIL 
 
 fibro-plastic^ fibrous and vascular elements of the uterine mucous 
 membrane. These utero- follicular polypi may be vascular containing 
 
 cavities in which sanguineous effusions are 
 produced, and occasionally becoming in 
 themselves the source of haemorrhages, un- 
 like the majority of fibrous polypi which 
 excite uterine hsemorrhage without them- 
 selves being the source of it. 
 
 3. Vascular polypi are rare, their ex- 
 istence being denied by some writers, whilst 
 by others they have been confounded with 
 sanguineous or fibrinous polypi (hsemato- 
 mata of Yirchow), which are only fleshy 
 Fig. 366. — Vesicular poly- moles or uterine clots ; by Levret they were 
 pus of the cervix pro- recognised under the name of fungous 
 SS^L'Tentilgh polypi- They are usually small, harder 
 the speculum (from a ^^d smaller when developed in the cervix, 
 drawing by Meyer). softer, more spongy, more bleeding when 
 
 developed in the uterine cavity. On section 
 more blood is discharged than one would suppose. I have seen 
 seven of the size of a cherry on the cervix; two of them, of 
 a dark red colour, seemed to be painfully swollen at certain periods, 
 especially during menstruation, like hsemorrhoidal tumours. Perhaps 
 they should be included in the class of mucous polypi rather than in 
 that of fibrous polypi, the vascular hypertrophy which causes them 
 only being produced at the expense of the vessels of the mucous mem- 
 brane and not of the tissue proper of the uterus. 
 
 Diagnosis — subjective signs. — Usually at the commencement of the 
 malady the general and local symptoms are very vague ; the polypus 
 causes expulsive pains, to which later on are added radiating pains, 
 dull achings and neighbouring disorders. — These are accompanied by 
 menstrual disorders, at first by menorrhagia, afterwards by metror- 
 rhagia, due in the majority of cases to thefluxionary movements which 
 the presence of the polypus excites in the womb. Hsemorrhage is the 
 greatest danger, caused by the presence of polypi in the uterus ; it 
 may carry the patient off without medical intervention.^ I give the 
 woodcut of a fibro-mucous polypus, which, notwithstanding its small 
 size, caused such serious hsemorrhage that if the patient had not suc- 
 cumbed to an intercurrent malady ablation would have been required 
 to save her life. — Mucous, purulent or sanguinolent leucorrhoeais pro- 
 duced in the interval between the haemorrhages or simultaneously with 
 them, owing to the irritation just described in the internal membrane 
 of the uterus. Yomiting, dyspepsia, impoverishment of blood, are 
 the usual consequences of the reaction produced upon the uterus and 
 nervous system by the presence of a polypus. Conception is not 
 impossible but abortion is very common. 
 
 1 Saxinger {Monatschr. filr GebiirtsTc., 1868, Bd. xxxii, S. 329) relates a case 
 in which death was caused by spontaneous and repeated hsemorrhage from a 
 mucous polypus, the removal of which was not attempted. 
 
POLYPI AND MOLES 
 
 675 
 
 Objective signs. — Direct examination is more or less easy and the 
 results more or less satisfactory according to whether the polypus is 
 
 Fig. 367. — Fibrinous uterine polypus of Velpeau and Kiwisch, or free polypous 
 hematoma of Vircliow. A large portion of the fcetal placenta is still 
 adherent to the projecting placental insertion {Die KranTchaft. Geschwulste). 
 
 still hidden in the uterine cavity, plugging the orifice, floating in the 
 
 Fig. 368. — Fibro-mucous polypus, re- 
 markable for the abundance of the 
 meti'orrhagia produced in spite of 
 its small size. \, tumour in situ ; b, 
 tumour raised so as to show its pos- 
 terior surface. 
 
 vagina or invading the pelvic cavity. The tumour does not become 
 
676 
 
 UTERINE DISEASES IN DETAIL 
 
 pediculated in passing through the cervix : the pedicle is acquired 
 whilst the tumour is still within the uterine cavity. When the tumour 
 is still retained in the uterine cavity the cervix must be dilated ; the 
 finger is then introduced into the uterus^ and with the help of the 
 
 sound we try to reach the highest part 
 of the tumour in order to discover the 
 pedicle. The tumour may even be seized 
 with the forceps, when by a movement 
 of rotation or torsion we find out 
 whether it is sessile or pediculated. Fre- 
 quently we can discover nothing unless 
 the investigation is made during men- 
 struation. The polypus often re-enters 
 the uterine cavity after having been seen 
 at the orifice. This alternate appearance 
 and disappearance may occur several 
 times.^ When the tumours have de- 
 scended into the cervix or into the 
 vagina it is of capital importance to 
 discover the cervix or os. After having 
 ascertained the size and consistency of 
 the intra-vaginal tumour the examining 
 finger should discover the state of the 
 cervix externally and internally, ex- 
 ploring the external surface, the utero- 
 vaginal culs-de-sac, the circumference of 
 the orifice and the cervical cavity, and 
 endeavouring to penetrate into the cavity 
 of the body to discover the insertion of 
 the pedicle. 
 
 Differential diagnosis. — It is much 
 easier to distinguish polypi than fibro- 
 mata from other tumours producing deformity of the uterus. Preg- 
 nancy, cystocele, vaginal hernia, prolapsus, cervical hypertrophy, 
 cannot be confounded with them. 
 
 There are only two diseases the differential diagnosis of which is 
 somewhat difficult : inversion and cancerous cauliflower excrescences. — 
 With regard to inversion we must remember that the body of the 
 uterus is no longer found in its normal position in the pelvic cavity, 
 nor can the uterine cavity be traced beyond the circular cul-de-sac 
 which forms the limit between the neck and the body of the womb. — 
 As to cancer, even the cauliflower variety differs so greatly from polypus 
 in the aspect and consistency of its tissue, the breadth of its insertion 
 over the whole surface of the cervix or of one of its lips, the inequality 
 of its surface, &c , that it is difficult to make a mistake as to its 
 nature. 
 
 * Larchev, Contributions a I'histoire des polypes fibreux intra-uterins a 
 apparitions intermittentes {Archiv. gener. de nied. Paris, 1867). — Robert 
 Johns {Gaz. med., 1858, p. 128). 
 
 Fig. 369. — Pediculated cervical 
 polypus (frora Boivin and 
 Duges). 
 
POLYPI AND jUOLES 677 
 
 Treatment. — There are two principal indications ; 1, to provoke the 
 expulsion of the polypus or, by dilatation of the os, to facilitate the 
 introduction of instruments for ablation ; 2^ to remove the polypus 
 by operation. 
 
 I. The first indication is fulfilled by all the medical and surgical 
 means which I have described as employed in the treatment of inter- 
 stitial fibromata and submucous fibroids. The rules of their applica- 
 tion are the same as in cases of submucous fibromata^ induced abortion 
 and extraction of any foreign body from the uterine cavity. Some- 
 times expulsion and even complete detachment is effected spontaneously 
 (out of 13 cases of spontaneous cure it has been observed 10 times^ in 
 the 3 other cases the polypus was destroyed by suppuration), but the 
 uterine contractions are sometimes so violent and continuous that they 
 may produce attenuation^ mortification, and perforation or rupture of 
 the uterus.i 
 
 II. The second indication is fulfilled by direct surgical intervention 
 which, to the honour of the art be it said, is usually successful. The 
 treatment of polypi constitutes, as Velpeau has justly remarked, one 
 of the triumphs of surgery. The methods used for the destruction of 
 polypi of the other organs have been successfully applied to the abla- 
 tion of uterine polypi. They are : cauterisation, crushing, torsion, 
 ulcerative ligature, extemporaneous ligature or ecrasement and exci- 
 sion. These methods should neither be adopted nor rejected without 
 consideration. There are some which are preferable to others, and 
 applicable to the majority of cases, such as ligature, ecrasement and 
 excision; these may be regarded as the best methods. Cauterisation 
 and crushing are extreme measures applicable to the body and not to 
 the pedicle of the polypus; torsion is not without danger, but this 
 exceptional method has its indication and ought to be adopted in 
 cases of polypi of a special nature or in certain conditions. The 
 general methods themselves ought not to be applied indifi'erently to all 
 polypi ; one or other is preferable according to the point of insertion 
 of the polypus, the size, consistency, structure and vascularity of the 
 tumour. Before describing these various methods and their indica- 
 tions or contra-indications I may remark that cauterisation is only 
 applicable to vascular or fungous tumours, or to those contained in the 
 uterine cavity and which cannot be seized by any instrument ; crushing 
 is applicable in similar cases, especially to intra-uterine or very hard 
 tumours, the pedicle of which can neither be reached nor divided nor 
 yet ligatured, and upon which caustics would have but little eff'ect. 
 Torsion is applicable to the ablation of small mucous follicular or very 
 vascular polypi, the pedicle of which may be ligatured beyond the 
 point on which torsion is brought to bear, but is dangerous in cases 
 of large and hard pediculated fibromata, the tissue of which is con- 
 tinuous with the uterine fibres, for laceration may occur beyond the 
 pedicle, affecting the uterine wall itself; ligature is preferable in cases 
 
 ^ Larclier, De la rupture spontanea de I'uterus et de qiielques autres particu- 
 larites dans leurs rapports avec les polypes fibreux intra-uterins {Archiv. gen. 
 de med., 1869). 
 
678 UTEEINE DISEASES IN DETAIL 
 
 of large, very vascular, utero-follicular, cystic, or even fibrous polypi 
 when there is a probability of the existence of large vessels in the 
 pedicle, or when it is applicable as a precautionary measure to be 
 followed immediately by excision; extemporaneous ligature and 
 ecrasement are applicable under the same circumstances when the 
 absence of hsemorrhage and tolerance on the part of the patient allow 
 of constriction of the pedicle being carried to the point of section or 
 laceration in place of waiting for ulceration, thus sparing the patient 
 and surgeon the drawbacks of sloughing of the tumour; lastly, exci- 
 sion is preferable in all cases of pediculated fibromata, for experience 
 proves that there are no large vessels in the pedicle, and that it is even 
 applicable to other polypi provided hemorrhage can be arrested by ice, 
 very hot injections, cauterisation, perchloride of iron and plugging, 
 
 1. Cauterisation. — This is only employed for very small tumours of 
 the cervix, or for larger polypi coDtained in the body, and which 
 cannot be reached by instruments. It may be applied in the form of 
 nitrate of silver, acids, caustic potash, the actual cautery for cervical 
 polypi and even for a polypus of the body ; but it is dangerous in the 
 latter case, and should only be applied very exceptionally. The gal- 
 vano-cautery may also be used after Middeldorpf^s^ method or Paque- 
 lin's thermo-cautery. 
 
 2. Orushiiig. — This may be performed with my uterine forceps, 
 either straight or curved. Simpson used very powerful small forceps ; 
 Thierry a pair of very strong curved toothed forceps; Nelaton a 
 punch-forceps ; Eichet crushing forceps. It is, however, to be feared 
 that the tissue of the polypus, being only partially crushed and not 
 immediately extracted, may become tumefied, may mortify at some 
 points and give rise to strangulation and putrefaction. 
 
 3. Evulsion is performed with polypus forceps with concave blades 
 which are rough, perforated or grooved, so as to fit tightly together. 
 It is applicable to the ablation of mucous polypi, small cystic, follicu- 
 lar polypi and small vascular polypi of the cervix. The pedicle should 
 always be compressed with elbow forceps above the point at which 
 traction is made. 
 
 4. Torsion, though dangerous for fibrous polypi with a broad 
 pedicle merging into the uterine tissue, is useful in the ablation of 
 small mucous and vascular polypi on account of its rapidity and com- 
 pleteness. I have frequently removed such tumours in a few seconds ; 
 and for this purpose have had forceps made with elbowed blades 
 deeply grooved fitting perfectly into each other, by means of which 
 the pedicle of the fungous or varicose tumour is easily seized, whilst 
 torsion is performed lower down with other forceps, till the tumour is 
 detached from the uterus.^ My uterine forceps are usually sufficient 
 for this operation. The actual cautery should be applied to the point 
 of insertion in order to prevent reproduction of the polypus. 
 
 ' Ressel, De polyporum iiteri extirpatione viethodo galvano-caustica in- 
 stituta. Diss, inaug. Vratisl., 1857, with plates. 
 
 ^ Puech mentions two cases, proving that torsion is applicable even to large 
 polypi when applied with proper precautious {Annates Cliniques de Montpellier, 
 1857, p. 218). 
 
POLYPI AND MOLES 
 
 679 
 
 5. Ligature. — This was recommended by Pare and Guillemeau, 
 adopted by Levret ^ and Desault,^ and further improved by Niessen/ 
 Mayor/ and others. The nature of the ligature, the manner of apply- 
 ing it round the pedicle and the method of constriction are variable, 
 
 Fig. 370. — Ordinary polypus 
 forceps with crossed blades. 
 
 Ei(J. 371. — Polypus forceps 
 with sliding fastener. 
 
 having been improved and modified so as to be applicable to all cases, 
 and to allow of the ligature being introduced into the interior of the 
 uterus provided the cervix is sufficiently dilated. Levret's ligature 
 was silver wire, a means of constriction at once flexible and resistant, 
 
 ' Memoire sur les polypes de la matrice et du vagin. Acad, de chirurg., 
 1749. — Observations sur la cure radicale des polypes de la matrice. Paris, 
 1759. 
 
 2 Journal de cliirurgie, t. iv. — CEuvres cliirurg. 
 
 3 Dissertatio de p)olypis uteri et vagina, novoque ad eorum ligatiiram in- 
 strumento. Goottingen, 1785. 
 
 '' Nouveau systeme de dcligation chirurgicale. Lausanne, 1837. 
 
680 UTERINE DISEASES IX DETAIL 
 
 and whicli can be managed by the fingers alone. Iron wire may be 
 substituted, but it has the drawback of oxidising, and of breaking 
 before the tumour falls ; ordinary strong waxed thread or whipcord is 
 better; silk may also be used and when well waxed is the most flexible 
 and resistant of all. I prefer an elastic ligature^ however, to all of 
 these. Instead of the ligature we may employ the method adopted 
 by Gensouli of seizing the pedicle with polypus forceps furnished 
 with curved blades for continuous constriction. Aveling invented his 
 polyptrite to serve instead of forceps. 
 
 The mode of applying the ligature round the pedicle is equally 
 variable. — Levret used two cannulse soldered together laterally, 
 through which the silver thread was passed so as to form a loop 
 between the two extremities at one end ; this loop was applied by the 
 instrument and arranged round the pedicle by the fingers ; the liga- 
 ture is arranged in the same way when de Graefe's serre-noeud is used 
 or any analogous instrument of larger size to grasp the pedicle and 
 increase the constriction day by day. Desault used two separate 
 cannulse ; one end of the ligature was passed into one of the cannulse^ 
 the other end was held by the double half ring at the end of a stylet 
 passed into the second cannula which could be closed or opened at 
 will ; the extremities of the two cannulse united by the loop being 
 applied to the pedicle of the polypus, one was held fixed whilst the 
 other was passed round the pedicle till meeting again with the former, 
 it had completely surrounded the pedicle by the ligature. By rotat- 
 ing the two cannulse the ligature was twisted and detached from the 
 tubes, when the two ends were passed through a serre-noeud ; Niessen 
 used two long separate silver cannulse with which the ligature could 
 be passed round the pedicle of the polypus, after which they were 
 held together side by side so as to allow the two ends of the liga- 
 ture to be tightened. Two gutta-percha catheters ^ may be substi- 
 tuted for ]Niessen''s double cannula, or two needles ^ a quarter of a 
 yard long may be used, the eyes serving to carry the constricting 
 ligature to the necessary depth. Lastly, we may like Mayor employ 
 two or three stems of steel or whalebone terminating in a claw. 
 
 The methods of constriction are as various. Levret, after having 
 tightened the loop as much as possible, tied the two ends of the liga- 
 ture to the rings at the outer end of his double cannula, which he 
 then rotated so as to twist the ligature on a level with the pedicle. 
 Desault, after having detached the two ends of the hgature united 
 them in one cord which he passed through the opening of a very 
 simple serre-noeud (a steel stem, one extremity of which is bent at 
 right angles and pierced with a circular hole, the other being also bent 
 at right angles like the first in order to hold the terminal extremity of 
 the hgature passed into the upper ring) ; Sotto^s serre-noeud has been 
 substituted for this. Niessen united his tubes by passing them into a 
 short double nozzle similar to a portion of Levret's double cannula i 
 
 ' Bevue medico-chirurg., 1851, p. 89. 
 
 "^ Favrot, Revue med.-chirurg., Jan., 1848. 
 
 "^ Hiilin, Memoires de vied, et de chir. pratiqiies. Paris, 1862. 
 
POLYPI AND MOLES 
 
 681 
 
 Gooch introduced the two tubes simultaneously into two double 
 metallic rings united by a single stem. Bowman adapted a rack to 
 the extremity of this little apparatus ; De Graefe's screw serre-noeud 
 
 Tig. 375. 
 
 Fig. 372. Fig. 373. Fig. 374. 
 Fig. 372. — Sotto's serre-noeud. 
 
 373. — Poi-te-lig^ature. a, holder; c, united in a serre-nceiid with screw d, 
 
 Fig. 
 
 invented to apply the ligature round the pedicle and to efEect constriction ; 
 
 this instrument may he substituted for those of Levret, Niessen, Gooch, 
 
 Bowman and Graefe. 
 Fig. 374. — Graefe's serre-nceud with perforated ivory balls. 
 Fig. 375. — Gooch's apparatus modified by Courty for the application of the 
 
 elastic ligature. //, india-rubber tube ; tn, metallic guide, by means of 
 
 which the india-rubber ligature is passed through the metallic tubes tt; 
 a a a, rings and iron stem, into which the tubes are adjusted ; t r, rack, 
 
 of no use when the elastic ligature is applied : the two ends of the india'- 
 
 rubber tube are fastened to it. 
 
 and the other instruments of the same kind by which, when the ends 
 
682 
 
 UTERINE DISEASES IN DETAIL 
 
 of the ligatures are once fixed, constriction may be slowly and pro- 
 gressively increased are usually preferable. I generally employ the 
 elastic ligature, the loop of which is applied round the pedicle by 
 Emmet^s porte-ligature or porte-chain, the ends being passed by 
 means of my metallic guide through two Gooch's tubes brought close 
 
 together and held by double metallic 
 rings. The elasticity of the elastic 
 tube or ligature when once fastened 
 to the rack at the end of this appa- 
 ratus is sufficient to keep up the con- 
 striction and produce ulceration of the 
 pedicle. 
 
 The ligature may cause immediate 
 or subsequent accidents. The most 
 serious primary accident is constric- 
 tion of the uterine wall resulting from 
 the application of the ligature above 
 the insertion of the polypus ; but this 
 is easily avoided with a little care if we 
 remember that it is useless to apply 
 constriction at the point of insertion 
 of the pedicle, and that it is even 
 better to run the risk of leaving a 
 portion of the tumour; this portion 
 usually mortifies and falls of itself like 
 the end of the umbilical cord included 
 between the ligature and umbilicus. 
 — The drawbacks resulting from mor- 
 tification of the tumour, foetid dis- 
 charges, purulent absorption, &c., 
 have been very much exaggerated and 
 may be generally avoided by frequent 
 detersive lotions, by more rapid con- 
 striction of the hgature or by complete 
 and instantaneous division of the pedicle below the ligature. 
 
 6. Linear ecrasement. — This is preferable when the polypus is very 
 vascular. I have performed it frequently and always successfully. — 
 Lerpiniere,^ L. Boyer and Pajot suggested dividing the pedicle of the 
 polypus by sawing it through by alternate movements in opposite 
 directions communicated to the extremities of a metallic loop or thread 
 of whipcord passed round the pedicle. — Chassaignac^s instrument is 
 undoubtedly preferable to the latter method ; a straight or curved in- 
 strument is used according to the case. I think it is usually easier to 
 pass a silk cord or metallic wire round the pedicle^ than the chain of 
 
 1 Journal des connaissances mSd.-cliir., 1834. 
 
 ^ To obviate this difficulty Sims has invented a, portet-chain (op. cit., pp. 79, 
 80, 81, figs. 28, 29, 30), and Emmet has devised a still simpler way of 
 adjusting the chain by means of a loop of thread carried to the end of the 
 vagina by the terminal ring of a long stylet (see fig. 376). 
 
 Fia. 376. — Emmet's porte-chain 
 round the pedicle of the tu- 
 
POLYPI AND MOLES 
 
 683 
 
 the ecraseur, and as the extremities of this h'gature may be attached 
 to a good serre-noeud and the constriction increased as rapidly as is 
 desirable^ so as to divide the pedicle in the same way as with the 
 
 Fig. 377. Fig. 378. Fig. 379. 
 
 Fig. 377. — Sen-e-nceud for effecting section of the pedicle by extemporaneous 
 
 Pig. 378. — Chassaignac's straight and curved linear ecraseurs. 
 Fig. 379. — Section of the pedicle of a uterine polypus by Chassaignac's curved 
 linear ecraseur. 
 
 Fig. 380. — Aveling's polyptrite : c, hook of the female blade ; a, b, male blade. 
 
 ecraseur, I think this method (called by Maisonneuve extemporaneous 
 lif/ature) is preferable to ecrasement in such cases. — The difficulties of 
 introducing the chain of the ecraseur suggested to Aveling^ the idea of 
 a new instrument composed of a kind of pliable grooved hook, in the 
 concavity of which the pedicle of the polypus may be seized and after- 
 wards crushed by compressing it more and more strongly by means of 
 a bent stem moved by a vice; this instrument is called a, polj/piriie. 
 
 7. Excision. — This is the quickest method. It has been adopted 
 by almost all surgeons, especially for fibrous polypi, ever since Dupuy- 
 tren showed its advantages and innocuity (out of 200 cases serious 
 hsemorrhage only occurred twice), and since Siebold^ and Mayer^ 
 
 ^ Transactions of the Obstet. Soc, vol. iv. 
 
 2 Frauenzhnmcrkrankheiten . 
 
 ^ Dissertatio de polypis uteri. Berlin, 1821. 
 
684 
 
 UTEEINE DISEASES IN DETAIL 
 
 publislied an account of the success of their cases.^ The facility of the 
 operation varies greatly according to whether the polypus has descended 
 into the vagina or is retained in the Momb, whether it is of small size, 
 allowing of its being encircled by the finger as a guide to the bistoury, 
 or so large that it can only be detached from the uterus after being 
 drawn down or divided into several fragments. 
 
 Fig. 381. Fig. 382. Fig. 383. Fig. 384 
 
 Fig. 381. — Chassaignac's tenaculum hook forceps with concave hlades. 
 Fig. 382. — Greenhalgh's sliding tenaculum hook forceps. 
 Fig. 383. — Eobert's tenaculum hook forceps with independent blades and 
 
 movable teeth. 
 Fig. 384. — McClintock's screw. 
 
 Means of prehension are applied generally to the periphery of the 
 tumour. If the polypus is easily torn it may be better to seize it 
 with polypus or ovum forceps ; if it is hard or sufficiently resistant it 
 is better to employ tenaculum hooks, either hooks with a handle and 
 
 1 It must not be forgotten that excision is not exempt from accidents 
 common to all operations. Simpson has seen tetanus supervene {Gaz. hebdoin., 
 1854, p. 686). 
 
POLYPI AND MOLES 685 
 
 of which the claws may be concealed or opened at will, and the number 
 of which may be multiplied according to necessity round the tumour ; 
 or Museux^s straight or curved tenaculum hook forceps; or Chas- 
 saignac's tenaculum hook forceps with strong teeth and concave blades ; 
 or Greenhalgh's sliding forceps, the blades of which can be made to 
 seize the tumour at difPerent heights right and left ; or Robert's strong 
 forceps with movable teeth, which can penetrate the tumour and be 
 detached from it at will. — When it is impossible to encircle the tumour 
 other means of prehension may be resorted to : for example, piercing 
 the accessible portion of the tumour with a curved needle carrying a 
 cord, by traction on the two extremities of which the polypus may be 
 drawn down and fixed ; or Lucres extractor, a kind of tenaculum hook 
 with a handle, the diverging points of which cannot be detached from 
 the tumour after they have penetrated it ; or lastly the ingenious in- 
 strument in the form of a screw or corkscrew invented by McClintock,^ 
 which is useful in extracting hard polypi. 
 
 Instruments of section are also very numerous. Lobstein adopted 
 the idea of Fabrice d'Aquapendente, and invented cutting spoons or 
 scoops. Mikschik invented a kind of ring ending in a sharp blade, to 
 be placed on the end of the index finger, allowing the pedicle of the 
 polypus to be cut as with the nail. Richerand used special scissors ; 
 Siebold and Mayer scissors with blunt points and bent in the form of 
 an S. Usually simpler instruments suffice : a long curved probe- 
 pointed bistoury, or long scissors with a more or less marked terminal 
 curvature or with excentric articulation, or the curved hook with con- 
 cealed blade- invented by Simpson under the name of polypotome.^ 
 The instrument is applied to the pedicle guided by the index finger of 
 one hand, and the tissue connecting the polypus with the uterus is 
 divided by repeated small incisions till the tumour is completely sepa- 
 rated. The operation is more difficult when the polypus is contained 
 within the uterus. Herbiniaux^, being unable to separate a polypus by 
 ligature, was the first to perform section of the pedicle in the uterus ; 
 but the tumour had passed the cervix and had descended into the 
 vagina. Dupuytren taught that the cervix should be divided by a 
 puncture from without inwards when there is question of excision of 
 a polypus contained within the uterus, and that even the vulva may 
 be incised when extraction cannot otherwise be made : he disapproved 
 of the previous use of dilators, which I on the contrary feel bound to 
 recommend associated with ergot : in such cases the rules should be 
 followed which I have laid down when describing the extraction of 
 submucous fibroids, their spontaneous enucleation and their pedicuiisa- 
 tion in the uterine cavity. 
 
 Adhesions of the tumour to the vagina or pseudo-pedicles* 
 
 ' Diseases of Women, p. 71. 
 
 ^ For figures of Simpson's polypotome and the various tenacuhim hooks 
 made by Aubry, Collin, Mathieu, &c., see Trousse gynecologique by Courty, 
 p. 37, and following. Paris, 1878. 
 
 ' Parallhle des differcnts instruments pour le traitement des polypes de la 
 matrice, p. 107. The Hague, 1771. 
 
 ■* Berard, Arch. c/dn. de med., t. ii, p. 88. 
 
686 UTERINE DISEASES IN DETAIL 
 
 may increase the difficulties of extraction and necessitate fresh 
 excisions which are not without danger. Another peril may arise 
 from inversion of the uterus, which we should beware of pro- 
 ducing by too strong traction, and the fatal consequences of which will 
 be avoided by following the rules laid down in the case of fibrous 
 bodies for distinguishing the tissue of the tumour from that of the 
 uterus and for avoiding section of the latter. Lastly, the excessive 
 size of the polypus may give rise to special indications. There may be 
 disproportion between its diameters and those of the vulva or even of 
 the outlet. In such cases there are only two courses to take : 1, to 
 make an incision in the vulva behind, towards the perinseum as 
 Dupuytren did, or two lateral incisions, as advised by Dubois in cer- 
 tain cases of dystocia; 2, to diminish the size of the tumour, which is 
 better ; this latter result is obtained by first incising the envelope of 
 the polypus and afterwards enucleating it ; or by separating a cunei- 
 form^ segment of it and bringing the two remaining halves together; 
 or by removing the tumour piecemeal, as one does the foetus in 
 embryotomy. 
 
 Subsequent treatment. — After extraction of the polypus, if there is 
 haemorrhage it may be arrested by injections, styptics and plugging. 
 The patient should be confined to bed in a posture of semi-fiexion, 
 pain being alleviated by the use of narcotics in various forms, and the 
 impoverished constitution restored by the use of tonics, bark, iron, good 
 wine and generous diet. 
 
 Eecovery is so speedy that it is usually difficult to prevent patients 
 from rising too soon : they should, however, be kept in bed for a week 
 or even a fortnight. 
 
 The origin of polypi shows that these tumours are liable to return. 
 Although recurrence is not common, it has been frequently observed,^ 
 therefore patients should be watched. When pregnancy and labour 
 are complicated by the presence of a polypus I recommend expectation 
 lest haemorrhage should follow excision. The reader may be referred 
 to the precepts already laid down for the treatment of fibrous tumours 
 in similar circumstances. 
 
 2. Uterine Moles 
 
 Moles, false germs, degenerated germs, are always degenerations of 
 one or other of the principal portions of the membranes of the ovum 
 which are destined to envelope the embryo and to serve for its protec- 
 tion and nutrition.^ They result from two causes : 1, from the death 
 of the germ or embryo, the body of which, being macerated and dis- 
 solved in the waters of the amnion, is absorbed, leaving no other trace 
 
 ^ Velpeau and Chassaignac, Bulletin de la Societe anatomique, 1833, p. 113. 
 The uterus was momentarily inverted, but was reduced spontaneously. 
 
 ^ Braxton Hicks mentions three cases of recurrence out of forty-two cases 
 {Chiy's Hospital Reports, 3rd series, vol. xiii, p. 128, 1868). 
 
 ^ Murat, Diet, des Sciences medicales, art. Mole, 1819. — Mme. Boivin, 
 Nouvelles recherches sur I'origine, la nature et le traitement de la mile vfsi- 
 cidaire. Paris, 1827. — Granville, Ilhistrations of Abortion, ISM. — Cruveilhier, 
 Anat. patliol., liv. i and xvi. 
 
POLYPI AND MOLES 687 
 
 than a fragment of the umbilical cord ; 2^ from the plastic_, nutritive 
 and hypertrophic tendency with which the appendages of the embryo 
 are endowed independently of the impulse conveyed to them by the 
 germ. The plastic tendency, ni8us formativus, being developed to the 
 highest degree, may persist even after the death of the embryo, even in 
 the transitory organs which constitute its apparatus for absorption 
 and nutrition. The energy and persistency of this tendency, diverted 
 from the young being that no longer exists, are transferred to its 
 appendages, which continue to preserve their normal intimacy of 
 connection with the uterus, and the faculty of absorbing and assimi- 
 lating nourishment, and which from that time turn to their own 
 profit the materials of nutrition intended for the embryo. Hence the 
 hypertrophic and progressive but at the same time irregular and terato- 
 logical evolution which the various embryonic envelopes undergo at 
 some point or another. When this evolution takes place in the pla- 
 centa or in the superimposed elements of the various membranes, sepa- 
 rated it may be by interstitial clots, it gives rise to a fleshy mole ; if it 
 goes on in the villi of the first chorion or allautois, with or without par- 
 ticipation in its vascular ramifications, the hydatidiform mole is pro- 
 duced (wrongly attributed to the production of hydatids). This origin 
 sufficiently justifies the names oi false germs, degenerated germs, by 
 which these moles have been designated. 
 
 1. The fleshy mole differs in appearance according to the time at which 
 it is expelled. It varies in size from that of an egg to that of a child's 
 head. When expelled shortly after the death of a very young embryo, it 
 preserves the form of an egg with or without the debris of the embryo in 
 its cavity ; this is the false germ^ of Boivin and Duges ; when expelled 
 long afterwards it has the appearance of a more or less hypertrophied 
 placenta. Should the amniotic fluid not have escaped before the expulsion 
 of the mole, the size of the tumour is larger, its tissue often gorged 
 with blood, its central cavity visible and filled with serum ; if this fluid 
 has escaped beforehand the tumour is harder, the cavity narrower, 
 sometimes filled with effused blood or with clots arranged in successive 
 layers, at other times containing fragments of the fcetus^ bones, hair or 
 some trace of the umbilical cord ; the surface of the mole may be en- 
 crusted with calcareous salts. These moles must not be confounded 
 with simple clots or fibrinous concretions formed in the uterine cavity. 
 
 2. The vesicular or hydatidiform mole is a kind of dropsy 
 of the villi of the chorion. The clusters are only ramifications of 
 chorial or placental villi, the subdivisions of which are dilated space by 
 space without the vesicles communicating with each other. This 
 increase of the vesicles and their distension with serum is due to the 
 fact that, after the death of the embryo, the chorion continues to 
 receive materials for nutrition from the uterine decidua in such propor- 
 tions that the size of the expelled mass may be very considerable. The 
 size of each vesicle varies from that of a millet seed to a pigeon^s ^^^g. 
 The entire mole often escapes surrounded by the thickened decidua. 
 
 ^ Op. cit., t. i, p. 276. — Courty, Mecanisme dc I'avortement. Montpellier, 
 1860, and Montpellier viedical, 1860. 
 
688 UTERINE DISEASES IN DETAIL 
 
 Diagnosis. — Moles often present symptoms of pregnancy. The 
 patient believes at first, and with reason, that she is pregnant. After 
 some time, whether the embryo dies owing to haemorrhage from the 
 chorion or placenta and sanguineous effusion between the membranes 
 of the ovum,^ or whether the membranes are torn as a consequence of 
 dropsy of the amnion, sanguineous efi'Qsion, or any other morbid con- 
 dition of the ovum, there may occur a discharge of amniotic fluid, 
 mucus, blood, or expulsion of the fragments of the ovum or embryo ; 
 or it may happen that the patient has not observed the escape of any 
 fragments coming from the product of conception or from the elements 
 contained in the uterus. However that may be, the symptoms of 
 pregnancy gradually disappear or, on the contrary, even when haemor- 
 rhage has occurred and the patient believes she has aborted, these 
 symptoms continue indefinitely without the size of the uteras and 
 abdomen increasing in proportion to the length of time which has 
 elapsed since conception. Therefore the duration of abdominal tume- 
 faction symptomatic of pregnancy beyond the ordinary term of gesta- 
 tion, the irregular form of the belly, the disproportion between the 
 size of the tumour and that which the abdomen ought to have at that 
 period of pregnancy, the absence of fcetal movements and cardiac 
 sounds combined with the appearance of the presumptive signs of 
 conception and pregnancy at the commencement of the malady : 
 such are the principal elements of a differential diagnosis be- 
 tween pregnancy and the presence of a mole in the uterus. 
 Amongst the most frequent symptoms which I have noticed are : 
 vomiting, great debility, leucorrhoea, foetid sero-purulent discharge, 
 oedema of the feet (seven times), great anaemia (five times), metror- 
 rhagia (forty-one times), and internal metrorrhagia followed by death 
 (once). In 9 cases the development of the uterus was not in propor- 
 tion with the period of pregnancy." After some time the symptoms of 
 pregnancy gradually disappear, being replaced by those characteristic 
 of uterine polypi. We must remember that in double pregnancies 
 one embryo may be replaced by a mole, or that a uterus containing a 
 mole may exceptionally become the seat of another conception or of a 
 kind of superfoetation. In these cases the expulsion of the foetus 
 almost always occurs before the end of pregnancy, the mole being 
 expelled either simultaneously or afterwards.^ Fourteen times the mole 
 has been found in the os at the moment of delivery ; in seven cases a 
 portion of the mole was discharged, four times shortly before delivery, 
 three times several v^eeks previously ; six times a foetus was present ; 
 twice there was double pregnancy ; once there was a placenta as well ; 
 four times there was multiple pregnancy. Lastly, the expulsion of 
 the mole may occur from the third to the fifth month, usually before 
 the end of pregnancy, but sometimes it occurs later. Madame Boivin* 
 
 ^ Courty, Mecanisme de I'avortement dans les premiers mots de la grossesse, 
 Montpellier viedicale, 1860, p. 215. 
 
 ^ Hayem, Revue des Sciences medicales, 1873, p. 734. 
 
 ^ Fabrice de Hilden, cent, ii, ohs. 52. — Duges and Boivin, op. cit., p. 279. 
 
 " Op. cit., p. 288. 
 
TUBEECLE 689 
 
 mentions a case of this kind in which the expalsion took place twelve 
 and a half months after conception ; while some moles have remained 
 in the uterus for several years. The weight of a mole may vary from 
 i lb. to 6 lbs. 
 
 Treatmerit consists almost exclusively in the extraction of the mole. 
 We should wait till uterine contraction or haemorrhage occurs. Some- 
 times nature herself effects the expulsion of the organic product and 
 there is a true dehvery of the mole. If, however, there is haemor- 
 rhage and other serious symptoms we may have to induce expulsion : 
 hemostatics, plugging^ dilatation of the cervix by sponge tents and 
 the administration of ergot excite uterine contractions and provoke 
 spontaneous expulsion. When this expulsion is not effected, or only 
 produced incompletely or too slowly, if the mole is adherent to the 
 uterine tissue it should be extracted without delay. The same instru- 
 ments are used for this purpose as in cases of soft polypi, the best 
 being Levret's ovum forceps. Care must be taken to remove the 
 whole : after extraction, the same care is necessary as after delivery : 
 rest, tonics, generous diet, iron (if there is impoverishment of blood), 
 ergot and hydropathy (if indicated by softening, defective involution, 
 the persistence of hypertrophy or chronic congestion of the uterus) ; 
 such is the treatment required. 
 
 Tubercle 
 
 Tubercular disease of the uterus and its appendages is probably the 
 rarest disorder of these organs, the least easy to diagnose and the most 
 difficult to cure. In fact the tubercular diathesis, which so frequently 
 manifests itself in the lungs and other organs, so seldom attacks the 
 female genital organs that cases of real tubercle confirmed by autopsy 
 may be counted. I have collected 4 cases of general tuberculisation 
 of the genital organs diagnosed during life and verified by autopsy : 
 1 of tubercular disease confined to the ovaries^ especially to the right 
 ovary, coinciding with pulmonary tubercle; 2 of utero-ovarian tuber- 
 culisation, also coinciding with pulmonary tubercle ; in one of these 
 latter patients tuberculo-purulent products had been expelled from 
 the uterus on several occasions during the latter months. 
 
 It is remarkable that these alterations are sometimes manifested 
 from childhood. Talamon {Amiales de Gijnecologie, t. ix, p. 416. 
 Paris, 1878) has mentioned a case of ovarian tuberculisation with 
 tubercular pelvic peritonitis and suppurative and encysted metritis 
 in a child of 6 years old. The ovaries as well as the uterus may be 
 attacked by tubercle ; only they are perhaps less frequently attacked 
 primarily : judging from the cases which I have collected, it is seldom 
 that they alone are attacked. The case is different with the Fallopian 
 tubes: they may be tubercular to the exclusion of other organs, and 
 although I cannot agree with Namias, Cristoforis and Ilokitansky, that 
 the malady always commences with them, I must admit it very fre- 
 quently does so. It may be the same with the uterus ; but it very 
 
 44 
 
690 UTEEINE DISEASES [N DETAIL 
 
 seldom happens that this organ is attacked by real tubercle without the 
 annexes and peritoneum being affected. Of all portions of the genital 
 economy the vagina is most seldom attacked. 
 
 In these various organs^ especially in the tubes and uterus, tubercle 
 may be met with in a state of crudity, softening or suppuration; even 
 caverns may be met with : in one patient there was such a loss of sub- 
 stance on a level with the recto-uterine and vesico-uterine culs- de-sac 
 that progressive degeneration might have caused perforation of the 
 bladder and rectum had life been prolonged. The mucous membrane 
 is sometimes softened, decomposed, even detached by suppuration in 
 more or less extensive patches, laying bare the already partially de- 
 stroyed fibres of muscular tissue. The genital organs are so seldom 
 affected by tubercle that in the immense majority of cases their tuber- 
 culosis coincides with pulmonary or general tuberculisation. Accord- 
 ing to the highest statistics, those of Namias, tubercle of the genital 
 organs is met with 12 times in 100 phthisical patients; in the records 
 of the Institute of Pathological Anatomy of Prague, published by Dit- 
 trich, we find 1 case of uterine tuberculisation in 40 autopsies on 
 tuberculous women ; Puech has only met with 3 cases in 150 autop- 
 sies; Cless of Stuttgart 1 in 70; and as for myself I have certainly 
 not met with more than 2 in 100. 
 
 Tuberculisation of the genital organs does not only coincide with 
 pulmonary phthisis, but is also met with in connection with osseous 
 lesions, tubercle in the bones, articulations^ and other organs. 
 
 In the numerous coincidences just mentioned tuberculisation of the 
 genital organs usually follows pulmonary phthisis, being the result of 
 the serious alteration of nutrition or cachexia, which often passes un- 
 noticed amidst the general disorder of all tlie functions. It may, 
 however, precede it. Tyler Smith has published a case of primary 
 tuberculosis of the uterus and ovaries followed by pulmonary phthisis 
 causing death. It may even exist alone and be discovered by autopsy 
 at a period in its development when the lungs are not as yet affected : 
 Siredey^ has published a remarkable case of isolated tubercle of the 
 Pallopian tubes and peritoneum ; Tomlinson^ one of tubercle of the 
 uterus, tubes and ovaries, with this peculiarity, that the uterus had 
 acquired a considerable size before the appearance of tubercle in any 
 other organ. In these cases in which, contrary to the law laid down 
 by Louis, the lungs are healthy or at least not attacked by the morbid 
 product, tubercle of the genital organs attracts the attention of the 
 physician to the phenomena manifested in the pelvis. 
 
 Diagnosis. — It is often ignored, sometimes suspected, seldom con- 
 firmed ; for there are no symptoms which allow of genital phthisis being 
 diagnosed with certainty.'^ It can never be ascertained with certainty 
 at one visit, as Brouardel has justly remarked; for of the three 
 
 1 Cruveilhier, Anat. path., iv, 674. — Crocq, Arch. gen. de mecl., 1860. 
 
 2 De la frequence des alterations des annexes de V uterus dans les affections 
 dites uterines. These de Paris, 1860. 
 
 3 Ohstet. Transact., 1864. 
 
 * Lebert [Archivfiir Gynekologie, iv, Heft 3, 1872). 
 
TUBERCLE 691 
 
 elements on which it may be based, the general condition, the local 
 state and the course of the disease, the latter is the most important. 
 
 Subjective sicjns. — The general symptoms are the most prominent, 
 the expression of the face, the phthisical habit of the body, symptoms 
 of tubercle in the lungs or other organs coinciding with the local phe- 
 nomena^ vague pains in the hypogastrium or loins, a disagreeable sen- 
 sation of fullness and weight in the pelvis and, when the uterus is 
 enlarged, frequent desire for micturition, constipation alternating with 
 diarrhoea, difficult micturition and defecation. From the beginning 
 menstruation is suppressed, especially when the ovaries are affected or 
 atrophied and there is amenorrhoea, as in the patients that I have seen. 
 Brouardel considers leucorrhcea to be the prelude to the disease : this 
 may be the case if the seat of the disease is in the uterus and especially 
 in its mucous membrane ; but usually the peritoneum is affected simul- 
 taneously with the genital organs, or at least is inflamed all round 
 them. Hence acute pain, nausea, vomiting, distension, fever, &c., due 
 to limited peritonitis recurring at intervals, to inflammatory exacerba- 
 tions and to attacks of acute inflammation which is grafted on to the 
 chronic phlegmasy. Lastly, when the malady progresses slowly, invad- 
 ing the whole of the genital economy, ascites is sometimes produced. 
 
 Objective signs. — Palpation shows increased size of the uterus or the 
 existence of a peri-uterine tumour, as well as the resistance indicative 
 of chronic peritonitis : the intestines are bound together by false 
 membranes and distended by gas. — Digital touch reveals a displace- 
 ment of the uterus ; this organ is carried out of the axis of the vagina, 
 especially behind, fixed and sometimes retroflexed. In the vagino- 
 uterine cids-de-sac we perceive inequahties, nodulations and bands of 
 adhesion, painful on pressure : small, rounded, hard, non-fluctuating 
 nodes are observed on depressing these culs-de-sac, especially the pos- 
 terior or lateral one, or by rectal touch. — The diagnosis is somewhat 
 facilitated by speculum examination, which discloses cervical erosions 
 and the existence of a leucorrhoeal discharge, which may be submitted 
 to microscopical examination. 
 
 Treatment. — The prognosis of this disease is very serious, though 
 less so than that of pulmonary phthisis : if phthisis is exceptionally 
 curable tuberculosis of the genital organs ought to be more so, as these 
 organs are not indispensable to life. The prognosis is probably also 
 less serious when tubercle is limited to the uterus and there is neither 
 peritonitis nor ascites : in this case we may hope to arrest the disease. — 
 We can, however, only treat the affection, having but little direct 
 influence on its local manifestation. Residence in a warm climate and 
 in the country, moderate exercise, generous diet, tonics, cod-liver oil, 
 preparations of iodine, sulphur waters and sea bathing should be recom- 
 mended. Attention should be paid to the chest, and the digestive func- 
 tions regulated and the strength supported. We must try to prevent 
 relapses by prescribing absolute rest for the genital economy. 
 
692 UTERINE DISEASES IN DETAIL 
 
 Cancer 
 
 Under the name of cancer I include every disease characterised 
 by the double tendency : 1, to destroy the tissue of the organ ; 2,, 
 to extend to the neighbouring organs more or less rapidly, whatever 
 may be the affections which assist in the development of this disease 
 or the anatomical forms which it assumes. The great number of 
 women attacked by uterine cancer shows the importance of studying 
 the commencement of this disease. Out of 87,348 persons who died 
 of cancer in England between the years 1847 and 1861, of whom 
 25,633 were men and 61,715 were women, there were about 3000 cases 
 of cancer of the uterus.^ In 1875, 3640 men and 7766 women died 
 of cancer in England.^ According to Tanchou^ the relative pro- 
 portions are 2996 cases of uterine cancer against 1147 cases of cancer 
 of the breast. Out of 8500 women observed by Mayer,* 332 were 
 affected with malignant tumours, 119 with cancer of the cervix, 146 
 with cancer of the uterus and vagina, 8 with cancer of the vagina, 10 
 with cancer of the vulva, 2 with ovarian cancer, 8 with mammary cancer 
 and 39 with cancer of organs not connected with the sexual economy. 
 
 Diagnosis. — This is especially difficult at the commencement. I 
 shall describe successively the signs of the first period, those of con- 
 firmed cancer and those of the subsequent cachexia. 
 
 I. Uterine cancel' at the commencement — subjective signs. — The 
 symptoms which may become presumptive signs are very equivocal at 
 the commencement of the malady. They ought to arouse the anxiety 
 of the physician who should attract the attention of his patients to 
 them. The local symptoms are pain, hsemorrhage and leucorrhoea.^ 
 
 1. Spontaneous pain and even induced pain is often absent. Pain 
 occasioned by walking is absent more frequently than that produced 
 by coitus, pressure and touch. This symptom, which becomes the 
 source of great suffering when the cancer is in full development, when 
 its ravages have destroyed a portion of the organ and especially when 
 it makes itself felt anatomically and physiologically by the neighbour- 
 ing organs, is on the contrary absent at the commencement of the 
 disease and even at a period when not only other symptoms have 
 attracted the attention of the patient, but when direct examination 
 proves to the physician that the most energetic treatinent is powerless 
 
 ^ Simpson, op. cit., p. 140. 
 2 West, op. cit., p. 367. 
 
 ^ Reclierches sur le traitement medical des twmeurs cancereuses dii sein, 
 p. 258. Paris, 1844. 
 
 " Monatsch., 1868, Bd. xxxii, S. 245. 
 
 * According to West, out of 166 cases the first local symptom was : 
 In 30, pains of diJEerent kinds, varying in intensity. 
 
 „ 77, haimorrhage usually profuse and without pain. 
 
 „ 23, lisemorrhage accompanied by pain. 
 
 „ 15, leucorrhoea, sometimes infectious, with pain. 
 
 ,, 21, leucorrhoea or other discharges without pain. 
 
CANCER (593 
 
 before sach extensive organic disease. I have seen women only suc- 
 cumb to uterine cancer several years^ sometimes seven or eight years, 
 after the probable period of its first development. I therefore regard 
 statistics on this point as mere approximations ; the average duration 
 of the life of a woman from the time she is attacked by cancer of the 
 womb is according to Lebert^ a little more than sixteen months and 
 according to West" a little more than seventeen months. On the other 
 hand there are cancers which run through their several stages much 
 more rapidly, e.g. in three and a half months; West, who gives them 
 the name of acute cancers, says that he has only observed these very 
 rare cases in young women shortly after delivery or miscarriage. I 
 have difficulty in accounting for the silence of writers as to the absence 
 of pain in the first period of the development of uterine cancer. Many 
 have been struck by the pains felt by patients at the time when they 
 were consulted ; few have inquired about the pains experienced before 
 this time. As for myself, I have observed that epithelioma is usually 
 indolent even at an advanced period, and indeed till its size, by caus- 
 ing an increase of weight and discomfort in the vagina, a difficulty in 
 marital intercourse, &c., produces a feeling first of discomfort and then 
 of pain j but as to these acute, darting pains, described as characteris- 
 tic of cancer, I have never known them appear till an advanced period 
 of the disease. I have often been consulted by women in whom I 
 discovered upon examination an incurable disease, death following 
 within three months, and yet the symptoms were so slight from the 
 absence of acute pain that attention had never been called to the 
 uterus. Some have been able to continue marital intercourse without 
 suffering and have become pregnant ; others have undergone great 
 fatigue without inconvenience. The majority have continued to sleep 
 the whole night without being awakened by pain. Even the most 
 characteristic forms of cancer, scirrhus and encephaloid may reach an 
 advanced period of their development without having produced pain, 
 at least those acute, darting pains described as characteristic of this 
 affection. I have seen a case of scirrhus which had destroyed the 
 posterior lip of the cervix and even a portion of the body of the womb, 
 reducing the patient almost to a state of marasmus, without pain 
 having ever assumed the acute character supposed to be characteristic 
 of cancer. Thus pain, far from being in proportion to the gravity of 
 the disease, is frequently the reverse, and indeed we may boldly lay 
 down as an axiom in such cases Nimium ne crede dolori. 
 
 2. Hcemorrliage is seldom absent at the commencement of this 
 terrible disease. Constant in internal and interstitial cancer it is even 
 usual in cancer of the cervix and in the most superficial cancroid 
 tumour of this organ. 
 
 At first the loss of blood usually assumes the simple form of 
 menorrhagia. This, however, is soon followed by metrorrhagia, occur- 
 ring at longer or shorter intervals in the intercalary period ; these 
 haemorrhages at last become almost continuous and are so abundant 
 
 ' Mill, cancer., p. 269. 
 - Op. cit., p. 3y<5. 
 
694 UTERINE DISEASES IN DETAIL 
 
 that they enfeeble the patient and produce anaemia. They are arrested 
 but recur again till at last they cease either spontaneously or under 
 the influence of the general and local hemostatics that have been 
 administered. 
 
 3. Leucorrhoea. — This symptom sometimes precedes hsemorrhagCj 
 frequently accompanies it, follows it, and may be considered a pre- 
 sumptive sign the value of which is greater than that of hsemorrhage 
 owing to the coexistence or succession of these two symptoms. The 
 leucorrhoea may be mucous when it expresses the reaction on the 
 uterine mucous membrane of cancer cells or cancerous infiltration into 
 the muscular tissue of the womb ; it is more frequently serous, result- 
 ing from the superficial exudations of a fluid on the internal surface 
 of the body or cervix, the papillary or epithelial element of which 
 begins to undergo a modification, soon giving rise to cancroidal vege- 
 tations which may be developed into cauliflower excrescences projecting 
 into the vagina. Serous in its origin before the appearance of 
 haemorrhage, it sometimes preserves this character in the interval 
 between these discharges of blood ; more frequently it becomes sero- 
 sanguinolent, sero-purulent, and at last ichorous. It differs entirely 
 from the glairy discharge of catarrh, the purulent discharge of inflam- 
 mation of the uterine mucous membrane, and from the muco-purulent 
 discharge which partakes of the characters of the two preceding in 
 its aspect and origin. It usually only becomes sero-purulent after the 
 hsemorrhagic period, and ichorous after confirmed disease has made 
 such progress that ulceration is imminent or even declared at some 
 points. Whether partly sanguinolent and partly purulent the loss 
 always assumes a very marked serous character ; it is abundant, stain- 
 ing the linen like reddish water in place of making a spot like milk, 
 starch or yellowish-green pus. This discharge, as described by 
 patients arouses the suspicion of the physician ; it is sometimes very 
 acrid, and cannot fail to be an important presumptive sign at the com- 
 mencement of the disease. Although it may not yet have acquired the 
 foetid odour which characterises it when ulceration and destruction of 
 the tissues have rendered it ichorous and mingled with it fragments of 
 normal or pathological tissue, yet the absence of this odour, which 
 afterwards becomes so characteristic, ought not to inspire the practi- 
 tioner with false security. 
 
 General symptoms are usually slight or altogether absent. Neither 
 digestion nor nutrition is disordered. These functions are only dis- 
 turbed when the disease, by its extension and ulceration, and by the 
 inflammation of the neighbouring tissues has reacted on the whole 
 economy, setting up fever, and revealing by undoubted local sym- 
 ptoms the existence of the organic lesion. Of all the general sym- 
 ptoms, the first to appear are usually sympathetic nervous disorders, 
 vague symptoms of vital uneasiness, hysterical symptoms, dragging at 
 the epigastrium and between the shoulders, &c., but it is very difficult 
 for patients to suspect the nature, gravity and even the seat of disease 
 from these symptoms. I do not think the age and history of the 
 patient are of much help to the practitioner. The climacteric has 
 
CANCER 695 
 
 been mentioned as a favorable age for the development of this malady. 
 My experience does not confirm this opinion. The most common 
 period for cancer as for most uterine maladies is that of sexual 
 activity, between the ages of thirty and fifty. I have, however, seen 
 it in young women of twenty and twenty-five, and in old women of 
 sixty and seventy. Nor must it be thought that married women alone 
 are subject to this disease, I have frequently seen virgins attacked by 
 it, but in the latter the development of cancer seems more frequently 
 to coincide with the approach of the menopause. As to heredity I 
 think its influence is undoubted notwithstanding the contrary opinion 
 expressed by Lebert.^ This circumstance should be taken into ac- 
 count not only in reference to the diagnosis but also in the prognosis 
 and treatment. I have seen a great many examples of heredity in 
 cancer of the uterus. Sometimes it can be traced to the mother, 
 grandmother, aunts or sisters of the patient, and sometimes to the 
 father or paternal side of the family. I attended a patient for cancer 
 of the cervix in whom the influence of heredity both as to nature and 
 locality was remarkably exemplified : two aunts had succumbed to 
 cancer of the cervix, and the father to cancer of the prostate. I am at 
 present attending a lady suffering from advanced uterine cancer, whose 
 mother died ten years ago of the same disease. I have another 
 patient who is almost in the same condition, whilst her daughter, aged 
 twenty-one, who was only married three months, having lost her 
 husband two years ago, has suffered since her marriage from metritis 
 accompanied by uterine granulations. 
 
 Objective signs. — These may enable us to form a certain diagnosis 
 from the very commencement of uterine cancer. The pain produced by 
 pressure, especially by the association of palpation with digital touch, 
 the increased size of the organ, its partial tumefaction on one surface 
 or point, the globular form of one or more tumours, the multiple and 
 submucous indurations of the cervix, or the development of hard 
 resisting excrescences which are at the same time friable and bleed- 
 ing : the dilatability of the cervix, the appearance of its nodosities, its 
 patches of violet colour with vascular venous injection round them, or 
 the appearance of characteristic excrescences of which I shall speak 
 immediately, are all symptoms which, when added to those of pain and 
 previous haemorrhage, of serous, or sero-sanguinolent discharges, dis- 
 ordered nutrition, puffiness of the face or emaciation, feverishness, &c., 
 soon become certain signs of the existence of cancer of the womb. 
 
 II. Confirmed uterine cancer. — When cancer is confirmed, or rather 
 when it has reached the period of ulceration, doubt is no longer possi- 
 ble. At this period the general symptoms are considerably aggra- 
 vated. They vary in different patients; but disorders of nutrition 
 always occur, emaciation follows, often accompanied by fever. When 
 a patient complains of pain, metrorrhagia, or serous leucorrhoea, we 
 may suspect the gravity of the malady by merely feeling the pulse : its 
 frequency, the dryness and heat of the skin, especially the palm of the 
 hand, are alarming presumptive symptoms. Pains, ichorous dis- 
 
 ' Op. cit,, p. 273, 
 
Q96 UTEEINE DISEASES IN DETAIL 
 
 charges, emaciation, debility, fever, the alteration of the features and 
 colour of the face leave no doubt as to the existence and nature of the 
 disease ; we have merely to ascertain the extent of it, and institute the 
 most appropriate treatment for arresting its progress and mitigating 
 its effects. 
 
 During this period, which may have a rapid evolution, although its 
 course is usually slow, the constitution of the patient is gradually 
 imj)aired by the establishment of the cancerous cachexia although 
 hsemorrhage has often ceased. There are, however, fungous cancers 
 or tumours which are developed rapidly and characterised by rich 
 venous circulation, great friability and a tendency to destruction : in 
 this case hsemorrhage continues to recur ; I have seen cases in which 
 it recurred to the very end, and so abundantly as to determine great 
 anaemia, hastening the end in such a marked way that death seemed 
 to be the immediate result of the loss of blood. With the exception 
 of these cases leucorrhoea is the only discharge which characterises the 
 advanced period of the disease. These discharges are reddish, sero- 
 sanguinolent, ichorous, fetid, and very abundant, and so characteris- 
 tic that they enable the experienced physician to form a probable if 
 not a certain diagnosis as soon as he enters the room or raises the dress 
 of the patient. The pain is not less characteristic ; in addition to the 
 feeling of weight and discomfort in the pelvis, aching in the groins 
 and thighs and the pain produced by pressure, there is dull constant 
 suffering aggravated at intervals, sometimes increased to an excruciat- 
 ing degree. The continuity, nature and acuteness of the pain depend 
 on several causes. 
 
 The nature of the tumour and especially its increasing size, its extension 
 to the sensitive organs whose functions it disturbs, the inflammatory 
 symptoms which it evokes in the neighbouring organs (the vagina, 
 bladder, rectum, and peritoneum), making the performance of their 
 functions difficult if not impossible, preventing all exercise and 
 change of posture owing to its extension as far as the neurilemma of 
 the nerves belonging to this region : these are the causes of those 
 exacerbations of pain which digital touch almost always produces with 
 significant intensity. The most serious local symptoms are then mani- 
 fested, in consequence of the invasion and destruction of the organs 
 contained in the pelvis. The inflamed bladder immovably fixed 
 by the invading cancer and compressed on a level with the cervix can 
 no longer expel the urine -^ the patient requires to be catheter- 
 ised, as spontaneous contractions of the viscus cause the most acute 
 pain. In the end a vesico-vaginal or vesico-uterine fistula is formed 
 by ulceration, so that patients after having experienced great diffi- 
 culty in passing their urine find it impossible to retain it. The same 
 phenomena take place in the rectum, the vagina becoming a cloaca 
 in which cancerous ichor and uterine discharges are mingled with 
 urine and fecal matters and are discharged by the vulva. Ulceration 
 
 ^ One of the ureters may be invaded, contracted, even obliterated, and after- 
 wards dilated above the contracted point, as well as the calices of the kidney, 
 the glandular substance of which atrophies. 
 
CANCER 697 
 
 of the uterine tissue may hasten the result when the body and especi- 
 ally the fundus of the uterus is attacked by cancer : I have seen a 
 
 Fia. 385. — Cancer of the cervix extending to fhe bladder, rectum and upper 
 portion of the vagina ; communication established by ulceration between 
 these three organs : u, uterus ; v. vagina ; r r, rectum ; b, bladder. 
 
 patient succumb to rapid peritonitis caused by perforation of the 
 fundus of the uterus ; another succumbed in a few days to pelvic 
 peritonitis consecutive to a similar ulceration of the posterior wall of 
 the organ. Digital touch enables us to ascertain the progress of the 
 disease, its seat, and the exact degree it has reached in its destructive 
 course. Sight confirms the information, but the use of the speculum 
 is often interdicted, owing to the pain caused by the introduction of 
 the instrument and the frequent impossibility of embracing the cervix 
 or even of discovering the orifice, on account of its position behind 
 and of the enormous tumefaction of its two lips, and also to the 
 facility with which the tissue may be lacerated and give rise to fresh 
 hsemorrhage. 
 
 Diversify/ of seat and form of uterine cancer. — It is at the period 
 when the malady is confirmed that we can distinguish the various 
 forms of cancer,^ at least from the symptomatic point of view. These 
 are the elements which sight, vaginal and rectal touch, combined with 
 palpation and the use of the sound, furnish for the differential diag- 
 nosis of the various forms of cancerous disease. 
 
 * Ernest Wagner, Zre&s der Gebarmutter. Leipsic, 1858. — Cornil, Des tumeurs 
 epitheliales du col uterin {Journal d'Anatoinie et de Physiologie de Robin, 
 1864). Scirrhus and encephaloid only differ in the density or rarefaction of the 
 solid elements proportionally to the abundance of the cancerous fluid (see Re- 
 cherches sur I'histologiedu cancer, inmy CUnique chirurg., p. 59. Montpellier, 
 1851). Cancroid, so nsimed. by hehevt [Physiologic pathologique. Paris, 1846), 
 better known by the name of epilhelioma, given to it by Hannover {Das Epi- 
 thelioma. Leipsic, 1852), and under which it has been described by Paget 
 {Lectures on Tamours, vol. il. London, 1852), is placed by Ilouel (Cruveilbier, 
 Anat. 'path, gen., t. v, p. 296. Paris, 1864) with fibro-i)lastic tumours in the 
 
698 UTERINE DISEASES IN DETAIL 
 
 A. Cancer of the Cervix 
 
 1. Epithelioma of the vaginal portion of the cervix. — The first 
 modification made in the normal form and structure of the cervix by 
 the development of epithelioma on its vaginal portion is the alteration 
 of its surface, which becomes irregular, being covered with numerous 
 elevations irregularly developed, situated like granulations round the 
 orifice or on one of the lips, always more on one lip than the other 
 although adjoining the orifice, having the appearance of papillary 
 hypertrophy, affecting the epithelial element much more than the 
 dermis of the papillse and presenting a striking analogy with epi- 
 thelioma developed on other parts of the body, especially at the natural 
 orifices, the vulva, anus, eyelids, and above all round the mouth, in 
 fact, with the usual form of buccal and particularly labial cancer. — 
 Frequently it is developed over the whole surface of the cervix, con- 
 tinuing regularly and forming a large excrescence in the form of a 
 cauliflower like an inverted mushroom, projecting in every direction 
 beyond the surface of the cervix itself, the orifice of which is often 
 found with difficulty. Frequently while produced in the same way it 
 invades the two lips unequally or is only manifested on one of them, 
 leaving the os uteri behind or in front according to whether the ex- 
 crescence is situated on the anterior lip, as occurs most frequently, or, 
 as is more rarely the case, on the posterior lip. At this period it is 
 important to distinguish epithelioma from other organic alterations of 
 the cervix, such as diphtheritic or fungous ulcers, granulations and 
 vegetations. This distinction is easy, for the principal characters of 
 epithehoma are : inequality of development of the elementary and 
 secondary groups, the latter being more voluminous and formed by 
 the association of epithelial cells, which the microscope reveals as 
 essential elements of their structure ; compactness of tissue, the rela- 
 tive fragility of which depends on this very compactness, hardness and 
 non-elasticity ; a tendency to bleed after the lacerations caused by 
 touch ; if the epithelioma is not vegetating, it offers a characteristic 
 aspect ; hard, nodulated, irregular, vascular and, on microscopical 
 examination, disclosing to view the epithelial cells ; there is a serous 
 or sero-sanguinolent secretion from the surface of the epithelioma, 
 or there is a purulent ichorous secretion from the ulcerated points of 
 
 class of pseudo-cancers. It is of little practical importance whether, after 
 Lebert and the French school, cancer is distinguished from cancroid by the 
 expressions heteromorphous and homceomorphous. the former being attributed to 
 the organisation of new elements in a diseased blastema, and the latter to 
 the morbid proliferation of normal epithelial cells ; or whether, after Virchow, 
 whose ideas have been adopted by the German and English schools, both of 
 these tumours are attributed to a morbid hyperplasia of normal cells deviated 
 from their type and urged into 'a course of pathological proliferation by the 
 unknown cause which presides over the development of cancerous affections. 
 
 The development of cancer in the uterus does not exclude that of fibroma 
 in the same organ, tubercle in the lungs if not in tlie womb, nor of syphilitic 
 chancre on the cancerous ulcer itself. Such cases have been known, and far 
 from neutralising each other these various affections seem to concur to hasten 
 death. 
 
CANCER 699 
 
 the tumour, it being seldom that some portion, some exuberance, is not 
 attacked by ulceration. 
 
 This form of cancer if not arrested by ablation is developed with 
 frightful rapidity. The tumour formed by these excrescences, the 
 various branches of which press against each other, presenting the 
 appearance of the vegetable from which they take their name, soon 
 exceeds the dimensions of an egg and sometimes acquires an enormous 
 size, even filling the cavity of the distended vagina, compressing the 
 neighbouring organs and mechanically hindering their functions, even 
 before it has invaded the upper portion of the uterus. As a rule, how- 
 ever, it gradually extends to other points; it may even assume this 
 mode of development altogether, only giving rise to slight excres- 
 cences, but spreading in every direction over a large surface all round 
 the central excrescence or starting-point. At first the vaginal portion 
 of the cervix is attacked and soon afterwards the vaginal mucous 
 membrane itself, behind, before, and on both sides ; the finger perceives 
 nodules of induration pressed one against the other round the cervix, 
 isolated a little further on, often disseminated at a great distance, pre- 
 ceding the excrescences which are soon developed on these centres ; 
 one would say that the cancer had spread its roots in these different 
 directions, or they are like suckers or seeds scattered profusely near the 
 centre of the disease and more sparsely further off. The tumour next 
 invades the uterine cavities, beginning with the cervix and ending 
 with the body. 
 
 Epithelioma of the cervical cavity is less easy to diagnose as its 
 situation conceals it from sight. The same circumstance hinders its 
 development as a vegetating excrescence, in consequence of which it 
 may extend more deeply, either towards the uterine cavity or in the 
 thickness of the muscular tissue before showing itself at the orifice. 
 It produces hsemorrhages and leucorrhoeal discharges, however, even 
 perhaps at an earlier date; and, as it tends to vegetate, it dilates the 
 cervical cavity, softens this organ and presents itself at the point which 
 offers the least resistance, i. e. the softened and dilated os, which soon 
 participates in the progress of the organic degeneration. 
 
 2. Parenchimatous cancer of the cervix, if it is allowable thus to 
 name cancer which is developed within the tissue proper of this organ, 
 especially in its muscular tissue, may also be diagnosed at an early 
 period and more easily than cancer of the body of the womb. It is cha- 
 racterised by increase of size and heat of the cervix, by its general in- 
 duration, irregularity and the sensation of hard, globular, often multiple 
 bodies on one of the lips observed in the thickness of the cervix at a 
 variable depth ; there is no resistance nor sensation of fluctuation, no 
 primary degeneration of the mucous membrane nor of its epidermis; 
 but there is a congestive condition, an unequal dark red coloration, red 
 on the projecting portions, violet on other parts, especially on the cir- 
 cumference of the globular projections, and capillary venous injection 
 round these deep tumours or nodulations which are sometimes very 
 painful on pressure (Fig. 121, p. 139). Cancer developed in the 
 tissue of the cervix may assume the form of scirrhus or encephaloid 
 
700 UTERINE DISEASES IN DETAIL 
 
 according to tlie density of its tissue^ the closer grouping of its ele- 
 ments, the predominance of fibres and fibro-plastic elements over the 
 cancer cells or the presence of a variable quantity of cancerous fluid ; 
 but as these forms when developed in the uterine tissue do not present 
 different characters from those which they offer when developed in 
 other tissues I shall not here give a comparative description of them, 
 but merely make two remarks on the subject. The first is that scirrhus 
 has seemed to me more common than encephaloid ; the second, that 
 when ulceration attacks these tumours and has a destructive tendency 
 it may cause as extensive destruction in scirrhus as in encephaloid. 
 I remember having seen a young lady in whom scirrhus of the cervix, 
 which was easily diagnosed by the tumefaction and hardness of the 
 anterior lip and of the rest of the uterus, and which was developed 
 originally in the cervix, had very soon extended to the whole body, 
 and when attacked by ulceration in a short time caused sach destruc- 
 tion that the whole posterior lip and almost the entire posterior seg- 
 ment of the uterus had disappeared, allowing the finger to penetrate 
 behind the cervix and the anterior segment of the organ into a vast 
 cavity full of ichor and cancerous detritus, at the end of which the 
 fundus of the womb could be felt. 
 
 B. Cancer of the Bodtf of the Uterus^ 
 
 1. There is no doubt that epithelioma may be developed in the 
 uterine cavity on the mucous membrane of the body as well as on that 
 of the cervix, and as on the vaginal portion of the latter assume 
 the vegetating form and propagate itself over the whole womb to the 
 neighbouring organs. Having ascertained the existence of the pre- 
 sumptive symptoms just described, direct examination by digital 
 touch, speculum and sound leads to a certain diaguosis. In the case 
 of cancer of the uterine cavity, as in that of polypi or any other pro- 
 duct developed in this natural cavity, contractility of the organ is 
 excited and is manifested by expulsive efforts, the effect of which is to 
 tumefy, soften, and dilate the cervix. If we take advantage of this 
 tendency, encouraging it by the introduction of dilators, not only may 
 the sound be introduced into the uterus but the finger itself, the deli- 
 cate sensibility of which discovers sufficient elements for forming a 
 certain diagnosis in the inequality of the cervix, the fragility of the 
 tissue, the form of the excrescences, and the presence of detritus apart 
 from the ichor, a certain quantity of which it brings away mingled 
 
 1 Although cancer of the body is undoubtedly less common than that of the 
 cervix, it is not very rare. I have seen some 20 cases, Seyfert has seen 5, 
 Kiwisch 2, Dittrich 2, Lebert 2, and Scanzoni 2. Out of 429 cases of uterine 
 cancer seen in the hospital at Vienna, there was only one case of primary 
 cancer of the body. Saxinger {Monatsch., xxiv, 71) has collected 2 cases, 
 Simpson 1 {Gaz. hebdom., 1854, p. 389), Ballard 1 (Provincial Medic. 
 Journal, May, 1851), Eecklinghausen 1 {Monatsch., xx, 169), I'orget {Gaz. 
 med., 1851, p. 640) has published 2 cases ; lastly La Gazette des liiipitaux, 
 1861, p. 208, has recorded 3 cases taken from Huguierand Demarquay's practice. 
 See also Pichot, Jititde clinique sur le cancer du corps ct de la cavite de 
 I'uterus. These de Paris, 1876. 
 
CANCER 701 
 
 with small fragments of epithelioma. This examination should be 
 made with great care, as cancer of the cervix does not always prevent 
 pregnancy. 1 
 
 But when recent haemorrhage and presumptive signs of cancer of 
 the body remove all idea of pregnancy, we may make such an exami- 
 nation in order to determine whether it is a case of cancer, uterine 
 catarrh, granulations, uterine fungosities, or polypi, because these 
 latter maladies are curable and require prompt and active therapeutical 
 treatment. We must, however, remember that if the malady is ad- 
 vanced perforation of the uterus weakened by ulceration is to be feared 
 {see p. 697). 
 
 3. Interstitial or parenchymatous cancer, developed in the thick- 
 ness, in the interstices of the tissue proper of the organ may, as has 
 been demonstrated by autopsy, be either scirrhus or encephaloid ; 
 may be developed in either of the two walls before extending to the 
 rest of the organ ; may, like fibroids, increase towards the external 
 surface of the uterus or towards its cavity, projecting in one direc- 
 tion or another ; and may, lastly, ulcerate at some point, especially 
 on the side which looks towards the uterine cavity. Apart, however, 
 from the general symptoms and from the tardy proof afforded by 
 products of ulceration, no symptom can be considered as certain nor 
 distinguish it positively from fibroids, tuberculous masses, or other 
 interstitial changes of the body of the w^omb. Besides, cancer may 
 exist in the uterus simultaneously with tubercle, pus, or fibroids. 
 Although, however, several practitioners have m"et with fibroids and 
 cancer in the same uterus, they have never seen fibroid bodies dege- 
 nerate into cancer.2 Only the differential diagnosis is more difificult 
 than the anatomo-pathological distinction. In such cases, therefore, 
 we must take into consideration the history of the patient, heredity, 
 general symptoms, and all the subjective signs which can increase 
 the mass of evidence, though it may not lead us to a certain diagnosis 
 until the disease has reached an advanced stage. 
 
 III. Cancerous cachexia. — Cancer invades the cervix from the body 
 and vice versa ; from these it extends to the vagina, bladder, rectum, 
 and the fibrous tissue interposed between these organs. The Fallo- 
 pian tubes and ovaries are affected less frequently, v\diilst on the con- 
 trary they participate more often in the extension of tubercular dis- 
 ease. The inguinal and pelvic ganglia are seldom enlarged in the 
 beginning but are attacked at a later period, especially the latter, as 
 well as the lumbar and mesenteric ganglia in cases of considerable 
 generalisation of these diathetic localisations. The lymphatic vessels, 
 even the thoracic duct, may like the ganglia be affected by the disease 
 
 ' It would soeui tliat pre<;'naticy arrests the course of cancer, except in the 
 cases in which it terminates prematurely b}' abortion. But it would also seem 
 that the course of tlie disease recommences more rapidly after delivery, hasten 
 int^ the death of patients. See West, op. cit. p. 409. London, 18(54. 
 
 ' Cruveilhier, A\wt. paih. grn., t. iii, p. ()!)8, and t. v, pp. 183, 288. Paris, 
 18(>4. 
 
702 UTEEINE DISEASES IN DETAIL 
 
 or contain cancerous fluid.^ Lastly^ the neighbouring veins are often 
 attacked^ either from the malady invading the tissue, or from the 
 transport of the cancerous fluid giving rise to malignant vegetations 
 on their internal membrane.^ The nerves themselves do not escape 
 from this propagation.^ 
 
 Cancer does not increase without damage to the surrounding tissues 
 and organs. The extension of the tumour and the ulcerative pro- 
 cess which manifests itself simultaneously determine the development 
 of inflammatory phenomena not only in the afiected organs but in 
 neighbouring tissues within a certain radius^ assuming different forms 
 according to the nature of the organs and tissues. Por example, in 
 parenchymatous and in fibrous tissue, inflammation produces indura- 
 tion ; at a later period it may cause softening and, though rarely, 
 abscesses, assisting the cancerous ulceration by acting in the same 
 direction and producing analogous results. On the surface of the 
 peritoneum, on the contrary, it produces albuminous, fibrinous and 
 purulent exudations which give rise almost always to adhesions 
 between the two contiguous surfaces of this serous membrane which 
 help to keep up displacement of the organs, to hold them fixed in 
 vicious positions and to increase pain ; thus the folds of the broad 
 ligaments adhere to each other, the Eallopian tubes or ovaries may 
 adhere to the uterus, rectum, and intestines, leaving between the adhe- 
 sions winding cavities filled with serum, the last retreat of chronic 
 inflammation of the peritoneal membrane. — Peri-uterine inflammation 
 is not the only cause' of the immobility and pain ; the invasion of the 
 organs contained in the pelvis gives rise to the formation of a can- 
 cerous mass in the period of cachexia which sometimes confuses 
 together the vagina, bladder and rectum, preventing the accomplish- 
 ment of their respective functions, or what is worse establishing a 
 communication between them so that the vagina becomes a kind of 
 cloaca common to all the excretions (Fig. 385). Happily for the 
 patient the cachexia gradually produces exhaustion and consumption ; 
 when a continued fever, increasing in the evening and assuming the 
 hectic form, soon produces the last stage of marasmus quickly 
 followed by death. 
 
 Treatment.' — There is no absolute cure for cancer as far as we know; 
 and the relative curability of uterine cancer appears to depend on the 
 nature of the malady, and on its position in the various parts of the 
 womb. 
 
 With regard to the nature of cancer epithelioma is evidently more 
 curable than scirrhus and encephaloid ; the vegetating form of epithe- 
 lioma seems to me also more curable than its corroding form, tuberous 
 cancer more so than ulcerous, and dry more so than moist cancer. 
 Epithelioma, whether of the uterus or lips, is usually less dependent 
 
 ^ Hourman, Memoire sur le cancer uterin (Bevue med. frang. et Strang., 
 1837). — And Lebert, Maladies cancereuses. 
 
 ' Cruveilhiev, Anat. path, du corps humain, t. ii, liv. 23, and Anat. path. 
 gen., t. v, pp. 226, 275. Paris, 1864 
 
 3 V. Supra, p. 696. 
 
CANCER 703 
 
 on a general affection than on an alteration of local vitality. There 
 are more examples of labial epithelioma successfully treated by opera- 
 tion without return than of scirrhus or encephaloid. It is the same 
 with epithelioma of the cervix ; I have seen so many examples of epi- 
 thelioma being operated on successfully and not followed by relapse 
 that I never despair of attempting complete ablation. Therefore it is 
 well worth while to discover the best methods of treatment and 
 operation. 
 
 With regard to the seat, cancer of the cervix is the only one which 
 admits of curative treatment. In the cervix itself scirrhus or ence- 
 phaloid, apart from being manifestations of a diathetic affection for 
 which we know no remedy, are usually developed too deeply to allow 
 of our exceeding the limits of the disease ; and operation in their case 
 is only practicable when they present themselves under certain favor- 
 able conditions. These conditions are the following : — The cancer 
 must occupy the vaginal portion of the cervix ; it must not extend to 
 the- vaginal insertions still less to the vagina itself, as often occurs j 
 the cervix above the organic alteration must be indolent, only slightly 
 tumefied, supple, soft, without suspicious indurations, in short, in a 
 normal condition. 
 
 I. Curative treatment. — We cannot count on any specific but must 
 limit ourselves to restoring the constitution by tonics and alteratives, 
 the value of which has been proved by experience. We should pre- 
 scribe a strengthening diet, milk, residence in the country, or at a 
 watering place appropriate to the temperament, hydropathy and, 
 according to the requirements of the case, the use of iron, preparations 
 of gold, arsenic and even of hemlock. Ablation, however, is the 
 only curative treatment effected either by the use of caustics or by 
 operation. 
 
 A. The destruction of cervical cancer by caustics is the most seduc- 
 tive means for an inexperienced practitioner. Unfortunately it is not 
 successful whilst its innocuity is only apparent. Caustics are useless 
 because they cannot reach even by repeated applications the whole 
 extent of the evil : caustics or solvents of cancerous elements such as 
 gastric juice (Sennebier of Geneva), acetic acid (Broadbent), tincture 
 of sesquichloride of iron (Kiwisch), the solution of nitrate of silver 
 (Thiersch, Hermann, Laurent, Kuhn, Nussbaum ^), perchloride of iron 
 (Gallard),^ only destroy a small portion of the tumour and may set up 
 fatal inflammation. 
 
 Caustics are hurtful not only because they may by spreading attack 
 other parts than those to which they are applied, but because their 
 action, though incomplete as a destructive, is energetic as an excitant 
 and frequently determines a proliferation the effects of which have 
 always seemed to me to increase the evil it was intended to lessen. I 
 neither except acids, nor acid nitrate of mercury, nor Canquoin's 
 caustic, nor the actual cautery. I would only sanction the use of the 
 
 Monatscli. fur Geburtsh., 1867, Bd. xxx, S. 230. — Bayerisches aerztliches 
 IntelUgenzbl, Heft 17, 23 April, 1867.— Gaz. liehdom., 1867, p. 333. 
 ^ Gaz. des hopitaux, July 6, 1867. 
 
704 UTEEINE DISEASES IN DETAIL 
 
 latter on a very superficial surface of epithelioma or on a very limited 
 corroding cancer which could be destroyed entirely by one application. 
 This is sometimes effected by applying a small circle of Canquoin's 
 caustic to the cervix and a cylinder of the same plaster in its cavity ; 
 I have for a long time adopted this method, which is somewhat similar 
 to that recommended by Maissoneuve under the name of cauterisation 
 enfieclie. We may also make an interstitial injection of a solution of 
 chloride of zinc (Guichard, Annales de Gynecologie, 1877). In what- 
 ever way the Canquoin is applied we should prevent the possibility of 
 its displacement and the consequent destruction of healthy parts by 
 retaining it in position by methodic plugging of the vagina with oiled 
 cotton wool and by keeping the patient in bed. It is left for a longer 
 or shorter period according to the depth of destruction required; and 
 it may be re-applied for several days, the plugging being continued to 
 prevent cauterisation of the vaginal mucous membrane by the detach- 
 ment of fragments from the scar of the cervix. It will be seen that 
 this application requires great care and cannot be made without danger 
 by an inexperienced practitioner. 
 
 B. Amputation of the cervix is the only means of completely removing 
 the disease. I have already laid down the indications and contra- 
 indications for and against amputation^ of the cervix. They may be 
 resumed as follows : amputation is contra-indicated when the cervix is 
 not the only point of localisation of the cancerous affection, even when 
 this diathetic affection has not reached the stage of cachexia ; when the 
 cancer, however local it appears, is deeply seated not only in the body 
 but also on the supra- vaginal portion of the cervix ; when, having 
 begun at the free extremity of the cervix, it is propagated even beyond 
 the level of the vaginal insertions of this organ ; when, the supra- 
 vaginal portion of the cervix remaining healthy, the vagina is invaded 
 by the cancer, even to a slight extent, except when under the form of 
 very superficial excrescences without deep roots, easily removed by 
 scissors without prejudice to a subsequent cauterisation, the conse- 
 quences of which cannot compromise the integrity of the bladder or 
 rectum. Amputation is indicated when the cancer is situated on the 
 free extremity of the cervix, whatever its size may be ; when no other 
 localisations exist either in the upper portion of this organ, or in the 
 body of the uterus, or in any other viscusj when the supra -vaginal 
 portion corresponding to the vaginal insertions, and especially that 
 part comprised between these insertions and the tumour, have pre- 
 served their normal size, suppleness and insensibility ; lastly, when the 
 organic alteration is not propagated in any direction on the vaginal 
 mucous membrane : under these circumstances amputation of the cervix 
 
 ' Amputation of the cervix was first performed in 1802 by Osiander, who 
 repeated it 23 times {Heilung des Mutterhrebses, dx., durch Schnitt., in Eeich- 
 anzeiger, 1803). — Langenbeck (De totius uteri extirpatione. Goettingen, 1842, 
 p. 26^. — Since then it has been often performed by Dupujtren {Journ. gen. de 
 vied., cix, 214), and by Lisfranc {Gaz. med. de Paris, 1S24, p. 387. Clinique 
 de la Pitie, iii, 645. JParis, 1843), Pauly {Maladies de I'tdenis. Paris, 1836), 
 Simpson {Edinb. Med. and Surg. Journ., 1841 ; Dublin Journal, 1846 ; 
 Medical Times, 1859), &c. 
 
CANCER 705 
 
 ou£jlit to be performed, this operation being the only means of saving 
 Hfe^ 
 
 I say under these circumstances, and I only speak of amputating the 
 intra- vaginal portion of the cervix ; i.e. I reject as useless or dangerous 
 amputation of the supra-vaginal portion of the cervix and^ still more 
 so, extirpation of the whole uterus in cases of cancer. Unfortunately 
 these operations were common enough at one period to afford materials 
 upon which to base a serious opinion as to their advisability.^ 
 
 1. When the cervix is amputated by linear ecrasement, chloroform 
 should first be administered. The patient should be in the lithotomy 
 position. An assistant on each side by passing a hand or arm under 
 the knee and seizing the instep with the other hand can hold the leg 
 flexed, separate the thighs, raise or depress the buttocks according as 
 the operator may require. If the uterus can be displaced easily 1 do 
 not see any contraindication to drawing it down gently to a level with 
 the vulva, which greatly facilitates the operation ; if not, a curved 
 ecraseur should be used, or better still a simple iron wire in place of a 
 chain which is passed round the pedicle of the tumour. To do this 
 the tumour must be seized as if it were to be drawn towards the 
 vulva. By fixing it in this manner we facilitate the application of the 
 chain. Museux's tenaculum hook forceps may be used for the 
 purpose or ani/ other form of polypus forceps (see p. 684) : the 
 tumour is seized at various points, a little behind if possible in 
 order to run less chance of lacerating it and to be more sure of apply- 
 ing the ecraseur beyond the limits of the disease. Robertas tenaculum 
 hook forceps although rather strong are sometimes better when we 
 wish to ensure their insertion into the deep portion of the cancer 
 towards the upper border of the tumour : their introduction is, besides, 
 very easy ; they are applied one after the other right and left of the 
 cervix and are then articulated like forceps ; they are separated more 
 easily than Museux^s forceps. Chassaignac's tenaculum hook with 
 diverging branches may also be used ; it is introduced closed into the 
 cervical cavity; the hooks are then made to diverge and by exercising 
 traction upon them the cervix is hooked from within and can be drawn 
 down more easily than by the claws of forceps. Here, however, a 
 difficulty presents itself. Whilst on the lower side we may be afraid 
 of not reaching the limits of the cancer, on the upper side, on the 
 contrary, there is reason to fear that a portion of the vagina may be 
 included in the chain with the cervix, especially if, owing to the 
 obliquity of the cervix, the greater development of the tumour on one 
 of the lips than on the other, the traction exercised on the cervix and 
 the movements imparted to it in order to facilitate the passage of the 
 
 ^ As to the advantages and di-awbacks of this operation consult Simpson, 
 op. cit., p. 169 ; West, op. cit., p. 415 ; Velpeau, Medecine operatoire, iv, 413. 
 Paris, 1839. 
 
 2 West, Diseases of Women, p. 412. — SeiTe, Pathologie et therajjeutique des 
 onaladies pour lesquelles on a prescrit diverses amputations de la viatrice; 
 examen critique de ces may ens, et description des diverses methodes de ees 
 amputations. Montpellier, 1834. — Langenbeck, op. cit. — Eobert, Z^es affections 
 granuleuses ulcereuses et carcinomateuses du col de I'uterus. Paris, 1848. 
 
 45 
 
706 
 
 UTERINE DISEASES IN DETAIL 
 
 chain, we fail to give it a direction perpendicular to the plane of 
 section passing through all the radii of the circle described by the 
 metallic ring of the ecraseur. This danger is not imaginary ; a real 
 difticulty is experienced in preventing the chain, tvhen it has been 
 adjusted on one side to the desired portion of the cervix, from 
 
 Fig. 386. — Chassaignac's diverg- Fig. 387. — Amputation of the cervix by 
 ing tenaculum hooks. linear ecrasement. 
 
 embracing on the other side a part of the vagina and with it a portion 
 of the bladder or rectum or at least of the utero-vagino-rectal ^ peri- 
 toneum. A ligature of thread should be first employed as Chas- 
 saignac recommends, as a preliminary in every operation for ecrase- 
 
 1 Scanzoni's Beitrclge, iii, 80. Wurzhurg, 1858. — Monatssch. filr Geburtsk., 
 March, 1858. 
 
CANCER 707 
 
 ment ; but it is not much easier to adjust this hgature in the exact 
 situation than to fix the chain. 
 
 With the object of preventing this accident I have invented an 
 instrument which is nothing but a pair of long disarticulating forceps, 
 the branches of which can be introduced successively and articulated 
 afterwards, their concave blades, which are bent at right angles, forming 
 when united a kind of ring which embraces the cervix above the diseased 
 part. It is easy then to grasp the organ and to make sure with the index 
 finger that it alone is seized by the instrument, or, if otherwise, to push 
 back the portion of the vagina which has been included, to bring the 
 axis of the cervix once more into a position perpendicular to the circular 
 surface of the projected section, to keep it there by tightening the 
 blades of the forceps, and to adjust with precision around the cervix, 
 immediately below the forceps, the metallic ligature or the chain of the 
 ecraseur, which may then be pushed back towards the blades as it is 
 tightened, so as to avoid the double danger of dividing the cervix too 
 high or too low.^ As soon as we are sure of the point of application 
 the operation proceeds by itself, its only drawback being its slowness; 
 every two or three minutes the chain is tightened by one notch, the 
 patient being kept under chloroform till the section is finished. 
 Sometimes I have performed the same operation with a metallic wire 
 and a good serre-nceiul, effecting constriction slowly by turning the 
 screw every quarter of an hour. I have done it in a day without 
 having recourse to chloroform, except at the commencement of the 
 operation which is always painful, and without causing the least hse- 
 morrhage. The operation may be extended over a still longer period 
 without harm if hot detersive injections are made from time to time, 
 as is done in cases of simple application of the ulcerative ligature. 
 Immediately after the fall of the tumour a hemostatic injection is 
 made, and care should be taken to ascertain by digital touch that no 
 suspicious tissue is left on the cervix, and a wooden speculum should be 
 introduced into the vagina in order to examine the wound. If any can- 
 cerous indurations are left, they may be excised with a long narrow 
 bistoury, perchloride of iron being afterwards applied to the womb 
 to stop hsemorrhage, or better still a mushroom-shaped cautery or a 
 jet of gas which has the advantage of destroying all traces of the 
 cancer, acting as a hemostatic as well as modifying the uterine tissues 
 and encouraging resolution of the chronic phlegmasia which has been 
 kept up to some depth by the long duration of the development of 
 the cancerous tumour. 
 
 2. When excision is performed we may dispense with chloroform on 
 account of the rapidity of the operation ; the patient should be in the 
 same position as for ecrasement; the cervix is seized by tenaculum 
 forceps and is either drawn down to the vulva or operated on in situ? 
 
 ' Simon of Darmstadt, Monatsch. fur Geburtsh., xiii, 418 and 434. 
 
 2 I do not enumerate the various metliods of excision of the cervix performed 
 by Osiander, Recamier, Dupuytren, Lisfranc and Simpson, or tliose invented by 
 Hatin {AmiJutation du col cle la matrice. Paris, 1827), Colombat {Hysterolo- 
 mie. Paris, 1828), Canella {Cenni suW esfArpazione clella bocca del collo dell' 
 utero. Milan, 1821) and Aronsohn {Zeitschriftfilr die gesammte Medicin,\, -I'Sd^. 
 
708 UTERINE DISEASES IN DETAIL 
 
 The first method is uudoubtedlj the best^ for by operating on the 
 uncovered tumour if there are any adhesions with the vagina we do 
 not run the risk of including them in the section. This danger is to 
 be feared when the cervix is left in place, but in such cases we may 
 apply the forceps with bent blades behind the line of projected section, 
 immediately in front of the vaginal insertions, or we may attack the 
 cervix from various directions, inclining it alternately in one direction 
 or another, always to the side opposite to that by which we wish to 
 attack it and protecting the corresponding portion of the vaginal wall 
 with dilators. When section is begun in this way all round, it is easy 
 by taking this first groove as a guide to finish ablation of the tumour. 
 If it is necessary to dissect the vaginal insertion at some point or to 
 pare the cervix into the shape of a funnel or hollow cone (which is a 
 good precaution to take when we suspect that the cancer is propagated 
 towards the cervical cavity) the bistoury is necessary ; it is better to 
 choose one with a long handle as being easier to manage, and with a 
 short blade which is easily inclined in various directions and which can 
 be carried all round the pedicle represented by the cervix. We may even 
 require a bistoury with a very long handle and a very short blade, 
 bent or concave like a small pruning hook when excision has to be 
 performed at the further extremity of the vagina. If we are sure of 
 removing all by one stroke, and without injuring any surrounding 
 organ, we may use very strong scissors slightly curved, when the 
 cervix is drawn down to the vulva. The same instrument with blunt 
 points, guided by the index finger, is very useful in commencing sec- 
 tion of the cervix at the further extremity of the vagina. It does not, 
 like the bistoury, present the risk of cutting the cervix at other points 
 than that to which it is applied. Whether the choice falls on a knife 
 or scissors section of the cervix should usually be begun at the poste- 
 rior lip and terminated at the anterior one, so as to begin with the 
 most difficult section and to avoid the blood issuing from the parts 
 already divided. 
 
 After complete separation of the cervix perchloride of iron or the 
 actual cautery should be appUed, the same precautions being used as 
 after ablation of the cervix by the linear ecraseur. 
 
 This operation is not so free from risk as might be supposed. Cruveil- 
 hier mentions the case of a young lady who died a few hours after- 
 wards, therefore it should only be performed when really indicated and 
 with all necessary precautions. Except in the rare cases in which it 
 has been followed by death the symptoms of reaction which it pro- 
 duces are usually moderate. In some patients there is perfect toler- 
 ance; but in the majority symptoms of metritis are manifested. The 
 loss of blood is not usually great ; it can be arrested when necessary 
 by perchloride of iron and plugging. Lumbar pain, however, due to 
 the dragging exercised on the uterus during the operation, lasts for 
 some hours and often for days. Pain is developed in the vagina and 
 hypogastrium and is aggravated by pressure, but is rarely of an alarm- 
 ing character, simple emollient cataplasms, sedative fomentations, 
 embrocations with camphorated oil sufficing to alleviate it. But 
 
CANCEE 709 
 
 however slight the symptoms of metritis or peritonitis appear^ no time 
 should be lost in treating them by the application of a number of 
 leeches, by frictions with mercurial and belladonna ointment made 
 every two hours, and afterwards by mild laxatives, emollient cataplasms, 
 and all the antiphlogistic and resolvent means applied to the treatment 
 of acute metritis. Patients should be confined to bed till these sym- 
 ptoms have disappeared. We should then await the fall of the scar 
 and pay attention to the cicatrisation of the wound. Even when 
 cicatrisation is neither slow nor irregular, if unhealthy looking granu- 
 lations appear on the surface of the wound we must not fear to destroy 
 them quickly and completely, by the actual cautery^ Vienna or arsenical 
 paste, which may be retained against the cervix with a pledget of 
 lint or cotton wool. I have found the latter method of great use in 
 such cases, as it induces speedy and healthy cicatrisation. I consider 
 it as a good supplement to the other caustics which effect mortification 
 or destruction of a certain depth of tissue, but the scar of which does 
 not always present the subjacent formation of a true cicatrix after its 
 fall. Arsenical paste applied at this time has usually seemed to me to 
 possess the property of producing real cicatrisation of the wound in place 
 of fresh destruction. In order to profit by the advantages offered by the 
 elastic ligature and Paquelin's thermo-cautery, I have modified the 
 operation in the following way. Let us take the case of a voluminous 
 tumour of vegetating epithelioma. And here I may remark that the 
 analogy of aspect to which the English have drawn attention between 
 the vegetating epithelioma of the cervix and the cauliflower (cauli- 
 flower excrescence) is more real than one would suppose on a super- 
 ficial examination. I have always remarked in these cancerous or 
 cancroidal cauliflower excrescences two distinct portions : 1, an exu- 
 berant friable part, formed of voluminous epithelial elements appended 
 to vascular arborisations which support thein like grapes in a cluster; 
 these parts form lobules and lobes the removal of which is often easy, 
 not being even accompanied by serious haemorrhage : therefore they 
 can always be removed more or less readily. Sometimes it is necessary 
 to have recourse to a ligature and then they fall very easily. When I 
 use the ligature it is to remove more of the tumour, or else because 
 the tissue of it is different; 2, a dense resistant portion, also sub- 
 divided into tapering parts which correspond with the principal and 
 even secondary lobes which they sustain and of which they form the 
 trunk and principal branches. This trunk, formed of much smaller 
 and denser epithehal elements than the preceding, of conical, oval, 
 tapering cells and of longer or shorter fibrillse and fibres, is hard and 
 resistant although sometimes very vascular and penetrating more or 
 less into the tissue from which it has arisen (the border of the lip, its 
 external or internal surface) and in which it is inserted by a more or 
 less broad base. It is this portion (the root of the vegetating pro- 
 duct) which must be destroyed as deeply as possible, at first with 
 instruments or the cautery, afterwards with caustics (arsenical paste) 
 so as to avoid fresh vegetation of the epithelioma. In order to use all 
 the precautions which prudence suggests, supposing the cauliflower 
 
■10 
 
 UTERINE DISEASES IN DETAIL 
 
 tumour is very large, I try to constrict the pedicle behind the vegeta- 
 tion by an elastic ligature. This produces ulceration of the trunk, or 
 at least the vegetations fall rapidly, leaving bare the trunk from which 
 they rose, which is of denser tissue. 
 
 It is this portion that must be completely removed if we would 
 avoid a recurrence of the disease. In order to succeed with as little 
 pain and hsemorrhage as possible we should amputate the whole cervix 
 (if it is the whole cervix which forms the base of the tumour) by 
 means of the galvano-caustic wire, or else excise the root of the disease 
 
 Fig. 388. — Excision of a cancerous tumour of the anterior lip of the cervix 
 by the actual cautery, s, a boxwood speculum, depressing the posterior 
 vaginal wall ; p, tenaculum forceps seizing the tumour ; c, cautery excising 
 the tumour, hollowing out the tissue of the anterior lip in order to reach 
 the extremity of its root. 
 
 (usually inserted in one of the lips) with curved sharp cauteries or 
 with the curved knife of the thermo-cautery (Collin has made a 
 thermo-cautery knife for me which has a curve fitting it for this little 
 operation). The vagina is protected by means of univalve boxwood 
 specula. The tumour is then seized by tenaculum forceps and 
 inclined in various directions, so that its root may be separated from 
 the healthy tissue as deeply as appears necessary by means of a cautery 
 in the form of a straight or curved knife. The third part of the 
 operation consists in directing the cicatrisation of the ulcer which 
 follows excision of the root of the cauliflower, and to attain this end 
 
CANCER 711 
 
 no preparations seem to me so good as those of arsenic. Fowler's solu- 
 tion or Eriar Gome's powder : these should be employed with great 
 care, for if too much is used at once poisoning may be produced.^ 
 
 Is surgical intervention impossible for epithelioma of the uterine 
 cavities? Whilst admitting that it is far less effectual than in the pre- 
 ceding case, I do not think it should be neglected. When epithelioma is 
 developed on the mucous membrane of the fundus, surgical intervention 
 ought to be confined to dilatation of the cervix with sponge tents, 
 scraping with the curette and the application of solid or liquid caustic 
 to the abraded surfaces. When epithelioma is developed on the 
 mucous membrane of the cavity of the cervix, especially when it 
 assumes the form of cauliflower excrescence, we may hope to destroy it 
 even if forced to incise one of the lips of the uterus, especially the one 
 that is healthy and distended by the development of the diseased 
 segment. 
 
 II. Palliative treatment. — I. General palliative treatment consists 
 in giving tone to the organism and in subduing nervous symptoms, 
 especially pain. — The physician ought to initiate an intelligent, ener- 
 getic and continuous struggle between the lesion which attacks and the 
 organism which defends itself. The best means for restoring the con- 
 stitution and so enabling it to resist the progress of cancer as much as 
 possible are : residence in the country, generous diet with plenty of 
 milk and the use of the medicaments which I have indicated as suit- 
 able to the treatment of tne accompanying dyspepsia : bitters, bark 
 and iron. — The nervous symptoms and paroxysms of pain should be 
 treated by antispasmodics or narcotics : preparations of hemlock, hen- 
 bane, belladonna, Indian hemp, opium and the difi'erent salts of morphia 
 alone or combined with ether and administered by the mouth, 
 or subcutaneously ; sedative embrocations with the oil of henbane 
 or belladonna either alone or mixed with chloroform ; laudanum 
 in small rectal injections given with a long cannula ; linseed poultices 
 made with the infusion of poppy-heads ; sitz-baths and even general 
 baths containing decoctions of poppy-heads, henbane or hemlock 
 leaves ; suppositories containing gr. \ of the extract of belladonna and 
 an equal portion of the extract of opium, which the patient may intro- 
 duce into the rectum every 24 hours or oftener. Vaginal pessaries of 
 iodoform (15 grains made with cacao butter"), &c. The poultices, 
 sitz-baths or general baths ought to be hot or tepid. 
 
 2. Local palliative treatment consists in the use of resolvents, 
 hemostatics and disinfectants. The resolvents are : mercurial and 
 belladonna ointment or an ointment composed of equal parts of the 
 iodide of lead and potassium applied by friction to the hypogastrium 
 and groins. Resolvents may also be applied to the cervix in the form 
 of plasters of hemlock and tampons saturated with strong solu- 
 tion of chlorate of potassium (said by Bergeron to be effectual in epi- 
 
 ^ Traitement palliatif du cancer de I'uterus. Communication made to the 
 Association for the Promotion of Science in France, 27 August, 1877. Gaz. 
 hebdomadaire de inedecine et de chirurcjie, Sept., 1877. 
 
 2 Greenhalgh, Eastlake {Obstet. Soc. of London, 1866 ; British Med. Journ., 
 1866) ; Demarquay {Bulletin de Thcrapeutique, 1867) ; G. Woiker (id., ibid.). 
 
712 DTEEINE DISEASES IN DETAIL 
 
 thelioma of the lips). These local applications prepare the tissues for 
 the direct and energetic action of other medicaments; the latter espe- 
 cially seems to soften the pathological tissue and facilitate its subse- 
 quent destruction, — Hemostatics are useful in preventing patients 
 from being weakened by hemorrhage. The tincture of cinnamon, 
 ergot and the various hemostatic vraters may be given internally, or 
 12 gr. of tannic or gallic acid may be given every 4 hours, or rhatany, 
 catechuj or 5 to 20 drops of perchloride of iron twice a day in a little 
 water, followed by a cup of milk. — As for the local application of 
 hemostatics, injections should be made with vinegar and cold water 
 or with perchloride of iron (5iss to the quart of water) or with 
 infusion of matico or oak-bark; or perchloride of iron may be applied 
 undiluted after having washed the ulcer well with injections of cold 
 water, taking care to remove all that remains of the perchloride with a 
 little cotton wool.^ Indirect means of hemostasis should also be em- 
 ployed, such as semi-flexion in a horizontal posture, very hot injections 
 morning and evening, absolute rest during menstruation, moderate 
 exercise in the intercalary period, the interruption of marital inter- 
 course, milk diet, &c. 
 
 The daily use of disinfectants is indispensable. In addition to 
 baths vaginal injections should be prescribed morning and evening, 
 in order to expel the ichor of the cancerous surfaces as well as 
 the decomposed debris. — Sedative injections have very little effect 
 owing to the very slight absorbing power of the vagina ; this defect, 
 however, is compensated for by the facility of applying narcotics 
 to the rectum, and the same remark applies to medicated pessa- 
 ries. The only injections that are of any use are those that are 
 disinfectant and detersive; they should be made with very hot water, 
 to which is added a spoonful of the solution of permanganate of 
 iron or potassium (1 per cent.) or carbolic acid. Some patients find 
 aromatic injections useful. After the injection the diseased surface 
 may be touched with one of the following medicaments : creasote^ 
 chromic, boracic or carbolic acid, perchloride of iron, solution of 
 tannin, concentrated solution of nitrate of silver (10 per cent.) or 
 Fowler's solution. They have the effect of preventing the exudation 
 of blood, of coagulating lymph and albumen and contracting the tissues ; 
 in fact of tanning the surface of the tumour to a considerable extent, 
 as they can be applied with a brush to the interstices and infractuosities 
 of the cancerous excrescence ; the result is a superficial desiccation of 
 the tumour or ulcer, and sometimes the course of the organic altera- 
 tion is arrested. I have found these local applications of great use 
 associated with other local and general means ; they make the cancer 
 tolerable till the period of cachexia arrives ; in fact this treatment may 
 prolong life when the cancer has not a very progressive tendency and 
 when the corroding ulcer is not very extensive. 
 
 I will end this chapter by a few words on the course to be pursued 
 during gestation or labour. If we have reason to hope that the life of 
 
 ^ Sims's speculum should be used, the patient being in the elbow and knee 
 position, which is the most convenient for dressings in cancerous diseases. 
 
CANCER 713 
 
 the patient may be prolonged^ whilst the disease is such as to render 
 delivery dangerous, we may produce abortion or premature delivery ; 
 if not we should wait. If labour has commenced we should wait till 
 expulsive eflbrts have become ineffectual ; if after a certain time no 
 part of the orifice nor inferior segment is sufficiently dilated to allow 
 of the passage of the child, deep incisions into the cervix and cervical 
 canal are indicated, and in desperate cases Csesarean section may be 
 necessitated (West, op, cit., p. 410). 
 
CHAPTEE V 
 
 DISEASES OF THE UTEEIJfE APPEXDAGES — PELVIC H^MOEEHAG-ES AND PEEI- 
 FTEEEN-E HEMATOCELE — CYST OF THE OYAET XSD GEXITO-PELTIC TTJIIOUE 
 — STEEILITT 
 
 The number of diseases which remain to be described is reduced to 
 three : 1^ pelvic lisemorrhages and hematocele which is often the 
 consequence of them ; 2, tumours of the ovaries and tubes, especi- 
 ally ovarian cysts, in the description of which I have included not 
 only ovariotomy but hysterectomy ; 3, sterility, the incurable causes 
 of which must not be confounded with those residing in the vagina 
 or uterus, which are more accessible to investigation and less difficult 
 to treat. 
 
 Pelvic Hjemoerhages and Peri-uterine Hematocele 
 1. Pelvic Kamorrliages 
 
 Heemorrhages which occur in the cavity of the pelvis' may arise 
 from different sources ; for the cavity contains, besides very vascular 
 organs, important arterial and venous vessels. 
 
 We shall confine our study to those which^ having their starting- 
 point in the uterine system in the state of vacuity, are capable of 
 forming a tumour and of being produced under the three following 
 conditions : absence of pregnancy, starting-point in the uterine 
 system, sufficient quantity. With regard to the theories which have 
 been expressed as to the origin of the extravasated blood, I shall make 
 the following remarks : 
 
 1. The theory of Nelaton and Laugier (menstrual haemorrhage of 
 the Graafian follicle and morbid vesicular hsemorrhage^), has no founda- 
 tion from a physiological point of view, since a Graafian vesicle 
 may be ruptured without any discharge of blood, and morbid vesi- 
 cular haemorrhage gives rise to passive effusions which are easily 
 absorbed on the spot.^ 
 
 ^ The exaggerated natural haemorrliage of the Graafian vesicle may occur at 
 the moment of dehiscence (Xelaton), or at repeated dehiscences (Laugier), or 
 from the passive exudation which precedes or accompanies the formation in the 
 vesicle of the coijms luteum. Morbid or pathological hjemorrhage of the 
 ovary is produced either in the vesicle or in the parenchyma (in the latter case 
 it is called apoplectic, from its analogy with the haemorrhage which causes 
 apoplexy). 
 
 ^ Eobert, Gaz. med. de Paris, 1857, p. 1. — Puech, De I'hematocele peri- 
 uterine. Paris, 1861, p. 9. 
 
PELVIC HillMOREHAGES AND PEEI-UTERINE HEMATOCELE 715 
 
 3. The theory developed by Gallard^^ who considers hematocele 
 an extra-uterine dehiscence, an extra-uterine pregnancy without the 
 product of conception, has by no means been proved. Where is 
 the proof that the ovule determines hsemorrhage on falling into the 
 serous membrane ? As to hsemorrhage due to extra-uterine preg- 
 nancy, it is possible though rare, the principal fact in such a case being 
 the extra-uterine pregnancy itself, that is, Huguier's pseudo-hema- 
 tocele. 
 
 3. Other writers, including Beau and Tardieu, think there is a 
 sanguineous exudation from the serous membrane of the pelvis ; 
 Perber^ has adopted this hypothesis, urging that some autopsies 
 have revealed hypersemia and capillary vessels of new formation, and 
 that it is nothing less than hsemorrhagic pelvic peritonitis (Yirchow). 
 
 4. We have still another hypothesis to examine, that put forth by 
 Bernutz in 1848 and again in 1860 ; he admits that the lumen of the 
 cervico- uterine canal may be closed by an obstacle depending on the 
 contractility of the uterus and that the blood may accumulate in 
 the cavity of the body, after having dilated which it enters the 
 Fallopian tubes and passes into the peritoneum. There is no doubt 
 that the blood may follow this course when there is any obstacle, 
 whether congenital or acquired, in the vulvo-uterine canal ; but it 
 has not been proved that it may occur when there is none. If, on 
 the one hand, the narrowness of the ostia uterina, their slight per- 
 meability and the relatively large size of the cervico-uterine canal, are 
 anatomical arguments which should not be forgotten, on the other 
 hand we have no right to avail ourselves in the argument of what 
 occurs in cases of atresia of the genital canal, that is to say in the 
 conditions most favorable to the reflex tlieory, as Aran calls it ; Puech^ 
 has proved that the fact is excessively rare; it only occurred 16 
 times out of 310 cases, and it never occurred suddenly ; excruciating 
 suffering was endured by the patients for several years before the 
 blood invaded the peritoneal cavity .''^ Therefore pelvic haemorrhages 
 can only have their source in the Fallopian tube, ovary, utero-ovarian 
 plexus, and in hsemorrhagiparous pachy-peritonitis. 
 
 I. Hcemorrhage from the Fallopian tube. — Indicated by Tilt in 
 1850 and by Eenerly in 1855, tubal hsemorrhage has only taken its 
 place in science with the works of Puech. A sufficient number of 
 cases are recorded to prove that the Pallopian tube is far from pos- 
 sessing immunity in this respect ; but in all these cases we may recog- 
 nise as a preliminary condition sanguineous congestion of the tube, 
 and although we know that the exanthemata, such as measles, small- 
 pox, and scarlet fever, encourage hasmorrhages, as in the cases seen 
 by Laboulbene,^ Helie,^ Scarizoni'' and Puech, we are incHned to 
 
 ^ Gaz. hebclom., 1858, p. 481, Archives de Medecine, 1860. 
 
 '^ ArcMv. der Heilkunde, 1862, 8th year, part 5. 
 
 ^ Des atresies des voies genitales. Paris, 1863, p. 61. 
 
 ■* See p. 279, chapter on Retention of the Menses. 
 
 * Gaz. ined. de Paris, 1853, p. 78. 
 
 " Journal de viedecine de la Loire-lnferieure, 1858, p. 80. 
 
 ' Op. cit., p. 363. 
 
716 UTERINE DISEASES IN DETAIL 
 
 admit that there is always acute fluxion or congestion. At other 
 timeSj on the contrary, we find in the previous history symptoms of 
 chronic sanguineous congestion, Bernutz's first case being a typical 
 example.^ 
 
 Whatever be the cause which has produced it, the hsemorrhage 
 may make its way either by the ostia uterina, by the abdominal opening, 
 or by rupture of the organ. The discharges of blood from these 
 different points are sometimes simultaneous and sometimes isolated ; 
 if they escape notice when the fluid is discharged by the first exit, it 
 is otherwise when the blood escapes by the latter channels. The 
 patient suffers pain in the lumbo-sacral region, and has colics suc- 
 ceeded by syncope and a feeling of weakness. Sometimes these with 
 paleness of the face are the only symptoms, at other times, when the 
 liEemorrhage endangers life, the pains are more violent, and there is 
 vomiting, hiccough, buzzing in the ears, abdominal distension and 
 cold sweats, soon followed by death. When on the contrary the 
 hsemorrhage is not great enough to cause this result, as seen by Follin,^ 
 Oulmont,^ Seuvre,* and otherSj a peri-uterine sanguineous tumour is 
 formed. 
 
 II. Ovarian hemorrhage . — These haemorrhages are frequently 
 described.^ Here also a marked alteration of the ovaries exists pre* 
 vious to any hsemorrhage ; apart from a case mentioned by Neuman, 
 of Berlin,^ in which hydatids were found, acute inflammation and 
 chronic congestion are the lesions which have been more specially 
 noticed. In acute inflammation the size of the organ is increased, the 
 colour is violet, and on section the blood gushes out, the cut surface 
 showing considerable hypersemia. In this state the tissues can neither 
 resist nor be distended ; they are easily ruptured, as remarked by 
 Denonvilliers''' and Demarquay.^ Chronic congestion is, I believe, the 
 most active cause of these hsemorrhages. The ovary is increased in 
 size, its outline is normal, but the stroma is hypersemiated, presenting 
 slight effusions of blood. As a rule this state is only manifested 
 externally by excessive menstruation ; at other times there is a sen- 
 sation of weight and burning heat in the pelvis, draggings in the 
 kidneys and groins, and colics, which are sometimes very acute, 
 before menstruation. Menstruation, besides being too abundant, is 
 prolonged more and more, leaving each time a marked aggravation of 
 the congestive phenomena. In this state accidents are imminent, and 
 menstruation is sometimes sufficient to produce hsemorrhage; but it 
 does not follow that there is a relation of cause and effect between 
 
 1 Nouveau Diction, de fried, et de chirurg. pratiques, article Hematocele 
 TTTEEijsTE, t. xvii, p. 310, fig. 29. In this figure a clot is seen emerging from 
 the Fallopian tube. 
 
 ^ Gaz. des hopitaux, 1855, p. 403. 
 
 ^ Union medicale, 1858, p. 530. 
 
 * Progres medical, 1874, pp. 815, 224. 
 
 ° Nouveau Diction, de med. et de chirurgie pratiques, article Hematocele 
 
 UTERINE. 
 
 * Bibliotheque medicals de Roy er - Collar d, t. Ixsviii, p. 113. 
 7 Gaz. med., 1856, p. 76. 
 
 * Gaz. des hopita^tx, 1862, p. 21. 
 
PELVIC HiEMOREHAGES AND PERI-UTEEINE HEMATOCELE 717 
 
 the peri-uterine hematocele which may be developed afterwards and 
 menstruation ; disorders of this function are only the index of the 
 concomitant state of the uterine system. At other times the sym- 
 ptoms are those of acute sanguineous congestion, apoplectic haemor- 
 rhage occurring in the. midst of apparently perfect health ; only in 
 such cases fluxion is more active and the afflux of blood more con- 
 siderable. 
 
 Whether the ovary is healthy or otherwise the haemorrhage may be 
 intra-ovarian only, or both intra and extra-ovarian ; whilst in the 
 interesting case published by Puech intra-ovarian hsemorrhage was 
 followed, four months afterwards, by fresh congestion, which on this 
 occasion ruptured the membrane, causing death by peritonitis. If 
 symptoms of intra-ovarian hsemorrhage often escape notice, or 
 at least are misinterpreted, it is very different when hsemorrhage 
 occurs in the pelvis ; in such cases we either see the signs of inter- 
 nal hsemorrhage which soon ends fatally, or the physical signs which 
 characterise sanguineous tumours of the pelvis, 
 
 III. Kamonhage from the utero-ovarian plexus. — Although analogy 
 would seem to indicate the possibility of rupture of the utero-ovarian 
 plexus, this source of hsemorrhage has been slow in taking the place 
 to which it is entitled. In vain two cases of it were published in 
 1853 and 1854, even in 1857 it was in vain that Eichet brought 
 forward a new argument in support of the fact,^ attention was directed 
 elsewhere, and it was only in 1858, in the works of Puech ^ and 
 Devalz,^ that these venous lesions obtained the rank that they deserve 
 as causes of pelvic hsemorrhage. This rupture may be followed by 
 extravasation of blood under the peritoneum, and between the folds of 
 the broad ligament (Raciborski), by a simple intra-pelvic thrombus or 
 by a more considerable hsemorrhage and a more or less abundant san- 
 guineous effusion into the pelvis. It affects the pampiniform plexus 
 whether varicose or not. Doubtless the nodosities presented at inter- 
 vals by the varicose veins and the attenuation of their walls favour 
 this accident ; but unfortunately these conditions are not indispensable 
 for its production : severe exercise, or external violence, sexual excite- 
 ment, or great menstrual fluxion, or the concurrence of these two last 
 circumstances may cause the malady. The hsemorrhage which occurs 
 is more or less violent ; in twelve cases it caused death rapidly;''' in 
 others, amongst which Saexinger^s case may be included,^ it was fol- 
 lowed by the formation of a peri-uterine hematocele.^ 
 
 IV. Hemorrhages from hamorrhagijmro^is pachy -peritonitis. — Bes- 
 nier has tried to furnish additional proofs of this theory in a long 
 
 * Anat. 7ned.-chirurg., 1857, p. 735. 
 ^ Op. cit., pp. 80— lUO. 
 
 ^ Du varicocele ovarien. Paris, 1858. 
 
 * In tlie case recorded by Maschka death was caused by the rupture of a 
 varicose vein attached to the fundus of the uterus {Wiener Medicinische Wo- 
 chenschrift, 1800, No. 102). 
 
 =- Monatschriftfilr Geburtslc, 1864, Bd.xxiii, S. 476. 
 
 ' Of the four sources of hematocele, this and the following may coincide 
 with regularity of the menstrual function. 
 
718 UTERINE DISEASES IN DETAIL 
 
 paper published in 1877 in the Annales cle Gynecologie, the conclu- 
 sions of which are : 
 
 " 1. Amongst intra-peritoneal hematoceles there is one which com- 
 mences with primary or secondary pelvic peritonitis^ either menstrual 
 or inter-menstrual, which is benignant or moderate on its appearance, 
 and increases progressively or by jBts. In this form of hematocele, 
 which is very different from those which commence suddenly and 
 violently and end fatally, the tumour, which is but a pathognomonic 
 sign of the affection, is only verified at a late ^^eriod relatively to the 
 commencement of the symptoms, and as a rule the termination is 
 favorable. 2. The cases included in this group cannot be regarded as 
 hematoceles connected with dehiscence or extra-uterine pregnancy, nor 
 with an ovarian lesion, nor with a sanguineous reflux by the tubes, 
 nor with rupture of the tubo-ovarian veins, &c. ; they ought to be 
 considered as hematoceles due to pelvic neo- membranes. Taken as a 
 whole these maladies are therefore cases of peritonitis which have 
 become hsemorrhagic accidentally or secondarily, otherwise called 
 hemorrhagic pachy -peritonitis. 3, Trom a clinical point of view, these 
 cases being the most numerous of all, as we may say they are the only 
 hematoceles which end in cure, it follows that ordinary intra-peritoneal 
 hematocele terminating favorably is, in most if not in all cases, a 
 hsemorrhagic pachy -peritonitis, either menstrual or inter -menstrual, 
 usually the former, that is to say, having commenced at a menstrual 
 period.^' 
 
 I do not deny the possibility of hsemorrhagiparous pachy-peritonitis. 
 I admit this new source of hematocele by analogy with neo-membranes 
 developed on other serous membranes (meningeal, vaginal, synovial, 
 &c.) and giving rise to loss of blood ; but I am far from regarding it 
 as the most frequent, as this would imply in all cases the existence of 
 previous peritonitis, slowness of the sanguineous efi'usion and a 
 number of other circumstances totally opposed to most of the sym- 
 ptoms on which we found the diagnosis of hematocele. Besnier's 
 case moreover does not seem absolutely decisive ; no autopsy, abortion 
 preceding the hematocele, rapidity in the invasion of the attack and 
 in the symptomatic manifestation, in short, nothing justifying the 
 asserted slowness of invasion and symptomatic obscurity of the com- 
 mencement. My own conclusion is that, of the various sources of 
 sanguineous effusion which can account for the formation of peri- 
 uterine hematocele, four only may be considered as proved by autopsy. 
 These are, in order of frequency : apoplectic haemorrhage from the 
 ovaries, hsemorrhagic pachy-peritonitis, rupture of one of the vessels 
 composing the utero-ovarian plexus and tubal haemorrhage. These 
 hgemorrhages terminate either fatally, or by absorption of the extrava- 
 sated blood, or by the formation of a sanguineous tumour (hematocele, 
 hematoma). In the latter case the hEemorrhage is the cause, tiie 
 hematocele the effect ; but the effect becomes in its turn a malady, 
 having its symptoms, its course, its termination, its indications. 
 
PELVIC H^MOREHAGES AND PERI-UTERINE HEMATOCELE 719 
 
 2. Peri-TJterine Hematocele 
 
 Hematocele'^ is an encysted tumour developed round the uterus and 
 formed of blood proceeding from the lesion of one or two of the 
 appendages, or from a cyst of extra-uterine pregnancy, from a rupture 
 of the utero-ovarian plexus, or from the peritoneum itself, more 
 frequently from a chronic inflammation of this serous membrane with 
 thickening and vascular hypertrophy. 
 
 The various sources of hsemorrhage explain the seat of the effusion, 
 and the frequency of this seat in any particular spot is the consequence 
 of the frequency of the hemorrhage at that point. Therefore whether 
 the hgemorrhage come from the ovary, from the Fallopian tube, from 
 
 Fig. 389. — Typical retro-uterine hematocele (intra-peritoneal) caused by rupture 
 of a diseased ovary, a, hematocele ; u, uterus pushed forward ; R, rectum 
 compressed behind (St. Thomas's Museum, Barnes). 
 
 an extra-uterine pregnancy or from pachy-peritonitis, the sanguineous 
 effusion must take place into the peritoneal cavity (which is the most 
 common case), preferably behind the uterus, where the serous mem- 
 brane is most developed ; the ovaries are also to be found there and the 
 Fallopian tubes always directed backwards and never forwards (on this 
 account hematocele is more frequently retro-uterine than peri-uterine). 
 This rule is so general that ante-uterine hematocele is considered as 
 being only secondary, formed only as a consequence of the peri-uterine 
 or retro-uterine hematocele which has preceded it, the continuation of 
 which has become impossible owing to adhesions and fibrous bands 
 
 ^ Poncet of Itjons, De Vheniatochle peri-uterine. These d'agr^gation. Paris, 
 1878. 
 
720 
 
 UTEEINE DISEASES IN DETAIL 
 
 uniting the uterus to the rectum and sacrum so as to prevent the con- 
 tinuation of any sanguineous effusion into Douglas's space. Such is 
 the case published by Schroeder in Wiener Medicin. Wochenschrift, 
 1873 ; and in ArcUvfur Gyn., 1873. 
 
 If the hsemorrhage come from the tubo-ovarian plexus the hemato- 
 cele may be limited to a thrombus of the broad ligament or be in- 
 sinuated under the peritoneum covering the uterus, in the peri-uterine 
 cellular tissue^ not only behind and in the broad ligament of the other 
 side, but also in front under the peritoneal fold which covers the an- 
 terior wall of the uterus and bladder. These sanguineous effusions 
 
 \'i ■ 
 
 /*i^ Hi/7 
 
 Fig. 390. — Lateral and ante-uterine iematocele (intra-peritoneal), due to 
 utero-rectal adhesions in Douglas's space, where the hematocele, which at 
 first was retro-uterine, was first produced, aaaa, solid blood and adhe- 
 sions ; h b, fluid blood ; d, extra-uterine tubal pregnancy, cause of the 
 hematocele ; from Schrceder {Archiv.fur Gyn., Bd. v, S. 357. Berlin, 1873). 
 
 into the broad ligament and peri-uterine connective tissue have been 
 well nsimed peri-titerine hematomata by Kuhn (These de Zurich, 1874), 
 a name which distinguishes this sanguineous tumour from hematocele 
 which is in the peritoneum and from hematometria which is in the 
 uterus, a name very preferable to that of extra-peritoneal or vaginal 
 hematocele, by which it was formerly designated. The blood is gra- 
 dually absorbed and the most frequent termination is in cure. The 
 prognosis, however, is more unfavorable than in the case of hemato- 
 cele, for this reason, that the opening of the tumour into the peri- 
 toneum is very dangerous, usually causing death. I copy a figure 
 (from Emmet) of a very rare case of such a hematocele or hematoma 
 formed in the right broad ligament and in front of the bladder, which 
 caused death by its rupture into the peritoneum (Fig. 392). 
 
 Whatever be the source of the hsemorrhage and wherever the blood 
 may be effused it is not long before it undergoes certain modifications 
 
PELVIC H^MOEEHAGBS AND PERI-UTERINE HEMATOCELE 721 
 
 producing around it an interesting pathological process. The blood, 
 which at first is liquid^ soon coagulates into more or less voluminous 
 resistant clots, the presence of which irritates the serous membrane 
 with which it is usually in contact; false membranes are produced; 
 some which are filamentous pass above the sanguineous mass, others 
 resembling bands of cellular tissue divide the collection by forming 
 partitions through it. At other times there are no fibrous adhesions 
 but a kind of membranous covering, which, spreading like a sheet, 
 seems to form a continuation of the peritoneum and has frequently 
 been taken for it. In other cases this is absent and the intestinal 
 loops, united and glued together, constitute the upper wall of the 
 cyst. When the adhesions are detached we penetrate into a winding 
 sac sometimes containing from 7 to 77 ounces of a wine-coloured 
 viscous fluid holding dark clots in suspension, or when the malady is 
 of longer standing a yellowish or more or less discoloured fibrinous 
 mass. The bladder, rectum and upper extremity of the vagina are 
 compressed ; when there has been suppuration and evacuation of pus 
 the walls of the rectum or vagina are perforated, either simultaneously 
 or singly. The uterus, dragged down by adhesions and inclined to the 
 right or left, has in some cases effected rotation on its axis, in others it is 
 
 Fig. 391. — Sub-peritoneal latevo and retro-uterine liematoma or hematocele 
 (extra-peritoneal) formed in the broad lig-ament. The posterior vaginal 
 wall was still more pushed forward (after Emmet). 
 
 inclined forwards or backwards without being fixed in its position. As 
 it usually shares in the congestion of which the annexes are the seat, 
 it is more frequently increased in size ; its walls may be softened and in- 
 filtrated with blood, the cavity containing either mucous or sanguineous 
 clots. The annexes are more or less changed : if there are cases in which 
 we can discover the source of the haemorrhage, there are others in which 
 
 46 
 
722 
 
 UTERINE DISEASES IN DETAIL 
 
 we can only guess at it. Thus the ovaries, or at least one of them, may 
 be reduced to a shell; at other times they are hypertrophied and hollowed 
 out into a cavity communicating with the principal centre. In other 
 cases or even simultaneously the tubes have their fimbriated extremity 
 and canal partly obliterated ; or else they are diseased, contaiaing de- 
 composed blood or presenting a dilatation which constitutes a part of 
 the centre of the tumour. 
 
 Besides these lesions we find others dependent on the general- 
 ised peritonitis or on purulent infection. In the former case the 
 abdominal viscera bear the more or less marked impress of in- 
 flammation. The intestines are shortened sometimes to half their 
 length, whilst some circumvolutions are drawn together and united 
 by false membranes. Sometimes the abdominal cavity is dis- 
 tended by a yellowish serum or by a milky fluid mixed with albumi- 
 nous flakes ; sometimes there is hardly any effusion, but the roughened 
 serous membrane presents patches of a blackish hue ; lastly, if the cyst 
 has been perforated and the contents have escaped we may find a portion 
 of this fluid pour*?d out into the peritoneal cavity. As to purulent 
 infection it leaves behind it well-known lesions on which it is needless 
 here to dwell. 
 
 Fig. 392. — Sub-peritoneal ante-uterine hematoma or hematocele (very rare) 
 opened by laceration or ulceration into the peritoneum, where the blood 
 has been effused and has formed an intra-peritoneal peri- uterine hematocele 
 which was the cause of death (after Emmet). 
 
 Diagnosis — subjective signs. — Peri-uterine hematocele being a hae- 
 morrhage followed by peritonitis we should find in its first stage the 
 characteristic symptoms of internal hcemorrhage : they exist in fact ; 
 but as they are obscure they generally escape observation. The period 
 which follows and of which the features are borrowed from peritonitis, 
 
PELVIC HiEMOREHAGES AND PERI-UTEEINE HEMATOCELE 723 
 
 is more marked, although it does not offer any very striking symptoms : 
 hence the possibility of committing errors of diagnosis. Pain is the 
 first phenomenon which shows itself : it is constant, but it varies greatly 
 in intensity. It is sometimes manifested under the form of intestinal 
 colics, sometimes under that of expulsive pains. It is often remittent, 
 but is aggravated by the least pressure or by the slightest movement. 
 Disorders of the digestive economy are intimately connected with these 
 pains : when the latter are intense there is nausea and vomiting ;i if 
 they are moderate there is frequently want of appetite. Thirst is 
 generally great, the abdomen is more or less distended, and there is 
 usually obstinate constipation, anal and sometimes also vesical tenesmus, 
 and even retention of urine. When the tumour compresses the crural 
 and sciatic nerves radiating pains and numbness are observed in the 
 lower limbs. OEdema has also been seen in addition to the preceding 
 symptoms, affecting either the side corresponding to the largest portion 
 of the pelvic tumour or the opposite one ; in the former case it would 
 be due to impeded venous circulation, in the second to phlebitis of the 
 corresponding veins. 
 
 Fig. 393. — Peri-uterine hematocele spreading uniformly round the uterus, which 
 has hardly undergone any displacement. Owen's case, University College 
 Hospital, 1866. Front view (after Graily Hewitt). 
 
 Objective signs. — The seat of pain and the distension of the belly 
 attract the attention of the physician to the hypogastric region and 
 enable him to verify the existence of a peri-uterine tumour. Sometimes it 
 is diagnosed immediately on account of the projection and the size which 
 it presents ; at other times it is only discovered after careful palpation. 
 Two tumours are then found in the pelvic cavity : the anterior one is the 
 uterus, the other, posterior and more or less lateral, is the morbid tumour, 
 the hematocele. The size of the latter varies from that of an apple to 
 a child's head. It is usually confined to the pelvis, but may rise above 
 the brim towards the umbilicus ; I do not think, however, that it ever 
 rises beyond the navel : observers who have mentioned such cases have 
 
 ' There may even be symptoms of internal strangulation as Hergott has 
 remarked ; they seem caused by an anomaly of the sigmoid flexure {Mem. Soc. 
 met. Strasbourg, 1872, p. 149). 
 
724 
 
 UTERINE DISEASES IN DETAIL 
 
 forgotten to take into account the inflammatory zone, which has led 
 them into error. As to the consistency of the tumour, it may be 
 
 Fig. 394. — Intra-peritoneal peri-uterine hematocele, seen in profile, spread 
 uniformly round and above the uterus, which has not been displaced at all 
 (after Emmet). 
 
 fluid and fluctuating; but unless it suppurates it becomes solid, hard 
 and immobile. Diagnosed in the abdomen by hypogastric palpation, 
 in the pelvis the tumour is defined by vaginal touch ; it is found behind 
 and at the sides of the uterus ; in three cases it extended in front of 
 this organ ; in a case published by Chassaignaci it was situated entirely 
 between the bladder and uterus. Usually it pushes down the posterior 
 cul-de-sac, contracting the vagina. Eectal examination reveals the 
 compression which it exercises on the intestine, making it difficult for 
 the finger to penetrate the canal. The uterus is pushed forwards and 
 upwards against the pubis, the neck under the pubic arch, sometimes 
 in the median line, sometimes a little to the right or left : it is fixed 
 in this position. Left to itself the tumour at first remains stationary ; 
 but sometimes it presents alternations of tension and relaxation which 
 depend chiefly on the increase or diminution of the inflammatory phe- 
 nomena. This increase lasts for some days ; then the tumour 
 diminishes in size and gradually enters the pelvic cavity, where it 
 remains finally concealed. Erom being soft and puffy at the com- 
 mencement the hematocele becomes as hard as wood ; it contracts 
 from the circumference to the centre more or less rapidly according 
 to the case. Occasionally numerous inflammatory accidents are de- 
 veloped, sometimes in the neighbouring peritoneum, sometimes in the 
 
 1 Traite de la suppuration, t. ii, p. 463. 
 
PELVIC HAEMORRHAGES AND PERI-UTERINE HEMATOCELE 725 
 
 cumour itself; febrile symptoms aud slight shivering; in the evening 
 indicating that suppuration is going on in the cyst. The clots of 
 
 Fig. 395. — Intra-peritoneal retro-uterine hematocele H, which has pushed the 
 uterus upwards, v rr u' u", and forwards (after Barnes). 
 
 blood become softened and disintegrated and assume a black and after- 
 wards a greyish hue ; pus is formed and tends to be evacuated ; once pro- 
 
 Fia. 396. — Intra-peritoneal retro-ntcrine hematocele, extending to the base of 
 the pelvic cavity from Douglas's pouch, pushing the uterus u upwards 
 and forwards, flattening the cervix against the pubis, and compressing the 
 bladder v', seen in profile (after Barnes). 
 
 duced, this fluid either pierces the cyst on the side of the serous mem^ 
 
726 
 
 UTEEINE DISEASES IN DETAIL 
 
 brane and sets up peritonitis which soon ends fatally ; or else making 
 its way towards the cellular tissue it succeeds in emptying itself more 
 or less completely either by the vagina or by the rectum. 
 
 Although evacuation of the contents of the tumour into the perito- 
 neum always ends fatally it is quite otherwise with the other two modes 
 of exit. They are both favorable, although less so than resolution of 
 the tumour : they are usually attended by diminution in the size of the 
 tumour and by marked alleviation ; they are accompanied by a dis- 
 charge somewhat like treacle or sepia ink, which may cease in two days, 
 but which usually persists from ten days to a fortnight. The escape 
 of blood and pus by the vagina has almost always been followed by 
 1 When the tumour, on the contrary, opens into the rectum the 
 
 cure. 
 
 little wound may remain fistulous, and the intestinal gases may pene- 
 trate into the interior of the mass, causing hectic fever and a kind of 
 putrid infection. To sum up, out of 52 cases in which the tumour 
 was left to itself absorption occurred 26 times, evacuation of the con- 
 tents into the peritoneum 6 times, by the rectum 13 times and by the 
 
 vagina 7 times 
 
 Differential diagnosis. — The diagnosis of peri-uterine hematocele is 
 easy from the beginning : the rapid appearance of the tumour, the 
 concomitant symptoms, of which the most marked are those of peri- 
 tonitis, the displacement of the pelvic organs, the cervix being squeezed 
 under the pubis and the uterus pushed forwards, the flattening 
 of the rectum and the consistency of the tumour are all data upon 
 
 Fig. 397.— Pelvic peritonitis and pelvic abscess, seen in profile, recognised 
 tlirougli the vagina (after Graily Hewitt). 
 
 which to form a certain diagnosis. It is not, however, always so : 
 
 time may have modified the symptoms, rendering them less marked, so 
 
 1 Ott {Dissert, de Tubingen, 1864) tas seen a case of death from septicaemia 
 
 under these conditions. 
 
PELVIC HililMOEEHAGES AND PEEI-UTEEINE HEMATOCELE 727 
 
 that the ablest physicians have sometimes been deceived and have 
 mistaken hematocele for perimetritis^ extra-uterine pregnancy, a cyst 
 or some other tumour of the ovary or tube, a fibroid tumour, retro- 
 flexion, &c. Peri-uterine inflammation is one of the diseases as to 
 which we may be easily mistaken : but apart from the symptoms common 
 to the two diseases there are radical differences : at the beginning the 
 low temperature (37'5°) distinguishes hematocele horn pelvic cellulitis 
 (38-1°) and from parenchymatous metritis (39"5°);^ pelvic abscess is 
 almost always connected with delivery or abortion, whilst hematocele 
 is very rarely the result of these, being rather connected with men- 
 
 FiG. 398. — Circumscribed and encysted pelvic cellulitis. Outline of the pelvic 
 abscess (phlegmon of the broad ligament) to the right of the uterus. 
 Case in University College Hospital, seen in profile (after Graily Hewitt). 
 
 strual disorders ; the former is developed slowly, the latter suddenly, 
 reaching its maximum of development in a few hours ; when digital 
 touch is practised the one gives the sensation of a kind of hard puffi- 
 ness which is never fluctuating or is only so towards the end, the other 
 is only fluctuating at the commencement, and becomes hard as the 
 effusion is absorbed ; in fact the abscess seems to make one mass with 
 the uterus, never producing displacements analogous to those caused 
 by sanguineous effusion, which is distinct from the womb, the latter 
 being pushed more or less out of place ; it never acquires so large a 
 size, and is comparatively long in being cured. 
 
 In adhesive suppurative pelvic peritonitis \)iit distinction is still more 
 difficult. Pelvic peritonitis often extends all round the uterus, the 
 annexes and pelvis, like peri-uterine hematocele ; but usually it does 
 not descend so low and often rises higher, above the brim ; like hema- 
 tocele, it fixes the uterus, but as it extends more equally round this 
 
 ' Ai-melli, Movimento 7ned. chirurg. de Naples (Annales de Gynecologie, 
 ix, 159). 
 
728 
 
 UTEEINE DISEASES IN DETAIL 
 
 organ it displaces it less frequently and less considerably. When the 
 malady is of long standing and its development has not been followed, 
 the diflBculties of diagnosis are still greater, and can only be overcome 
 by analysing the antecedent history carefully. Extra-uterine preg- 
 nancy is developed slowly and often without any appreciable functional 
 reaction, whilst usually hematocele begins suddenly, reaching its 
 maximum of development all at once. But the diagnosis is difficult 
 when rupture of the fcetal cyst has caused hsemorrhage and produced 
 a tumour analogous to hematocele : in such a case as a rule the 
 
 Fig. 399. — Extra-uterine pregnancy, mistaken at first for retroflexion of a 
 gravid uterus, diagnosed only by means of the sound. Cervix directed 
 downwards and backwards, the reverse of retroversion and flexion. 
 Puncture of the cyst, vaginal and rectal opening. Expulsion of small 
 bones, contraction of the cyst. Cure {Annalesde Gynecologie, after Barnes). 
 
 diagnosis is posthumous, unless spontaneous opening of the tumour 
 and expulsion of foetal fragments put the practitioner on the right 
 track. 
 
 Retroversion and retroflexion of the uterus, especially in the third 
 month of pregnancy, may be mistaken for hematocele, as mentioned by 
 Jourel,^ Penerly^ and Mikschik.^ Puech has recently seen a case 
 which had been mistaken first for imminent miscarriage and afterwards 
 for retroversion of the uterus ; the escape by the vagina of a brownish 
 fluid proved that he had been right in diagnosing peri-uterine hema- 
 
 * Bulletin de la Faculte de medecine de Paris, 1812, No. 8. 
 2 Op. cit., p. 40. 
 
 ' De lapathol. des ovaires. Leipsic, 1856, in Canstat's JahresbericM, 1856, 
 p. 425. 
 
PELVIC H^MOREHAGES AND PERI-UTERIXE HEMATOCELE 729 
 
 tocele. Stoltzi has published a case in which he made the mistake of 
 diagnosing an extra-uterine /(5roir/ tumour. In other cases it has been 
 
 Tig. 400.— Eetro-flexion o£ the gravid uterus. Cervix close to the pubis, di- 
 rected downwards and forwards. Fundus thrown backwards towards the 
 perineum (after Barnes). 
 
 Fig. 401. — Fibroma projecting from the posterior wall of the uterus and 
 compressing the rectum. 
 
 Engelhardt, Thtse de Strasbourg, 1856, No. 364. 
 
730 
 
 UTEEI^"E DISEASES IN DETAIL 
 
 difficult to distinguish hematocele either from a hydatid cyst of the 
 pelvis or from an ovariati cyst fallen into the retro-uterine cul-de-sac. 
 
 Fia 402. — Outline of the abdominal tumour in ovarian dropsy (after Graily 
 
 Hewitt). 
 
 When the cyst occupies its usual place it is too independent of the 
 pelvic cavity, acquires too large a size and is too spheroidal in form 
 not to be easily distinguished from hematocele. 
 
 The following table gives a resume of the principal elements of the 
 differential diagnosis : 
 
 Phlegvion of the broad ligament and 
 swppurative pelvic peHtonitis] 
 
 Connected witli delivery, abortion, or 
 any other inflammation of the geni- 
 tal economy. 
 
 Phlegmon, a tumour of moderate size, 
 not displacing the cervix, often at 
 the side, fonned after the com- 
 mencement of symptoms, hard at 
 first and very sensitive, gradually 
 softening and becoming fluctuating. 
 
 Pelvic peritonitis rises above the brim, 
 not displacing the fixed uterus to 
 any gi'eat extent. 
 
 General symptoms, continuing till the 
 pus makes a way of escape for 
 itself. 
 
 hematocele 
 
 Unconnected with any of these cir- 
 cumstances, and manifested at other 
 periods than those of deliveiy. 
 
 Large tumour, pushing fonvards the 
 cervix behind which it is situated, 
 f oi-med at the commencement of the 
 disease, soft at first, not sensitive, 
 hardening with time and losing the 
 character of fluctuation, descending 
 to the lowest portion of the cavity 
 and displacing the flxed uterus to a 
 great extent. 
 
 General symptoms, diminishing after 
 a few days, long before the temii- 
 nation of the malady. 
 
PELVIC H^MOEEHAGES AND PEEI-UTEEINE HEMATOCELE 731 
 
 Extra-uterine pregnancy 
 
 Proceeds slowly. 
 
 At first no functional disorder, after- 
 wards the disorders of normal preg- 
 nancy. 
 
 Fcetal sounds, foetal movements. 
 
 Sometimes amenorrhoea, sometimes re- 
 gular menstruation, but no metror- 
 rhagia. 
 
 Retroflexion and retroversion 
 
 In the state of vacuity : slow develop- 
 ment, no diminution in size. 
 
 In the gravid state : symptoms of 
 pregnancy. 
 
 Fibroid tumours 
 
 Development slow, always increasing. 
 Sometimes occur at the time of the 
 
 menopause. 
 Amenorrhoea, abundant leucorrhoea or 
 
 metrorrhagia. 
 Nodulations, density unequal. 
 Softening rare. 
 
 Ovarian cysts 
 very slow, 
 
 Development 
 
 limited. 
 No symptomatic disorders. 
 Tumour at first fluctuating, and then 
 
 hard. 
 
 Extra-peritoneal hematocele 
 (Hematoma) 
 
 Tumour descending into the recto- 
 vaginal septum. 
 
 Uterus pushed upwards and forwards, 
 more distinct from the abnormal 
 tumour. 
 
 Violet colour of the vaginal cul-de- 
 
 Hematocele 
 
 Commences suddenly. 
 General symptoms more or less serious 
 from the beginning. 
 
 Results from auscultation nil. 
 Menstrual disorders coinciding with 
 metrorrhagia. 
 
 The uterus and tumour mutually in- 
 dependent. 
 
 Rapid development, subsequent dimi- 
 nution, always in the period of 
 sexual activity. 
 
 Menstruation and metron-hagia. 
 
 Regularity of outline, density equal. 
 Softening frequent. 
 
 but un- Rapid evolution followed by decrease. 
 
 General symptoms more or less serious. 
 Tumour always fluid and fluctuating. 
 
 Intra-peritoneal hematocele 
 
 Tumour higher up, projecting at the 
 sides and behind the uterus. 
 
 Uterus fixed (in varying directions) so 
 that it cannot be raised. 
 
 No discoloration, frequent paleness of 
 the mucous membrane. 
 
 It will be seen that a sanguineous tumour of the pelvis is easily 
 diagnosed if due attention is paid, but it is often very difficult to say 
 what has been the source of the hgemorrhage. 
 
 Treatment. — Peri-uterine hematocele, although not to be compared 
 in gravity with peri-uterine phlegmon, is yet a serious affection. It 
 not only places life in danger and requires long continued treatment 
 and rest, but it also leaves adhesions which may prevent conception. 
 Or, even admitting the possibility of conception, there would be 
 reason to fear that these adhesions might become causes of abortion. 
 Therefore the prognosis is always grave. Hematocele is not always 
 fatal, but it is always serious, the intra-peritoneal form more so than 
 the extra-peritoneal. Eecamier's treatment of hematocele consisted at 
 first in puncture of the tumour by the vagina ; but ha3morrhage having 
 occurred in one of Malgaigne's patients and symptoms of purulent 
 
732 UTERINE DISEASES IN DETAIL 
 
 infection in other cases^ this physician gradually abandoned the 
 operation. Nelaton, who had adopted it in principle, was the first 
 to restrict its application, only employing it in cases in which the tumour 
 was liquid, and in which the pains were very intense. This opinion 
 has been adopted universally. Seyfert^ of Prague has only once 
 resorted to puncture out of 66 cases that he has treated in four years. 
 Although I do not recommend puncture by the vagina^ unless capillary 
 puncture be attempted, it should be performed when necessary : the 
 surgeon being placed in front of the patient, the left index and middle 
 fingers are introduced into the vagina and applied to the most 
 projecting part of the tumour. The cannula of the trocar is placed 
 between the two fingers and kept against the tumour ; the stylet is then 
 introduced into the cannula with the right hand and plunged into the 
 cyst. The stylet is then withdrawn and the fluid allowed to escape, or 
 it may be drawn off by aspiration before the cannula is withdrawn ; 
 injections should not be used unless they become necessary. 
 
 As our knowledge of these tumours has increased, medical treatment 
 has more and more usurped the place of surgical treatment, which is a 
 subject for congratulation. If we remember that hcBmorrhage always 
 precedes sanguineous tumours of the pelvis and that peritonitis, more or 
 less circumscribed, is the consequence and that suppuration may ensue, 
 we may deduce from these data the principal therapeutical indications 
 [hemostatic antiphlogistic treatment). If we knew the exact moment 
 of the hEemorrhage we could, by the application of ice to the hypogas- 
 tric region, and by the use of perchloride of iron, ergot and other 
 astringents internally, arrest its course and so avoid the formation of 
 large hematoceles. These therapeutical means might be applied even 
 when the hsemorrhage seems to be arrested, being suspended only when 
 symptoms of peritoneal inflammation make their appearance. If peri- 
 tonitis is developed, leeches should be applied (from 15 to 25), either 
 on the side of the abdomen corresponding to the tumour, or at the 
 anus, but in the latter case the number should be small, and the 
 application should be repeated the next day ; or they may even be 
 applied to the cervix or on that part of the tumour which projects into 
 the vagina. Opium should be given in large doses either by the rectum 
 or mouth (three to four grains in the 24 hours) . The state of the 
 bladder should be inquired into, for there is often tenesmus and 
 sometimes retention of urine. In the latter case the catheter should 
 be used (a gum-elastic one is the most suitable, as it accommodates 
 itself more readily to the torsion undergone by the urethra). If 
 peritonitis is accompanied by repeated vomiting, recourse should be 
 had to anti-emetics (seltzer-water, ice, belladonna, &c.) associated with 
 blisters on the hypogastrium, mercurial preparations (calomel in small 
 doses and frictions with mercurial ointment) ; but as a rule it is well 
 to reserve these means till pain has ceased and the tumour has a ten- 
 dency to resolution. Mild purgatives such as castor-oil or magnesia 
 are useful in overcoming the constipation kept up by compression of 
 the rectum. Belladonna should also be substituted for opium as it 
 ^ Saexinger, Spitalszeitung, 1863, Xos. 43 — 45. 
 
OVAEIAN CYSTS 733 
 
 exercises a different action on the intestines. Eest in bed^ fomentation, 
 sedative cataplasms^ spare diet, are necessary adjuvants in serious cases; 
 in simple cases they alone suffice to effect a cure. When the tumour 
 has a tendency to suppurate and there is slight erratic shivering, 
 sulphate of quinine is useful. When there is pus, the strength should 
 be kept up by good wine, bark and iron, associated with wholesome 
 and nourishing diet. By these means it is possible to cure hematocele 
 and to prevent purulent infection which is greatly to be feared when 
 the tumour opens into the rectum. To sum up, prophylactic treatment 
 consists in preventing pelvic haemorrhage, in putting the patient on 
 her guard against everything that could have a tendency to increase 
 menstruation or to suspend it suddenly. 
 
 Curative treatment may be either medical or surgical. 
 
 Medical treatment is most successful. The following are the 
 principal indications : 1, to moderate sanguineous fluxions and arrest 
 the hsemorrhagic molimen ; 2, to subdue the symptoms of partial peri- 
 tonitis which almost invariably occur at the commencement of hemato- 
 cele; 3, to promote and increase absorption; 4, to modify the secreting 
 peritoneal irritation, confining it within the limits necessary for the 
 resolution of the clot and the absorption of its elements ; 5, to prevent 
 or moderate the exacerbations which are manifested at the menstrual 
 period ; 6, to tonify, even by the use of preparations of iron, in order 
 to promote absorption and avoid purulent infection. 
 
 Surgical treatment is only applicable to extra- peritoneal hemato- 
 mata or hematoceles (Nonat) and to intra-peritoneal encysted hemato- 
 celes which threaten to rupture and pour out their contents above the 
 pelvis, causing fatal peritonitis (Nelaton). It may be indicated by 
 the large size of the tumour, the compression of the neighbouring 
 organs, the imminence of rupture, the acuteness of the pain, the gravity 
 of the reaction. Puncture, in place of being made by the abdomen, 
 hypogastrium or rectum ought to be performed through the vagina. A 
 simple trocar or capillary aspirator, a bistoury and lithotome may be 
 substituted for the pharyngotome employed by Recamier, for Nonat^s 
 lancet trocar, Robertas flat trocar, &c. To empty the cyst, to extract 
 the clots contained in it, to make detersive injections, and to fill the 
 vagina with an india-rubber bladder : such are the means for prevent- 
 ing purulent infection. 
 
 Cysts of the Ovary and Genito-Pelvic Tumours 
 1. Ovarian Cysts 
 
 Ovarian cysts are tumours which may acquire a considerable size, 
 formed as the name indicates by one or several membranous sacs of 
 various dimensions, developed in most cases at the expense of the 
 ovarian tissue and distended by a fluid of variable consistency and 
 composition. They are developed very frequently even when they do 
 not constitute the original disease of the ovary, in virtue of the law by 
 
734 UTEEINE DISEASES IN DETAIL 
 
 which there is a more or less marked predisposition in all our organs 
 to the formation of morbid products resembling the normal structure. 
 
 From the pathological point of view cysts may be divided into 
 simple and compound^. 
 
 Their structure and composition vary in the different kinds of 
 cysts according as they are : 1, uni-locular, 2, multiple and multi- 
 locufer, 3, mixed or composite. 
 
 1. tfni-locular cysts. — The structure of the sac is usually very 
 simple : there are, however, three membranes. The peritoneum 
 forms the external envelope. Then comes a fibrous tunic, which 
 is sometimes thin and transparent, at other times thick and formed 
 of fibrous tissue; this tunic is traversed by vessels especially by 
 large veins and arteries frequently presenting a tortuous course; 
 muscular fibres are also occasionally seen in it. The third layer, the 
 internal envelope of the wall of the cyst, has a serous or sero-mucous 
 appearance, is lined with epithelial cells and formed by the internal 
 membrane of the Graafian vesicle. In some old uni-locular, multi- 
 locular or mixed cysts the envelope is encrusted with cartilaginous or 
 calcareous matter exactly like the middle coat of the arteries in cases 
 of ossification. The contents usually consist of a lemon or amber- 
 coloured serous fluid ; but they vary in different patients, according to 
 the size of the cyst and according to the period at which the fluid is 
 extracted, the number of punctures which have been made, &c. Thus 
 the fluid is sometimes colourless, viscous and albuminous, or rather par- 
 albuminous (Koeberle), coagulated by heat and nitric acid, being pro- 
 duced from the cavity of the granular membrane (ovisac) -^ sometimes 
 it is very thick, containing a number of crystalline lamellse of choles- 
 terine, or a variable quantity of blood, which gives it a chocolate 
 colour (hsemorrhagic cysts, lymphatic cysts, consecutive to the fall of 
 the capsule and of its rich sanguineous and lymphatic vascular net- 
 work); at other times it is greenish yellow and contains a considerable 
 quantity of pus which denotes inflammation of the cyst and modifies 
 the prognosis. 
 
 3. Multiple and muUilocular cysts.^ — These are the most nume- 
 rous; only it must be observed that in the majority of cases 
 one of the divisions is developed disproportionately with regard 
 to the others, and that although the latter may be multiplied, 
 they remain fixed against one side of the cyst, usually towards the 
 
 ^ Kiwiscli von Eotterau {Klinische Vortrdge ilher specielle Pathologie und 
 Therapie der Kranhheiten des weiblichen Geschlechts. Prague, 1849). — Paget 
 {Surgical Pathology, vol. ii, p. 26). — Cruveilhier {Anat. pathol gen., t. iii, 
 p. 398). 
 
 ' The microscope reveals the existence of yellowish gi-anular globules 
 of .^-^^ mm. in diameter, the envelope of which is made more apparent by 
 acetic acid, the granulations not being dissolved by ether (Bennet, Koeberle, 
 Drysdale). 
 
 3 Farre {Cyclopcedia of Anat. and Phys.; Uterus and its Appendages. 
 London, 1859) confines the term muUilocular to cysts in which partitions have 
 been formed in consequence of endogenous proliferation, and multiple to those 
 formed by the aggregation of several simple cysts, developed simultaneously in 
 the same ovary. 
 
OVARIAN CYSTS 735 
 
 pedicle of the ovary, a circumstance which, from a clinical point 
 of view, reduces all cysts of this category to the condition of unilo- 
 cular cysts. In other cases the sacs of which the cyst is composed 
 
 Fig. 403. — Eight ovary showing numerous unilocular cysts, consisting pro- 
 ' bably of dilated Graafian vesicles. Left ovary similar, unopened (after 
 Hooper). 
 
 may be the result of the division of one large cyst or of the aggre- 
 gation of small cysts which were originally independent (these are 
 very rare), or rather as the result of endogenous proliferation, a kind 
 of budding of the internal membrane, giving rise to smaller or 
 secondary cysts, from which are developed cysts of the third order. 
 
 Fig. 404. — Left ovary distended into one large cyst, in the interior of which 
 numerous smaller cysts of the second order project. 
 
 The various divisions rarely communicate with each other; this 
 peculiarity is only manifested in cysts divided by septa, and 
 there is then always a good number of sacs which remain inde- 
 pendent. In all these multilocular cysts, especially in those re- 
 
736 
 
 UTEEINE DISEASES IN DETAIL 
 
 suiting from an aggregation of smaller cysts or from proliferation of 
 the internal membrane, some of the sacs are larger than others ; 
 generally there are one or two large sacs, a larger number of average 
 size, and a still greater number quite small, from the size of a millet- 
 seed to that of a nut. The septa are often very resistant, and 
 we can only penetrate from one into another by successive 
 punctures. 
 
 The contents may resemble those of the unilocular cysts, presenting 
 the same differences in different patients. But usually they are 
 viscous, gelatinous, more or less thick, escaping with difficulty by the 
 cannula of the trocar, especially when all the sacs are moderately de- 
 veloped and nearly equal, and sometimes producing no precipitate 
 with heat or nitric acid (colloid cysts, cysto-adenomata, adenoid 
 tumours of the ovaries). But what proves that the various divisions 
 are independent, and gives reason to presume that in certain cases 
 this independence is primary, is that we can sometimes see that the 
 fluid of one division differs more or less in nature, consistency and 
 colour from that of another. 
 
 3. Mixed or composite cysts. — They are characterised by the addi- 
 tion in variable proportions to the cystic products of new pathological 
 elements, normal or abnormal, simply hypertrophic or the result of 
 degeneration, or even peculiar to the ovary. The cyst is formed not 
 
 Fig. 405.— Compound and proliferant Fig. 406.— Ovarian cyst^ containing 
 ovarian cyst. Secondary and ter- hair, fatty matter, adipose tissue, 
 tiary cysts. sebaceous glands, hair follicles, &c. 
 
 (after Cruveilhier). 
 
OVARIAN CYSTS 737 
 
 only by the hypertrophied envelope of the ovisac or of the tissue 
 proper of a follicle, but also by the hypertrophy of a portion of the 
 stroma of the ovary with infiltration of serum or other pathological 
 fluids, giving to the envelope at one or several points an abnormal 
 thickness and a peculiar appearance characterised by the term areolar ; 
 or by the hypertrophy of the fibrous tissue, forming in the ovary one 
 or several fibroids analogous to uterine fibromata, projecting more 
 or less into the cavity of the cyst and encrusted with calcareous 
 matter at one or several points, and sometimes attaining to so con- 
 siderable a size as to constitute more than the half of the ovarian 
 tumour ; or by the formation of epithelial cells, multiplying with great 
 rapidity and in such a manner as to make them resemble other tumours 
 formed by the proliferation of the epithelial cells of tubular glands and 
 known as adenomata, adenoid tumours, heteradenic tumours ; or by a 
 matter more or less liquid, more or less solid, presenting in its structure, 
 its consistency, its external form, its nodulated appearance and its 
 development the characters of colloid matter, scirrhus, encephaloid, 
 or melanosis, in short of the different varieties of cancer. 
 
 The contents of one division may differ from those of another, 
 or those of the cavity of the true cysts from those of the cystoids 
 and of the lacunse, which are often hollowed out in the pathological 
 tissues formed around them. In this way serum, albuminous fluids, 
 sanguinolent serosity, pus, epithelial debris, crystals of cholesterine, 
 cancerous fluid are sometimes met with simultaneously or separately 
 in the various cavities of mixed cysts. 
 
 Dermoid tissue and the products depending on it, such as sebaceous 
 or fatty matter, tufts of hair, bones, teeth, nails,^ &c., which have 
 been falsely attributed to ovarian pregnancy, are products which may 
 be considered as partly belonging to the cyst and partly to its con- 
 tents. As for hydatid cysts, few cases are recorded of their develop- 
 ment in the ovary .^ 
 
 Of all these varieties of ovarian cysts which is the one which most 
 frequently occurs ? The only statistics which we have are those of 
 Scanzoni, which are based on too small a number of cases to allow of 
 the question being determined. But the following interesting remark 
 made by Cruveilhier shows that all these varieties may exist in a rudi- 
 mentary condition in ovaries the size of which is hardly increased. 
 " The ovaries may present in miniature all the varieties of large 
 ovarian cysts. For instance, we find in these little ovaries, hardly as 
 large as a pigeon''s egg, serous unilocular cysts, serous multilocular 
 cysts, multiple cysts, areolar cysts, the whole being in infinitely small 
 proportions but remarkably clear ; they are perhaps cysts in the first 
 stage which abort for want of nutrition.^'^ 
 
 1 Cruveilhier {Anat. path, gen., t. iii, p. 572). Accoiding to Kocberl^ der- 
 moid cysts are more frequently to the right. Patients affected by them usually 
 enjoy good health. 
 
 * Bauchet, Anat. path, des Icystes de I'ovaire, &c. {Mem. de I' Acad, de med., 
 t. xxiii, p. 49. Paris, 1859). — Charcot, Mem. sur les tumeurs hydatiques, &c. 
 {Gaz, med., 1852). — Davaine, Traite des entozoaires. 
 
 ^ Cruveilhier, Anat. path, gen., iii, p. 445. Paris, 1856, 
 
 47 
 
738 UTEEINE DISEASES IN DETAIL 
 
 The origin and development of these various kinds of cysts are 
 hardly doubtful. Exceptionally they are external to the ovary ; but 
 the development of considerable cysts formed at the expense of Eosen- 
 miiller's organ, the remains of the Wolffian body, or at some point of 
 the broad ligaments is a fact which, although verified, is very rare.^ 
 In the immense majority of cases it cannot be denied that it is the 
 ovary which is the seat of development of ovarian cysts. Neither can 
 it be denied that the tissue, improperly called stroma, of this organ is 
 usually foreign to their formation, and that it is equally difficult to 
 trace their origin to vesicles said to be formed any how or first coming 
 to light in the interstices of this stroma. Both indirectly by the 
 method of exclusion and by direct observation we are led to seek the 
 origin of these cysts in the development of the ovisacs or Graafian 
 vesicles (which Cazeaux called ovarian cysts in miniature 2), and to verify 
 the alterations of nature and direction which vitiate this development,^ 
 rendering it pathological and deviating it from its destination of the 
 ovigenous capsule to the monstrous development of a more or less 
 complex cyst. In short, these cysts are simple or complex dropsies of 
 Graafian vesicles (follicular dropsy). 
 
 It is not rare, especially in pregnant or puerperal women, for a 
 number of follicles to become dropsical and for ovules to be found 
 when the fluid which is obtained in opening each separately is care- 
 fully preserved ; conditions of this kind usually coincide with catarrhal 
 leucorrhceic affections of the genital economy ; they may simulate 
 menstruation, being accompanied by a sanguineous discharge (pseudo- 
 menstruation), and merit the name of catarrh of the Graafian follicles.* 
 
 Not only do Cruveilhier/ Eokitansky,^ Lebert,''' and the majority of 
 pathological anatomists admit this origin, at least for simple unilocular 
 or multilocular cysts, but Wilson Eox^ has described the manner in 
 which the increase, proliferation, and endogenous multiplication of the 
 internal membrane of the vesicle are produced in the formation of a 
 multilocular cyst. The excrescences which arise from the internal 
 wall of these cysts and which have obtained for them the name of 
 proliferous cysts, are papillary fibroid excrescences, dendritic or 
 
 ^ Bauchet, op. cit., p. 54. — Rafael Herrera Vegas, i^tudes sur les Jcystes de 
 I'ovaire et l' ovariotomie, p. 16, note by Oi'donez. These de Paris, 1864. — ■ 
 Spencer "Wells, Diseases of the Ovaries, i, pp. 91, 240, 303. London, 1865. See 
 further on the origin of cysts of the broad ligament (p. 781). 
 • '^ Des kystes de I'ovaire, these pour I'agregation. Paris, 1844 (a remarkable 
 work). — Bulletin de I' Acad, de med. de Paris, 1856. 
 
 ^ Hsemorrhage into an ovisac appears sometimes to be the origin of this 
 pathological development, as several preparations in Guy's Hospital seem to 
 prove (Bright, Guy's Hospital Beports, vol. iii, pp. 181 and 193. London, 1831). 
 
 * Virchow, op. cit., t. i, p. 259. 
 
 •'' Anat. path, gen., iii, 395. Paris, 1856. 
 
 ® Lehrbuch der patholog. Anat., iii, 424. Vienna, 1861. — Wiener Wochen- 
 blatt, 1855, No. 1, and Abnormitaten des Corp. luteum, in Wiener allg. 
 med. Zeitung, 1859, pp. 34 and 35. 
 
 '' Physiologic pathologique, ii, p. 65. Paris, 1845. — Anatomie pathologique. 
 Paris, 1855—61. 
 
 * On the Origin, Structure and Mode of Development of the Cystic Tumours 
 of the Ovary {Medico-Chirurg . Transactions, xlvii, p. 227. London, 1804). 
 
OVAEIAN CYSTS 
 
 739 
 
 cauliflower^ villous or vascular, or it may be glandular, formed by the jux- 
 taposition of these latter ; they are probably multiplied by the same patho- 
 logical process which leads to the formation of vesicular moles, i.e. 
 which produces multiplication, hypertrophy^ and dropsy of the chorial 
 villi. The fusion in places of 
 these excrescences and their 
 ulterior development, the divi- 
 sion by septa of glands of new 
 formation, the elongation and 
 division of the numerous micro- 
 scopic cysts contained in the 
 wall, account sufficiently for 
 the development of the sacs, 
 which are often so numerous 
 and of such different dimen- 
 sions, in ovarian cysts. 
 
 Diagnosis — subjective signs. 
 — Ovarian cysts, like all ute- 
 rine maladies, are usually pro- 
 duced during the age of sexual 
 activity,^ but they may be met 
 with in childhood^ (I have seen 
 one in a child of 'eleven who had 
 never menstruated), and may also 
 be developed in old age ; in the 
 latter case they are very seldom 
 fully developed but appear as if 
 atrophied. When they have 
 commenced during the period 
 of sexual activity without deter- 
 mining serious accidents they may continue to develop after the 
 menopause and become enormous even in women of 60. Ovarian 
 •cysts are met with in virgins and widows as well as in married 
 women,^ which shows the slight influence exercised by coitus on their 
 development. They also occur in women who have never con- 
 ceived,* and so frequently that we may conclude that probably the 
 
 ^ The frequency of ovarian tumours with regard to age is as follows : 
 According to Chereau, out of 230 there are 133 between 17 and 37 years of age. 
 Lee, „ 135 „ 82 „ 20 „ 40 
 
 „ Scanzoni, „ 97 „ 70 „ 18 „ 40 „ 
 
 West, „ 94 „ 64 „ 25 „ 40 
 
 ^ And even in the newborn infant. See Boullard and Mayer of Bonn, quoted 
 by Bauchet, op. cit., p. 7. — Cullingworth, quoted by Hayem, Revue, t. v, 
 p. 762. — Kiwisch, op. cit., ii, p. 79. 
 ^ There were according to 
 
 Lee, out of 136 patients, 88 married women, 37 virgins, 11 widows. 
 Scanzoni, „ 97 ,, 45 ,, 4f) „ 1 ,, 
 
 West, „ 94 „ 57 „ 24 „ 13 
 
 Tilt, _ „ 475 „ 289 „ 166 „ 20 
 
 '' According to Scanzoni, out of 97 patients 51 were n\illipara3 (out of the 
 51 there were 16 virgins). According to West, out of 70 married women or 
 widows 26 were nulliparae. 
 
 Fig. 407. — Part of the wall of an ovarian 
 cyst, covered on the internal surface 
 with cauliflower excrescences and py- 
 riform vesicles (after Paget). 
 
740 
 
 UTERINE DISEASES IN DETAIL 
 
 Fig. 408. — Follicular 
 dropsy of the ovary 
 in a cliild of ten 
 (Vircliow) . 
 
 ovaries were (before the apparent development of the tumour) in a 
 pathological state incompatible with the normal accomplishment of 
 their functions. They may be developed in either ovary, but more 
 frequently in the right, at least in the case of 
 dermoid cysts (according to Koeberle albumi- 
 nous cysts are more frequently situated on the 
 left side), and in a number of cases in both 
 ovaries simultaneously. Tilt^ has observed out 
 of 475 cases of ovarian cysts that the seat of 
 the malady was in the right ovary 260 times, in 
 the left 170 times, and in both ovaries 43 times. 
 These statistics, as well as those of Lee, Che- 
 reau, Scanzoni and West,^ seem to confirm 
 the relative frequency of the development of 
 cysts in the right ovary ; but it is only based, 
 like the others, on the rather uncertain data of 
 a diagnosis made during life. The post-mortem 
 examination of 80 cases recorded by Scanzoni, Lee, and West does 
 not exactly confirm this result ; for in these 80 cases the malady 
 only occupied the right side 28 times, the left 26 times, and both 
 ovaries 26 times. Sometimes they are developed without the slightest 
 disturbance of. the neighbouring organs and general economy, or 
 they produce only a sensation of discomfort j after a time, however, 
 they increase rapidly. At other times symptoms are manifested in 
 the pelvis, such as a sensation of weight, rectal or vesical tenesmus, 
 retention of urine, menstrual and other functional disturbances. If 
 the tumour is formed rapidly or accompanied by irritation or inflam- 
 matory phenomena, the commencement even may be marked by 
 shooting pains in the diseased ovary. In some women pain is never 
 felt at all, whilst in others on the contrary it is produced in proportion 
 to the rapid development of the cyst, to the congestion caused by the 
 catamenial fluxion in the diseased ovary, to the development of inflam- 
 mation in it, or to the degree of inflammation set up in the peritoneal 
 serous membrane by which adhesions are formed between the cystic 
 envelope and the visceral or parietal peritoneum, which by interfering 
 with the mobility of the cyst produce additional pain. At an advanced 
 period pain is also produced by the compression which the cyst exer- 
 cises on the neighbouring organs — the bladder, rectum, intestine, 
 stomach, ureters, sciatic nerve, &c. — and by the difficulties which it 
 places in the way of their functions. 
 
 The increase in the size of the cyst is not continuous ; sometimes 
 the tumour remains stationary for a long time, and then suddenly 
 makes great progress, which only ceases when the ovarian sac and ab- 
 
 1 The Lancet, Dec, 1849, Feb., March, 1850. 
 
 ^ The seat of ovarian tumours is according to 
 
 Chereau, out of 215 cases, 109 to the right, 78 to the left, 28 on both sides. 
 
 Lee, _ „ 93 „ 50 „ 35 „ 8 
 
 Scanzoni, „ 41 „ 14 „ 13 ,, 14 „ 
 
 West, „ 92 „ 35 „ 38 „ 19 
 
 BlofE, „ 54 „ 31 „ 23 „ 
 
OVARIAN CYSTS 741 
 
 domiual cavity are distended to their utmost limits. At other times 
 the increase of the tumour is intermittent, the fits of development 
 often corresponding with the menstrual period. The compression of 
 neighbouring organs, whether in the pelvic or abdominal cavity, gives 
 rise to new symptoms. The bladder being at first compressed on a 
 level with the cervix, and afterwards pushed against the pubis, or 
 raised upwards towards the abdomen, there is at one time dysuria, 
 vesical tenesmus and retention, and at another incontinence of urine. 
 If the ureters themselves are compressed the catheter is powerless, and 
 the urine accumulates in these excretory canals which become enor- 
 mously distended. Compression of the intestines often causes con- 
 stipation and occasionally alternations of constipation and diarrhoea; 
 but I have seen many patients in whom the bowels acted regularly 
 owing to the fact that the sigmoid flexure and rectum experienced but 
 slight compression from the tumour, as it had risen into the abdomen ; 
 on the other hand compression may be strong enough to determine 
 intestinal occlusion^ and stricture of the rectum. Compression of 
 the intra-abdominal vessels causes dilatation of the superficial ab- 
 dominal veins, which form blue networks under the skin to take the 
 place of the deep venous circulation, oedema of the vulva, especially 
 of the lahla majora, more rarely oedema of the lower limbs and ab- 
 dominal walls and, more rarely still, ascites. Pressure on the sciatic 
 nerve determines a pricking sensation, pulsating, darting pains shooting 
 down the thigh of the diseased side. The phenomena of compression 
 of the pelvic organs are manifested especially at the beginning, when 
 the cyst is contained in the pelvis ; in proportion as it rises and as 
 the utero-ovarian pedicle is elongated, these phenomena disappear, and 
 it is on this account that we often see the lower limbs emaciated and 
 wrinkled, and forming a singular contrast with the enormous disten- 
 sion of the belly. 1 have even seen cases in which the excavated 
 form of the tumour behind (owing to a movement of torsion effected 
 by the ovary in the first period of the development of the tumour) 
 allowed the large vessels in the abdomen to escape all pressure. 
 Lastly, at the most advanced period the effect of the compression 
 exercised by the cyst is felt especially by the thoracic organs, disturb- 
 ing respiration and the cardiac circulation. 
 
 Menstruation is variable. In some patients the appearance of the 
 tumour is preceded by menstrual disorders (according to Scanzoni, 
 37 times out of 57); after the cyst is developed it may seem to exer- 
 cise no influence on the regularity of the monthly period, especially 
 if one ovary remains normal ; it sometimes is accompanied by metror- 
 rhagia, more frequently by dysmenorrhoea or amenorrhoca ; the per- 
 sistence of the cystic tumour does not prevent the menopause from 
 being established normally ; the definite increase of the cyst and the 
 cessation of the catamenia seem in a few patients to be two concurrent 
 phenomena. When the menses cease completely from the commence- 
 ment of the malady we may suppose that there is some serious disorder, 
 i. e. a cancerous or other degeneration of the tissue of both ovaries ; 
 ' Cniveilhier, Anat. ludh. g<hi., iii, p. 412. 
 
742 
 
 UTEEINB DISEASES IN DETAIL 
 
 for the menses continue even with cysts in the two ovaries if any 
 portion of the organs preserves its normal structure and is able to 
 perform its functions. It is impossible for so large a tumour to distend 
 the abdominal cavity without the general health suffering greatly ; 
 therefore, although some patients only succumb after repeated punc- 
 tures, and after carrying the tumour for more than twenty years, there 
 are others in whom the cyst reaches an enormous size in six months, 
 weighing 55 lbs., and rapidly ending fatally. The average duration 
 
 Fig. 409. — " Facies ovariana," from 
 the photograph of a patient of 
 42 who had a compound ovarian 
 cyst, operated on and cured by 
 Spencer Wells. 
 
 Fig. 410. — External aspect of the ab- 
 dominal tumour formed by a 
 multilocular ovarian cyst in a 
 woman of 32 (ovariotomy, cure, 
 birth of a child 15 months after- 
 wards). (After Spencer Wells.) 
 
 of life is from two to three years. The tumour injures the con- 
 stitution in three ways ; by the mechanical obstacle it opposes to 
 the movements of the organs, to their circulation and to the accom- 
 plishment of their functions ; by the irritation or sympathetic dis- 
 orders which it occasions in others ; lastly, by the change of direc- 
 tion given to nutrition, the growth of the cyst and the increase in its 
 secretion taking place at the expense of the general assimilation 
 throughout the system. 
 
 The alteration in the general health is especially noticeable in young 
 women and when the tumour is rapidly developed. Without speaking 
 of such complications as inflammation of the cyst, secretion of pus. 
 
OVARIAN CYSTS 743 
 
 &c., which greatly accelerate the course of the disease, we may say 
 that in such cases digestion is difficult and slow, the intestines swell, 
 respiration is impeded, especially after meals ; circulation is not per- 
 ceptibly affected, there is little or no fever, but the difficulty which the 
 blood has in circulating through the large vessels causes a small and 
 frequent pulse, palpitations and a tendency to syncope. Under the in- 
 fluence of these disorders of the principal functions, of their reaction 
 on the nervous system, of the anaemia which results, and of the 
 attraction exercised by the cyst on the elements of nutrition, increasing 
 emaciation is produced. The lower extremities when not oedematous 
 acquire a dryness and spareness contrasting with the infiltration to 
 which they are subject in the case of ascites ; the hands and arms 
 become thin; the chest and neck contrast by the angular projection 
 of their bones with the spheroidal tumefaction of the upper portion 
 of the abdomen ; the face, too, is affected by this general emaciation ; 
 it becomes wrinkled, the lips are pinched, the nose pointed, the eyes 
 sunk, all the features acquiring the look of premature old age, 
 although the still briUiant eye shows that vitality is stifled by the de- 
 velopment of a parasite rather than disorganised in its constituent 
 elements. This appearance differs considerably from that which 
 cancer, chlorosis, chloro-ansemia, and even recent delivery and uterine 
 diseases impart to the countenance, so much so that Spencer Wells 
 has designated it by the name of '' facies ovariana" to contrast it with 
 the " facies uterina " which I have already described. 
 
 Objective signs. — Palpation must be combined with vaginal and 
 rectal touch in order at the beginning to be able to diagnose in the 
 pelvis the presence of a tumour which is often indolent, varying in 
 size from that of a nut to that of a fretal head, round, resistant, but 
 depressible and elastic, or soft and fluctuating, escaping from the grasp 
 of the fingers, mobile in several directions, pushing the uterus for- 
 wards or on one side, and compressing the rectum more or less. 
 When the cyst is situated above the brim it increases the size of the 
 belly. This symptom seems to strike the patient less than the phy- 
 sician, when the tumour is indolent; but the increased size of the 
 abdomen as ascertained by measurement, the form of the tumour, the 
 results furnished by palpation, percussion and touch, leave no doubt 
 as to the origin and nature of the malady. The abdomen is not only 
 tumefied but altered in its form. In place of being distended in every 
 direction as by ascites it is manifestly raised by a globular tumour, 
 recalling that of the gravid uterus, but sometimes nodulated instead 
 of simple, less central, less inchned to the right, commencing usually 
 on one side and directed towards the hypogastrium, making the 
 abdomen project in its median portion where it yields more than 
 elsewhere, and rising towards the epigastrium or hypocliondrium. 
 Ovarian cysts may acquire an enormous size, filling the whole belly 
 and distending the envelopes and skin excessively, producing streaks 
 and vibices and describing broad blue undulating lines due to the dis- 
 tension of the subcutaneous veins, descending in front of the thighs to 
 the knees and pushing the false ribs and xiphoid cartilage of the 
 
744 UTEEINE DISEASES IN DETAIL 
 
 sternum upwards and outwards, weighing as much or even more than 
 the patient herself. I have seen some which measured more than two 
 yards in circumference, and from which I extracted thirty quarts of 
 fluid.^ The density of this fluid being greater than that of water and 
 the weight of the cystic envelope and of the tumours adhering to it 
 varying from eleven to thirty-three pounds, we can judge of the 
 enormous weight which the presence of such a tumour adds to that of 
 the patient, which emaciation sometimes reduces below 110 pounds. 
 The weight of the tumour has been known to exceed 165 pounds 
 (Kimball). 
 
 Palpation discovers the size and limits of a round tumour, occasion- 
 ally nodulated, regularly circumscribed, usually indolent; sometimes 
 mobile, being easily displaced under the combined influence of palpa- 
 tion and change of posture, falling to the most dependent side ; some- 
 times retained in one of the iliac fossse or towards the upper portion 
 of the abdomen ; usually tense, seldom depressible or soft ; however 
 mobile, fixed in the pelvis by a more or less loose pedicle ; difficult to 
 circumscribe and still more so to move when it completely fills the 
 abdominal cavity and distends the cutaneous envelope excessively. 
 Palpation often enables us to verify the simultaneous presence of solid 
 tumours and of an encysted fluid by the difference in consistency, 
 hardness, or resistance. On percussion dulness is perceived through- 
 out the whole extent of the tumour, at its summit, at the apex of the 
 belly if the patient is lying, as well as near the pubis and iliac fossae. 
 There is tympanitic resonance in the posterior portions, in the flanks, 
 towards the loins, in the epigastrium and in the hypochondriac 
 regions, especially on the left side. The dulness does not change per- 
 ceptibly on the patient changing her position. Fluctuation should be 
 carefully sought for. It is well marked when the cyst is large, serous 
 and unilocular ; in other cases it is obscure and may even be absent. 
 Sometimes in trying to discover fluctuation the displacement en masse 
 of the contents of the cyst is perceived, pushed back by one hand 
 of the examiner towards the other ; but what Cruveilhier calls the 
 choc par contre-cou'p is not perceived ; that is when the contained 
 matter is soft rather than fluid or when there are several contiguous 
 cysts. At other times we perceive very distinctly this choc par contre- 
 coup, i.e. the result of the molecular disturbance produced by very 
 rapid percussion suddenly imprinted on the point diametrically oppo- 
 site that on which the hand is placed ; but this shock can only be felt 
 at short distances, the undulation is shut off (multilocular cysts), or it 
 is perceived from one pole of the tumour to the other (unilocular 
 cysts) ; sometimes a multilocular cyst with one large predominating 
 cyst is diagnosed in this way. 
 
 Yaginal touch (which when necessary should be followed by rectal 
 touch), either alone or combined with palpation and percussion, 
 enables us to diagnose deviations and even displacements of the uterus, 
 
 ^ I have recently extracted nearly 50 qitarts from an enormous cyst, which 
 I have reason to suppose was developed from the broad ligament, for the 
 transparent, serous, slightly yellowish fluid did not coagulate on boiling. 
 
OVAEIAN CYSTS 745 
 
 sometimes ascent, sometimes prolapsus, at other times compression 
 towards the pubic symphysis and auteversion, more frequently a lateral 
 or posterior inclination/ and a certain degree of torsion. It is impor- 
 tant to determine at the same time whether the uterus is mobile; this 
 mobility depends on the variable length of the pedicle of the ovarian 
 tumour formed by the Fallopian tube and the peritoneal fold enclosing 
 the ovarian vessels and nerves. Vaginal touch also reveals the pre- 
 
 FiG. 411. — External aspect of the abdominal tumour formed by a compound 
 ovarian cyst in a woman of 34, complicated with ascites, dilatation of the 
 subcutaneous veins, impossibility of sleeping except in a chair, &c. (ovari- 
 otomy and death the fifth day). After Spencer Wells. 
 
 sence of the cyst in the pelvic cavity when the tumour is as yet but 
 slightly developed, or when it presents prolongations and inequalities 
 on its lower portion. In other cases it hardly allows of our reaching 
 the cyst, or only when pressure of the other hand on the abdomen 
 pushes down the cyst and enables the tip of the finger to perceive its 
 rounded surface, and to recognise its resistance, depressibility and 
 fluctuation. It also enables us to form an opinion as to whether the 
 cyst is in the right or left ovary, according to whether the uterus 
 inclines to right or left. The sound will help us to judge of the 
 mobility of the uterus, of the length of the pedicle, of the presence or 
 absence of adhesions between the cyst and the uterus, &c. 
 
 Auscultation furnishes valuable indications as to the presence of 
 vessels in the pedicle or in the broad ligament in front of the tumour 
 in consequence of torsion, enabling us to avoid wounding them by 
 puncture. It also enables us to perceive the vibrations resulting from 
 friction of the tumour against the parietal peritoneum due to the 
 absence of adhesions, whilst in other cases it allows us to hear a 
 rougher and more or less extensive friction, coinciding with a tliril. 
 (falsely attributed to hydatids) caused by inequalities produced on the 
 
 '' According to Buinet, (lie cervix is always pushed to tlie opposite side from 
 the cvst. 
 
746 UTEEINB DISEASES IN DETAIL 
 
 serous membrane by an inflammation which has only developed partial 
 adhesions more or less distant from each other. 
 Differential diagnosis : 
 
 1. Other tumours which may be confounded with ovarian cysts. — 
 1. Amongst pelvic tumours parovarian cysts of the broad ligament 
 are developed more slowly, are smaller, are hardly ever adherent, may 
 be enucleated from the peritoneum, the two folds of which cover them 
 and contain a limpid, slightly salt but never paralbuminous fluid, and 
 never emaciate the patient so much as ovarian cysts. However, they 
 also may become very voluminous, giving rise to errors of diagnosis.^ 
 Peritoneal and subperitoneal serous cysts analogous to the preceding, 
 with walls constituted by false membranes or a kind of ectasia of the 
 lymphatic vessels, seldom attain a considerable size, contain albumen 
 but not paralbumen and have sometimes a pediculated form.^ As for 
 other pelvic tumours I have described them sufliciently when treating 
 of ovaritis, tumefaction and inflammation of the tubes, dropsy of these 
 organs, anteflexion, retroflexion, extra-uterine pregnancy, uterine 
 tumours, especially fibromata, commencing pregnancy, hematocele, &c., 
 to make it unnecessary to distinguish them here from ovarian cysts. 
 
 2. Amongst abdominal turnours ascites is easily distinguished by 
 the uniform distension of the belly, the absence of any tumour percep- 
 tible to palpation, the marked tympanitic note at the summit of the 
 abdomen with dulness in the dependent parts, the displacement of the 
 resonance and dulness agreeing with change of position of the trunk, 
 pelvis and abdominal cavity, the frequent oedema of the lower limbs or 
 real anasarca, &c. Serous, purulent, or hydatid cysts or solid tumours 
 of the abdominal walls, of the peritoneum, epiploon, mesentery, liver, 
 spleen or kidneys are usually distinguished by the origin of the 
 tumour, its initial seat above, in front, to right or to left, its develop- 
 ment from above downwards, from one side to the other or from before 
 backwards, instead of from below upwards, the possibility of limiting 
 the tumour beiieath with the hand and of defining its lower outline, 
 the absence of any pedicle or pelvic adhesions^ verified by raising the 
 pelvis and lowering the shoulders so as to make the abdominal organs 
 weigh on the diaphragm and not on the pelvis, the independence of the 
 uterus with regard to these tumours, an independence verified by digi- 
 tal touch, and lastly, by the local or general symptoms manifested in 
 the organ in which the abdominal tumour is developed. Nevertheless 
 there are tumours the diagnosis of which is very difficult, all the more 
 so that fluctuating tumours, encysted peritonitis,^ cysts analogous to 
 
 ^ Arning of Hamburg successfully operated upon an enormous cyst of the 
 broad ligament, taken by Spencer Wells himself for an ovarian cyst {Annales 
 Gynecol., 1877). 
 
 ^ Kojberle {Gaz. med. cle Strasbourg, 1876, No. 1). 
 
 ^ Puistienne, Remarques et observations sur qiielques tumeurs enhystees 
 pelviennes ou abdominales cliez la femvie, p. 82. Paris, 1867. — Kuackenbusch 
 of Albany (the Medical Record, Feb , 1875. — Annales de Gynecologic, vi., 
 237) relates two cases of sub-peritoneal cystic tumours which were taken for 
 cysts of the ovary. 
 
OVARIAN CYSTS 747 
 
 areolar gelatiniform cysts of the ovary/ and hydatid cysts/ may 
 originate in the subperitoneal cellular tissue intermediate between the 
 uterus and bladder, or retro-uterine or even in the broad ligament. 
 Such tumours of the epiploon^ have been taken for ovarian cysts. 
 When the tumour is a hydatid cyst enclosing echinococci, more fre- 
 quent in the liver, spleen, kidneys and epiploon than in the other 
 abdominal organs, the thrill which is said to be pathognomonic can 
 be felt by palpation. Pibrous or fibro-cystic tumours of the womb, 
 all the more difficult to diagnose that they may be complicated with 
 ovarian cysts, are distinguished by the countenance of the patient 
 which is usually normal, and by the uniformly hard or flabby consis- 
 tency of the tumour. I do not speak of advanced extra-uterine preg- 
 nancy nor of advanced normal pregnancy characterised by the signs of 
 gestation, nor of retention of urine nor of the accumulation of fsecal 
 matters which are easily recognised. 
 
 II. The different varieties of cysts and other ovarian tiimours. — 
 Multilocular cysts are sometimes distinguished from unilocular cysts 
 by the appearance of several globular or spheroidal projections; more 
 frequently by the impossibility of perceiving fluctuation except by 
 placing the hands at a short distance from each other, or of emptying 
 the cyst by an exploratory puncture unless the several divisions can 
 be punctured successively by inclining the trocar in different directions 
 after the contents of the first sac have been evacuated ; even then we 
 frequently only succeed in withdrawing small quantities of fluid and in 
 slightly diminishing the size of the tumour. We can also ascertain 
 the nature of the fluid which is more gelatinous and thicker in multi- 
 locular cysts, or which may differ in one secondary cyst from another. 
 
 Compound cysts may be recognised by the presence of hard, resistant, 
 non-elastic, non-fluctuating, solid portions, having a dulness more 
 marked at some point of the periphery of the cyst, either at its upper 
 portion and sides or at its lower portion. Diagnosis becomes easier 
 "when the exploratory puncture has evacuated a part or the whole of 
 the fluid contained in the cyst. 
 
 Like other ovarian tumours, cysts may be developed either to the 
 right or left ; we can easily ascertain this when the cyst is only slightly 
 developed, and we may suspect it in other cases from various indica- 
 tions given by the patient. In rarer cases they are simultaneously 
 developed on both sides. It is important to diagnose this before 
 operating. 
 
 Solid tumours of the ovary are usually distinguished by being harder 
 and smaller than cysts, by the irregularity of their form and the sym- 
 ptoms of compression of the pelvic and abdominal organs which are more 
 marked than in cysts; for the latter on account of their globular form, 
 their elasticity, &c., are displaced more easily. Benignant tumours, 
 such as fibroids, are tolerated as easily as cysts, the general symptoms 
 which they produce being more dependent on their size than on their 
 
 1 Craveilhier, Anat. path, gvn., v, p. 191. 
 
 2 Puistienne, op. cit., p. 12. 
 
 ^ Cruveilhier, quoted by Puistienne, op. cit., pp. 31 and 36. 
 
748 UTERINE DISEASES IN DETAIL 
 
 reaction on the economy. Malignant tumours, cancerj scirrhus, euce- 
 phaloid, colloidj rarely reach the size of cysts,-^ and are nodulated and 
 constituted by the aggregation of multiple tumours of variable size 
 and consistency, forming globular excrescences of the ovary rather 
 than a regularly rounded tumour. They compress the neighbouring 
 organs more and have more intimate relations with the uterus. They 
 more frequently determine cedema in the lower limbs or anasarca, as 
 well as ascites and partial peritonitis. 
 
 111. Complications of ovarian cysU and their relations with the 
 neighbourhig parts. — 1. The principal complications of ovarian cysts 
 are the following : rupture, which when preceded by adhesions with 
 the neighbouring parts, by discharging the fluid incessantly into the 
 peritoneum may induce the cure of a unilocular cyst ; but, if produced 
 suddenly, it gives rise to acute peritonitis, and if the fluid is discharged 
 into an adherent organ (bladder,^ intestine, vagina, abdominal wall, 
 &c.) the patient succumbs to suppuration or septicaemia. Haemorrhage 
 may be suspected from the occurrence of symptoms of internal hsemor- 
 rhage ; but it can only be diagnosed by the sanguinolent appearance of 
 the fluid withdrawn by puncture. Partial or general inflammation is 
 recognised by the symptoms of ovaritis ; by rigors, feverish attacks 
 symptomatic of suppuration, by the pains, nausea and tympanitis which 
 accompany the development of peritonitisj &c. Ascites may conceal 
 the presence of an ovarian cyst when the peritoneal cavity is much 
 distended by the fluid ; it is, however, seldom that some of the charac- 
 teristic signs of these two maladies are not observed simultaneously, 
 especially in emptying either the peritoneal fluid or the contents of the 
 cyst. The simultaneous existence of pregnancy and an ovarian cyst 
 may be very difficult to diagnose in the first period of gestation, espe- 
 cially if the cyst has existed for some time and has attained a consi- 
 derable development ; later on, the characteristic signs of the presence 
 of the fcetus leave no doubt. The simultaneous existence of a cyst 
 and of another tumour, whether uterine, ovarian or independent of the 
 genital organs is more easily determined at the commencement of the 
 development of the two tumours, especially when the tumour which 
 complicates the cyst comes from some organ situated at a distance 
 from the ovary. 
 
 2. The relations of the cyst with the neighbouring parts are perceived on 
 the patient assuming different postures, by raising the cyst in difterent 
 directions, either through the abdominal wall or by the vagina, by 
 pushing it by graduated pressure in a certain direction, by examining 
 the woman when standing and observing the tympanitic note between 
 the diaphragm and the upper surface of the cyst, by ascertaining that 
 the various displacements do not produce pain, and lastly by observ- 
 ing the retraction of the cyst after puncture and evacuation of its 
 
 ' Clarens, however, once found in a woman of 42 a medullary sarcoma of the 
 left ovary weighing 80 lbs. {Deutsche Klinik, 1873, No. 3), and I have dis- 
 sected one of more than 50 lbs. in weight. 
 
 * Breisky of Berne {Revue de Haijem. v, 178). Eupture of ovarian cyst into 
 he bladder, with which adhesions had been formed. 
 
OVARIAN CYSTS 749 
 
 contents. We may then be almost certain of the independence of the 
 cyst ; besides, deep adhesions of the pelvic cavity seldom exist in 
 the absence of abdominal adhesions. The spontaneous pain, on the 
 contrary, experienced previously by the patient at those spots where 
 mobility of the tumour is doubtful or absent, the other symptoms of 
 peritonitis, whether circumscribed or otherwise, having possibly been 
 already developed, the acute pains of dragging or tearing produced by 
 attempts made to remove the cyst from the organs to which it seems 
 to adhere (from the liver, spleen, abdominal wall and iliac fossa), the 
 impossibility of verifying this separation after repeated ineffectual 
 attempts, the pain experienced by patients either from a full or empty 
 stomach, from the peristaltic movements of the intestine during di- 
 gestion and from the contractions of the rectum for the expulsion of 
 foetal matters, are symptoms which prevent us from making a mistake 
 as to the existence of adhesions between the cyst and the parts with 
 which it is in contact. According to Koeberle abdominal adhesions 
 are observed more especially round the umbilicus ; adhesions to the 
 epiploon are known by the absence of vibrations at this point ; 
 adhesions to the liver, diaphragm and edge of the ribs can only be 
 ascertained by puncture ; those with the intestines cannot be diagnosed 
 beforehand, even under such conditions ; those with the pelvic cavity 
 are recognised when the cyst cannot be pushed back into the abdomen, 
 even after puncture. 
 
 Shortness of the pedicle may be presumed from the impossibility of 
 raising the tumour in the abdomen or of imparting to it the slightest 
 movement, from the defective mobility of the uterus, from the presence 
 of globular tumours in the cavity behind or around the uterus, pro- 
 jecting more or less into the vagina, contributing to fix the womb 
 and experiencing a direct reaction from movements transmitted to the 
 cyst. When the pedicle is long, the tumour is sufiiciently raised 
 above the pelvis to prevent the finger reaching more than a spheroidal, 
 broad surface, more or less independent of the uterus, which has pre- 
 served to some extent its mobility. 
 
 Treatment. — Medical treatment ought to be tried, for there are ex- 
 amples of spontaneous absorption of the contents of the cyst followed 
 by cure, but they are very rare. No one knows better than I do the 
 resistance usually offered by ovarian cysts to all medical treatment. 
 Nevertheless, I have never undertaken ovariotomy without having 
 previously tried all other rational means of treatment, and have been 
 so fortunate as to see the use of these means succeed in two very 
 characteristic cases^ in which I had little hope that resolvent treatment 
 would prove effectual. The treatment employed in these cases may be 
 summed up as follows : chloride of gold and sodium, from two milli- 
 
 * Large right ovarian cyst, probably unilocular, wbicb had never been punc- 
 tured, in a single woman of 43 ; circumference of the abdomen at the umbilicus, 
 one yard. Cure eight years ago. Right ovarian cyst, apparently multilocular, 
 never punctured, in a child of 12 who had never menstruated ; circumference 
 of the abdomen at the umbilicus, f yard. Cure six years ago. The enormous 
 size of the cysts in both cases authorised the presumption that they were 
 ovarian and not connected with the Wolffian bodies or the broad ligaments. 
 
750 UTEEINE DISEASES IN DETAIL 
 
 grammes to five centigrammes daily ; tonics and restoratives, iron, 
 bark, &c. ; solvents, Yichy water, bicarbonate of soda ; resolvent ab- 
 dominal frictions of iodide of lead and potassium ; diuretics, squills, 
 digitalis, nitre ; lastly, and above all, methodic and increasing com- 
 pression of the whole abdominal surface by means of Bourjeaurd's^ 
 excellent elastic belts. In other patients (about a twentieth of the 
 whole) the cyst has appeared to remain stationary or even to diminish 
 in size for some time under the influence of this treatment (sometimes 
 preceded by the evacuation of the fluid), which was tolerated for 
 several years without seriously injuring the health of patients affected 
 by them. 
 
 Torsion of the pedicle of the tumour is another means of spon- 
 taneous cure. It may extend from half to two and a half turns, and 
 is probably dependent on movements made by the patient while lying 
 and while the tumour is still small. Cysts and even fibrous tumours 
 of the ovary sometimes undergo natural torsion round their axis, 
 which may explain spontaneous cure. This torsion, recently de- 
 scribed by Eokitansky and Klob,^ has been attributed by the latter 
 (after experiments made on a dead body to the ovary of which he had 
 attached a membranous sac of the size of an orange) to the rotation 
 imparted to the ovary, always in the same direction, by the alternate 
 repletion of the bladder, which makes the sac turn from within 
 outwards, and depletion of this organ, which lets it fall without 
 turning in the opposite direction. Tor this effect to be produced the 
 sac must be attached to the external side of the ovary ; if on the in- 
 ternal side the same effects are produced, but in the opposite direc- 
 tion. It is accompanied by strangulation of the vessels of the pedicle, 
 the result being, according to Koeberle, congestion of the cyst, in- 
 ternal haemorrhage, inflammation and even mortification of the cyst, 
 and complete rupture of the pedicle. Unfortunately we cannot help 
 nature in accomplishing this singular phenomena. 
 
 The natural evacuation of the contents externally, after the forma- 
 tion of salutary adhesions, may produce cure, amelioration (especially 
 when the cyst is evacuated through the vagina or abdominal wall), or 
 inflammation of the sac, septicsemia and death (especially in cases 
 where the cyst opens into the intestine or bladder). — Rupture with 
 effusion of the fluid into the closed cavity of the peritoneum is still 
 more frequently a cause of death ;^ Thomas Keith (the Lancet, 10th 
 March, 1877) has, notwithstanding, performed ovariotomy successfully 
 in a case of rupture ; it is the result of a suppurative inflammation, 
 gangrene of the cyst, traumatism, or puncture. Chereauhas collected 
 70 cases of rupture of ovarian cysts with effusion of fluid into the 
 peritoneum, or evacuation through the bladder, uterus, vagina, and 
 abdominal wall. Puech, by collecting 33 additional cases, has raised 
 the total number of these ruptures to 103 ; out of this number there 
 were 33 deaths, 22 ameliorations, and 48 cures ; as examples of the 
 
 ' 'Note sur les kystes de I'ovaire ; Bulletin de I'Acad. de ined., 1857. 
 
 2 (Esterreicliische Zeitschrift, No. 18, 1865. 
 
 ^ Spiegelberg has recorded three new cases {Archiv fur Gyndk., 1870). 
 
OVAEIAN CYSTS 751 
 
 latter Richard^ has added 5 cases to some others already known of 
 communication between the ovary and Fallopian tube, and of the 
 evacuation of the fluid by this means. ^ We have therefore still less 
 hope from this mode of natural termination or its imitation than from 
 torsion of the pedicle. 
 
 Inflammation may attack the internal membrane of the cyst making 
 the contents purulent, or it may extend from the sac to the entire 
 ovary and be propagated to the peritoneum, determining adhesions or 
 suppuration. Whether spontaneous or excited by a puncture, injection 
 of iodine, a seton, &c., as has too often happened, it is soon fatal. 
 Recovery after such an accident is quite exceptional. Exhaustion is 
 the usual termination; most frequently, the progress of the tumour 
 alone suffices to cause a daily increasing emaciation, exciting a hectic 
 fever which consumes the strength of the patient, throwing her into a 
 state of marasmus quickly followed by death. The physician therefore 
 has to do with a tumour which may be developed at any age, making 
 continuous and usually rapid progress and resisting all treatment, 
 whilst occupying an organ the preservation of which is not necessary 
 to life and the ablation of which is the only means of obtaining definite 
 cure. 
 
 We shall now compare the various means of surgical treatment, 
 some of which (puncture, aspiration, injection, drainage, seton, 
 incision, excision) usually only procure a palliation of the evil whilst 
 seriously endangering life, whilst others, on the contrary (extirpation), 
 without being really more dangerous, offer the hope of radical cure. 
 
 I. Puncture. — This is a purely palliative means which alleviates the 
 patient temporarily when threatened with asphyxia and helps the 
 diagnosis. But this operation, although apparently simple, is not free 
 from danger. Death may occur instantaneously from syncope or 
 haemorrhage, or at a later period from peritonitis or from inflammation 
 of the sac and suppuration in the cyst, or from the rapid reproduction 
 of the fluid. Puncture ought therefore to be deferred as long as 
 possible, as it is evident that additional punctures will probably be 
 necessary at increasingly shortened intervals, the patient at last suc- 
 cumbing to exhaustion.^ When it has been decided on we must make 
 sure that the patient is not pregnant and that there is no urine in the 
 bladder. This operation is usually performed with a large trocar on 
 account of the consistency and viscosity of the fluid. It is usually 
 made on the abdomen, on the linea alha, in the centre of the space 
 separating the umbilicus from the pubis : at that point there is no fear 
 of encountering the vessels of the abdominal walls and still less chance 
 of opening one of the large arteries which rise from the base of the 
 cyst and ramify in it. Tt must be previously ascertained by ausculta- 
 
 ' Sur les Jcystes tubo-ovariques {Mem. cle la Soc. cle chirurg., 1853, t. iii, 
 
 " Nepveu {Ann. cle Gynec., t. iv, p. 14, juillet, 1875). — Brjzan {Dissertaf. 
 inavgurale. Halle, 1875). 
 
 •^ Vast {Soc. de chirurg., 1875). — Bczard {Bulletin cle la Soc. mecl. d'emula- 
 tion, 1815. Revue de Hayem, vi, 1G8). 
 
752 UTEEINE DISEASES IN DETAIL 
 
 tion that there is no vascular souffle at this point. Care should be 
 taken to compress the abdomen strongly when the fluid is evacuated, 
 either by means of my belt or by that of Bourjeaurd. If haemorrhage 
 occurs it should be arrested by means of acupressure, applied according 
 to SimpsonV ingenious method. The cannula invented by Panas may 
 be used in puncturing ovarian cysts in order to avoid accidents from 
 haemorrhage and from the escape of liquid into the peritoneum. 
 
 II. Aspiration. — Buys^ has recently proposed sustained aspiration 
 in order to provoke the continuous discharge of fluid and retraction of 
 the cyst whilst preventing the entrance of air and the development of 
 inflammation and suppuration in the sac, these accidents having led to 
 the abandonment of the plan of leaving a cannula in the wound. In 
 place of aspirating the fluid suddenly and only at intervals, as can be 
 done by means of the instruments invented by Monro, Guerin, and 
 Boinet, it should, according to Buys, be aspirated slowly but con- 
 tinuously and with increasing force so as : 1st, to evacuate the tumour 
 slowly and prevent the patient from being inconvenienced by a too 
 sudden raptus ; 2ndly, to maintain the vacuity of the cyst by a more 
 energetic suction, aspirating each drop of serum as soon as it is formed 
 and thus exciting contraction of the sac ; 3rdly, to stimulate the retrac- 
 tion of the cyst, producing an exudation of plastic lymph fitted to make 
 the opposite surfaces of its internal wall adhere together. It is useless 
 to describe the trocar a ciirseur, or the sort of india-rubber bags of 
 different degrees of thickness invented by this surgeon to increase the 
 strength of aspiration gradually, experience not having yet decided as 
 to the value of this method. 
 
 III. Bar ill's cannula. — A cannula for perforating the abdomen and 
 cyst at two points so as to remain there without allowing the sac to 
 become separated from the abdominal wall, was first proposed by Barth,^ 
 and was the subject of the academic discussion on ovarian cysts and of 
 Bauchet's paper. The simple seton and Chassaignac's^ drainage are 
 only different ways of carrying out the same method, and can none of 
 them be applied without risking the danger of the entrance of air, 
 inflammation of the sac, destructive suppuration, &c. I think that in 
 the small number of cases in which they have been employed they have 
 always been followed by death. 
 
 IV. Iodine injections. — Iodine injections preceded and followed by 
 other injections (gas, hot wine,^ solution of nitrate of silver, weak 
 solution of caustic potash or tincture of cantharides,^ or an alkaline 
 
 ^ Acupressure, a Naw Method of Arresting Surgical Hemorrhage and of 
 Accelerating the Healing of Wounds. Edinburgh, 1864 
 
 2 Journal de medecine et de chirurgie, t. xl, 33. Bruxelles, 1865. — Traite- 
 ment des Tcystes de I'ovaire, du pyothorax, de I'hydrothorax, des plaies, &c., 
 par la compression et I'aspiration continues, procedes et appareils nouveaux, 
 by Buys. Bruxelles, 1870. 
 
 ^ Bulletin de I' Acad, de med., xxi, 583. Pai'is, 1855-6. 
 
 •* Soc. de chirurg., 27 Nov., 1861. 
 
 5 Holscher, Archiv, 1838, i, 224. 
 
 ' OUenroth, London Med. Gaz., 1835. 
 
OVARIAN CYSTS 753 
 
 sulphite^)^ have been employed and recommended by Boinet.- But 
 iodine injections can only be attempted with any chance of success in 
 the case of unilocular cysts containing a serous fluids and success even 
 then is so doubtful that Boinet himself seems to be converted to 
 ovariotomy. 
 
 V. Incision and excision. — These are still less acceptable methods ; 
 their object usually is to provoke suppuration of the cyst and that is 
 enough to condemn them. It is evident that before incising the cyst, 
 adhesions should be estabhshed by only incising as far as the peri- 
 toneum, as advised by Graves in 1827 for abscesses of the liver, and 
 by Begin ^ in 1830 for all fluid collections in the abdomen, or by 
 making successive cauterisations of the walls of the abdomen and cyst 
 as performed by Uecamier in the same circumstances. Supposing, 
 however, that inflammation and suppuration are not developed in the 
 cyst and that we may hope for amelioration and contraction of the sac, 
 we must never count on a definite cure as long as there is a fistulous 
 opening. The excision of a portion of' the walls of the cyst, the object 
 of which is to allow the contents to be evacuated into the peritoneum 
 in order to be reabsorbed, or rather to provoke suppuration there, is 
 an almost necessarily fatal operation ; therefore it has only been per- 
 formed in cases in which extirpation has been undertaken and could 
 not be finished, owing to the adhesions being too strong or too 
 numerous. 
 
 VI. E^iucleation. — Miner of Buffalo {Americ. Journ. of Med. 
 Science, October, 1872) proposed ovariotomy by enucleation, with- 
 out clamp, ligature or cauterisation, a method which he had been led to 
 adopt by chance (Hayem, Revue des Sciences med., i, 200). He per- 
 formed it thrice without haemorrhage, but he lost two patients. Meade, 
 of Bradford, has published a successful case, and Gaillard Thomas three. 
 Enucleation has also been performed by Logan and Ford (Hayem, id., 
 1873, p. 748), and by Burnham {id., id.). It is certainly very 
 w^onderful to be able by one simple dissection, one detachment gradu- 
 ally effected, to enucleate a cyst entirely without having to cut the 
 pedicle or to ligature any vessel. This operation is probably only 
 practicable for cysts of the broad ligament (Rosen miiller's organ or 
 others), enclosed between the two layers of this great peritoneal fold, 
 without pedicle and without vascular connections, and should not 
 be attempted in the case of other tumours. If the cyst upon which we 
 intend to operate by enucleation has a pedicle, and if lipemorrhage 
 occurs it should be arrested by one of the means which I shall 
 describe when treating of ovariotomy, 
 
 VII. Ovariotomy. — However serious this operation may appear, it 
 is now so well managed that in spite of the gravity imparted to it by 
 the size and connections of the tumour, and in spite of other unfore- 
 seen dangers, it takes an increasingly important place among surgical 
 
 ' Gritti, Annali universali di medicina, 1864, p. 272. 
 
 2 lodotherapie, ou de I'emploi medico-chirurgical de I'iode et de ses com- 
 poses, 2^ edit., p. 531. Paris, 1865. 
 
 3 Journal liebdom. de med., i, 417. Paris, 1830. 
 
 48 
 
754 UTERINE DISEASES IN DETAII^ 
 
 operations. In comparing ovariotomy with the other major opera- 
 tions we find by statistics that the rate of mortality is lower than in 
 operations for strangulated hernia, than in lithotomy in the adult, 
 ligature of the subclavian, &c. ; i.e. than in all the great surgical 
 operations indicated and performed daily for incurable lesions for which 
 they afford the only chance of recovery to the patient. The comparison 
 would not be justifiable if ovarian tumours were curable by less dangerous 
 operations ; but with the exception of a few cases which may be treated 
 by puncture or iodine injections, ovarian cysts, especially those that 
 are multilocular and complicated by the presence of solid tumours, 
 are necessarily fatal within a variable but short period. Death is 
 advanced rather than retarded by punctures and iodine injections. 
 Extirpation therefore is the only chance of safety for patients. Not 
 only is the rate of mortality greatly diminished, but peritonitis, the 
 accident most to be feared, has become much rarer, experience having 
 proved that extensive wounds of the peritoneum are not necessarily 
 fatal. It is more than forty years ago since Blundell, in a paper 
 printed in his I'hysiological Researches, tried to prove that the danger 
 of peritonitis consecutive to local lesions was exaggerated, and he 
 appealed from the opinion of his contemporaries to that of posterity. 
 When we consider the large wounds made by MacDowel, Walne, 
 Clay, Koeberle, Pean and others, in order to allow of large tumours 
 being extracted from the abdominal cavity without previous puncture, 
 we cannot doubt the comparative tolerance of the peritoneum for 
 long incisions. It is true that we regard the reduced size of the 
 incisions as a progress ; but the incision itself does not seem to 
 have a direct influence on the development of peritonitis. Spencer 
 Wells has recently proved by his remarkable success, not only that 
 peritonitis is not necessarily developed after operation, but further, 
 that pre-existing peritonitis or even the complication of pregnancy, do 
 not necessarily contra-indicate ovariotomy when performed by a skilful 
 surgeon. However exceptional this success may be it is too remark- 
 able not to be recorded here.^ 
 
 We have now to consider the question of the indications and contra- 
 indications for ovariotomy. 
 
 1. The indications become increasingly easy to determine. In this 
 respect there are tumours which may be left to themselves ; there are 
 some which may be treated by puncture or iodine injections ; and 
 others which should be extirpated ; whilst there are some which the 
 surgeon should leave alone for fear of compromising surgery by under- 
 taking impossible operations. It is right to remark that neither 
 puncture nor injections on the one hand nor ovariotomy on the other 
 ought to be applied to the treatment of all ovarian cysts indiscrimi- 
 nately, and it would be wrong to compare the results of the one 
 
 ^ Case. — Ovariotoinfiy performed successfully in the fourth month of pregnancy 
 after rupture of the cyst and peritonitis (the Lancet, Sept. 18, 1869. — Lyon 
 medical, 7 Nov., 1869). There are several other cases on record of ovariotomy 
 performed during pregnancy {Annales de Cfynecologie, viii, 153. Paris, 1877, 
 p. 1280). 
 
OVARIAN CYSTS 755 
 
 method with the other as an exclusive method. It appears to me on 
 the contrary rational to make a distinction between the cysts to which 
 puncture or iodine injections may be applied, and those which require 
 extirpation. — Puncture and iodine injections may be very successful in 
 simple serous unilocular cysts, only exceptionally developing formid- 
 able and fatal symptoms. If applied, on the contrary, to viscous, 
 purulent, complex, multilocular cysts they cannot ameliorate and 
 usually develop rapidly fatal symptoms. — Applied to cysts of the 
 first class ovariotomy is very frequently successful ; but it is not indis- 
 pensable, and as it may be followed by formidable accidents inherent 
 to the method itself, it should be reserved for more serious cases. 
 Applied, on the contrary, to cysts of the second class, or to those of 
 the first which have passed into the second from the ineffectual use of 
 punctures and injections, it is doubly superior to puncture and injec- 
 tion because it then becomes a rational means of treatment, and 
 besides is the only means of cure for a malady which puncture and 
 injection could only increase and render rapidly fatal. 
 
 Therefore, on the one hand puncture and injections may be 
 attempted in cysts of the first kind, because they may be curative 
 means or at least sufiiciently palliative, while their failure would not 
 absolutely prevent the application of the radical method of extirpa- 
 tion, although lessening the chances of cure. On the other hand 
 ovariotomy is the only practicable method for cysts of the second 
 class, to which puncture is only applicable as an exploratory means. 
 Such is, according to my opinion, the limit between the indication and 
 contra-indication of punctures or iodine injections, and such is the 
 limit between the contra-indication and the indication for ovario- 
 tomy. 
 
 2. As for the contra-mdications for ovariotomy there are some 
 which may be drawn from the age and strength, or on the contrary 
 from the extreme debility of patients; but these are not only 
 common to ovariotomy but to all operations of equal gravity. They 
 are not of less consequence on that account : for experience proves 
 that the danger of death. after ovariotomy depends more on the 
 general state of health than on complications of the malady, such 
 as the size of the tumour, adhesions and difficulties attending the 
 operation.^ Nevertheless, I shall only occupy myself with the special 
 contra-indications connected with the operation itself. One of these 
 is the existence of solid constituents and especially cancer in the 
 tumour, which may make pediculisation of the latter impossible or 
 relapse likely ; hence the utter inutility of the operation in such 
 cases. I know that Koeberle has set an example which might be 
 followed by removing the uterus as well as the ovaries and so 
 making pediculisation of the tumour absolutely possible. Some 
 day we shall perhaps enter on the path opened up by Atlee and 
 Clay for the extirpation of utero-peritoneal fibrous tumours. These 
 
 ^ Spencer Wells, 'Fifty Cases of Ovariotomy, second series. London, 1867 ; 
 from the Medico -Chirurgical Transactions, 1865. 
 
756 UTERINB DISEASES IN DETAIL 
 
 cases, however, are too exceptional to authorise our introducing 
 into practice precepts contrary to those which I think should form the 
 basis of these contra-indications for ovariotomy. 
 
 Another contra-indication is the number, extent and solidity of 
 adhesions (especially in multilocular cysts), either with the abdominal 
 wall or viscera, especially with those which are high up, such as the 
 stomach, liver, &c. I saw with Simpson a girl of 15 affected with 
 an enormous multilocular cyst, with viscous greenish-grey contents, 
 the puncture of which, after several sacs had been evacuated, did 
 not determine retraction at any point, from the epigastrium to the 
 pubis or from one flank to the other. It seemed imprudent to 
 attempt the extirpation of such a tumour, the adhesions of which 
 were so strong and so extensive, and yet the operation was performed 
 by Keith with complete success. Such adhesions, with the existence 
 of solid tumours, as well as errors of diagnosis may account for the 
 operations which were undertaken by some of the first ovariotomists, 
 but which could not be terminated. 
 
 Lastly, after having endeavoured to arrive at the most probable 
 diagnosis by all ordiuary means, especially by puncture, we may 
 attempt to convert this probability into certainty by an exploratory/ 
 incision ; for experience proves that, when carefully done, this incision 
 does not greatly increase the chances of death. Supposing that this 
 last element of diagnosis is in favour of operation the latter is in such 
 a case already begun, and the surgeon has only to continue it. 
 
 Freparatory treatment was considered a few years ago to have more 
 influence on the success of the operation than is now admitted. This 
 influence, however, although indirect is not the less real, and when the 
 operation can be delayed I think the preceding time should be taken 
 advantage of for putting the patient into the best possible conditions. 
 The best means for preventing the most dangerous accidents attending 
 ovariotomy, such as hseraorrhage, debility, suppuration and purulent or 
 putrid infection are: strengthening and nourishing diet; residence in 
 a bracing climate, baths followed by frictions and other hygienic mea- 
 sures ; to which we may also add the use of iron and other tonics. 
 Simpson attached great value to the latter agent in preparing patients 
 for operations, and preferred the tincture of the perchloride. The use 
 of iron preparations should not be reserved for the days previous to 
 operation ; it is quite as useful after ovariotomy. Like all other 
 serious operations the extirpation of ovarian cysts should be per- 
 formed when menstrual congestion has entirely passed, i. e. about 
 eight days after the cessation of the monthly period. Although 
 Koeberle performed an operation during the catamenial period and 
 succeeded, that is no reason for admitting that there is not more 
 danger in performing ovariotomy then than at another time. In order 
 that the intestines may have rest after ovariotomy, it is useful to 
 empty them not only by an enema but also by a mild purgative 
 given the day previous to operation. I agree with Koeberle in 
 preferring an ounce of castor oil, mixed with an ounce of syrup 
 of tartaric acid, followed in the evening by 30 to 60 grains of 
 
OVARIAN CYSTS 
 
 subnitrate of bismuth^ in order to decompose the sulphurous gases 
 remaining in the digestive canal. 
 
 The first operations having been performed before the discovery of 
 ausesthetics, the patients were not able to have the benefit of such 
 relief. But since its introduction into surgery no operator has failed 
 to employ it before proceeding to the extirpation of ovarian cysts. We 
 should remember that the opening of a large cavity like the abdomen 
 and its prolonged exposure to the air have a tendency to chill the 
 body considerably : therefore the chest and lower limbs should be 
 covered with warm flannel. 
 
 The operation strictly speaking is divided into six stages : abdominal 
 section ; puncture and evacuation of the cyst ; rupture of adhesions 
 and extraction of the ovary ; constriction and section of the pedicle ; 
 cleansing of the abdominal and pelvic cavities ; closing of the wound. 
 
 1. Abdominal section (\x\c\\xA\u^ that of the tegtinients and perito- 
 neum) is always made on the tinea alba. An incision of 4 or 5 inches 
 at equal distances from the umbilicus and pubis suffices as an explora- 
 
 FiG. 412. — Incision in the direction of the linea alba without touching the 
 peritoneum, enlarged with scissors guided by the index finger or the direc- 
 tor (after Savage, as well as the following figures relating to ovariotomy). 
 
 tory incision, and it can be increased when necessary. If circum- 
 stances require its being extended beyond the umbiHcus care should 
 be taken to direct it to the left so as to avoid the navel. In such 
 cases Koeberle incises the umbilicus directly, and if there is an umbili- 
 cal hernia he incises the sac at the same time to obtain a radical cure. 
 When the peritoneum is reached the incision presents some diffi- 
 culty. The wound should be kept dry by sponging and by seizing 
 with artery forceps the veins, which are sometimes very much deve- 
 loped, and which may give rise to profuse hemorrhage. Next it is 
 important to distinguish the peritoneum from the wall of the cyst. 
 
758 
 
 UTEEINB DISEASES IN DETAIL 
 
 The serous membrane is raised with a tenaculum hook or mouse- 
 toothed forceps, and a small opening is made through which an ordi- 
 
 /^^^^^, 
 
 Fig. 413. — Manner of opening 
 the peritoneum, whicli is 
 incised in the same direc- 
 tion and to the same extent 
 as the teguments. 
 
 Fig. 414. — The operator, by passing his 
 hand round in various directions 
 between the tumour and the peri- 
 toneum, assures himself of the 
 extent and nature of the adhesions 
 if there are any. 
 
 nary director or the index finger can pass from above downwards, the 
 serous membrane being divided by passing a bistoury or scissors along 
 the director so as to give the same extent to this incision as to that of 
 the teguments. 
 
 2. F^mctiire (preceded by separation of adhesions') and evacuation 
 of the cyst (^preventing at the same time the escape of the fluid into 
 the peritoneal cavity) constitute the second part of the operation. 
 Before performing these the hand should be passed between the ab- 
 dominal wall and the cyst to ensure there being no adhesions, any 
 slight ones which may exist being ruptured by the finger. The nature 
 of the tumour is verified at the same time, as well as the relative 
 size of the cysts composing it, as the largest and the one which should 
 be punctured first may not be directly opposite the abdominal opening. 
 
 Fig. 415. — Spencer Wells's ingenious trocar in the form of a wide tube, bevelled 
 of£ at one of its extremities into a very sharp point which makes 
 the puncture ; towards its central part there is a circular and notched catch, 
 into which fit two strong semicircular claws, which retain the cyst on a 
 level with the puncture ; the other extremity is furnished with a raised 
 border, to which a large india-rubber tube can be fastened, allowing of the 
 rapid evacuation of the fluid without its escaping externally. 
 
 We should, however, beware of using much force in separating 
 adhesions, especially if there is reason to suppose that the wall of the 
 cyst is thin, as there would be a risk of rupturing it and of determin- 
 ing evacuation of the whole of the fluid into the abdominal cavity. 
 
OVARIAN CYSTS 
 
 759 
 
 After this exploration has been made the cyst is punctured. The 
 best instrument for the purpose is Spencer Wells's trocar, the point of 
 which is hollowed out into a tube, like the cannula, and may be con- 
 tained within the latter, or project beyond it according to the wish of 
 the operator, and the cannula of which itself holds a secondary 
 cannula, soldered on to it at right angles and furnished with an 
 india-rubber drainage tube, at the extremity of which is a weight, 
 directing it into a tub placed on the right-hand side of the bed ready 
 to receive the fluid from the cyst. The instrument has a sufficient 
 diameter to allow of the fluid, which is usually thick and viscous, 
 being discharged without difficulty. As the cyst is emptied care 
 should be taken to keep the edges closely applied to the cannula of 
 the trocar, lest the contents should escape into the abdomen. Evacu- 
 ation of the fluid is then completed without further precaution ; any 
 other secondary cyst or chamber, which is too much distended to 
 
 Fia. 416.— Puncture o£ the tumour by means of the trocar and syplion cannula. 
 
 allow of the passage of the tumour through the abdominal orifice, is 
 punctured in the same manner, and in this way (unless there are 
 solid tumours or a considerable agglomeration of small cysts) we 
 are able to make the ovary supple and mobile enough to allow of 
 its passing, when drawn carefully little by little, through the abdomi- 
 nal opening. If this evacuation is too slow it is better to enlarge 
 the opening of the sac and even the abdominal incision with the 
 bistoury, in order to facilitate the escape of the cyst, than to lose 
 time and run the risk of haemorrhage by^ puncturing the secondary 
 cysts. 
 
 3. Extraciion of the cyst (assisted hj ramug the cyst and hr-eaking 
 
760 UTJlEINl!; DISEASES IN DETAIL 
 
 ^lp secondary cysts, and especially by tlie rupture of adhesions^ may 
 be very simple or very complicated. The breaking up of secondary 
 cysts and the raising of the tumour do not present serious difficulties, 
 but it is different with regard to adhesions. When adhesions do not 
 exist or are few and unresisting, extraction of the cysts is playwork. 
 When, on the contrary, they are numerous and resistant this part of 
 the operation may become dangerous, necessitating manceuvres which 
 may afterwards determine serious accidents compromising the success 
 of the operation. When I have finished the description of the opera- 
 tion I shall speak of the conditions which may make it impossible 
 for the surgeon to terminate it ; but for the present I take for granted 
 that it can be accomplished. This result is obtained more frequently than 
 formerly, as the operator does not now allow himself to be discouraged 
 by the existence even of very firm adhesions except that he leaves 
 
 Fi&. 417.— Method of preventing tbe escape of the fluid into the abdominal 
 cavity from the opening made by the trocar. An assistant with both hands 
 aids the withdrawal of the cyst. 
 
 portions of the cyst on the organs to which they adhere. Experience 
 has proved that success may be obtained even in apparently very un- 
 favorable circumstances. But great precautions should be taken in 
 the rupture or dissection of these adhesions, not only of those which 
 unite the cyst to the abdominal wall and epiploon, but especially of 
 those which unite it to the intestines, stomach, liver, spleen, or 
 pelvic cavity, to the uterus, other ovary, bladder, &c. We not only 
 run the risk of injuring these organs, and in such a case it is 
 better to leave a portion of the cyst, which should be cut off round 
 the adhesion, making it as thin as possible ; but we also risk 
 causing haemorrhage, and this is why we should try to staunch 
 the blood, tying all the djyided vessels which threaten a secondary 
 hsemorrhage, either on the epiploon, where this most frequently occurs, 
 or elsewhere. Sometimes we must first of all search for the pedicle, 
 
OVAEIAN CYSTS 
 
 761 
 
 and ligature it if possible before destroying the adhesions in order 
 to stop the hsemorrhage. After having succeeded by this manceuvre 
 
 Fig. 418. — The operator Is obliged 
 to complete the withdrawal 
 of the cyst by the introduc- 
 tion of the other hand below, 
 with which he raises the 
 cyst. 
 
 Fig. 419. — The operator reduces the size of 
 a multilocular cyst incompletely evacuated 
 by breaking up the remaining cysts with 
 his hand, which he introduces into the 
 interior, keeping hold at the same time of 
 the borders so that the fluid cannot escape 
 into the peritoneum. 
 
 in isolating the whole of the cyst, or in removing successively the 
 various fragments of the tumour which are detached (of which I have 
 given examples), the rest of the tumour is drawn outside the abdominal 
 opening, which can be enlarged when necessary, and the pedicle is 
 seized firmly. At this difficult and dangerous period of the operation 
 we must not fear to give the necessary time required. The gravity 
 of ovariotomy is always in proportion to the complications that it 
 presents, and the best means of diminishing the influence of these 
 complications is the use of the most effectual methods ; now, rupture 
 of adhesions and hemostasis after this rupture, either by momentary 
 compression (by artery forceps) or by astringents (alcohol, perchloride 
 of iron, &c.), by the cautery, or by metallic, silk, or catgut liga- 
 ture, are necessary proceedings to prevent troublesome results from 
 these local complications. Tlie actual cautery and the short ligature 
 are the most certain hemostatics. 
 
 . 4. The fourth part of the operation is the constriction and section of 
 the pedicle which varies according to whether the pedicle is retained in 
 the angle of the wound or is returned to the pelvic cavity. It may be 
 that we have no choice as to the various methods successively emjjloyed 
 to attain this end, and if the pedicle is short, or if it cannot be 
 lengthened artificially by applying constriction to the base of the cyst 
 
762 
 
 UTERINE DISEASES IN DETAIL 
 
 when firmly folded in place of applying it to the utero-tubo-ovarian 
 pedicle, it is necessary to employ one of the means which I shall describe. 
 At first it was thought better to keep the pedicle attached to the abdo- 
 minal wound and as much as possible outside this wound, in order to 
 avoid suppuration in the pelvic cavity. Although Tyler Smith's success 
 seemed to remove all ground for exaggerated fears on this point 
 Langenbeck was the first who laid down and applied this precept. 
 
 One suture may be passed at once through 
 the pedicle and the two lips of the lower 
 angle of the wound, or the pedicle may 
 be retained at this point by a strong 
 needle or it may simply be compressed 
 against one of the lips of the wound or 
 against the neighbouring portion of the 
 abdominal wall (when it is too short), 
 by means of the ingenious method of 
 acupressure invented by Simpson.^ But 
 the clamp or clipper invented by Hutchiu' 
 son in 1838 is preferable. Koeberle also 
 has a clamp, but he prefers his serre- 
 noeuds. The most convenient of these 
 instruments is one which I have seen 
 Spencer Wells use. Constriction should 
 be made carefully, not only to prevent 
 consecutive haemorrhage but also be- 
 cause tetanus has been occasionally de- 
 veloped from incomplete constriction of 
 the pedicle. Cases of death from 
 tetanus have occurred after ovario- 
 tomy. {Annales de G^necologie, t. xi, 
 p. £31.) 
 
 Whatever method be employed, all that 
 remains to be done to complete the ex- 
 traction of the cyst is to cut the corre- 
 sponding portion of the pedicle, at five 
 or six millimetres from the constriction. 
 
 When the pedicle is very short and 
 cannot be drawn into the lower angle 
 of the wound on a level with the in- 
 tegument without considerably twisting 
 or dragging tlie uterus it has necessarily 
 to be left at a more or less considerable 
 depth. If it is thin, if it can be com- 
 pressed by a thread in one or two liga- 
 tures, and if it can be cut close to the 
 thread, I see no reason against imitating Tyler Smith and letting 
 it fall back into the pelvis, except in those cases in which the 
 
 ' Acupressure, a New Method of Arresting Surgical Hemorrhage, &c. 
 Edinburgh, 1864. 
 
 Fig. 420. — Clamp, the handles 
 of which may he re- 
 moved by the catches, 
 A A, It resembles that of 
 Spencer Wells, except in 
 the absence of the small 
 triangular blade which re- 
 stores the parallelism of 
 the branches when they 
 are close together. 
 
OVARIAN OTSTS 763 
 
 rupture of numerous adhesions may lead us to fear the establishment 
 of suppuration. In the contrary case, especially if it is necessary to 
 apply more than one ligature, or to extirpate both ovaries and there- 
 fore to multiply the ligatures, I think it is better to keep the threads 
 in the lower angle of the wound, stretching them by means of an 
 india-rubber catheter or director passed through the loops of the 
 various ligatures and resting across the wound so as to retain them 
 with more or less force against the teguments, or to maintain constric- 
 tion of the pedicle by means of a serre-noeud as Koeberle does.^ This 
 surgeon interposes between the lower portion of the lips of the abdo- 
 minal incision two valves of lead, intended to prevent the occlusion of 
 the wound before the end of suppuration, to keep open a kind of drain 
 for promoting the escape of fluid and pus, and to isolate this from 
 the rest of the abdominal cavity, and especially from the rest of the 
 wound. Section of the pedicle by the ecraseur has even been proposed 
 which would facihtate union of the wound and prevent the drawback of 
 leaving the ligature of the pedicle in its lower angle ; but I confess 
 that I should be too much afraid of secondary haemorrhage from the 
 arteries of the pedicle to venture to prefer this means to those just 
 described, or to section of the pedicle by the cautery, or to its return to 
 the pelvis with a short ligature. Netzel, of Stockholm, who has em- 
 ployed the clamp forty -seven times, and cauterisation eight times, as 
 
 Fig. 421. — Tumour, just witMrawn, is held by an assistant so as to prevent 
 laceration of the pedicle, whilst the operator compresses it in a metallic 
 clamp and divides the pedicle with the actual cautery. 
 
 well as the silk ligature left in the pelvic cavity with the stump of the 
 pedicle, prefers the latter method {Annales de Gijnecologie, t. ix, p. 
 464). Terrier once found in a ])atient who died two years after ovari- 
 
 * Ligature of the pedicle in omj or two masses separated by double iron wire 
 by means of Kceberl6's little serre-noiud may be adopted as a general method. 
 
764 UTEfilNB DISEASES IN DETAIL 
 
 otomyj two silver sutures, which could not be removed at the time of 
 the operation. They were discovered in the midst of the cellular 
 adipose tissue dragged to the side of the peritoneal cavity by the 
 retraction of the epiploon^ not encysted, slightly blackened by the 
 sulphide of silver, surrounded on every side by adipose cellular tissue 
 and perfectly tolerated; a fact which authorises our giving the preference 
 to the short ligature {Annales de Gynecol., t. vii, p. 459). Alban Doran 
 has seen exudations of plastic lymph surrounding and isolating the 
 pedicle in a woman of 37 who died of septicsemia six days after 
 ovariotomy, whilst in another woman operated on by Bantock the 
 hempen thread had disappeared seven months after the operation and 
 the pedicle had contracted adhesions with the epiploon and the broad 
 ligament {St. Bartholomew'' s Hospital Reports, vol. xiii, p. 195, 1877). 
 Now that antiseptic precautions are taken the clamp is seldom used, the 
 pedicle being returned to the pelvis after having been compressed by a 
 strong ligature which is cut close to the section of the pedicle, or 
 cauterised with the actual cautery whilst constriction is maintained by 
 means of Baker-Brown^s clamp. This latter method is chiefly employed 
 when the pedicle is short and broad, and has often been used by 
 Baker-Brown, Krassowsky, Pean, and Koeberle. In order to liberate 
 the pedicle after it has been cauterised the clamp should be loosened 
 slowly, and without shaking, so as to avoid lacerating the walls of the 
 compressed vessels. The short ligature may be ot catgut, silk, or 
 metal, single or multiple, according to the size of the pedicle. 
 
 The other ovary should then be examined and should be extirpated 
 if it is found to be the seat of commencing disease. At other times it 
 is plain from the beginning that the case is one for double ovariotomy. 
 Winkler of Dresden has even had to perform a triple ovariotomy 
 necessitated by the presence of a supernumerary ovary also the seat of 
 a cyst [Ann. de Gynecol. , t. xi, p. 74). 
 
 5. Cleansing of the abdominal and pelvic cavities.— \l\i\QQA, cjstic 
 fluid, clots or fragaaents of the tumour are still found in the peritoneal 
 cavity they should be removed most scrupulously. English surgeons 
 rightly ascribe a great deal of their success to this precaution. There 
 need be no fear of introducing the hand several times into the pelvic 
 cavity and of afterwards applying thoroughly clean sponges, in order 
 to ensure the peritoneum being perfectly dry, and by sufficient delay or 
 the application of fresh ligatures to prevent consecutive haemorrhage. 
 It is however right to mention that Koeberle is not so strict with regard 
 to the cleansing of the peritoneum ; he uses soft napkins and hot flan- 
 nels in preference to sponges. 
 
 6. The last part of the operation is union of the lips of the wound, 
 which should take place if possible by first intention. Care is taken 
 to replace the epiploon and intestines into the abdominal cavity if they 
 have escaped. (During the operation an assistant is entrusted with the 
 task of pushing them back with hot wet flannels whenever they present 
 themselves at the upper angle of the wound.) The pedicle, well com- 
 pressed and cauterised, is either left in the pelvic cavity or else main- 
 tained by the clamp in the lower angle, the lips of the wound are then 
 
OVARIAN CYSTS 
 
 765 
 
 seized and the suture applied in superimposed layers, i.e. a deep and a 
 superficial suture. Koeberle used lo employ the quilled suture for the 
 deep suture, but now contents himself with the interrupted suture not 
 involving the peritoneum. The simple zigzag suture may also be used 
 after the manner of the English surgeons. Spencer Wells, who only 
 leaves the sutures in place for the few days necessary for union, 
 merely uses ordinary strong thread. The ends of each suture are 
 passed through the eyes of two needles and he then pushes each needle 
 alternately from the peritoneum (at five or six millimetres from the 
 incision) to the skin (at the distance of about from two to three centi- 
 metres from the wound), he then secures the two ends on the line of 
 union. The sutures are placed at the distance of two centimetres apart. 
 
 Fig. 422. Fig. 423. 
 
 Pig. 422. — The method of passing the needle for the metallic suture, including 
 
 the peritoneum. 
 Fig. 423. — Wound closed, edges united, pedicle secured hy a permanent clamp. 
 
 and in the intervals a few superficial sutures are passed. The last deep 
 suture passes close to the clamp so as to retain the pedicle in place 
 without piercing it. The other London surgeons whom I have seen 
 operate do not pierce the peritoneum and make use of silver sutures. 
 Simpson employed iron wire, which he left indefinitely in the wound. 
 Like Spencer Wells, Simpson and Keith included the peritoneum in 
 the suture, and I have always done the same. Since 1874 Kreberle 
 leaves the peritoneum, only piercing the fibrous tissues by a deep inter- 
 rupted suture, the ends of which directly cross the wound, and he uses 
 a harelip suture to unite the skin. The pins of this harelip suture 
 only remain in place for twenty-four hours and are then replaced (with 
 the exception of the last which remains) by a dry collodion suture which 
 remains solid for four weeks. The deep sutures fall from the eighth to 
 the fifteenth day. 
 
 We have now to speak of the immediate results of ovariotomy as 
 regards the operation and the means for preventing or overcoming 
 accidents. The knowledge of these means is all the more important, 
 as all ovariotomists agree in thinking that it is to the after-treatment, 
 in a great measure, that the success of the operation is due. Acci. 
 
766 UTERINE DISEASES IN DETAIL 
 
 dents may occur even during operation. Nussbaum once divided the 
 right ureter ; Simon and Tauffer of Pribourg the left ureter {Annates 
 de Gynec, vii, 466. Paris^ 1877). Nussbaum made an artificial 
 ureter, Tauffer sutured the upper border of the bladder, and the 
 patient recovered ; Simon performed nephrotomy successfully. 
 Chambers wounded the intestine and cured it by a continued suture 
 two inches in length ; in another case of intestinal wound he was 
 equally successful {Lancet, 1877, p. 312). Lyon {Glasgow Med. 
 Journ., 1868) has seen an abnormal anus formed after an intestinal 
 wound which in spite of energetic treatment was not cured at the end 
 of a year. Keith {Glasgow Med. Journ., 1869, No. 2) has seen an 
 intestinal fistula origuiating in the same way and persisting after 
 twenty-five months. Spencer Wells (id., No. 86), Atlee {American 
 Journ. of Med. Science, 1872), and Hennig {Archiv fur Gynaec, 
 iii, 287) have observed analogous cases. Heath {Lancet, 1871, 
 Nos. 4 and 11) has seen an abnormal anus follow an intestinal wound 
 made directly with scissors. Elischer {Centralblatt f. Gynaecol., 1877, 
 p. 204) has observed an analogous case : the wound was sutured, cure 
 following immediately. Pean has twice wounded the intestine : in 
 such cases the wound should be united with sutures of carbolised cat- 
 gut, and this portion of the intestine must be retained near the lower 
 angle of the wound, as in Chambers's case. If the bladder is injured 
 the edges should be sewed together and a catheter left in the urethra. 
 This accident happened to Lauffer once and the patient recovered ; 
 to Pean once, his patient also recovered ; once to Henry Smith, when the 
 accident ended fatally ; twice to Spencer "Wells, one patient recovered, 
 the other died ; three times to Thornton, in two cases recovery was 
 rapid, the other patient died ; once to Bantok, the patient died ; once 
 to Eustache, when the patient recovered (Eustache, De la lesion des 
 organs icrinaires pendant I'operation de Vovariotomie. Journ. des 
 Sciences med. de Lille, 1880). 
 
 The most formidable accidents after operation are : shock, exhaustion, 
 haemorrhage, accumulation of pus, purulent infection, and lastly peri- 
 tonitis, which according to some surgeons is the most frequent accident, 
 whilst Spencer Wells, on the contrary, thinks it rarer than either puru- 
 lent or putrid fever, or exhaustion. According to Marion Sims septi- 
 Ccemia is the most frequent cause of death; therefore he advises 
 perforation of Douglas's cul-de-sac and Lister's antiseptic dressings. 
 
 Anaesthesia is one of the best means of preventing shock ; when 
 it occurs the patient should be covered with flannel and have hot- water 
 bottles placed at the extremities to warm her ; anti-spasmodics may 
 be administered when necessary, or stimulants, such as wine, brandy, 
 carbonate of ammonia. Exhaustion should be prevented by perfect 
 rest and by giving small quantities of beef tea and wine, as well as 
 tonics, remembering that the risk of hemorrhage and peritoneal in- 
 flammation requires us to prescribe a somewhat strict diet for some 
 days in order to give absolute rest to the digestive canal, Tyler Smith 
 carries precautions so far as to leave a catheter in the bladder in order 
 to avoid the movements necessitated by micturition. Uterine and in- 
 
OVARIAN CYSTS 767 
 
 testinal cramp, hiccough and vomiting may be developed, placing 
 patients in danger by rupturing sutures, and the same may be said of 
 tympanitis. They should be soothed by means of chloroform or other 
 ansestheticSj and antispasmodics. In order to prevent the fluxionary 
 abdominal movements, which may determine haemorrhage, or the deve- 
 lopment of peritonitis, Kceberle applies ice to the abdomen in two 
 bladders placed one on each side of the wound for a few days. I'have 
 never seen this precaution used by English surgeons, and their patients 
 do not succumb any oftener than others to the accidents which the con- 
 tinuous application of ice seems fitted to prevent. It is of great 
 importance to ensure rest to the intestines and to prevent all movement 
 and dragging in the belly which could draw down the pedicle, rupture 
 the healthy adhesions established in the wound, or by repeated dis- 
 placements of the organs produce hsemorrhage or peritonitis. This 
 condition is fulfilled by covering the abdomen with cotton wool and a 
 bandage, which maintains it in a state of absolute immobility by 
 moderate but methodic compression. It is also fulfilled by the 
 administration of opium or morphia. Kceberle is in the habit of 
 giving morphia to all his patients after operation. In England, how- 
 ever, narcotics are only resorted to when there is pain or sleeplessness. 
 During the course of peritonitis it is useful to empty the stomach and 
 to wash it out with the cesophageal sound, and to retard organic 
 fermentation by the administration of sulphate of quinine (Kceberle). 
 Alcohol and opium associated with anti-emetics have been of great 
 service to me in these circumstances. 
 
 Lastly, there is an accident which it is important to prevent or 
 subdue, that is, suppuration of the wound itself, which may gradually 
 produce that of the peritoneum ; the accumulation of pus is not long 
 in engendering septicaemia or pygemia ; suppuration or rather putre- 
 faction of the pedicle mortified by constriction is sufBcient by contact 
 or absorption to produce not only inflammation of the peritoneum but 
 purulent and putrid fever. Hence the necessity of maintaining great 
 cleanliness of the wound by dressings repeated three times a day, by the 
 frequent change of lint, by removing some of the sutures the first day, 
 and others the fourth or fifth day when they are not metallic, by laying 
 little bags filled with absorbent powders, such as calcined oyster shells 
 and quinine, rhubarb and chalk, magnesia and cinnamon (Spencer 
 Wells), on the parts from which fluid is oozing out; lastly, by mum- 
 mification of the pedicle painted with caustic perchloride of iron 
 (Koiberle, Keith, Simpson), and even by irrigation of the wound and 
 neighbouring parts which threaten to become inflamed with an aqueous 
 solution of sulphate of iron (Kceberle). 
 
 If in spite of these precautions pus is produced in the pelvic cavity, 
 its accumulation should be prevented either by the introduction of a 
 glass tube or a vulcanised caoutchouc drainage tube through the lower 
 angle of the wound (Kojberle), or by drainage giving exit to the pus 
 by the posterior vaginal cul-de-sac ^ as performed by Spencer Wells, 
 
 1 The drainage of the peritoneal cavity by Douglas's cul-de-sac has been 
 practised by Peaslee {Americ. Journ. of Med. Science, 1856, 1863 and 1864). 
 
768 UTEEINE DISEASES IN DETAIL 
 
 Koeberle, or Pean. The latter surgeon pierces the md-de-sac twice 
 from within outwards by means of a trocar, guided by the finger 
 passed through an incision made above the crural arch, and leaves in 
 it an india-rubber tube, the loop of which^is in the retro-uterine cavity 
 whilst the two ends hang from the vagina. As a rule, however, peri- 
 toneo-vaginal drainage has been abandoned for peritoneo-abdominal 
 drainage which is rightly considered quite as useful and less dangerous. 
 T^ortunately the antiseptic treatment, i.e. the application of Lister's 
 method to ovariotomy (during operation as well as in the dressings) 
 by diminishing the chances of septicaemia, has given fresh guarantees 
 of success to ovariotomy. 
 
 To sum up, the dangerous accidents of ovariotomy seem to be san- 
 guineous oozing into the peritoneum and the accumulation of pus 
 followed by septicaemia. We must therefore try to prevent the devel- 
 opment of these accidents. 
 
 Keith's great success is apparently due to the application of as 
 many hemostatic ligatures as the sanguineous oozing necessitates, to 
 peritoneo-abdominal drainage when indicated, and to the use of Lis- 
 terism, both preventive and consecutive, other circumstances being 
 seemingly secondary to this kind of therapeutic tripod on which the 
 operative success of ovariotomy appears to rest.^ It is needless to add 
 that supposing the consequences of operation have been benignant 
 and that nothing has hindered the regular course towards cure, the 
 quantity of food administered to the patient ought only to be in- 
 creased gradually, and the permission to rise, and especially to walk, 
 ought to be delayed as long as possible, for it should always be 
 remembered that a certain time is required to give to recent adhesions 
 sufficient firmness to enable them to withstand the various movements 
 natural to women in normal health. 
 
 I have mentioned the itnpossihility of terminating operation as one 
 of the most serious accidents of ovariotomy. This danger becomes 
 less frequent every day. It is evident that if adhesions absolutely 
 prevented the extraction of the cyst it would be necessary to reunite 
 the lips of the abdominal wound and to enclose the walls of the cyst 
 in such a way as to make them adhere to it, either by trying to obtain 
 the obliteration of its opening, which would turn the operation into 
 one of simple puncture, or by leaving the orifice of the cyst open, by 
 enlarging it even, and so preserving the possibility of introducing into 
 its cavity various alterative fluids or perchloride of iron, which would 
 almost reduce the operation to incision of the cyst, as advised by 
 Ledran and performed by several modern surgeons, but, according to 
 Tock's statistics, not very successfully. 
 
 Pean has brought this method again into favour by his success in 
 cases where he could not complete extraction : in order to succeed, it 
 is very important to make the borders of the cyst adhere exactly to 
 
 ' Mr. Lawson Tait has poibliahed an account of 186 cases of abdominal 
 section he has performed since Nov., 1879, with only 14 deaths. _He has entirely 
 abandoned Lister's antiseptic treatment, considering^ that it is productive of 
 more harm than good (Paper read before the Birmingham Branch of the Brit. 
 Med. Assoc, Nov. 11, 1880.— Med. Times and Gazette, Nov. 5, 1881.— Trans. 
 
OVARIAN CYSTS 
 
 769 
 
 the edges of the abdomiDal wound and to prevent all communication 
 with the peritoneal cavity. Before these surgical improvements exci- 
 sion of a portion of the cyst had only given poor results/ therefore 
 when it is possible we should try to reduce the operation, by the exact 
 union of the wound, to the conditions of a simple puncture. 
 
 The remote consequences of ovariotomy are usually as satisfactory as 
 could be desired. Patients recover perfectly, perform all their func- 
 tions and regain flesh. I have seen some who had been operated on 
 ten years previously and who had been in perfect health ever since. 
 Nevertheless painful sensations of dragging may persist for some time, 
 due to the slight displacement undergone by the uterus, to the adhe- 
 sion of the pedicle to the abdominal wall and to cicatrix of the 
 ovarian ligament. I have seen patients in whom, owing to defective 
 union of the linea alba at some point below the skin, there existed 
 real eventration and enterocele of the linea alba, the retention of which 
 necessitated the use of a belt or a bandage with a large pad similar to 
 
 Fig. 424. — Appearance of the abdomen with cicatrix three weeks after extirpa- 
 tion of a small ovarian cyst without adhesions (after Spencer Wells). 
 
 the umbilical bandage. When both ovaries have been removed men- 
 struation does not return and there is absolute sterility ; but when one 
 only has been extirpated, menstruation returns after operation, resum- 
 ing its usual course. In the latter case conception may take place 
 and be followed by normal pregnancy. 
 
 ' See Clay's statistics at the end of his translation of Kiwisch. 
 
 49 
 
770 UTERINE DISEASES IN DETAIL 
 
 More than twenty of Spencer \Yells^s ' patients, three of Koeberle's, 
 and several operated on by other surgeons have become pregnant, and 
 each time the pregnancy has terminated normally; the first patient 
 operated on by Koeberle (June, 1863) has had seven children since, 
 two of which were twins. A woman operated on by Lane, who had 
 had an abundant suppuration and phlebitis for fifteen days previously, 
 has had five children since. 
 
 Lastly, relapse, i.e. development of the disease in the other ovary, 
 lias sometimes been observed. Atlee, Bird, Spencer Wells, Boinet, 
 Joiion of Nantes have had to extirpate a second ovarian cyst some 
 months and even years after ablation of the first in the same patient. 
 Out of seven operations performed on the second ovary, Spencer 
 Wells has had five successes. The integrity of the tissues correspond- 
 ing with the cicatrix of the first operation was ascertained, no trace of 
 the latter being discovered in the majority of cases. Once even, as I have 
 already mentioned, a triple ovariotomy was successfully performed. 
 
 Ylil. Exiirj)atio7i of normal ovaries. — This operation, which is 
 nothing else than castration, and which has received the name of 
 Battet/'s operation, or that of normal ovariotomy, has been performed 
 so often on various occasions that there can be no doubt as to the 
 possibility of terminating it successfully, and of saving patients in a 
 o-reat number of cases. In 1863 Kceberle performed this operation 
 and recommended simultaneous extirpation of both ovaries and of the 
 womb in cases of hysterectomy or supra-vaginal amputation of the 
 uterus when attacked by fibrous tumours. Nevertheless till 1872 no 
 gynsecologist had proposed the extraction of apparently healthy ovaries 
 (or castration) with the sole object of modifying disorders of innerva- 
 tion, the starting-point of which seemed to be in the organs them- 
 selves. It was at this time that Battey performed what he calls 
 normal ovariotomy, '^with the object," he says, "of producing an 
 artificial change in the conditions of existence, and of suppressing 
 maladies which may depend on them, such as neuralgia, dysmenor- 
 rhoea, hysteria, mental derangement,'" &c. According to this surgeon 
 the indications for the operation are : " 1, absence of the uterus and 
 serious permanent disorders caused by the presence of the ovaries; 
 2, obliteration of the uterus and vagina beyond the possibility of 
 restoration; 3, the exceptional gravity of nervous, hysteriform and 
 epileptiform disorders depending on an ovarian affection and resisting 
 ail ordinary means of treatment; 4, mental and physical sufferings 
 produced by congestion of the ovaries which have resisted all treat- 
 ment" {Transact, of the American Gmiecol. Soc, 1876). In 1878 
 Battey had performed a dozen ovariotomies (two by the abdomen, 
 the others by the vagina) with the object of curing obstinate 
 nervous affections; in four cases there was complete cure, in six cases 
 the result was nil, in the remaining two the patients died. 
 
 Another indication is uncontrollable metrorrhagia, especially dan- 
 gerous catamenial haemorrhage. Hegar of Tribourg, who, in 1876, 
 
 1 Gaz. med. de Paris, 20 Oct., 1869. Since then the number of these cases 
 Las considerahly increased. 
 
OVARIAN CYSTS 771 
 
 removed the ovaries of two women affected in this way, with the object 
 of arresting the loss of blood and of putting a stop to the congestion 
 dependent on ovulation, performed the operation "by the abdomen with 
 short ligatures, and had the satisfaction of saving his patients after 
 having seen them pass through the greatest danger. Sims, out of 
 seven operations by the abdomen, saved six patients; but out of 
 four operations by the vagina for dysmenorrhoeic ovarialgia, he lost 
 all [Bid. de med. et de cJiir., art. Ovaire). 
 
 If the efficacy of castration in the case of nervous affections is 
 problematical, there is hardly any doubt as to the services this 
 operation might render by bringing on the menopause prema- 
 turely in women affected with dangerous hsemorrhage. This is the 
 opinion of Sims, Hegar, and of several others {Medical Times and 
 Gazette, 1877). Goodell [American Journal, July, 1878) also per- 
 formed castration for a large posterior fibroma with symptomatic 
 menorrhagia ; after eight months the hsemorrhage had ceased, the 
 tumour had diminished to less than half its size, and the patient^'s 
 health was excellent. Exceptionally, menstruation has continued after 
 castration. Goodell mentions two cases of double normal ovariotomy 
 in which a more or less regular and abundant discharge of blood like 
 menstruation continued afterwards; but in seventy-eight other cases or" 
 ablation of both ovaries collected by the same writer menstruation was 
 completely suspended. Unfortunately the operation, serious as it is by 
 the abdomen, is still more so by the vagina on account of the adhe- 
 sions and variations in the size and position of the ovaries, which have 
 always suffered from inflammatory or other maladies when operation is 
 indicated, and which are therefore far from being in the favorable con- 
 ditions in which the same organs are when they have never been 
 diseased. Goodell rejects Battey's expression of normal ovariotomy, 
 preferring that of castration. Trenholme had a case [Obstet. Journ,, 
 Oct., 1876) in which both ovaries were removed and the pedicles left 
 in the abdomen, with the object of diminishing uterine fibroids, by 
 taking from them their means of existence by the suppression of erec- 
 tion and of the monthly ovarian congestion which react on the whole 
 genital economy. It is certainly very problematical; nevertheless two 
 cases of Hegar's and one of Nussbaum's seem to justify the idea. 
 Goodell also has performed it with the same object and operates in 
 the following way. The vagina is depressed by a Sims^s speculum 
 whilst a fold of the mucous membrane is seized by a tenaculum hook 
 behind the cervix. An incision of 4 centimetres is made there with 
 Kiichenmeister's scissors; the peritoneum is then divided and the 
 index finger of the left hand being introduced, it follows the course of 
 the l^allopian tube, hooks the two ovaries successively, seizes them 
 with a pair of fenestrated forceps and brings them into the vagina 
 where they are hgatured and excised. Their pedicles are firmly liga- 
 tured with antiseptic silk and replaced in the pelvic cavity. There is 
 little haemorrhage and no suture in the vaginal wound. In Goodell^s 
 operation which I have just mentioned the fibroid was discovered with 
 great difficulty six months afterwards, although previously it had been 
 
772 UTERINE DISEASES IN DETAIL 
 
 very painful and had formed one body with the uterus in acute anti- 
 flexion. As for the other cases of dangerous hsemorrhage and of 
 nervous, organic or psychical symptoms which have withstood all 
 means of treatment, I do not see any formal contraindication. Opera- 
 tion may also be indicated when the life of the patient is endangered 
 by a malady which no other treatment can cure. In spite, however, 
 of the advantage presented by operation by the vagina, if we were 
 certain of finding the organs in normal condition, the absence of certi- 
 tude is a sufficient reason for preferring operation by the abdomen. 
 
 IX. Mxtirpation of fibrous tumours and of the uterushy gastrotomy. 
 — Gastrotomy has also been applied to the ablation of large uterine 
 sub-peritoneal myomata, either in consequence of an error of diagnosis 
 which led to the discovery of a fibrous tumour in place of the ovarian 
 cyst which was expected, or else from the express desire to apply the 
 radical cure of the latter malady in the treatment of the former. The 
 first attempt at extirpation of the uterus and of peritoneal fibromata 
 was made by Heath (of Manchester) in 1843, in consequence of an 
 error of diagnosis ; he thought he had a case of ovarian cyst ; the 
 patient died. The first successful operations were performed by two 
 American surgeons, Barnham in 1853, and Kimball in 1855. Some 
 years ago. Clay (of Manchester), believing that he had to do with a 
 multilocular cyst and discovering instead uterine fibrous tumours, 
 removed the uterus, or at least the fundus of the organ with the 
 tumours, ovaries and Fallopian tube, after having applied a strong 
 ligature to the cervix immediately above the vaginal insertion which 
 he retained in the inferior angle of the wound till it fell : the patient 
 was cured. The fibroids with the portion of uterus and the ovaries 
 weighed eight pounds ; the anatomical preparation is in Edinburgh.^ 
 About the same time Koeberle successfully extirpated a uterine fibroid 
 and the two ovaries, also amputating the whole of the supra- 
 vaginal portion of the womb.^ This operation which at first was called 
 liysterotomy has sioce received the more correct name of hysterectomy, 
 since it is a question of extirpating and not only of dividing the uterus. 
 In my opinion we do not yet possess a sufficient number of cases to 
 authorise our forming a judgment as to the justifiabiHty of the opera- 
 tion,3 but I must admit that the number of successful cases seems to 
 increase in proportion to the number of operations performed and with 
 improved methods. Amongst the encouraging cases I may mention 
 that of Storer (of Boston) quoted by Koeberle which was followed by 
 cure ; one of Spencer Wells's,^ in which the fibroma was separated from 
 the fundus of the uterus by linear ecrasement, haemorrhage was 
 arrested by ligature and the point of section of the womb was retained 
 in the lower angle of the wound ; the patient recovered ; that of Tran- 
 holme in which there was ablation of the uterus and both ovaries for a 
 fibro-cystic tumour in a negress of about 40, who recovered and soon 
 
 1 London Med. Gaz., 18 April, 1863. 
 
 2 Communication to the Acad, des Sciences, 15 June, 1863. 
 
 ^ Pozzi, Valeur de I'hysterotomie dans le traitement des tumeurs fibreuses 
 de I'lderus. Paris, 1875. 
 * Med. Times, 1871. 
 
OVAEIAN CYSTS 773 
 
 afterwards resumed marital intercourse [Ha^/etn Revue, t. v,pp. 1 79, 761); 
 Tillaux's case [Annates de Gynecol., 1879, t. xii, p. 118) of uterine 
 fibroma in the left lateral wall with dangerous hsemorrhage, unbearable 
 pain, intestinal occlusion from compression, extirpation and success \ 
 Kimball's successful case {Annales de Gynecol, t. ix, p. 61), which 
 however did not prevent the operator from condemning hysterectomy 
 at the Congress of Chicago in 1877; a number of other cases might 
 be mentioned. 
 
 There can however be no doubt that hysterectomy is more dangerous 
 than ovariotomy. Koeberle [Diet, de med. et chir. prat., art. Ovaire, 
 t. XXV, p. 594), out of 20 cases of hysterectomy performed by 
 himself, counts 10 deaths and ]0 cures. Terrier has performed 
 hysterectomy twice and has lost both patients. Pean has performed 
 the operation 43 times, has had 33 successful cases, and 10 deaths 
 (oral communication). These are, I think, the most favorable 
 statistics known, and they are not very encouraging. These 
 cases do not include operations performed for cancer : they may be 
 analysed thus : hysterectomy has been performed by Pean 35 
 times for fibromata (22 cures, 13 deaths), of this number one 
 was complicated with an ovarian cyst, another with a cyst of the 
 broad ligament; once for hypertrophy complicated with pelvic 
 cyst (cure) ; eight times for fibro-cystic tumours (5 cures, 3 
 deaths) ; four times for uterine -cystic tumours (4 cures) ; once for 
 hypertrophy from sarcomatous degeneration of the mucous membrane 
 and retention (cure).^ Whilst admitting that hysterectomy may 
 be resorted to when nothing can be expected from any other treatment, 
 we should be all the more disposed to delay decision if the tumour 
 does not progress rapidly, as experience has proved the occasional 
 efiicacy of the continuous current, ergotine, hot injections, resolvent 
 alteratives and other means in arresting the development and even in 
 producing diminution of these tumours. We shall therefore limit the 
 indications to the following cases : danger from haemorrhage, threaten- 
 ing of rapid and enormous development of the tumour, compression 
 of the ureters, which has caused death (Matthews Duncan, Brit. Med. 
 Journ., 29th April, 1877), fibroma of the posterior wall wedged 
 tightly into the pelvis causing constipation and threatening death. 
 
 X. Puerperal hysterectomy of Porro. — Laparo-etytrotomy of 
 Thomas. — Ovariotomy has so familiarised surgeons with opening the 
 peritoneum, and hysterotomy for fibroids has so frequently led gyneco- 
 logists to consider the best manner of reaching the uterus either to 
 open it or to excise a more or less considerable portion of it, that they 
 have led to the practice of Caesarian section, i.e. hysterotomy in the 
 puerperal state, and to the invention of new methods with the object of 
 facilitating extraction of tlie foetus and of saving the life of the mother. 
 I shall merely say a few words about these operations which belong 
 exclusively to obstetrics. 
 
 1 Pean and Urdy, De Vahlation partielle ou totalc de I'uterus par la gas- 
 trotomie. Paris, 1873. — Diagnostic et traitement des tumours de I'abdomen et 
 du hassin. Paris, 1880. 
 
774 UTERINE DISEASES IN DETAIL 
 
 The idea was conceived of performing amputation of the uterus after 
 C<Bsarian section ; it had been applied to animals and the operation was 
 afterwards performed on a woman by Storer in 1860; unfortunately 
 the patient died. In 1876 Porro^ ignorant of the case, being obliged 
 to perform Caesarian section and having delivered a healthy child, ampu- 
 tated the uterus and its appendages immediately afterwards, employing 
 igorous antiseptic treatment. In spite of numerous cases of puer- 
 peral fever then reigning at the Maternity Hospital of Pavia the patient 
 recovered and left the hospital with her child the fortieth day after 
 >peration. We must admit that the judgment which attributed the 
 subsequent dangers of Caesarian section to the presence of the wounded 
 uterus and which regarded extirpation of this organ as the radical 
 remedy of the evil was correct, and that the conditions of success were 
 to be found in the performance of the operation assisted by antiseptic 
 treatment. Since then, out of 83 patients who have undergone Porro^'s 
 operation in maternity hospitals, 15 have died, 18 have been cured, 
 and the majority of the children have been saved, a far more favor- 
 able result than had ever been attained by the ancient method of 
 Caesarian section (Pinard, De V operation cesarienne suivie de V ampu- 
 tation utero-ovarique ou operation de Porro. Annates de Gynecol., 
 1879. Masson, I)e la g astro-Sly trotomie. Theses de Paris, 1877). 
 
 The laparo-elytrotomy of Gaillard Thomas is a lateral incision from 
 the spine of the pubis to the antero-posterior iliac spine parallel to 
 and above the crural arch, through which the vagina is opened at its 
 junction with the uterus, so as to allow of extracting the child from 
 it in place of extracting it from the fundus of the uterus through the 
 linea alba which constitutes Caesarian section. Gaillard Thomas com- 
 municated this method to the Academy of Medicine of New York 
 on the 21st March, 1878 ; out of five operations he had saved four 
 children and three mothers (^Annates de Gynecol., t. x, p. 232). 
 Lateral incision is necessary here, laparotomy meaning lumbar incision, 
 which was resorted to in the first ovariotomy ; afterwards, however, 
 MacDowell adopted the central line, 
 
 2. Tumours of the Annexes and Pelcic Cavity. 
 
 According to Leopold (Arc/iiv f. Gyn., Bd. vi, 2) solid tumours of 
 the ovai'ies are rare, in the proportion of 1*5 per cent, of liquid 
 tumours or cysts. They retain the normal shape of the organ by 
 which they are distinguished from cysts. They have a variable con- 
 sistency, from that of false fluctuation to that of stony hardness. Their 
 exterior wall has also a variable thickness. The pedicle is usually 
 short, and although the tumour may be closely attached to the uterus 
 the latter remains normal. Among these tumours we may distinguish : 
 1. Fibromata, simple or complex (fibro-myomata, fibro-sarcomata), or 
 with sanguineous lacunary spaces interposed (Waldeyer), or presenting 
 an analogy with certain osteoid tumours, i.e. points of ossification;^ 
 there are also areolar fibromata (Spiegelberg), presenting a frame- 
 
 ^ Koplierle does not believe in fibro-myoma of the ovanes {Diet, de med. 
 et de cMr.W'cdiq., art. Ovaiees, t. xxv, p. 508). I have undoubtedly seen tliem. 
 
PELVIC TUMOURS 775 
 
 work of fusiform cells with a cavernous vascular development like 
 that of sarcoma. 2. Enchondromata (exceptional), which must not 
 be confounded with fibromata of cartilaginous consistency. 3. Sarco- 
 mata (rare), the blood-vessels of which are numerous and small in 
 little tumours, but in large tumours, on the contrary, are very much 
 dilated, have a thin wall without any muscular tunic or tunica adven- 
 titia, and furnished with simple endothelium. 4. Carcinoma, which 
 I shall afterwards describe. 5. Cystomatous lymphangiomata have 
 also been seen in the ovary (cysts remarkable for the dilatation of the 
 lymphatics and the proliferation of the stroma). 
 
 Ziembicki [Essai cUnique stir les tumeurs solides des ovaires. Theses 
 de Paris, 1875) has collected 38 cases (11 of sarcoma, 10 of fibroma, 
 6 of carcinoma, 3 of colloid tumours, 5 of cystic adenoma, 3 undeter- 
 mmed), the result of which is that solid ovarian tumours are more apt 
 to be met with in young women. The peripheric vessels were very 
 large in five cases only_. We know, however, that very small tumours, 
 a hematic cyst of the right ovary for example of the size of a chest- 
 nut, may cause intra-peritoneal haemorrhage ending in death in thirty- 
 six hours (Curt Wallis and Linden, Hi/geia, 1876; Hayem, Revue, t. 
 ix, p. 623). As a rule ovaries attacked by these tumours have few or 
 no adhesions. Ascites is common without peritonitis or vascular com- 
 pression; it is a serious sign when the tumour occupies the iliac fossa, 
 which it usually does. The writer has divided them into three groups : 
 one including tumours of rapid formation developed in from three 
 months to two years (carcinoma, sarcoma) ; another, tumours of slow 
 formation of from two to ten years (fibromata, dermoid cysts, cysts 
 with thick contents) ; and another rare form in which ascites is 
 absent, and the economy does not seem to be disturbed, although this 
 is of tlie worst kind. We must beware of making an exploratory 
 puncture in such cases, it being better to perform ovariotomy early. 
 In these cases, however, success is not common : out of eight opera- 
 tions mentioned by Leopold only three were successful. Menstruation 
 may continue in spite of the most serious degeneration of both ovaries ; 
 conception and pregnancy may even occur (Treille, Tameurs de Vovaire 
 dans leurs rapports avec robstetriqiie, c'est-a-dire avec la conception, 
 la grossesse, U accouchemerit, la puerjoeralite. Theses de Paris, 1873). 
 Yernich thinks that an ovarian tumour may become malignant through 
 pregnancy and the puerperal state. He mentions the case of a young 
 woman attacked by a tumour which for a long time was painless, 
 but which increased during pregnancy, and at the autopsy proved to 
 be a medullary carcinoma {Du pronosttc des tumeurs ovariqnes com- 
 pliquant la grossesse. Beitraege zur Geburtsk. und Gynecol., Bd. 
 ii, 2). Hempel {drc/dv f. Gynecol., Bd. vii, 3, 1875) mentions a 
 case of carcinomatous degeneration of both ovaries during pregnancy. 
 Several analogous cases have been published by Braxton llicks^ 
 Kiirsteiner, Spencer Wells, Ilecker, Buhl, Hempel, Wallis, 
 Linden, &c. 
 
 I. Malignant tumours of the ovaries. — These are nothing but cancer 
 under various forms. Whether classed as sciirhus, encc])haloid. 
 
776 
 
 UTEEINE DISEASES IN DETAIL 
 
 ceplialoma, hematoma, fungus hematoides, fibro-medullary carcinoma, 
 cysto-carcinoma, melanic cancer, &c., they have all the aggressive, 
 destructive and cachectic tendency wliich characterises cancer. How- 
 ever, the various forms which these names recall may be met with in 
 the different cases of cancer of the ovaries; this organic alteration may 
 be combined with the existence of colloid or gelatinous matter, with 
 the so-called areolar degeneration, as well as with the production of 
 fibroids, or the development of cysts whether follicular or interstitial. 
 
 Fig. 425. — Colloid cancer of the ovary (Cruveilhier). The uterus and Fallo- 
 pian tube remaining attached to the tumour by the ligament of the 
 diseased ovary, we may form an idea of the enormous development of this 
 tumour. 
 
 i.e. vesicular dropsies or cystoids. These morbid associations and the 
 varieties which they engender depend on the real identity which cancer 
 may present under these various appearances, and on the natural ten- 
 dencies which the development of the degenerated tissue brings into 
 play in an organ so disposed to hypertrophy in the form of fibromata 
 or cysts. Cancer of the ovary seems to present itself more frequently 
 under the form of encephaloid than of any other tissue.^ It may- 
 attain considerable dimensions. I have lately seen one occupying the 
 right ovary, weighing more than 11 lbs., forming a globular nodu- 
 lated mass with very distinct spheroidal projections, of considerable 
 size and occupying the whole of the right iliac and hypogastric 
 regions, associated with integrity of the tube, congestive hypertrophy 
 of the uterus and the recurrence of haemorrhage simulating menstrua- 
 tion in a woman who had passed the menopause. The encephaloid 
 masses, diffluent at several points, appeared to have originated in 
 Graafian vesicles they were so well encysted; they seemed even, in 
 several of these cysts, to have vegetated on the internal membrane of 
 the vesicle, preserving an areolar or alveolar aspect, whilst the centre 
 ^ Lebert, op. cit., p. 323. 
 
PELVIC TUMOURS 777 
 
 was filled with fluid and especially with blood ; several of these cysts 
 were distended by black blood, partly coagulated, apparently poured 
 out by internal hsemorrhages, analogous to those which endanger the 
 life of patients in cases of external encephaloid ; lastly, in several cysts 
 was to be seen yellow matter similar not only to that which is some- 
 times met with in cancer, but also to that of a corpus luteum, situated 
 in a superficial portion of the sac, and suggesting the idea that the ence- 
 phaloid had been developed in ruptured Graafian vesicles and in the 
 midst of true degenerated corpora lutea, an alteration mentioned by 
 Rokitansky ; in others, black pigment was seen accumulated against 
 the wall of the cyst between its internal membrane and the encepha- 
 loid tissue occupying the cavity of the chamber. 
 
 The signs of ovarian cancer are those of all ovarian tumours, especi- 
 ally of cysts ; but there are other differential signs. They are : the 
 more advanced age at which it is usually manifested (after 40 and 
 even 50),^ the rapidity of its development and course (patients 
 usually succumb within the year), the nodulated form, the smaller 
 size, the hardness and sensitiveness of the tumour, the pains (?) experi- 
 enced by the patient, the symptoms of internal or intra-cystic haemor- 
 rhage which may occur, the premature disturbance of the functions 
 and of the general health, oedema of the lower limbs, ascites (which 
 may conceal the evil, but the evacuation of which by puncture allows 
 of a most certain diagnosis and procures temporary alleviation to 
 the patient), lastly, the engorgement of the mesenteric ganglia, the 
 earthy look of the skin, the straw or leaden-coloured complexion, 
 hectic fever and the signs of cachexia. 
 
 Treatment is merely palliative. Attention to hygiene, plenty of 
 good air and milk, associated with tonics, preparations of iron, arsenic, 
 hemlock j narcotics, sedatives by the rectum or skin ; abdominal para- 
 centesis to evacuate the fluid accumulated in the peritoneum, repeated 
 as frequently as may be necessary ; these are the means to be em- 
 ployed. 
 
 II. Avulsion and transmutation of the degenerated ovary. — What- 
 ever difficulty there may be in diagnosing this malady in practice, it 
 is well to know that the ovary sometimes contracts such adhesions 
 with the pelvic walls or abdominal viscera that the dragging produced 
 by the subsequent development of these viscera or of the uterus may 
 lacerate its natural attachments rather than its abnormal adhesions. 
 Eokitansky^ published seven cases of this very rare pathological fact. 
 In all of them the ovary was degenerated : three times into a cyst filled 
 with fat ; twice into osteo-calcareous tissue ; once into a sac filled with 
 blood ; once into a sac containing fatty and calcareous matter. In all 
 the cases except one avulsion had occurred in the left ovary. In all 
 the displaced ovary adhered either to Douglas's cul-de-sac, to the sig- 
 moid flexure or to the pubis, rectum, epiploon, mesentery, or abdomi- 
 
 ^ Bucquoy {Soc. med. cles Hopitaux, Dec, 18G6), quotod by Mauriac iu his 
 translation of West. 
 
 2 Momoire sior I' arrachement des trompes et des ovaires, &c. {Allgemeine 
 Wiener medizinische Zeitun<j, ISIO, Nos. 2 — 4). 
 
778 UTERINE DISEASES IX . DETAIL 
 
 nal wall^ the adhesions being the last traces of circamscribed peritoni- 
 tis. In cases of intestinal adhesions laceration appeared to be caused 
 by the dragging resulting from the alternations of distension and 
 vacuity^ and from the peristaltic and antiperistaltic movements of the 
 intestine. In two other cases^ originating probably in childhood, the 
 cause of avulsion was undoubtedly the physiological development of 
 the uterus, and in two others gestatory hypertrophy. In one case 
 there was strangulation of the Pallopian tube and ovary from twisting 
 round their axis. 
 
 Turner^ found in the necropsy of a woman of 75 a tumour of the size 
 of a foetal head firmly adherent to the peritoneum on a level with the 
 sacro-vertebral angle, rising above the brim, fixed by adhesions and 
 presenting all the characters of an ovarian cyst. It appeared that the 
 uterus had been united to the floor and to the left wall of the pelvis 
 by long-standing perimetritis. The left ovary, increasing in size in 
 consequence of its cystic degeneration, had probably risen gradually 
 out of the pelvis, dragging the Pallopian tube and broad ligament to 
 the left side. These organs not having been able to yield more on 
 account of the uterine adhesions and of the contraction of these adhe- 
 sions, had become atrophied, and finally the left ovary had separated 
 from the uterus. 
 
 III. Tubal tumours. — I have already spoken of several maladies 
 which may produce general or partial increase of size and even a 
 solution of continuity of the tubes : inflammation, catarrh, circum- 
 scribed obliterations, the accumulation of mucus, of epithelial ele- 
 ments, suppuration, abscesses, haemorrhages, with free discharge or 
 retention of blood and pus, with peripheric adhesions, dilatation or 
 ruptures of the oviducts, fibroids, tubercle, &c. Cancer is rarely seen 
 in the tubes. It is more apt to appear there as an extension of 
 uterine cancer than of cancer of the ovaries ; for the Pallopian tube 
 may be seen in a healthy state lying on the diseased ovary, contrasting 
 by its small size and integrity with the enormous tumefaction and 
 serious degeneration of the germinative organ. The only tumours 
 which yet remain to be described are tubal dilatations, due either to 
 excessive or disordered mucous secretion, usually coinciding with 
 contraction or atresia of their canal, either from a cyst developed 
 within their walls, in their neighbourhood, or even in the cor- 
 responding ovary, and possibly communicating with the enlarged 
 cavity. 
 
 1. When there is tubal dropsi/, i.e. dilatation of these organs by 
 the accumulation of a sero-sanguinolent fluid or of a mass of cells or 
 debris of epithelium which may have been taken for tuberculous 
 matter, the malady may appear under various aspects. Sometimes 
 only one tube is aft'ected, sometimes both organs are attacked almost 
 equally and symmetrically. Earely the diseased oviduct is free and 
 presents no alteration at its periphery : usually it bears traces of pre- 
 vious inflammation, and is connected with the neighbouring parts, 
 with the posterior surface of the uterus or ovary by pseudo-mem- 
 ^ Edinburgh Medical Journal, 1861. 
 
PELVIC TUMOUES 
 
 779 
 
 brauous adhesions wliicli deprive it of all mobility. The disorder 
 may extend the whole length of the tube^ but more frequently it is 
 limited to one half of this canal : the portion which appears the most 
 prone to disease, the one in which the mucus accumulates in greatest 
 quantity and the distension of which is most frequent and most con- 
 siderable is the external or ovarian half. When the whole tube, or 
 half of it, is dilated by the uniform accumulation of fluid, the organ 
 in spite of its dilatation preserves to some extent its normal form and 
 presents the appearance of a portion of the intestine with somewhat 
 incomplete circumvolutions, unequally distended by its contents; 
 when on the contrary the dilatation is limited by neighbouring oblite- 
 rations, or by the resistance of a cystic envelope in which the fluid 
 
 Fig. 426. — Falloxjian tubes distended in tiieir external or ovarian portion by a, 
 fluid collection, and a small cyst attached to one of tbe tubes (Hooper). 
 
 which occasions the distension is contained, the tumour is circum- 
 scribed and globular, and the rest of the organ, hardly exceeding its 
 normal size, is neither perceptible to touch nor to sight. I have 
 sometimes seen tumours like those I have just described and similar 
 to those mentioned by De Haen,^ Monro,- Boivin and Duges,^ 
 Kiwisch,* Becquerel,^ Scanzoni,'' Rokitansky,'^ Klob,^ &c. 
 
 ^ Pract. Med., iii, 313. 
 
 ^ An Essay on Dropsy. London, 1765. 
 
 3 Op. cit., ii, 590. Atlas, pi. xx.w, fig. 1. 
 
 '' Klinik. Wortrdg., ii, 202. Prague, 1849. 
 
 « Op. cit., t.ii, p. 278. 
 
 « Op. cit., p. 371. 
 
 ' Lchrhuch dcr imtliol. Anat.. iii, 410. Vienna. 1861. 
 
 * Path. Anat. der ivelb. Scijualorgaacn, p. 288. Vienna, 1864. 
 
780 UTEEINE DISEASES IN DETAIL 
 
 It is evident that there are no other elements for diagnosis than 
 those which I have already described in speaking of salpingitis and 
 tubal abscesses ; and there is no doubt that the difficulties of diagnosis 
 have frequently led to tubal cysts being taken for ovarian tumours.^ 
 
 2. The existence of Mo-ovarian cysts is established by five very 
 interesting cases described by Adolphe Eichard/ and by others 
 already quoted by Morgagni, Franck, Chambon, Boivin and Duges, 
 Kiwisch, Follin, &c. It is proved by these cases that ovarian cysts 
 may open into the uterus by the medium of the tube ; that after having 
 received the cystic fluid the Fallopian tube continues to undergo patho- 
 logical change ; that its calibre increases, its length doubles, its walls 
 thicken, and the folds of its mucous membrane partly disappear; 
 that the dilatation gradually reaches the internal portion of the oviduct, 
 that a communication is established between the canal of the dilated tube 
 and the cyst, and that from that time the complex cyst is formed, rightly 
 designated as tubo-ovarian by Eichard, which is probably somewhat 
 allied to the malady described by Eokitansky under the name of 
 projluent dropsy of the tubes. It is in cases of this kind that cathe- 
 terism of the tubes may be performed. Although in normal conditions 
 tubal catheterism is absolutely impossible, nevertheless in cases of 
 menstrual retention or of dragging upon the tube by a fibroma above 
 and in the axis of the uterus or of profluent tubal dropsy, the sound 
 can really be passed from the uterus into the tube. This penetration, 
 seen by Biedert and others, has been verified at an autopsy made by 
 Bischoff (Hayem, Revue des sciences med., 1878, t. xi, p. 583). This 
 malady or a tubal abscess is apt to be confounded with a purulent col- 
 lection, circumscribed by peritoneal adhesions round the ovary and 
 tube, and evacuated directly by the genital canal through the medium 
 of the oviduct, a disease which was once seen by Kceberle (Nouv. 
 Diet, de med. et de chir. prat., art. Ovaire, t. xxv, p. 500, fig. 
 Paris, 1878. 
 
 It is not possible to give any rule of treatment for these cysts or for 
 tubal dropsies. Nevertheless evacuation by the vagina may be tried 
 if symptoms occur which seem to indicate it, and in the absence of any 
 centra-indication. 
 
 IV. Tumours of the broad ligaments. — These are fibrous tumours, 
 myomata, cysts of Eosenmiiller's organ, hydatid cysts, &c., without 
 counting the abscesses described when treating of perimetritis and 
 tumours of the tubes, ovaries, or uterus insinuated by their progressive 
 development between the folds of these ligaments. 
 
 1» Fibrous tumours and myoynata of the broad ligaments. — These 
 must not be confounded with sub-serous or intra-parietal myomata of 
 the displaced uterus which have been expelled as an effect of their 
 development and have become intra-ligamental. They may also be 
 developed in the round ligament, as in the case of stone in the round 
 ligament mentioned by Walter. Diagnosis is uncertain, treatment is 
 the same as that for ovarian and peri-uterine fibroma. 
 
 > Puistienne, op. cit., p. 47. 
 
 " Memoires de la Societe de chirurgie, t. iii, p. 121. Paris, 1856. 
 
PELVIC TUMOURS 781 
 
 2. Cj/sts of the broad ligaments occur more frequently in children 
 than in adult women, in the folds of the broad ligament, between the 
 l^allopian tube and ovary, and especially in the lower portion of the 
 tube near the fimbriated extremity; they are small cysts varying in 
 size from that of a millet seed to a small nut, sometimes sessile, more 
 frequently attached by a pedicle of from one quarter to two inches 
 long ; the envelope and contents are transparent and are usually 
 regarded as the remains of one or more blind tubes of Eosenmiiller^s 
 organ (fragments of the Wolffian body).i Whether they are produced 
 by an abnormal dilatation of one of the elements of the Wolffian body, 
 or whether they result from a new formation, as Yirchow- supposes, 
 pediculated cysts are chiefly met with in children and cannot be diag- 
 nosed during life ; interstitial cysts (between the folds of the broad 
 ligament) may attain the size of an egg, an apple, or even of a foetal 
 head. They have a tendency to remain stationary, and may disappear 
 suddenly by rupture.^ Diagnosis is uncertain. If they do not dis- 
 appear by resolution, and if they become large, they may be removed 
 by operation similar to that for ovarian cysts. It is for these cysts that 
 enucleation without either section or ligature of the pedicle may be tried. 
 As for hydatid cysts of the ovaries and broad ligaments, the same re- 
 marks apply to them as to the same tumours in any other part of the 
 abdominal or pelvic cavities. 
 
 V. Abdominal and pelvic tumoitrs common to both sexes, but giving 
 rise in the woman to errors of diagnosis, — Those which seem to me to 
 have a special claim to mention are : the so-called encysted dropsy of 
 the peritoneum, hydatid cysts, and floating tumours of the abdomen. 
 
 1. Sero-purulent cysts of the peritoneum. — These are serous and 
 sometimes purulent collections between the peritoneum and the abdo- 
 minal muscles, or rather abdominal walls, in the sub-peritoneal 
 cellular tissue, sometimes between the parietal or visceral peritoneum 
 and a broad false membrane limiting an enclosed space in some region 
 of the serous membrane, especially in the pelvic cavity. Therefore we 
 may distinguish : parietal cysts and intra-abdominal cysts. The former 
 are usually situated in front, but are occasionally found behind.^ The 
 latter are formed either in the epiploon or by adhesion and the encyst- 
 ing of a fluid in an accidental intra-peritoneal cavity. Sometimes even 
 a hydatid cyst may exist simultaneously in the abdominal wall.^ These 
 collections, described as early as the 16th century, were attributed by 
 Nuck^ to an effusion in the space between the peritoneal fold which was 
 supposed to be double ; but they could not have such an origin. Not 
 only do they seem to be exclusively situated either in the sub-peritoneal 
 
 ' Verneuil, Recherches sur les kystes de I'organe de Wolff {Memoires de la 
 Sac. de chir., t. iv, p. 58. Paris, 1854). — Kceberle, art. Ovaike in Diet., &c. 
 
 ■' Op. cit., t. i, p. 260. 
 
 ^ West, op. cit., p. 521. 
 
 ■* Boinet, Bulletin de la Sac. Anal., t. xix, p. 285 ; t. xxvii, p, 20. — Puis- 
 tienne, Tumeurs enhystees pelviennes et abdominales, p. 75. Paris, 1866. 
 
 * Degner, Act. nov. curios, naturae, t. v, Obs. 2. 
 
 fi Observations rares de medecine, t. ii, p. 176. Paris, 1758. 
 
782 UTERINE DISEASES IN DETAIL 
 
 cellular tissue or in an adventitious^ intra-peritoneal cavity, but they 
 are apparently almost always the consequence of peritonitis. The 
 researches of Bernutz^ tend to include the so-called encysted dropsy of 
 the peritoneum among cases of peritonitis encysted by adhesions, as 
 they have also included the majority of peri-uterine phlegmons 
 among cases of adhesive suppurative and encysted peritonitis. Bernutz 
 has compared all the cases of encysted dropsy of the peritoneum 
 analysed by Morgagni, as well as ail those indicated more recently, 
 as examples of this so-called encysted dropsy ; he has collected in all 
 36 cases^ and has not found in one any proof of the reality of this 
 malady. The diagnosis is sometimes so difficult that they have been 
 taken for ovarian cysts. The treatment, more difficult still, does not 
 differ from that of pelvic peritonitis or of other sero-purulent intra- 
 peritoneal collections. 
 
 2. Hydatid cysts. — Charcot^ has collected 12 cases of hydatids of 
 the pelvis, 6 in women, 2 in which the hydatids were originally de- 
 veloped in the ovary. Several coincided with the development of 
 hydatids in other parts of the body. Their usual starting-point is the 
 sub-peritoneal cellular tissue, either between the rectum, vagina and 
 uterus^ under the peritoneum -which forms the recto-vaginal cul-de- 
 sac, or between the uterus and bladder, or in the broad ligaments, 
 forming a tumour to the right and left in the vagina (Eoux). In 
 cases in which the ovary appeared to be transformed into a hydatid 
 cyst it had fallen into the vagino-rectal cul-de-sac and had contracted 
 adhesions with the neighbouring parts. Hydatids of the pelvis form, 
 in woman, a smooth, rounded, fluctuating, indolent tumour, project- 
 ing towards the rectum and vagina, or even above the pubis, when it 
 is developed in front of the uterus. The symptoms are those of com- 
 pression and sometimes of inHammation. The presence of hydatid 
 tumours in other parts of the body is a valuable element of diagnosis. 
 The hydatid thrill is seldom perceived. The escape of the hydatids is 
 the only certain sign. These tumours are often confounded with 
 commencing or even with large cysts of the ovary, especially when 
 they are developed in front of the uterus, or in the epiploon, in the 
 left hypochondriac region, in the liver, and even in the kidney. The 
 treatment is the same as for hydatid cysts of the abdomen in man : 
 the potential cautery, opening of the sac, destruction and expulsion 
 of the hydatids, injection and compression of the cyst. 
 
 3. Floating tumours of the abdomen are ovoid, of the size of a 
 turkey's egg, solid in consistency, usually situated in the right hypo- 
 chondriac region or in the loins, rarely on the left, sometimes on both 
 sides symmetrically, descending even to the iliac region ; they are 
 seldom seen in man but frequently in women. According to Cru- 
 veilhier,^ Pritz,^ West,*^ and other observers they are only floating 
 
 ^ Guyon, Diet, encyclopedique des sc. medic, art. Abdomek, i, 183. 
 ^ Unpublished paper, quoted by Puistienne, op. cit., p. 76. 
 ^ Mem. sur les tumeurs hydatiques du petit hassin {Gazette medicale de 
 Paris, 1852). 
 
 ■• Anatom. patholog. generale, t. ii, p. 72.3. 
 
 ^ Archiv. gen. de med., 1859, t. ii. pp. 158, 301. 
 
 « Op. cit., p. 559. 
 
PELVIC TUMOURS 783 
 
 hiclneys, expelled from their natural position by a sudden shock or by 
 the exaggerated and continuous compression of corsets (Cruveilhier). 
 They are more easily distinguished from tumours of the ovaries, broad 
 ligaments and tubes than the majority of the other abdominal or pelvic 
 tumours which I have just described. 
 
 VI. Extra-uterine pregnancy. — Wherever the seat of the extra- 
 uterine pregnancy may be, whether it is ovarian, tubal, tubo-inter- 
 stitial or abdominal, it has among other consequences that of pro- 
 ducing a tumour which owing to its position and the variable sym- 
 ptoms by which it is accompanied, often passes either for a malady of 
 the uterus or of the annexes. I shall only consider it from this 
 point of view ; for its complete history special works should be cou- 
 sulted.i 
 
 Biagnosis. — Three periods should be distinguished : 1, that which 
 corresponds with the beginning of pregnancy and extends to the fourth 
 or fifth month, till the foetal movements are perceptible ; 2, that which 
 extends from this time to the natural term of gestation ; 3, that which 
 follows the normal period when delivery should take place, and 
 which is characterised by the death of the foetus, its mummification, 
 its various alterations, the suppuration of the sac, &c. 
 
 1. Interrupted menstruation, which is so important in the diagnosis 
 of simple pregnancy, is much less so here : whilst there are cases in 
 which the menses continue abundantly and normally during the first 
 period, there are others in which they cease to flow from the first appear- 
 ance of pregnancy, only reappearing after the death of the child. In 
 the majority of cases vomiting occurs ; it appears even more obstinate 
 and violent than in normal pregnancy. The mammary glands are also 
 usually enlarged, the areola becomes brown, the tubercles described by 
 Montgomery are developed, but it may be that this change of size is not 
 very marked, and that the colour of the areola loses its importance 
 from the fact of a previous pregnancy. A more marked phenomenon, 
 described in all cases that have been carefully observed, is a more or 
 less acute abdominal pain analogous to that which is designated under 
 the name of uterine colic. Commencing in most cases shortly after 
 conception it lasts to the end of pregnancy, with alternations of in- 
 crease and diminution \ the seat of this pain is in the hypogastrium 
 and the flanks. To give an idea of the difficulties of such a diagnosis 
 I reproduce the accompanying figure which shows the general appear- 
 ance of a tubal pregnancy and the interesting peculiarities which 
 characterised this ad-uterine pregnancy (i. e. in one cornu of the 
 uterus), which in this exceptional case was taken for a tubal preg- 
 nancy. 
 
 2. Towards the fourth month, and especially in the beginning of 
 the fifth, we are authorised to be more explicit, without, however, 
 being secure from all error. There was a well-known case not long- 
 ago of a woman who was examined by most of the physicians and 
 
 ' Velpeau, Did. de vied, en 30 vol., t. xi^. — Dezeimeris, Journ. des connais- 
 sances medico-chirurgicales, 1836. — Triadou, Des grossesses extra-uterines. 
 These d'agregation. Montpellier, 1866. 
 
784 
 
 UTERINE DISEASES IN DETAIL 
 
 ^^/^ 
 
 Fig. 427. — Pregnancy in a closed cornu of a uterus bicornis, taken for a tubal 
 pregnancy (Kussmaul, op. cit., p. 155, fig. 45 ; from a preparation by 
 Heyfelder) : a, body of the right unicorn uterus, the cavity of which was 
 lined with a decidua ; 6, its cervix ; c, vagina ; d, top of the right cornu ;/, 
 right ovary ; e, right oviduct ; g, right round ligament ; 7i, left rudimentary 
 cornu in gestation ; i, tissue uniting the left to the right cornu, in the 
 midst of which were found the remains of a canal destined probably for 
 a means of communication between the cavities of the two horns ; Tt, left 
 round ligament ; I, muscular fibres proceeding from it to be inserted into 
 the body of the right horn ; m, peritoneum ; n, left oviduct ; o, left ovary, 
 with a very large corpus luteum ; p, laceration of the gestatory portion ; 
 q, placenta ; r, membranes of the ovum ; s, umbilical cord ; t, embryo. 
 
PELVIC TUMOURS 785 
 
 surgeons of the Paris hospitals^ and considered as having an extra- 
 uterine pregnancy, and who was delivered naturally at the end of the 
 ninth month to the great astonishment of Huguier, who pubhshedthe 
 instructive case : it is right to mention that Dubois was not mistaken 
 in it. In an analogous circumstance Pajot diagnosed a normal 
 pregnancy in an exceptionally attenuated uterus, a diagnosis which 
 proved to be correct. I have seen a similar case taken for extra- 
 uterine pregnancy by a justly esteemed practitioner ; I not only cor- 
 rected the diagnosis but prognosed premature delivery, which soon 
 occurred. In another case Schlesinger^ diagnosed an ovarian preg- 
 nancy in a woman who was delivered normally at term : the cause of 
 this error was a tumour in the right inguinal region. 
 
 Though in such cases it is easy to make a mistake, there are nume- 
 rous indications authorising the physician to pronounce a decided 
 opinion. We observe on the one hand that there is pregnancy, from 
 the foetal movements and from the information furnished by ausculta- 
 tion ; on the other hand, that it has an unusual position, as examina- 
 tion by the vagina and abdomen discovers a tumour situated on one 
 side, painful on pressure and distinct from the uterus, the upper limits 
 of which can often be felt. 
 
 The difficulty of effecting iutra-uterine hallottement, the small size 
 of the womb, the displacements of this organ above, below, or to one 
 side, according to the position of the extra-uterine cyst, are all indi- 
 cations of extra-uterine pregnancy. Lastly, when the natural term 
 of pregnancy arrives, the patient is attacked by labour pains ; these 
 pains are prolonged for three or four days, cease and return at 
 intervals without ejffecting anything. This symptom alone would 
 serve as a certain basis for diagnosis if any was required at this 
 period. 
 
 3. When the foetus is dead, we must judge from the history of the 
 case, i.e. from the previous symptoms which may pass as signs of ges- 
 tation and of extra-uterine pregnancy. Besides these, direct examina- 
 tion, palpation, touch, the perception of irregularities characteristic of 
 the various segments of the foetus through the sac which encloses 
 them, &c., will help in distinguishing the foetal cyst from ovarian, 
 tubal or abdominal tumours, whether solid or fluid, serous or puru- 
 lent, traumatic, inflammatory, or diathetic, with which they might be 
 confounded. 
 
 Treatment. — It is rare for extra- uterine pregnancy to reach its 
 natural term : the statistics of Campbell, Hecker and Mattei, as well as 
 those which Puech has communicated to me, prove that it is quite an 
 exceptional circumstance. In three quarters of the cases the cyst is 
 ruptured before this period. This termination, which is rather less 
 frequent in abdominal pregnancy, may be said to be the rule in inter- 
 stitial, tubal and ovarian pregnancies. 
 
 Extra-uterine pregnancies are susceptible of different terminations. 
 Sometimes the cyst is ruptured, and then this rupture either produces 
 a hsemorrhage which is fatal in a few hours, or acute peritonitis fatal 
 1 Casper's Wochenschrift, 1845, No. 31. 
 
 50 
 
786 UTEEINE DISEASES IN DETAIL 
 
 in from two to ten days^ or circumscribed peritonitis which may be 
 successfully treated. In the latter case, matters may go on just as 
 when the cyst does not rupture. Sometimes the cyst does not rupture 
 and resists the pressure exercised on it from within by its contents. 
 The embryo then dies prematurely, or it reaches the ultimate limits of 
 its development and dies from insufficient nutrition. In both cases it 
 may happen that the cyst is tolerated, or that nature makes efforts to 
 expel it. When tolerance is established the cystic walls are modified, 
 vascularisation diminishes and the amniotic fluid is absorbed; the 
 product of conception shrinks and shrivels up, and undergoes the 
 waxy transformation of which there are numerous examples, Puech 
 having collected 35 cases. When tolerance cannot be established, 
 which is especially observed when the foetus is large, the latter irri- 
 tates the neighbouring parts by its presence, provoking expulsive 
 efforts. The cystic walls become inflamed, contract adhesions with 
 the neighbouring parts and cause death more or less rapidly, accord- 
 ing to the degree of inflammation, and also according to the strength 
 of the patient. Peritonitis is therefore the most frequent cause of 
 death ; next to it come exhaustion, hectic fever and purulent infec- 
 tion. More frequently nature creates an exit for the contents of the 
 cyst, either externally or into a cavity. After more or less serious 
 symptoms have lasted for some time, an abscess is formed and opens 
 at some part of the abdominal walls, into the interior of the rectum, 
 or more rarely into some other point of the intestinal tube, into the 
 vagina, into the bladder, or it may be that it escapes by several of 
 these channels simultaneously : vagina and umbilicus, rectum and 
 bladder, rectum and vagina. Nothing is more variable than the 
 period when this work of elimination commences ; it has occurred 
 immediately after the death of the foetus, and at other times ten or 
 twenty-five years later. Of all points of exit the rectum is undoubt- 
 edly the most dangerous, but it is not so serious as has been said, for 
 out of 69 cases there were 45 cures. It is, however, serious enough, 
 causing as many deaths as all the others put together. 
 
 Extra-uterine pregnancy is one of the most dangerous conditions 
 that can be met with ; although the maximum of danger is at the 
 beginning, since a woman in apparent heaUh may succumb in a few 
 hours, it must not be forgotten that danger continues to the end ; 
 hence the necessity of medical intervention and the obligation of laying 
 down rules for the conduct of such cases. The indications vary 
 according to the three principal periods of the disease already men- 
 tioned. 
 
 1. In consequence of the danger which threatens the mother, and 
 the inevitable death of the child, we are justified in considering 
 whether it would not be better to arrest this pregnancy from the 
 beginning by preventing the development of the embryo. There are, 
 however, serious practical difficulties in the way of various kinds, 
 especially those relating to the difficulty of diagnosis ; for it is really 
 impossible to diagnose an extra-uterine pregnancy with certainty 
 before the second month. Now statistics prove that it is at this 
 
STEEILITT 787 
 
 period that the most serious consequences of interstitial or tubal preg- 
 nancies might be most certainly prevented, and that there is some 
 chance of triumphing over the dangers inherent to this state. 
 
 However that may be, if we succeed in making a diagnosis we 
 should not hesitate to inject atropine or morphia into the tumour, 
 using a syringe with a long cannula, as Friedreich ^ did, to arrest the 
 development of the embryo and the increase of the tumour simultane- 
 ously. We could also arrive at the same result by electro-acupunc- 
 ture as employed by Burci and Bartoloni ^ in a case of tubal pregnancy 
 at the third month ; I should however prefer the former method. 
 
 2. The difficulties of diagnosis diminish in the fourth and fifth 
 month ; therefore I hesitate less to recommend injections being made 
 into the cyst at that time, being convinced that they would be useful 
 and that we could act with more chance of certainty. 
 
 It is true that at that time the foetus would only be sacrificed at an 
 advanced stage of gestation, and that the ulterior accidents of elimina- 
 tion would not be so surely prevented. This serious decision however 
 should never be made without a consultation ; even at this period it 
 is not always easy to diagnose extra-uterine pregnancy. If the child 
 has reached the ninth month and is still living and if the mother 
 desires an operation, gastrotomy might be attempted, although there 
 is little hope of success. In this case as in those in which the child 
 is dead, an incision should be made as nearly as possible at the point 
 where the foetal head is supposed to be, the only reason for another 
 point being chosen would be the fact of its being lower down and of 
 the skin being thinner. 
 
 3. When pregnancy is more advanced, when the child is dead and 
 the mother suffers only moderately, we may wait, but if a process of 
 elimination is developed, intervention is indicated, either by opening 
 the tumour with Yienna paste, or, if it is already opened, by enlarging 
 the orifice with the bistoury, so as to be able to extract the bones and 
 foetal fragments more rapidly. 
 
 As for the point of incision in such cases it ought to be where this 
 work of elimination is being carried on ; if this points in several 
 directions, the abdominal wall should be preferred. 
 
 Sterility 
 
 Sienl'ity^ may be the result of three distinct conditions, the cause 
 of which is more especially dependent on the woman, the seat of 
 which is deeper, and the cure more difficult in proportion as we pass 
 from the first to the second and from the second to the third. 
 
 1 Gaz. hehdom., 1864, p. 716 
 
 ^ Union medicale, 4 April, 1857. 
 
 ' As for the importance of sterility in gjnsscologj, it is sufficient to mention 
 that Simpson, making investigations as to the frequency of sterility, found 
 that out of 1252 marriages, 146, that is, aboTit 1 in S"5, were sterile. Spencer 
 Wells found also that 1 out of every 8 married women is sterile. Sims 
 arrived at the same result, and I am surprised at the increasing number of 
 women who consult me on this matter. 
 
788 UTEEINE DISEASES IN DETAIL 
 
 These three conditions are : 
 
 1. Inaptitude for coitus or impotence. 
 
 2. Inaptitude for conception or infertility. 
 
 3. Inaptitude for germination or sterility strictly speaking. 
 These various inaptitudes may be temporary or permanent, relative 
 
 or absolute, curable or incurable. They are so in different degrees : 
 inaptitude for germination, for example, is the one which is most 
 frequently incurable and the most complete. 
 
 I. Inajptitude for coitus or impotence. — It is more limited in the 
 woman than in the man. The woman in a manner playing a passive 
 part in coitus it sufiices for the vulva and vagina to be sufficiently 
 open to receive the penis and permit of copulation. There are, 
 however, malformations of the external genital organs, congenital or 
 accidental, teratological or pathological, which may render a woman 
 temporarily or permanently impotent. 
 
 Vulva. — Apart from adhesions of the labia, which are always of 
 accidental origin and which hinder intercourse, I do not know of any 
 vulval lesions, strictly speaking, capable of causing sterility except 
 the conformation designated by the name of transverse female herma- 
 phrocUsm, for in such cases, although menstruation is regular preg- 
 nancy is exceptional. 
 
 If consulted for a case of this kind, we should imitate Coste"^ in 
 making a vagina and amputating the clitoris : and perhaps the desired 
 result would be obtained. It is needless to say that this attempt 
 should not be made unless one is assured of the existence of menstrua- 
 tion and of the development of the uterus. The same precautions 
 should be taken in a case of absence of the vulva ; for, with the 
 exception of Magee's^ and Rossi's^ cases, this is usually accompanied 
 by the absence or atrophy of the uterus. I have seen women in 
 whom excessive length of the nymphse, inclining towards the vagina 
 at the moment of intromission, constituted, if not an insurmountable 
 obstacle, at least a serious difficulty in the way of coitus : in one case 
 I removed them, and attributed to this circumstance the cessation of 
 absolute sterility which had lasted for five years ; in another case, this 
 excessive length coincided with a congenitally narrow os. The 
 influence of the nymphse on sterility ought to be much more marked 
 when they are affected with elephantiasis or even with simple hyper- 
 trophy, the consequence of syphilis for example. 
 
 Vagina. — The anomalies of deficiency, bifidity, and the abnormal 
 opening of this canal may be causes of impotence. Anomalies of 
 deficiency may be either congenital or accidental, partial or total. 
 The total or partial absence of the vagina from defective formation or 
 arrest of development, imperforate hymen, membranous occlusion of 
 the lower part of the vagina, and extreme narrowness of this canaP 
 
 '' Journ. des connaissances med.-cMr., t. iii, p, 276, 1835. 
 " The Lancet, 23 July, 1842, p. 575. 
 3 Annales de Montpellier, t. xiii, p. 39. 
 
 ■* Delaunay, Etude s^i,r le cloisonnement transversal du vagin. Tlieses de 
 Paris, 1877. 
 
STERILITY 789 
 
 should be mentioned in the first rank. I shall confine myself to men- 
 tioning that, in such cases, the treatment instituted for the re- 
 establishment of menstruation is the appropriate one for the cure of 
 sterility. Only it is to be remarked that, when retention of blood is 
 prolonged for several years, subsequent disorders of the uterus, 
 ovaries and tubes may result, rendering conception impossible. The 
 sterility observed by Becasseau, Kluyskens, Chevalier and Patry^ in 
 the patients on whom they operated may be explained in this way. 
 
 Congenital narroivness of the vagina throughout its whole extent is 
 rare. Nevertheless, Antoine,^ de la Toison,^ Plenck,* Benevoh,^ 
 Denman^ and Scanzoni'^ have given very curious examples of it. In 
 these cases it was not so much menstrual disorders as difficulties in the 
 way of coitus that attracted the attention of these physicians. The 
 remedy for this condition is dilatation. When occlusion of the vagina 
 is not complete conception may occur exceptionally, even when intro- 
 mission is impossible. I knew a woman in whom the vesico- vaginal 
 septum was destroyed and the vagina obliterated at the vulva, except 
 at one point, where there was an opening large enough to admit a 
 female catheter, by which the urine escaped ; since her confinement, 
 the cause of this lesion, more than a year before, menstruation had 
 not occurred; in spite, however, of these unfavorable conditions, 
 conception took place, pregnancy arrived at term, and the patient died 
 from the consequences of labour. 
 
 Bifidity of the vagina, i. e. its longitudinal division, is only a cause 
 of sterility when the calibre of the two vaginal canals is so contracted 
 as only to allow of imperfect intromission, or when the half of the 
 organ in which coitus is practicable ends in an atrophied half of a 
 uterus. Laaser^s^ case may be mentioned as an example of the latter 
 category. In such circumstances the physician may dilate one of the 
 two vaginte artificially, or, if dilatation be insufficient, the division 
 may be removed as was done by Laaser. In a case of the same kind 
 (double uterus, double vagina and congenital vagino-rectal fistula) I 
 succeeded in destroying the longitudinal division of the two vaginae 
 by the application of a long enterotome and the obliteration of the 
 fistula by suture. 
 
 There may be abnormal orifices from the vagina into the bladder, 
 urethra or rectum. The first anomaly, which is the rarest, has only 
 been observed four times.^ It is only curable by surgical interven- 
 tion, i. e. by the formation of a vagina, and the obliteration of the 
 
 ^ Puech, Des atresies des voies genitales de lafemme, p. 131. Paris, 1861. 
 
 ^ Histoire de I'Academie des sciences, 1712, p. 36. 
 
 3 Ibid., 1738, p. 58. 
 
 ^ L'art d'accoucher, translated by Pitt, p. lit), 
 
 ° Delle hernie intest. Florence, 1747. 
 
 ^ Diet, en 60 volumes, art. Vagin. 
 
 ' Op. cit., p. 480. 
 
 ^ Monatschrift fiir Geburtshunde, 1864, Bd. x\iv, S. 441. 
 
 ' Chevreuil, Journ. de med. et de cldr., 1772, t. xli, p. 447. — Kingdon, Gaz. 
 m(''d. de Paris, 1838, p. 283. — Coste, Journ. des conn, med.-chir., 1835, t. iii, 
 p. 276. — Huguier, in Lefort, op. cit., p. 203. — Puech, Mt^m. sur le cloaque uro- 
 genital (Montpellier medical, 1868). 
 
790 UTERINE DISEASES IN DETAIL 
 
 abnormal opening : by enabling the menstrual blood to escape by the 
 normal channel we may at the same time restore the power of concep- 
 tion to the woman. The opening of the vagina into the rectum ^ is 
 observed, on the contrary, much more frequently : it would take too 
 long to mention all the cases that I have collected, nor is this the 
 place to establish between them distinctions and divisions interesting 
 from other points of view; it is enough to add that the artificial 
 /ormation of that portion of the vulvo -uterine canal which is wanting 
 and obliteration of the abnormal opening are indicated. There are 
 cases in which the vagina, though apparently normal, is nevertheless 
 affected with some imperfection the influence of which on sterility is 
 more real than would be supposed. Such are extreme shortness of the 
 vagina^ which favours the formation of a copulative sac and projec- 
 tion of the semen outside the axis of the uterine canal; excessive 
 length and breadth of this organ, which greatly increases the chances 
 of the fertilising fluid being lost in the anfractuosities of this mem- 
 branous canal without penetrating the uterus ; lastly, inequality of the 
 two vaginal walls, the posterior one which is usually the longer form- 
 ing a cul-de-sac behind the cervix, in which the sperm is accumulated. 
 When a congenital or acquired narrowness is added to extreme short- 
 ness of the vagina it may lead to most troublesome consequences. 
 Barnes says (op. cit., p. 113) that after the menopause, especially in 
 women who have not had uninterrupted conjugal relations, the uterus, 
 vagina and vulva undergo a kind of atrophic involution, by which 
 they lose their dilatability, and which may render coitus not only pain- 
 ful but dangerous. In the museum of St. George's Hospital (series 
 xiv, 108) is to be seen a vagina the fundus of which was lacerated 
 in coitus. 
 
 Vicious insertions of the vagina into the uterus are also causfs of 
 inaptitude for fecundation. An anterior or lateral copulative sac is 
 formed, or ofteuer still a posterior one (the uterus apparently being 
 inserted in the anterior wall of the vagina, sometimes very near the 
 vulva). This sac, most frequently congenital, sometimes acquired, 
 forms a receptacle for the sperm, which is always unfavorable to 
 fecundation. 
 
 In place of being originally narrow, or subsequently contracted, 
 the vagina and vulva may be in a state of coarctation produced by 
 vaginismus or spasmodic contraction of the vagina and of the sphincter 
 cunni. The efi'ect of this nervous malady is, that the introduction of 
 even a small foreign body into the vaginal canal sometimes determines 
 such acute pain as to produce syncope, which makes coitus for the 
 time impossible. This state may last for years if not remedied by 
 forced dilatation or other means. In a case of the kind conception 
 was effected during antesthetic sleep. ^ 
 
 1 Murat, Diet, en 60 vol., art. Vagin. — Isid. Geoffroy-Saint-Hilaire, Ano- 
 malies cle V organisation, t. i, p. 501. — Boiiisson, Des vices cle conformation de 
 I'anus et du rectum, p. 39. Paris, 1851. Eoubaud, op. cit., t. ii. 
 
 ^ I have several times seen the vagina shorter than usual, as in Pfau's case, 
 where after maniage it was only 1^ inch long. 
 
 ' Sims, op. cit., p. 343. 
 
STERILITY 791 
 
 II. Inaptitude for conception or infertility/ may either depend on 
 mechanical or physiological causes. The sperm is hindered from 
 coming in contact with the ovum sometimes by direct obstacles to the 
 penetration of the semen, or by disease of the parts which the sperma- 
 tozoa have to traverse ; sometimes by a merely functional impo- 
 tence, a physiological alteration of the means of transport for the 
 fertilising fluid or the localisation in these organs of a general morbid 
 condition. Obstacles to conception are the most common causes of 
 sterility : some are incurable ; others_, although numerous and depen- 
 dent on various conditions, may be overcome and frequently yield to 
 local or general treatment which may be applied according to the 
 indications. 
 
 1. Mechanical and organic obstacles to conception. — They may 
 exist in the uterus or in the tubes, or may result from the presence of 
 pathological fluids in these organs, or of secretions unfavorable to the 
 preservation of the germs. The sterility is sometimes incurable, at 
 other times, on the contrary, it may be treated with more or less 
 chance of cure, according to the nature and extent of these obstacles. 
 
 Absence of the uterus and the embryonic condition of this organ 
 cause absolute sterility .^ 
 
 The uterus sometimes preserves its foetal or infantile characteristics 
 even after puberty; it may be either simple, imperforate (Duplay), or 
 bicorn (Wehr of Cassel). This condition is apparently incurable, 
 whichever variety occurs. Meadows,^ in a case of this kind, has 
 tried galvanic sounds and pessaries, which however only produced 
 acute irritation. 
 
 Under the name of pubescent ^ uterus Puech has designated the 
 uterus which preserves after puberty the characteristics peculiar to 
 this organ during the period of transition between childhood and 
 puberty. He has seen two cases, one of which was confirmed by 
 autopsy. In the latter case, although the woman had been a prostitute 
 for twelve years, she had never menstruated ; in the other, a woman 
 of forty, haemorrhage from the vulva had only occurred three times at 
 long intervals. The vaginal portion of the cervix is small and conical 
 or presenting a warty projection of the size of a pea, the meatus is 
 very small. The incomplete development of the uterus is discovered 
 by vaginal and rectal touch ; by the latter, the upper borders of the 
 organ are easily reached or exceeded. A probe introduced through 
 the cervix demonstrates with certainty the defective length. Notwith- 
 standing what has been said by Scanzoni as to the incurability of this 
 lesion, it should be treated by the means indicated for uterine atrophy, 
 
 ' If absence of the uterus is the result of an operation, sterility is not 
 absolute. I have mentioned the case of a lady on whom Ivoiberle had operated 
 (ablation of the uterus), but in wliom he had unfortunately left the ovaries. 
 A small fistula having persisted, which formed a communication between 
 the vagina and abdominal cavity, this unfortunate woman had an extra- 
 uterine abdominal pregnancy, a most remarkable occurrence, showing the 
 limited part which the uterus plays in the accomplishment of reproduction. 
 
 2 Gaz. vied., 18(35, p. 10. 
 
 ^ Incomplete development of Kiwisch, Rokitansky and Scanzoni. See p. 80. 
 
792 UTERINE DISEASES IN DETAIL 
 
 especially by electricity or by Simpson's galvanic pessary, the intro- 
 duction of which may be accompanied when necessary by dilatation. 
 Iron and other tonics should also be administered. The uterus may 
 be to all appearance normally developed and yet have no cavity, either 
 owing to arrested development of Miiller's canals when they are still 
 solid, from the eighth to the tenth week, or as the result of precocious 
 adhesions of the opposite walls of the mucous membrane. This very 
 rare state, of which Boivin and Duges give an example, is like the pre- 
 ceding compatible with perfect health, and is manifested by the 
 absence of menstruation, and of the signs of menstrual retention, not- 
 withstanding the existence of symptoms of monthly ovulation ; by the 
 impossibihty of conception, although intercourse may be easy ; by the 
 imperforation and impenetrability of the uterus in spite of the deve- 
 lopment and external appearance of this organ being almost normal. 
 . Uterine atrophy is all the more deserving of attention because it may 
 be followed by cure, and consequently by the cessation of sterility. It is 
 caused in the same way as atrophy of the ovaries or is produced after 
 labour from the excessive retrograde evolution which takes place in the 
 uterus at this period (p. 621). I have already spoken of the cases 
 mentioned by Simpson in describing this remarkable malady ; I have 
 seen several myself ; Puech has observed the same disease in a woman 
 after delivery and eleven months^ lactation ; and in another after 
 repeated miscarriages. Although there is little hope of cure for this 
 state when it is of long standing, the physician should not remain 
 inactive; he should on the contrary strengthen the constitution by 
 tonics, hydropathy and sea-bathing, and also apply electricity to the 
 uterus, introduce galvanic stems, and so endeavour to produce new 
 vitality in the organ. There will be all the more chance of success, if 
 treatment is instituted soon after delivery. Uterine atrophy may affect 
 the whole uterus, or only one of its segments. The same treatment is 
 appKcable to either segment, and to the whole uterus. 
 
 Simple or complicated imj)erf oration of the cervix is a cause of 
 sterility which may be treated successfully, especially if it coincides 
 with normal conformation -, for it is frequently accompanied by an 
 abnormal position and form. It is the same with septa situated in the 
 vagina more or less near the cervix, imperforate or pierced with a hole, 
 or membranous contractions of this canal which, without being a 
 cause of impotence, yet prevent conception ; it is the same with con- 
 genital narrowness or accidental contractions of the os, which is so 
 frequent a cause of mechanical dysmenorrlicea.-^ I have already spoken 
 of these pathological states (p. 305) ; and shall only remark here that 
 they play an important part in sterility, and that as they are not always 
 accompanied by menstrual disorders, it is easy to misinterpret the real 
 cause of sterility in these cases if a direct examination is not made. 
 I have also described the treatment which is suitable for them during 
 the paroxysms of pain attending menstruation, as well as in the inter- 
 calary periods, in palliative as well as in radical cure ; and shall only 
 further remark, that radical cure is only produced by dilatation or 
 
 Oldham was the first to use tliis name {London Med. Gaz., vol. ii, p. 919). 
 
STEEILITY 793 
 
 double incision of the cervix (p. 313). Local treatment should always 
 be followed by general tonic treatment and diathetics, according to the 
 case, and by the use of ergot, electricity, purgatives, &c., with the 
 object of resolving the congestive condition due to the long-standing 
 atresia or contraction. 
 
 Congenital or consecutive contractions may affect the os internum. 
 They should be treated in the same way as those of the vaginal orifice, 
 by gradual dilatation, which is less dangerous and more lasting in its 
 effects than simple incision. It is the same when they affect the two 
 orifices of the cervix simultaneously, and provided there is neither 
 contraction nor atrophy of the cervical cavity, we may hope for cure. 
 Dilatation has the great advantage of being resolvent as well as dilative ; 
 so that in some cases gradual dilatation by sponge tents may not only 
 procure a palliative but a radical cure in contractions of the uterus as 
 in contractions of the urethra, especially if we associate with the 
 mechanical action the chemical one of medicaments such as bella- 
 donna, the red oxide of mercury and others, in the form of resolvent 
 ointment covering the tent; it is also useful to administer these drugs 
 in enemata, and to pour glycerine on the cervix, keeping it there by a 
 large plug of cotton wool ; for it softens the cervix as well as con- 
 tributing to the cessation of the contraction or relaxation of the 
 orifice. 
 
 Torsion-oi the body on the cervix (pp. 309, 430) is another mecha- 
 nical alteration producing effects of the same kind, and in consequence 
 of which a deviation occurs which renders penetration of the sperm 
 difficult or impossible. The long continued use of laminaria tents, 
 which act simultaneously by enlarging and straightening the isthmus, 
 greatly facilitates conception. It is unnecessary to say, that the asso- 
 ciation of general means with local applications is still more important 
 here than in the preceding cases ; for torsion of the isthmus is almost 
 always dependent on flexion, softening of the uterine tissue, or con- 
 secutive chronic congestion, and consequently requires the use of 
 resolvents, restoratives, tonics, sea-bathing and especially hydro- 
 pathy. 
 
 Flexions ^ are causes of sterility when well marked, and the sterility 
 is incurable when the flexion is kept up by adhesions and cicatricial 
 bands which make it impossible to straighten the uterus. There are 
 two causes of sterility in such cases : the first is the mechanical 
 obstacle, which hinders facility of communication between the cervical 
 and uterine cavities at the isthmus : the second, the alteration of 
 tissue, the morbid state, the softening under the influence of which 
 flexion is produced and maintained. It is unnecessary to add that 
 when adhesions prevent reduction of the flexion, especially of retro- 
 flexion, these adhesions not only prevent conception by hindering the 
 straightening of the organ, but further, are the indications of a previous 
 inflammation of the uterus. Fallopian tubes and ovaries, or of peri- 
 uterine inflammation. In such cases there are almost always altera- 
 
 1 Lumpe, Considerations sur la sterilite causee par Vinjiexion de I'uterus 
 {Monatschr., &c., 1864, Bd. xxiv, S. 69). 
 
794 UTERINE DISEASES IN DETAIL 
 
 tions of the uterine mucous membrane, obliterations of the tubes, 
 alteration of the normal relationship of the ovary with the oviduct, 
 vicious adhesions of the uterus and annexes, which are additional 
 causes of sterility. I do not therefore speak of the means of treat- 
 ment to be employed in such circumstances. In the case of simple 
 flexion we must endeavour, especially in a young woman, to straighten 
 the organ (p. 420). In cases of complex flexion we may be obliged 
 to perform partial section of the convex lip of the cervix, in order to 
 form a direct course for the semen through the cervico-uterine canal 
 (see rig. 283, p 426). 
 
 Sometimes simple version, or defective relations between the male 
 organ which ejaculates the semen and the uterine meatus which ought 
 to receive it, is sufficient to render penetration of the sperm very 
 difficult if not impossible and to prevent conception.^ 
 
 Sterility caused bj retroversion may be remedied by means of 
 Hodge^s, Meigs's or Sims's ring pessaries, which take up very little 
 room in the vagina and which are no obstacle to marital intercourse. 
 Sims 2 gives several examples, among others that of a lady who had 
 three children, conception being due to the use of an annular pessary 
 during coitus ; he mentions the case of other women who by the use 
 of these pessaries till the fifth month were able to bring their preg- 
 nancy to the full term. If permanent cure cannot be obtained tem- 
 porary replacement is easily effected by posture, the association of 
 palpation with digital touch, and by the use of the sound. Provided 
 this replacement lasts for some hours, or can be effected by the 
 husband during intercourse, it is sufficient to make conception pos- 
 sible. I have seen several remarkable cases of this kind. 
 
 Every alteration in the cervix and os uteri (alteration in size, form 
 and structure, ulcerations, induration, &c.) becomes a cause of 
 sterility from the difficulty which it places in the way of the accom- 
 plishment of the cervical functions. The erection of the uterus ex- 
 cited by ovulation and coitus, as Houget's researches show, plays an 
 important part in conception. The effects of this erection on 
 the cervical portion cause an increase in its size and induration, suc- 
 ceeded by relaxations and divergence of the walls, producing actual 
 aspiration,^ as observed by Beck* on the cervix of a multipara affected 
 with prolapsus, which, when lightly touched, made five or six move- 
 ments of aspiration within twelve seconds, accompanied by a voluptuous 
 
 1 According to Sims (op. cit., p. 237), out of 250 married women, wlio liad 
 never had children, 108 were ailected with ante version and 68 with retro- 
 version ; out of 255 who had had children, hut who had ceased to conceive 
 before the menopause, 61 were afEected with anteversion and 111 with retro- 
 version ; that is to say, out of 505 patients affected with sterility, natural or 
 acquired, 343 pi-esented deviations or flexions of the womb ; besides, as about 
 one half of these women had previously been pregnant, it is probable tliat 
 their acquired sterility depended on the mechanical lesion of the organ. 
 
 2 Op. cit., p. 281. 
 
 ^ Wemich {Beitrllge zur Gehurtshunde u. Gfyndc, i, 296, 308). 
 ■* How do the spermatozoa enter the uterus? {Med. and Stirg. Bepovier, 
 1872). 
 
STERILITY 795 
 
 sensation. It is easy to understand the importance of any alteration 
 which prevents the production of these movements. 
 
 Hypertrophy is the simplest of all these alterations. Sterility 
 usually accompanies the hypertrophic elongation of the supra-vaginal 
 portion which simulates prolapsus. Sterility is never more certain 
 than when there is a concurrent alteration in the tubes or ovaries, 
 often consecutive to hypertrophic elongation and prolapsus of the 
 uterus. Huguier^ says — "I never knew a woman to conceive when once 
 the elongated uterus had been so prolapsed as to have caused com- 
 plete procidentia and inversion of the vagina, by which I do not mean 
 to say that it has never occurred ; science would refute this assertion ; 
 all that is necessary to make conception possible being for the utero- 
 ovarian canal to be free.^' 
 
 Hypertrophy of the vaginal portion is also a cause of inaptitude for 
 conception, whether this slight hypertrophy is associated with marked 
 conicity of the cervix, or whether it affects the whole of the cervix, or 
 only attacks one lip. It was Lisfranc^ who first recognised conicity 
 of the cervix as a cause of sterility, and who recommended section of 
 the cone as the best treatment. There is no doubt that it is usually 
 in cases of conical cervix that the penis slips over the cervix, dis- 
 charging the sperm in an accidental copulative sac in which it runs a 
 great chance of being lost. It is certain also that in such cases the os, 
 whether situated at the apex of the cone or on one of its surfaces, is very 
 narrow and circular, and may be included in the class of orifices con- 
 genitally contracted, for which I have advised dilatation and division. 
 A considerable sub-vaginal hypertrophy, whether with elongation or 
 with tumefaction of the lower portion of the cervix, is also a cause of 
 sterility. This cause is not absolute, but it only yields to surgical 
 treatment ; if therefore we can be sure that it is not incurable, we 
 may also he certain that it cannot be cured without amputation of the 
 hypertrophied portion. Dupuytren^ has mentioned cases in which 
 excision of the cervix was followed by conception. I have seen a 
 sufficient number of cases to convince me on this point, and I can 
 affirm that this operation affords patients a great chance of being 
 cured when there are no complications. It is the same with hyper- 
 trophy confined to one lip, for the orifice is then necessarily deviated, 
 or partly obliterated, or at least concealed by the hypertrophied lip. 
 If the reader wish to consider the causes of sterility due to hyper- 
 trophy of the cervix from an exclusively practical point of view, he 
 may refer to what I have said as to the various forms which hyper- 
 trophy may assume, and which may be summed up in the following 
 table : 
 
 1 Op. cit., p. 123. 
 ^ Clinique de la Pitie, ii, 139. 
 
 3 F. G. Dumont, 8ur I'agenesie, Vvmpuissance et la dysgenesie. These de 
 Paris, 1830, 
 
796. 
 
 UTEEINB DISEASES IN DETAIL 
 
 1. Hypertrophy of the whole ") .i , ■, i-j ... 
 cei'Tix \ -^^^0^^ always morbid, even in virgms. 
 
 2. Partial hypertrophy of ( Supra-Taginal-Almost always morbid, 
 the cervix \ . .. .Sub-vaginal (Congenital. 
 
 C ^ (, Acquired. 
 
 f Total . . . Very rare ; it causes incurvation. 
 
 3. Hypertrophy of one seg- \ C^^ the central portion or of the 
 ment,anteriororposterio",<^ ^'^^'^^'\ t^' '''"^^T i *^' 
 of the cervix. ^/^P^^ °^ ^^^ cervical portion. 
 
 Ur the upper extremity (utenne 
 Partial. . .^ uvula). 
 
 /'Exuberance of 
 Of the lower \ one lip. 
 extremity . j Dovetailing of 
 (^ V. the two lips. 
 
 Hypertrophy of the whole of one of the segments causes incurvation 
 of the cervixj the convexity corresponding to the hypertrophied seg- 
 ment (usually the posterior one), and, like flexion of the cervix, some- 
 
 FiG. 428. — Total hypertrophy of 
 the posterior segment with in- 
 curvation. 1. section of the 
 free extremity of the vaginal 
 portion (1st part of the opera- 
 tion). 
 
 Fig. 429. — -Total hypertrophy of 
 the posterior segment. 2. me- 
 dian division of the remain- 
 ing vaginal portion (2nd part 
 of the operation). 
 
 times necessitates amputation of the lip corresponding to this segment 
 (Pig. 428, 1), followed by division of the rest of the vaginal portion 
 of this segment on the median line (Pig. 429, 2), so as to make a 
 direct course for the penetration of the semen into the uterine canal ^ 
 {seeY\^. 283, p. 426). 
 
 Partial hypertrophy of one of the segments affecting the median 
 portion has especially the effect of developing the size of the central 
 pilaster, which is the trace of the raphe of the two primitive uteri, and 
 of exaggerating the dovetailing of this central column of the arbor vita 
 with that of the opposite segment, or of one of the secondary fleshy 
 columns which are connected with it with the corresponding columns 
 in the other segment. It is often indeed complicated .with unequal 
 hypertrophies, either sessile or partly pediculated, which give to the 
 cavity of the cervix a broken and mammillated appearance. The best 
 surgical treatment, in addition to resolvent medical treatment, consists 
 
 ^ Sims, op. cit., p. 214. 
 
STEEILITY 
 
 797 
 
 in introducing sponge tents repeatedly and in performing excision or 
 simply abrasion of the dilated cervical cavity, as well as in the local 
 application of resolvents, with which the sponge may be saturated or 
 covered, and finally in the cauterisation of projecting portions of the 
 hypertrophied organ which impede conception. In order to make 
 
 Fig. 430. 
 
 Fig. 431. 
 
 Fig. 430. — Valvular projection of the anterior portion of the isthmus. 
 
 Fig. 431. — Sims's curette. I have had the concavity sharpened, so as to use it 
 for abrading the valvular projection of the isthmus, when caught in the 
 terminal fenestra of the instmment. By suppressing one side of this 
 fenestra we have a small pruning hook, still more convenient than the 
 curette, and which I have frequently had occasion to use. 
 
 this cauterisation easily and to preserve the healthy segment from 
 contact with or from the radiation of the actual cautery, I take care 
 to seize the cervix with divergent tenaculum hook forceps or to intro- 
 duce one of Recamier's large curettes, the blade of which serves as a 
 conductor for the very small cautery employed for this purpose. 
 
 Partial hypertrophy affecting one of the segments at its upper 
 extremity sometimes gives rise to a kind of valve or projecting tubercle 
 (uterine uvula), which must not be confounded with a projecting 
 angle of flexion, with which it sometimes coexists. The cervix having 
 
798 UTEEINE DISEASES IN DETAIL 
 
 been previously dilated by sponge tents, this little projection (Fig. 
 430, 3) may be abraded by means of a small hook with a somewhat 
 malleable stem, to allow of variation of its inclination. 
 
 Partial hypertrophy of the lower extremity of one of the segments, 
 i.e. one of the lips, has a different effect according to whether it most 
 affects the lip on the side of the vaginal surface or on the side of the 
 cervical cavity. If it affects it on the vaginal side it renders the lip 
 exuberant, so that it projects beyond the orifice which is above or 
 below it ; hence the acuminated and rostral forms of the conical 
 cervix, the blade and apron-like forms (by flexion) of the cuneiform 
 cervix, and the snout-like forms of the cylindrical cervix; in such cases 
 it should be cauterised or amputated. If the hypertrophy affects it 
 on the side of the cervical cavity, it distends the opposite lip, attenuates 
 it, becomes embedded in it, giving to the orifice a characteristic semi- 
 lunar form (see p. 618, Eigs. 355, 356). As a rule I content myself 
 with applying the actual cautery, more or less deeply, to the centre of 
 the hypertrophied lip, thereby provoking suppuration, which being 
 followed by resolution and contraction, raises the convex border of 
 this lip and rectifies the upper outline of the orifice (Pig. 193, p. 213). 
 I have often seen conception follow this little operation. In such 
 cases the patient should be advised to adopt the prone posture during 
 coitus. 
 
 In case the difficulty of rectifying the uterine canal should suggest 
 to any practitioner the idea of attempting artificial fecundation, I wiU 
 here describe the best method of proceeding so as to preserve the 
 vitality of the sperm and the characteristic movements of the sperma- 
 tozoa. The male organ should be covered with a shield, care being taken 
 not to apply it tightly. Coitus being terminated the ejaculated fluid 
 will remain in the shield which is then cut and the fluid received into 
 a small glass syringe (previously heated by being placed for a few 
 minutes in water at a temperature of 40*^ C.) furnished with a metallic 
 or gutta-percha sound, by means of which and by using great care it 
 will be easy to make it penetrate into the cavity ; the patient should 
 then rest for a day. 
 
 Rigidity of the cervix may be the consequence of long-standing 
 continuous congestion, or of indurated metritis. It should be treated 
 successively by antiphlogistics, glycerine, alkalines, and resolvents 
 capable of softening the uterine tissue, then by sponge tents and 
 scarifications, ignipuncture and, lastly, by division and, if necessary, by 
 section of a pyramidal fragment of the tissue of one of the lips. Or- 
 ganic alterations, fibroids, polypi and cancer, although not necessarily 
 causes of sterility (I have mentioned cases of pregnancy in all these 
 cases), considerably hinder the uterine functions, preventing in most 
 cases the contact of the sperm with the ovum, or uterine pregnancy, 
 or the continuation of a pregnancy beyond a few weeks. 
 
 Lastly, abundant or abnormal secretions may prevent conception in 
 two ways : mechanically or chemically. By a purely mechanical action 
 an abundant leucorrhoea filling the uterus (even without going so far 
 as to form hydrometria and pneumatosis), or a viscous, coherent, 
 
STERILITY 799 
 
 tenacious leucorrhoea, completely obstructing the cervix by a gela- 
 tinous plug (analogous to that of pregnancy)^ make conception very 
 difficult, either by preventing the semen from penetrating into the 
 uterine cavity or by expelling the sperm (supposing it has penetrated) 
 by their abundance and the uterine contractions which impel them 
 naturally towards the vagina.^ Chemically, the abnormal secretions of 
 the utero-vaginal fluid (from the mucus of the womb being too alka- 
 line or from that of the vagina being too acid) may kill the sperma- 
 tozoa.^ It is probable that the latter, unless very abundant and very 
 acid, has not much action on the mass of the ejaculation, the central 
 portion of which it can hardly reach ; but it is probable that the 
 former has an injurious influence on the relatively small quantity which 
 penetrates into the uterine cavity.^ In a number of cases the abund- 
 ance of the leucorrhoea and even its purulence does not prevent con- 
 ception. 
 
 Tubal maladies cause sterility by preventing the ovum from being 
 received and the sperm from being transported by these canals, or 
 both these elements from coming into contact and from undergoing 
 the reciprocal influence known as fecundation. They may exist either 
 without or within these organs. 
 
 3. Physiological obstacles to conception. — They depend on con- 
 genital or acquired physiological imperfection or on functional dis- 
 order caused by some morbid state. With regard to disorder of the 
 normal i)hysioJogical act, it may either be one of defect or excess. 1 
 have already mentioned the conditions of erection, general muscular 
 contraction and orgasm in which the genital economy of woman should 
 be at the time of periodical dehiscence, menstruation and coitus ; there 
 is no doubt that the divergence of the uterine walls, and the dilatation 
 of its cavities produced by erection, greatly facilitate the entrance of the 
 sperm. It is easy to understand that defect of orgasm, indicated by 
 the absence of any voluptuous sensation, suffices to prevent erection 
 and consequently the bringing into play of utero-tubal conditions 
 equally favorable to the transport of the ovum and to that of the 
 sperm. We do not know all the conditions connected with the accom- 
 plishment of the internal acts of this function ; for instance it has been 
 asserted that women have conceived in spite of themselves, after rape, 
 or unknown to themselves, during intoxication and sleep, or even after 
 intercourse to which they had consented, but which had given them 
 no pleasure. Although these facts can only be received with reserve 
 I can afhrm that I have known women who not only have never 
 experienced the least pleasure, but have felt positive repugnance for 
 an act which they only performed from duty, and yet have had several 
 pregnancies. That is undoubtedly because vital orgasm, erect io 
 
 ^ Jobert de Lamballe published a work on dropsy of the cervix and its in- 
 fluence on conception in 1843. 
 
 " Donne, E.q^erlences sur les animalcules spermatiques et sur quelqi.ies-unes 
 des causes de la sterilite de lafemme (Gaz. 'ined., 1837). It should be remem- 
 bered that alkaline fluids excite the movements and prolong the life of sperma- 
 tozoa. 
 
 ^ Joulin, op. cit., p. 162. 
 
800 UTEEINE DISEASES IN DETAIL 
 
 and the involuntary movements of the uterus and tubes may escape 
 sensibility and perception, and may be produced independently of all 
 voluntary participation, and of all voluptuous feeling. These cases, 
 however, are exceptional. The proof of this is, that in most women 
 the voluptuous sentiment is only gradually awakened, as if by the 
 education of a new sense, and that in such cases conception only 
 occurs some time after marriage. According to Spencer Wells, out 
 of seven fertile marriages delivery only occurs four times before 
 eighteen months. 
 
 When alteration of the physiological acts which influence impreg- 
 nation depends on a definite morhicl condition it is easier to seize the 
 indications and to apply an appropriate treatment. These morbid 
 states, or rather the general affections which keep them up (inflam- 
 mation, rheumatism, scrofula, herpetism, &c.), usually cause sterility 
 on account of the material alterations which they eff'ect in the tissues 
 of the internal sexual organs, such as tumefaction, ulceration, &c., 
 or from alterations of secretion, such as leucorrhoea, or from haemor- 
 rhage.^ These morbid states often produce functional disorder, 
 amenorrhoea, dysmenorrhoea, pains, absence of desire, ko,.; hence the 
 repugnance which a number of women affected with uterine disease 
 experience for coitus. 
 
 III. Inaptitude for germination or ovulation. — This is the most 
 certain cause of sterility strictly speaking ; for inaptitude for fecun- 
 dation (whether for the transport and union of germs or for the 
 reception of the semen) is only an accident preventing the evolution or 
 development of the germ, but in nowise affecting aptitude for repro- 
 duction. Ovulation is the best proof that a woman can give of her 
 aptitude for procreation. If the ova are formed normally in the ovary, 
 if they reacli their maturity there and are expelled periodically, the 
 woman furnishes the reproductive element peculiar to her, and thereby 
 gives the best proof of reproductive capacity. If this physiological act 
 cannot be established, or is suspended, or extinct, the woman becomes 
 sterile. Sterility in such a case is often permanent ; it may however 
 be relative or temporary : the former depends on the absence of the 
 reproductive organ, on defective development, atrophy, or on an organic 
 alteration or disorganisation of the ovary ; the latter on the suspension 
 of the reproductive function of this organ under the influence of a 
 local pathological state, of a more or less considerable partial degenera- 
 tion of its tissue, or else on the reaction which it experiences from a 
 general morbid affection, from the debilitating influence which is 
 exercised upon it by a serious disorder of the health and con- 
 stitution. 
 
 Me7tstruation in its relations tvith sterility. — The causes of sterility 
 which I have just rapidly reviewed are really so numerous that, in order 
 to diagnose them, it is necessary to follow an artificial method based on 
 
 ■> Menon-hagia is particularly formidable on account of its tendency to_ be 
 reproduced when the ovum is newly fertilised, in which case there is abortion. 
 In these instances sterility does not arise from defective conception but fi-om 
 some inpediment to gestation. 
 
STEEILITY 801 
 
 the alterations which the most apparent sexual phenomenon^ menstrua- 
 tion, may undergo. We should therefore, first of all, ask a sterile 
 woman whether this function is absent, anomalous, or regular. 
 
 Absence of menstruation may depend on congenital absence, atrophy, 
 arrest of development, or imperfection of some portions of the sexual 
 economy, or on accidental lesions, suppuration, gangrene, adhesions, 
 or obliterations of the same parts. The prognosis is almost always 
 serious as regards the fertility of the woman ; except in slight uterine 
 atrophy there is hardly anything to hope from treatment. Absence of 
 menstruation may be associated, although rarely, with normal con- 
 formation of the genital organs, merely constituting a physiological 
 anomaly or imperfection, as is proved by the fact that women who 
 have never menstruated have had children. Ptondelet and Joubert^ 
 have both published cases; the former of a woman, who had twelve 
 children, the latter of one who had eighteen, neither of whom had ever 
 menstruated; Colombat^ knew another who had a child; Tlechner^ 
 speaks of a woman in similar conditions having had six pregnancies in 
 thirteen years ; Barbieri,^ Bruck^ and Elsasser have each seen a case 
 of the same kind. Stark's^ work on this subject should be consulted. 
 It must however, be admitted that the physiological absence of 
 menstruation is usually accompanied by sterility, and it is not certain 
 whether it does not sometimes depend on a serious disorder, not only of 
 the function but of the sexual economy. Therefore when consulted 
 about a case of this kind, we cannot be too careful in giving an 
 opinion, which cannot be based on a complete examination of organs 
 inaccessible to our investigations. 
 
 Anomalies of menstruation are produced either by mechanical causes 
 or morbid states. The former are manifested under the form of 
 menstrual retention, deviated menstruation, dysmenorrhoea, &c. ; the 
 physician should discover the congenital or acquired origin and the 
 superficial or internal seat of the obstacle to the free discharge of 
 blood. The latter include amenorrhcea, leucorrhoea, dysmenorrhoea, 
 menorrhagia, &c. ; it is important to know whether they depend 
 on a merely local or a general condition, whether there is disease 
 of the uterine mucous membrane, deviation or flexion of the womb, 
 active or passive congestion, &c. ; or whether the patient is suf- 
 fering from chlorosis, anaemia, plethora, organic disorders, scrofula, 
 constitutional syphilis, or any other diathesis. As these maladies 
 do not always produce menstrual disorders, they ought to receive 
 great attention when they do so and they then indicate the neces- 
 sity for the association of general with local treatment. There is one 
 which is all the more deserving of attention because apparently it 
 does not prevent conception. 1 mean menorrhagia or metrorrhagia ; 
 
 ' Erreurs populaires, liv. ii, ch. 1. 
 
 2 Op. cit., p. 34. 
 
 ■^ Gaz. mid., 1841, p. 91. 
 
 " Gaz. med., 1843, p. 207. 
 
 •"■ Allgem. unedic. central. Zeitung, 1854, No. 14. 
 
 * Des grossesses survenues en I'absence de la menstruation, Stark's Arcliiv 
 
 fur die Geburtshiilfe. .Jena, 1787. 
 
 6] 
 
802 UTEEINE DISEASES IN DETAIL 
 
 these are not in one sense absolute causes of sterility, because when 
 haemorrhage is arrested conception may occur (and frequently does) ; 
 but from their tendency to be reproduced periodically, or under the 
 influence of the slightest provocation, or even without any known 
 cause, they expel the recently impregnated ovum, causing early 
 abortion and recurring so frequently as to be equivalent to sterility. 
 
 Lastly, whilst regularity of menstruation cannot coexist with certain 
 malformations and organic disorders, or even with certain morbid 
 conditions just described, it may do so with lesions of the uterine 
 economy, with diseases of the neighbouring organs, or with general 
 affections which cause sterility. 
 
 The true cause of sterility, therefore, must be sought in one of the 
 conditions just enumerated. If it cannot be so explained, it would 
 yet be unjustifiable to assume the existence of one of the causes hypo- 
 theticaUy suggested by investigators of this subject, such as defective 
 sympathy or physiological incompatibility between the husband and 
 wife. If we succeed in identifying the cause, it will still be necessary 
 to act with great caution j holding out only moderate hopes to those 
 whom we expect to cure ; while we abstain from disclosing abruptly 
 or unnecessarily to others the fact that in their case there is little 
 ground for a favorable prognosis. 
 
INDEX 
 
 Abdominal tumours, 774 
 Ablation of polypi, 229 
 
 — of fibroids, 229 
 
 Abortion, influence of, on uterine disease, 
 236 
 
 Abrasion of uterine fungous growths, 
 225 
 
 Abscess, pelvic, v. Peri-uterine inflam- 
 mation. 
 
 — peri-uterine, 556, 566 
 
 Acid nitrate of mercury as a uterine 
 
 caustic, 209 
 Adenitis and angioleucltis, peri-uterine,. 
 
 537 
 Age, influence of, on the development of 
 
 uterine disease, 238 
 Amenorrhoea, 259 
 
 — symptomatic, 260 
 
 — idiopathic, 261 
 
 — sympathetic, 261 
 
 — psychical, 261 
 Amputation of the cervix uteri, 387 
 Anaemia, symptomatic of uterine disease, 
 
 104 
 Anatomical characteristics of the sexual 
 
 system in woman (variability of), 3 
 Anomalies of the genital apparatus, 65 
 
 — of the ovaries, 70 
 
 — of the tubes, 73 
 
 — of the uterus, 75 
 Apoplectic dysmenorrhoea, 323 
 Appearance, external, of abdomen (signs 
 
 of uterine disease furnished by), 
 122 
 
 Appendages, inflammation of, v. Peri- 
 uterine inflammation. 
 
 Arsenical powder of Friar Come, 210 
 
 Arteries, helicine, of uterus, 36, 47 
 
 Ascent of uterus, 355 
 
 Ascites, uterine, 581 
 
 Asthenia, a characteristic of certain 
 uterine diseases, 156 
 
 Atresia, vulval, 271, 274 
 
 — vaginal, 271, 275 
 
 — uterine, 271, 275 
 
 — congenital (linperforation), 271 
 
 — accidental (obliteration), 272 
 
 Atrophy of the womb, 620 
 
 — excentric, 620 
 
 — concentric, 621 
 Auscultation, a means of diagnosis, 121 
 Autoplasty, gynaecological, 229 
 
 — after amputation of cervix, 229 
 
 — of cervical orifice, 316 
 
 Ballottement in diagnosis of uterine 
 
 disease, 121 
 Baths, use of, in the treatment of uterine 
 
 disease, 176 
 
 — hot, 176 
 
 — cold, 179 
 
 — medicated, 183 
 
 Belts in the treatment of uterine diseases, 
 190 
 
 — abdominal, 190 
 
 — Courty's, for methodic compression, 
 
 191 
 
 — hypogastric, 191 
 Bleeding, 169 
 
 Blisters to the cervix, 190 
 
 Cancer of the uterus, 692 
 
 — diagnosis, 692 
 
 — subjective signs, local symptoms, 
 
 pain, 692 
 
 — haemorrhage, 693 
 
 — cauliflower excrescence, 698 
 
 — distiactiou between scirrhus and 
 
 encephaloid, 700 
 
 — treatment, 702 
 by caustics, 703 
 
 by amputation of the cervix, 
 
 704 
 
 by ecrasement, 705 
 
 by excision, 707 
 
 Cancroid, v. Cancer of the uterus. 
 Carbonic acid, application of, to cervix, 
 
 205 
 Castration, 770 
 Cataplasms to cervix, 202 
 Catarrh, uterine, v. Leucorrhcca. 
 
 — of the Graafian foUlcles, 738 
 Cauliflower excrescence, 698 
 
804 
 
 INDEX 
 
 Causes, predisposing, of uterine diseases, 
 
 234, 238 
 Caustics, liquid, 209 
 
 — acid, 209 
 
 — alkaline, 209 
 
 — solid, 209 
 
 — canquoin, 209 
 
 — Vienna paste, 209 
 
 — chloride of zinc, 210 
 
 — Friar Gome's arsenical powder, 210 
 
 — nitrate of silver, 210 
 Cauteries, 211 
 
 — gas, 215 
 
 — galvanic, 216 
 
 — Paquelin's thermo-cautery, 216 
 Cauterisation of the cervix, 208 
 
 — — by potential cautery, 209 
 
 — — by actual cautery, 211 
 
 — — by ignipuncture, 211 
 by gas, 215 
 
 — — by electrolysis, 216 
 
 — of uterine cavity, 218 
 
 by intra-uterine injections, 219 
 
 — — by nitrate of silver crayon, 221 
 Cavity, pelvic, division of, 24 
 
 — uterine (means of exploration of), 
 
 147 
 
 Celibacy, influence of, on uterine diseases, 
 238 
 
 Cellular tissue of broad ligaments, 26 
 
 Cellulitis, pelvic, v. Peri-uterine inflam- 
 mation. 
 
 Cervix uteri, 28, 32, 40 
 
 — anomalies of, 80 
 Changes of position, 343 
 
 — of the rectum, due to development 
 
 producing changes of situation in 
 the uterus (Freund), 345 
 
 — displacements, 346 
 
 — deviations, 388 
 
 — flexions, 407 
 
 — inversion, 441 
 Characteristics, general, of uterine dis- 
 eases, 233 
 
 — their frequency, 233 
 
 — preponderating influence of predis- 
 
 posing causes, 233 
 
 — their double nature, general or dia- 
 
 thetic and local, 246 
 
 — their chrouicity, 249 
 
 — difiiculty of cure, 250 
 
 — diversity, 251 
 
 Chlorate of potassium, its use in mem- 
 branous dysmenorrhoea, 330 
 
 Chloride of zinc for cauterisation of 
 uterus, 210 
 
 Chloroform, vaginal injections of, 206 
 
 Chlorosis, symptomatic of uterine dis- 
 eases, 104 
 
 Chronicity of uterine maladies, 157, 
 249 
 
 Cicatrisation after cauterisation, applica- 
 tions for hastening, 218 
 
 Classification of uterine diseases, 253 
 
 Climate in the treatment of uterine 
 
 diseases, 169 
 Cloaca, 58 
 
 Collodion, painting the cervix with, 203 
 Colpodesmoraphy, 382 
 Colporaphy, 383 
 
 Complexity of uterine diseases, 252 
 Complications as a source of indications 
 
 in treatment, 160 
 
 — of uterine diseases, 248 
 Congestion, uterine, 466 
 
 phvsiological and pathological, 
 
 466 
 
 — — idiopathic and symptomatic, 466 
 active and passive, 467 
 
 anatomical changes consequent 
 
 on, 467 
 
 diagnosis, 467 
 
 subjective signs, 467 
 
 objective signs, 468 
 
 — — treatment, 469 
 
 — peri-uterine, v. Peri-uterine inflam- 
 
 mation. 
 
 Constipation, its disastrous effects (co- 
 pr^mia), 105, 106 
 
 Constitution, influence of the, upon the 
 development of uterine diseases, 
 239 
 
 Contusions of the uterus, v. Traumatism. 
 
 Copreemia, 106 
 
 Corpus luteura, 9 
 
 Cough, uterine, 102 
 
 Cupping in uterine diseases, 170, 173, 
 226 
 
 Cura famis, 186 
 
 Cure, spontaneous, rare in uterine dis- 
 eases, 151, 250 
 
 Curette, Recaraier's, 225 
 
 — Sims's, 225 
 
 — buttonhook, 225 
 
 — Courty's, 226 
 Curvature of the uterus, 409 
 Cysts of the ovary, 733 
 
 — — composition, 734 
 unilocular, 734 
 
 — — multiple or multilocular, 734 
 compound, 736 
 
 origin and development, 738 
 
 in the newly born, 739, noie 
 
 in the married and single, 739 
 
 — — duration, 742 
 
 — — termination, 742 
 
 — — deterioration of health, fades 
 
 ovariana, 743 
 
 treatment, 749 
 
 ovariotomy, 753 
 
 — tubo-ovarian, 780 
 
 — hydatid, 782 
 
 Depots laiteux, 556 
 
 Descent of uterus, v. Prolapsus. 
 
 Deviation of the menses, 292 
 
 — diagnosis, 293 
 
 — treatment, 298 
 
INDEX 
 
 805 
 
 Deviations, 388 
 
 — three degrees, 388 
 
 — anteversion, retroversion, and latero- 
 
 version, 388 
 
 Diagnosis of uterine diseases in general, 
 96 
 
 Diathesis, influence of, on the develop- 
 ment of uterine diseases, 240 
 
 Digestion, disorders of, 99 
 
 Dilatation in stenosis of the cervix, 309 
 
 — by dilating instruments, sounds and 
 
 bougies, 309 
 
 — by sponge tents, 310 
 
 — by incision, 310 
 
 Dilator, uterine, of Lemenant-Deschenais, 
 147 
 
 of Mathieu, 147 
 
 of Busch and Huguier, 147 
 
 of Aussandon, 148 
 
 intra-uterine pessary, 148 
 
 Diseases of the appendages, 714 
 Dispareunia, 110 
 Displacements, 346 
 
 — of the ovaries, 346 
 
 — of the Fallopian tube, 348 
 
 — of the uterus, 344 
 (hernia), 351 
 
 horizontal displacements, 354 
 
 — — ascent, 355 
 descent, 356 
 
 Diversity of uterine diseases, 251 
 
 Division of cervix, 227, 311 
 
 Double character of uterine diseases, 
 
 diathetic and local, 246 
 Douglas, folds of, pouch of, 23, 24 
 Dropsy of the uterus, 581 
 
 — encysted of the ovary, 733 
 
 — profluent of the tubes, 780 
 Dysmenorrhcea, 300 
 
 — idiopathic, 301 
 
 — congestive, 302 
 
 — ovarian, 302 
 
 — treatment, 303, 309, 328 
 
 — mechanical, 305 
 
 — obstructive, 305 
 
 — dilatation of cervix, 309 
 
 — incision of cervix, 310 
 
 — division of cervix by elastic ligature, 
 
 315 
 
 — autoplasty, 316 
 
 — membranous, 319 
 
 — villous, 322 
 
 — apoplectic, 323 
 
 Ectropion of the cervix, 441 
 Electricity, use of, 184 
 Elytrnrapby, 383 
 
 Emaciation symptomatic of uterine dis- 
 eases, 104 
 Eucephaloid of uterus, v. Cancer. 
 Endometritis, 477 
 
 — exfoliative, 323, note 
 Engorgement, uterine, 472 
 
 Engorge-.nent, uterine, anatomical cha- 
 racters and definition, 472 
 
 — — diagnosis, 473 
 treatment, 474 
 
 Episio-perineoraphy, 381 
 
 Episioraphy, 380 
 
 Epispastics in treatment of uterine dis- 
 eases, 189 
 
 Epithelioma of uterus, v. Cancer of 
 uterus. 
 
 Erectility of uterus, 47 
 
 — of the ovary, 48 
 
 — erection produced artificially on the 
 
 cadaver, 48 
 
 — absence of erectility in vagina and 
 
 Fallopian tube, 48 
 
 — of bulbs of the vagina and of the 
 
 clitoris, 49 
 
 — connection between utero-ovarian 
 
 erection and coitus, ovulation and 
 menstruation, 49 
 Eruptions on the cervix uteri, v. Ulcera- 
 tions. 
 
 — different forms, as in cutaneous 
 
 diseases, 635 
 Evacuants in the treatment of uterine 
 
 diseases, 174 
 Eversion of the cervix, 441 
 Examination, complementary means of 
 
 external, 120 
 
 — percussion, 120 
 
 — fluctuation, 121 
 
 — ballottement, 121 
 
 — change of posture, 121 
 
 — auscultation, 121 
 
 — external appearance of abdomen, 
 
 122 
 
 — exploratory puncture, 122 
 
 — tapping, 122 
 
 Exercise in the treatment of uterine 
 diseases, 167 
 
 Exfoliation of the uterine mucous mem- 
 brane, 319 
 
 Exfoliative endometritis; 323, note 
 
 Exometritis, puerperal, 503 
 
 Exploration of the uterine cavity (com- 
 plementary means), 147 
 
 Extirpation of normal ovaries (Battey's 
 operation), 770 
 
 Extra-uterine pregnancy, 783 
 
 — differential diagnosis, 783 
 
 — treatment, 785 
 
 Exutories in the treatment of uterine 
 diseases, 189 
 
 Fades ovariana, 743 
 
 — uferina, 105 
 Fallopian tube, 13 
 
 — development of, 56 
 
 — anomalies of, 73 
 
 — hernia of, 348 
 
 — inflani Illation of, 526 
 
 — and ovary, inflammaLion of, 530 
 — ' tumours of, 778 
 
806 
 
 INDEX 
 
 False conceptious, v. Moles. 
 Fibroids, v. Fibrous tumours. 
 Fibromata, v. Fibrous tumours. 
 Fibrous tumours of the uterus, 648 
 
 — interstitial, 649, 657 
 
 — sub-mucous, 649, 658 
 
 — sub-peritoneal, 649, 659 
 
 — tbeir influence upon conception, 
 
 pregnancy and delivery, 654 
 
 — influence of pregnancy upon, 655 
 
 — diagnosis, 655 
 
 — prognosis, 664 
 
 — medical treatment, 665 
 
 — surgical treatment, 667 
 
 — hysterectomy, 668 
 
 — treatment of, during pregnancy, 671 
 delivery, 671 
 
 Fistulse, congenital, 61 
 Flexions of the uterus, 407 
 
 — congenital, 407 
 
 — accidental, 407 
 
 — simple, 408 
 
 — complicated, 408 
 
 — seat of, 408 
 
 — degree of, 409 
 
 — curvature, 409 
 
 — diagnosis, 417 
 
 — subjective signs, 417 
 
 — common symptoms, 418 
 
 — objective signs, 419 
 
 — treatment, 420 
 
 — reduction, 421 
 
 — retention, 422 
 
 — mechanical means of retention, 422 
 
 — flexion of the cervix, 425 
 
 — anteflexion, 428 
 
 — retroflexion, 433 
 
 — lateroflexion, 431 
 
 — torsion, 431 
 
 — changes in the uterine tissue, 434 
 Floating tumours of the abdomen, 782 
 Fluctuation, signs of uterine disease 
 
 furnished by, 121 
 Fluor albus, v. Leucorrhoea. 
 Fluxion, 461 
 
 — diagnosis, 462 
 
 — treatment, 463 
 
 Fluxions, methodical treatment of, ap- 
 plied to uterine diseases, 172 
 Forceps, Courty's, 201 
 
 — tenaculum, 208 
 Frequency of uteriae diseases, 233 
 
 — relative, of uterine diseases, 255 
 Functional disorders, 257 
 Fungosities, uterine, v. Granulations. 
 
 Gaertner's canal, 57 
 
 Galvanic stem pessary, 200 
 
 Gas, application of, to cervix, 205 
 
 — — carbonic acid, 205 
 apparatus for, 206 
 
 Gastrotomy, 772 
 
 Genital system of woman, v. System, 
 
 Giraldes, corpus innominatum of, 57 
 
 Glycerine, application of, to cervix, 202 
 Graaf, De, vesicles ot^ 5 
 Granulations, uteriue, 623 
 predisposing causes, 623 
 
 — — influence of diathesis, 624 
 varieties, 627 
 
 treatment, 632 
 
 Haemorrhage, uterine, 334 
 
 — idiopathic, 335 
 
 — symptomatic, 335 
 
 — diagnosis, 336 
 
 — predisposing causes, 336 
 
 — determining causes, 337 
 
 — symptoms, 837 
 
 — treatment, 338 
 
 — hemostatics, 341 
 Hsemorrhage, pelvic, 714 
 
 tubal, 715 
 
 — — ovarian, 716 
 
 from the utero-ovarian plexus, 
 
 717 
 
 hsemorrbagiparous pachyperito- 
 nitis, 717 
 Hematocele, peri-uterine, 719 
 
 — retro-uterine, 719 
 
 — latero-uterine, 720 
 
 — ante-uterine, 720 
 
 — hematoma, 720 
 
 — modifications undergone by the 
 
 efl'used blood, 721 
 
 — diagnosis, 722 
 
 — prognosis, 731 
 
 — treatment, 731 
 
 — puncture, 733 
 Hermaphrodism, true, 67 
 
 — lateral, 69 
 
 — vertical or double, 69 
 
 — transverse, 69 
 
 — coincides with imperfect develop- 
 
 ment, 69 
 
 — apparent, 70 
 
 — female, 70 
 
 — male, 70 
 Hernia of uterus, 351 
 
 during pregnancy, 351 
 
 — — of the linea alba, 351 
 
 of the unimpregnated uterus, 352 
 
 — — inguinal, 353 
 
 crural, 353 
 
 umbilical, 353 
 
 ventral, 353 
 
 diagnosis, 354 
 
 — — treatment, 354 
 
 — of the ovary, 346 
 
 — — inguinal, 347 
 
 crural, 347 
 
 ischiatic, 347 
 
 — — umbilical, 347 
 
 — — simple and double, 347 
 
 congenital (inguinal), 348 
 
 accidental (generally crural), 348 
 
 — — Fallopian tube, 348 
 
 — diagnosis, 349 
 
INDEX 
 
 807 
 
 Hernia, treatment, 350 
 
 Hydatid cysts, 782 
 
 Hydrometria, 581 
 
 Hydrorrhoea, 580 
 
 Hydrotherapy in the treatment of ute- 
 rine disease, 179 
 
 Hymen, v. Vulva. 
 
 Hypertrophic tendency of the uterus, 
 its part in the production and 
 cure of uterine disease, 243, 244 
 
 — elongation of the cervix, 370 
 Hypertrophy, uterine, 590 
 
 — — common, 590 
 special, 591 
 
 — — essential, 591 
 
 arrested involution, 594 
 
 — partial, of cervix, 598 
 
 — — subvaginal, 598 
 
 — — supra-vaginal, 609 
 
 limited to one segment or to one 
 
 lip, 616 
 Hysteralgia, 330 
 Hysterectomy, 228 
 Hysteria symptomatic of uterine disease, 
 
 ioi 
 
 Hysterocele, 351 
 
 Hysteromata, v. Fibrous tumours. 
 
 Hysterotoine, simple, 228, 311 
 
 — double, 228, 311 
 Hysterotomy, 310 
 
 — Porro's operation, 773 
 
 Ice, plugging with, 203 
 
 Idiometritis, 482 
 
 Ignipuncture of the cervix, 211 
 
 Impotence, 788 
 
 Inclination of the uterus, 388 
 
 Incurvation of the uterus, 407 
 
 Indications to fulfil in the treatment of 
 uterine diseases, 151 
 
 Inertia, uterine, 100 
 
 Infarctus (engorgement), 472 
 
 Infecundity or inaptitude for impregna- 
 tion, 791 
 
 Inflammation, necessity of subduing, in 
 the treatment of uterine diseases, 
 156 
 
 Inflammation, the only contra-indication 
 to the use of the cautery, 217 
 
 Inflexions of the uterus, 407 
 
 Infraction of the uterus, 409 
 
 Injections, vaginal, 176 
 
 — intra-uterine, 219 
 
 — hot, in metrorrhagia, 341 
 Injuries of the uterus, v. Traumatism. 
 Inversion, uterine, 441 
 
 its different degrees, 442 
 
 — — incomplete or partial, 442 
 
 complete or total, 442 
 
 causes, 443 
 
 — — mechanism, 445 
 
 — — diagnosis, subjective signs, 445 
 
 — — objective signs, 446 
 
 — — differential diagnosis, 447 
 
 Inversion, uterine, treatment, 477 
 Involution of the uterus, arrest of, 594 
 subinvolution, 595 
 
 — — superinvolution, 595 
 
 diagnosis, 595 
 
 subjective signs, 596 
 
 treatment, 596 
 
 Irrigation, vaginal, 178 
 
 single vaginal irrigator, 178 
 
 double vaginal irrigator, 178 
 
 Irritable uterus, 331 
 
 Isthmus, torsion of the, 309, 414 
 
 Lactation, neglect of, its influence on 
 the development of diseases, 237 
 
 Laminaria digitata (tents of) for dilata- 
 tion of the cervix, 149 
 
 Leiomyomata, v. Fibrous tumours. 
 
 Leucorrhcea, 569 
 
 — idiopathic, 573 
 
 — symptomatic, 575 
 
 — herpetic or dartrous, 575 
 
 — catarrhal, scrofulous, 576 
 
 — vulval, 576 
 
 — vaginal, 576 
 
 — uterine, 576 
 
 — differential diagnosis of the different 
 
 forms of infantile leucorrhcea, 577 
 
 — hydrorrhoea, 580 
 
 — treatment, 582 
 Ligaments of the uterus, 20 
 
 means of suspension, 20 
 
 broad ligaments, 20 
 
 round ligaments, 22 
 
 utero-sacral, 23 
 
 utero- vesical adhesions, 23 
 
 — — suspensory ring, 23 
 
 — broad (tumours of), 780 
 
 — — fibrous tumours and myomata 
 
 of, 780 
 
 cysts of, 781 
 
 Ligature, elastic, for section of the 
 
 cervix, 315 
 Lotion, vaginal, 177 
 Lymphatics of the uterus, 36 
 
 — their importance, 37 
 
 Means of exploration of the uterine 
 cavity, 147 
 
 — intra-uterine speculum, 148 
 
 — uterine dilator, 148 
 Mechanical dysmenorrhcea, 305 
 Medications employed in the treatment 
 
 of uterine diseases, 161 
 
 — common, 162 
 
 — special, 163 
 Membranous dysmenorrhcea, 319 
 Menorrhagia, 334 
 
 Menstrual disorders, 257 
 Menstruation, 257 
 
 — its influence upon uterine disease, 
 
 235 
 Mensuration, abdominal, 122 
 Methods of treatment, 160 
 
808 
 
 INDEX 
 
 Methods of treatment, generally analyt- 
 ical and empirical, 161 
 Metritis, 476 
 
 — pathological anatomy, 476 
 
 — divisions, 480 
 
 — causes, 482 
 
 — course, 484 
 
 — subjective signs, 486 
 
 — local symptoms, 486 
 
 — general symptoms, 487 
 
 — objective signs, 489 
 
 — uterine abscess, 493 
 
 — table of differential diagnosis, 494 
 
 — treatment, 497 
 
 of complications, 501 
 
 — — of metrorrhagia, 501 
 of leucorrhcea, &c., 502 
 
 — puerperal, 503 
 
 — of the fundus, 506 
 
 — of the cervix, 506 
 
 — endometritis, 507 
 
 — parenchymatous metritis, 508 
 
 — treatment, 509 
 Metrorrhagia, 334 
 Metrotome, 227 
 Moles, uterine, 686 
 
 fleshy, 687 
 
 vesicular or hydatidiform, 687 
 
 diagnosis, 688 
 
 treatment, 689 
 
 Morbid states without neoplasm, 461 
 Mucous membrane of the uterus, 38 
 
 — of the fundus, 38 
 
 — its tubular glands, 39 
 
 — its periodical thickening, 40 
 
 — of the cervix, 40 
 
 — its glands, 40 
 
 — Naboth's eggs, 40 
 
 — mucus of the uterus, alkaline, 40 
 
 — uterine (monthly formation of), 324 
 Miiller's ducts, 56 
 
 — their separation, 58 
 
 — their approximation, 58 
 
 — their union, 58 
 
 — anomalies of development, 75 
 Muscles of the uterus, 40 
 
 — three layers, 43 
 
 — their continuity with the muscular 
 
 layers of the tubes, 43 
 
 — their connections with the ovaries 
 
 and oviducts by the muscular layer 
 of the broad ligament, 45 
 Myomata of the uterus, v. Fibrous tu- 
 mours. 
 
 Naboth's eggs, 40 
 
 Necessity for treating uterine maladies, 
 151 
 
 Neoplasms (morbid states without), 460 
 
 Nerves of the uterus, 37 
 
 Nervous disorders, 100 
 
 Neuralgia, symptomatic of uterine dis- 
 eases, 101 
 
 — uterine, 330 
 
 Nutrition, disorders of, symptomatic of 
 uterine disease, 104 
 
 Obesity, symptomatic of uterine disease 
 
 105 
 Obliquity of the uterus, 388 
 Obliteration of the vagina, 387 
 (Edema, acute purulent peri-uterine, 532 
 Oophoritis, 510 
 Ovaries, anatomy of, 4 
 
 — ectopia of, 72, 346 
 
 — extirpation of (Battey's operation), 
 
 770 
 Ovarioncia, 346 
 Ovariotomy, 753 
 
 — indications for, 754 
 
 — pregnancy as a complication, 754 
 
 — contra-indications, 755 
 
 — preparatory treatment, 756 
 
 — adhesions as coutra-indications, 756 
 
 — six principal stages of the operation, 
 
 757 
 
 — treatment of adhesions, 760 
 — • immediate consequences, 765 
 
 — accidents, 766 
 
 — shock, 766 
 
 — exhaustion, 766 
 
 — haemorrhage, 767 
 
 — purulent infection, 767 
 
 — antiseptic precautions, 768 
 
 — remote consequences, 769 
 Ovaritis, 510 
 
 Ovary, cysts of, 733 
 
 — solid tumours of, 774 
 Oviducts, 13 
 
 Ovisacs, 6 
 Ovum, 8 
 
 Pad, perineal, 192 
 Pain, 107 
 
 — symptomatic of uterine diseases, 107 
 
 — spontaneous, 107 
 
 — caused by mode of decubitus, 108 
 
 — by sitting, 108 
 
 — by standing, 109 
 
 — by movements and walking, 109 
 
 — by coitus, 109 
 
 — by tight garments, 110 
 
 — elicited artificially, 110 
 
 — by movement, 110 
 
 — by palpation, 110 
 
 — by the touch, 110 
 
 — three principal seats of. 111 
 
 — iliac. 111 
 
 — lumbar. 111 
 
 — hypogastric, 112 
 
 — three secondary seats of, 112 
 
 — anal, 112 
 
 — vaginal, 112 
 
 — pelvic, 112 
 
 — radiating, 112 
 
 — continuous, 113 
 
 — intermittent, 113 
 
 Painting the cervix with collodion, 203 
 
INDEX 
 
 809 
 
 Palpation, abdominal, 118 
 
 — rectal, 131 
 
 Paralysis symptomatic of uterine disease, 
 103 
 
 Parametritis, 531. v. Peri-uterine in- 
 flammation. 
 
 Parturition, influence of, on tlie develop- 
 ment of uterine disease, 236 
 
 Pelvic cavity, division of, by tbe broad 
 ligaments, 24 
 
 — peritonitis, 534. v. Peri-uterine in- 
 
 flammation. 
 
 — tumoui's, 774 
 Perforation of the hymen, 228 
 Perimetritis, 531, 534 
 
 Peritoneum, sero-purulent cysts of the, 
 
 781 
 Peritonitis, peri-uterine, 534 
 Peri-uterine inflammation, 531 
 
 — adenitis and angioleucitis, 537 
 Pessaries, 193 
 
 Phlegmon of the broad ligament, 533 
 
 — peri-uterine, 535 
 Physometria, 582 
 Pneumatosis, 582 
 Polypi of the uterus, 673 
 
 — fibrous, 673 
 
 — mucous, 673 
 
 — vascular, 674 
 
 — diagnosis, 674 
 
 — treatment, 677 
 
 Position of patient for operations, 207 
 Posture, signs furnished by change of, 
 
 121 
 Pregnancy, in relation to the symptoms 
 
 of uterine disease, 107 
 
 — influence of, on the development of 
 
 uterine diseases, 236 
 
 — extra-uterine, 783 
 
 — — diagnosis, 783 
 treatment, 785 
 
 modes of termination, 785 
 
 Prolapsus uteri, 356 
 
 — degrees of, 356 
 
 — cystocele and rectocele, 359 
 
 — of the whole uterus or of the cerviz 
 
 only, 357 
 
 — anatomo- pathological alterations, 
 
 357 
 
 — causes, 360 
 
 — relaxation of suspensory ligaments, 
 
 361 
 
 — frequency, 362 
 
 — diagnosis, 363 
 
 — subjective signs, 363 
 
 — objective sii^ns, 366 
 
 — differential diagnosis, 368 
 
 — treatment, 370 
 
 — hypertrophic elongation (prolapsus 
 
 without procidentia of the fun- 
 dus), 370 
 
 — reduction, 373 
 
 — retenticm, 374 
 
 — episioraphy, 380 
 
 Prolapsus uteri, episio-perineoraphy, 381 
 
 — colpodesmoraphy, 382 
 
 — elytroraph}"^ or colporaphy, 383 
 
 — obliteration of the vagina, 387 
 
 — amputation of the cervix, 387 
 Prolapsus of uterus without descent of 
 
 the fundus (Virchow), 370 
 Pruritus, vulval, 118 
 Puerperal metritis, 503 
 Puncture, exploratory, 229 
 Purgatives, use of, 174 
 
 Rectal palpation, 131 
 Reduction of prolapsus, 373 
 
 — of flexions, 420 
 
 — of inversions, 449 
 
 Regimen as a means of treatment, 168 
 Resolvents, their use, 184 
 Retention of the menses, 270 
 Ring, suspensory, of the uterus, 23 
 Rosenmiiller (organ of), 56 
 
 Salpingitis, 526 
 
 Scirrhus of uterus, 699, 701 
 
 Sedatives in the treatment of uterine 
 
 diseases, 188 
 Serous membrane of uterus, 38 
 Signs, presumptive, of uterine disease, 98 
 
 — furnished by direct examination of 
 
 the genital organs, 118 
 Situation and structure of the uterus, 
 
 influence of, on development of 
 
 iiterine disease, 234 
 Sound, uterine, 144 
 
 — — its use as a means of diagnosis, 
 
 144 
 
 its invention, 144 
 
 mode of introducing, 145 
 
 Speculum, Fergusson's, 134 
 
 — trivalve, 134 
 
 — bivalve, 135 
 
 — quadrlvalve, 135 
 
 — Cusco's, 136 
 
 — Jobert's, 136 
 
 — Bozeman's, 137 
 
 — Sims's, 137 
 
 Sponge tents, method of preparing, 148 
 
 — their inti'oduction, 149 
 
 — exploration of uterus after dilatation 
 
 by, 149 
 Stenosis of cervix uteri, 305 
 Sterility, 787 
 
 — symptomatic of uterine disease, 107 
 Strangury, uterine, 302 
 Subinvolution, 595 
 Superinvolution, 621 
 Suppositories, 204 
 
 Suspension, means of, of the uterus, 20 
 
 of the fundus, 20 
 
 of the cervix, 23 
 
 Suspensory ring of the uterus, 23 
 Symptoms, general, of uterine disease, 98 
 
 — local, of uterine disease, 105 
 
 — of neighbourhood, 105 
 
 52 
 
810 
 
 INDEX 
 
 Syringe, uterine, 219 
 System, genital, of woman, 3 
 
 its constant mutability, 3 
 
 its development, 55 
 
 comparison of, with male genital 
 
 system, 62 
 
 teratology, 65 
 
 Teratology of the sexual organs, 65 
 Therapeutics of uterine diseases in 
 
 genera], 96 
 Thermocautery of Paquelin, 216 
 Tonics in the treatment of uterine 
 
 diseases, 186 
 Topical applications to the cervix, 203 
 Torsion of the isthmus, 309, 430 
 Touch, vaginal, 123 
 
 — rectal, 130 
 
 — vesical, 133 
 Traumatisms of the uterus, 483 
 Treatment of uterine diseases in general, 
 
 151 
 Tubercle of uterus, 689 
 Tubo-ovaritis, 530 
 Tumours, fibrous, of uterus, 648 
 
 — of the annexes and pelvic cavity, 774 
 
 — solid, of ovary, 774 
 
 — of Fallopian tubes, 778 
 
 — of broad ligaments, 780 
 
 — floating, of abdomen, 782 
 Tympanitis, uterine, 582 
 
 Ulcer of pregnancy, 640 
 
 — of uterine catarrh, 640 
 
 — of chronic metritis, 641 
 
 — dartrous, 641 
 
 — scorbutic, 641 
 
 — scrofulous, 641 
 
 — syphilitic, 641 
 
 — cancerous, 642 
 
 Ulcer of pregnancy, rodent, 642 
 
 — diphtheritic, 643 
 
 Ulceration and ulcers of the cervix uteri, 
 
 634 
 Urethra, female, 65 
 Urogenital groove, 61 
 Uterine cough, 102 
 Uterus, 16 
 
 — changes in, at different ages, 28 
 
 — structure of, 36 
 
 — deficiens, 75 
 
 — unicornis, 75 
 
 — duplex, didelphis, 76 
 
 — bicornis, 76 
 
 — cordiformis, 78 
 
 — globularis, 78 
 
 — septus, bilocularis, bipartitus, 79 
 
 — subseptus, semipartitus, 79 
 
 — embryonic, festal, infantile, 79 
 
 Vagina, 49 
 
 — absence of, 86 
 
 — anomalies of, 86 
 
 — double, 88 
 Veins, uterine, 36 
 Versions of the uterus, 388 
 
 — treatment of, 397 
 
 Vesical irritation symptomatic of 
 
 uterine disease, 106 
 Vesicles of De Graaf, 6 
 Villous dysmenorrhoea, 322 
 Vulva, 49 
 
 — glands of, 53 
 
 — anomalies of, 89 
 
 — absence of, 89 
 Vulval pruritus, 118 
 
 Waters, mineral, in treatment of uterine 
 
 disease, 182 
 Wolffian bodies, 55 
 
 EEEATA. 
 
 Page 79, line 3rcl,/or " bipartitis," read " bipartitus." 
 118, „ 12th,/or "pruritis," >-ea(i "pruritus." 
 
 303, note 2, /or " Philosophical," read " Obstetrical." 
 
 304, line 16th from bottom, /«• "attractions," read " attractives." 
 392, note Ijfor " nMario," read " Marion." 
 498, line 12th from bottom, /or " mauve," read " marshmallow." 
 563, „ ind, for " is," read "are." 
 628, „ 2nd from bottom, /or " hysteralgia uterine colics, and " read 
 
 " hysteralgia and uterine colics." 
 643, „ 18th from bottom, for " abscess," read " abscesses." 
 
 FEINTED BT J. E. ADI/AEB, BAETHOLOMEW CLOSE. 
 
UATALOGUE NO. 1. 
 
 CATALOGUE 
 
 OF 
 
 Medical, Dental, Pharmaceutical 
 
 AND 
 
 SCIENTIFIC PUBLICATIONS, 
 
 PUBLISHED BY 
 
 WITH 
 
 CLASSIFIED 
 
 LIST 
 
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 iPUBLlSHERiBOOKSEUER&iMPORTERf' 
 
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 AND 
 
 SUBJECT 
 
 INDEX. 
 
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 PHILADELPHIA. 
 
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NOW READY, THE SEVENTH REVISED EDITION. 
 
 MEIGS AND PEPPER, ON CHILDREN. 
 
 THE MOST THOROUGH, COMPLETE AND PRACTICAL WORK 
 ON THE SUBJECT NOW BEFORE THE PROFESSION. 
 
 A PRACTICAL TREATISE ON THE DISEASES OF CHILD- 
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 lin Institute, Philadelphia. 
 
 YLQ^N TO WORK WITH THE MICROSCOPE. 
 
 A Complete Manual of Microscopical Manipulation, containing a full descrip- 
 tion of many new processes of investigation, with directions for examining ob- 
 jects under the highest powers, and for taking photographs of microscopic 
 objects. Fifth Edition. Containing over 400 Illustrations, many of them colored. 
 Octavo. Price $7.50 
 
 "The Encyclopaedic character of this last edition of Dr. Beale's well known work on the Microscope renders 
 it impossible to present an abstract of its contents ; suffice it to say, that anything in his department upon which 
 the physican can desire such information will be found here, and much more in addition. It is, moreover, a store- 
 house of facts, most valuable to the physician, and is indispensable to every one who uses the microscope." — 
 Atnerican yournal of Medical Science. 
 
 BIOPLASM. 
 
 A Contribution to the Physiology of Life, or an Introduction to the Study of 
 Physiology and Medicine, for Students. With numerous Illustrations. 
 
 Price $2.25 
 PROTOPLASM; or MATTER AND LIFE. 
 
 Third Edition, very much enlarged. Nearly 350 pages. Sixteen Colored 
 
 Plates. Part I. DISSENTIENT. Part 11. Demonstrative. Part iii. Suggestive. 
 
 One volume. Price ^3.00 
 
 LIFE THEORIES ; Their Influence upon Religious Thought. 
 
 Six Colored Plates. Price $2.00 
 
 ONE HUNDRED URINARY DEPOSITS, 
 
 On two sheets, for the Hospital, Laboratory, or Surgery. Each Sheet $1.00, or 
 on Rollers, Price $1.25 
 
 BERNAY, CHEMISTRY. 
 
 Notes for Students in Chemistry. Compiled from Fowne's and other manuals. 
 By Albert J. Bernay, PH.D. Sixth Edition. i2mo. Price {^1.25 
 
 BOCK, ANATOMY. 
 
 An Atlas of Human Anatomy. By Prof. C. E. BoCK, of Berlin. Thirty-seven 
 Colored Plates, containing about 200 figures. Quarto. Half Roan. Price $15.00 
 
 This is one of if not the best Anatomical Atlas now to be had, and its produc- 
 tion in Germany makes it certainly the cheapest. 
 
PRESLEY BLAKISTON' S 
 
 BEASLEY. THE BOOK OF PRESCRIPTIONS. 
 
 Containing over 3100 Prescriptions, collected from the Practice of the most 
 Eminent Physicians and Surgeons — English, French and American ; a Com- 
 pendious History of the Materia Medica, Lists of the Doses of all Officinal and 
 Established Preparations, and an Index of Diseases and their Remedies. By 
 Henry Beasley. Sixth Edition, Revised and Enlarged. Price 
 
 BY SAME AUTHOR. 
 
 THE DRUGGIST'S GENERAL RECEIPT-BOOK. 
 
 Comprising a copious Veterinary Formulary; numerous Recipes in Patent 
 and Proprietary Medicines, Druggists' Nostrums, etc.; Perfumery and Cos- 
 metics; Beverages, Dietetic Articles and Condiments; Trade Chemicals, Scien- 
 tific Processes, and an Appendix of Useful Tables. Eighth Edition. Price $2.25 
 
 THE POCKET FORMULARY and Synopsis of the British and 
 Foreign PharmacopcEias. 
 
 Comprising Standard and Approved Formulae for the Preparations and Com- 
 pounds Employed in Medical Practice. Tenth Edition. 511 pp. i8mo. 
 
 Price $2.25 
 
 BENTLEY AND TRIMEN'S MEDICINAL PLANTS. 
 
 A New Illustrated Work, containing full botanical descriptions, with an account 
 of the properties and usesof the principal plants employed in medicine, especial 
 attention being paid to those which are officinal in the British and United States 
 Pharmacopoeias. The plants which supply food and substances required by the 
 sick and convalescent are also included. By R. Bentley, f.r.s.. Professor of 
 Botany, King's College, London, and H. Trimen, m.b., f.h.s.. Department of 
 Botany, British Museum. Each species illustrated by a colored plate drawn 
 from nature. In Forty-two parts. Eight colored plates in each part. 
 
 Price %2 each, or handsomely bound in 4 volumes. Half Morocco, $90.00 
 
 ■ It would be impossible to emimerate all the new 
 
 " This work may be recommended as a most useful 
 one to druggists, and all who desire to be familiar 
 with the Botany of Medicinal Plants." — Druggists' 
 Circular . 
 
 " The work when complete (it is now complete) 
 will be the most valuable compend of Medical Botany 
 
 plants that are here delineated. The result is a work 
 which, from all points ofview, isa credit to the scientific 
 literature of the day." — London Lancet. 
 
 "It is an indispensable work of reference to every one 
 interested in harmaceutical Botany." — London Fhar- 
 maceutical 'j' urnal. \ ever published." — Bosto'ii journal of Chemistry 
 
 BRADLZY, ANATOMY. 
 
 Comparative Anatomy and Physiology. By S. M. Bradley, f.r.c.s. Sixty 
 Illustrations. Third Edition. Price $2.00 
 
 BRUNTON, ACTION OF MEDICINES. 
 
 Experimental Investigation of the Action of Medicines. Part I, Circulation. 
 By T. Lauder Bruntox, m.d., f.r.s. Second Edition. [Preparing. 
 
 BYFORD. DISEASES OF WOMEN. New Revised Edition. 
 
 The Practice of Medicine and Surgery, as applied to the Diseases of Women, 
 By W. H. Byford, a.m., m.d., Professor of Obstetrics and The Diseases of Wo- 
 men and Children, in the Chicago Medical College. Third Edition. Revised 
 and Enlarged, much of it rewritten, with numerous additional illustrations. 
 
 Price, in Cloth $5.00; Leather, $6.00 
 
 "The treatise is as complete a one as the present 
 state of our science will admit of being written. We 
 commend it to the diligent study of every practitioner 
 and student, as a worlc calculated to inculcate sound 
 principles and lead to enlightened practice. — Nevj 
 York Medical Record. 
 
 " The author is an experienced writer, an able teach- 
 er in his department, and has embodied in the present 
 work the results of a wide field of practical obser\-a- 
 tion. We have not had time to read its pages critically, 
 but freely commend it to all our readers, as one of the 
 most valuable practical works issued from the Ameri- 
 can press." — Chicago Medical Examiner. 
 
 BY SAME AUTHOR. 
 
 ON THE UTERUS. The Chronic Inflammation and Displace- 
 ment of the Unimpregnated Uterus. 
 
 An Enlarged Edition, with Illustrations. 8vo, Price $2.50 
 
 "A good book from a good man." — American Journal Medical Science. 
 
 "It is a sensible, practical work, and cannot fail to be read with interest and profit."— fioj/o« Medical and 
 Surgical yournal. 
 
PUB Lie A TIONS. 
 
 BRAUNE, TOPOGRAPHICAL ANATOMY. 
 
 An Atlas of Topographical Anatomy. Thirty-four Full-page Plates, Photo- 
 graphed on Stone, from Plane Sections of Frozen Bodies, with many other illus- 
 trations. By WiLHELM Braune, Professor of Anatomy at Leipzig. Translated 
 and Edited by Edward Bellamy, f.r.c.s., Lecturer on Anatomy, Charing 
 Cross Hospital, London. Quarto. Price, Cloth, $8.00 ; Half Morocco, $10.00 
 
 "As a whole the work cannot fail to meet with a hearty reception by every progressive student of the human 
 body. To the surgeon it is a contribution to the study of topographical anatomy which needs to be known to be 
 properly appreciated To such practitioners who reside in large cities, where anatomy can be studied upon the 
 cadaver, it will afford a valuable aid, while to those who are without such means of study it is an almost indis- 
 pensable addition to a working library." — New York Medical Record. 
 
 " We commend the book most heartily to the Profession." — American Journal ef Medical Scietice. 
 
 BUCKNILL AND TUKE ON INSANITY. 
 
 A Manual of Pyschological Medicine : containing the Lunacy Laws, the 
 Nosology, (Etiology, Statistics, Description, Diagnosis, Pathology (including 
 morbid Histology), and Treatment of Insanity. By John Charles Bucknill, 
 M.D., F.R.S., and Daniel Hack Tuke, m.d., f.r.c.p. Fourth Edition, much 
 enlarged, with twelve lithographic plates, and numerous illustrations. Octavo. 
 
 Price $8.00 
 
 " We have read no book in any language, and certainly none in English, which ought to be preferred to this 
 for a text book, by those who wish to make a thorough study of the subject. — Edinburgh Medical Journal. 
 " We can heartily commend the work. — American Journal o/ Insanity. 
 
 BURDETT, HOSPITALS. 
 
 Pay Hospitals and Paying Wards throughout the World. Facts in support 
 of a rearrangement of the system of Medical Relief. By Henry C. Burdett. 
 8vo. Price $2.25 
 
 " Mr. Burdett displays and discusses the whole scheme of Hospital ^rmmmnAat^nin with a comprehensive 
 understanding of its nature and extent. — American Practitioner. 
 
 BY SAME AUTHOR. 
 
 COTTAGE HOSPITALS. 
 
 General, Fever, and Convalescent : their Progress, Management, and Work. 
 Second Edition, rewritten and much Enlarged, with many Plans a-rd Illustra- 
 tions. Crown 8vo. Price $4.50 
 
 Contents. — Chap. — i. Origin and Growth of the Cottage Hospital System. 2. Comparative Success of 
 Treatment in large and small Hospitals. 3. Finance. 4. Cottage Hospital Construction and Sanitary Arrange- 
 ments. 5. The Medical and Nursing Departments. 6. Domestic Supervision and General Management. 7. 
 Cottage Hospital Appliances and Fittings. 8. Cottage Fever Hospitals. 9. Midwifery in Cottage Hospitals. 10. 
 Remunerative Paying Patients. 11. Convalescent Cottages . 12. Cottage Hospitals in America. 13. Mortu- 
 aries. 14. A more Detailed Account of certain Cottage Hospitals, with Plans and Elevations. 15. Selected and 
 Model Plans criticised and compared, with a detailed description of various Hospitals. 16. Peculiarities and 
 Special Features in the Working of Cottage Hospitals. With an Appendix containing much statistical and useful 
 information. 
 
 " Mr. Burdett's book contains a mass of information, statistical, financial, architectural, and hygienic, which has 
 already proved of great practical utility to those interested in cottage hospitals, and we can confidently recom- 
 mend this second edition to all who are in search of the kind of information which it contains." — Lancet. 
 
 BUZZARD, NERVOUS DISEASES. 
 
 Clinical Lectures on Diseases of the Nervous System. By Thos. Buzzard, 
 M.D. Illustrated. Octavo. ' Price $5.00 
 
 CARPENTER, THE MICROSCOPE. Sixth Edition. 
 
 The Microscope and its Revelations. By W. B. Carpenter, m.d., f.r.s. 
 Sixth Edition. Revised and Enlarged, with over 500 Illustrations. Price $5.50 
 
 " Not only the student of medicine, but amateurs, 
 and others interested in the study of natural history, 
 will find this volume one of great practical value." — 
 JWw/ York Medical Journal. 
 
 " It is by far the most complete and useful treatjse 
 now accessible to the student." — The Technologist. 
 
 "As a text book of Microscopy in its special relation 
 to natural history and general science, the work before 
 us stands confessedly first, and is alone sufficient to 
 supply the wants of the ordinary student." — American 
 Journal 0/ Microscopy. 
 
PRESLEY B LA KIS TON'S 
 
 CARTER, EYESIGHT. New Edition now ready. 
 
 Eyesight, Good and Bad. A Treatise on the Exercise and Preservation of 
 Vision. By Robert Brudenell Carter, f.r.c.s. Second Edition, with 50 
 Illustrations, Test Types, etc. i2mo. Price, Cloth, $1.25 
 
 "It is written in a lucid and agreeable style, conveying an easily comprehensible account of the structure of 
 the eye and the function of vision, and gives a description of the principal anomalies of the latter, at the same 
 time inculcating such salutary advice as may be beneficial for the preservation of sight." — London Medical 
 Times and Gazette. 
 
 " There is much wholesome advice given on the ' Care of the Eyes in Infancy and Childhood,' and on this 
 account, if no other, the book should be in the hands of every parent and teacher." — St. Louis Courier of 
 Medicine. 
 
 CARTER, PRACTICE OF MEDICINE. 
 
 Elements of Practical Medicine. By Alfred H. Carter, m.d., London, 
 Member of the Royal College of Physicians ; Physician to the Queen's Hos- 
 pital, Birmingham, etc. Crown 8vo. Price $3.00 
 
 " The object of this volume is to provide the student with a general introduction to the study of Medicine, 
 and to bring the essentials of the subject, so far as required for the ordinary medical qualifications, within the 
 grasp of those who have not the time or leisure to read the larger and more elaborate works on Practice." — 
 Pre/ace. 
 
 " Dr. Carter is favorably known as a London physician of learning and experience, and a clear writer. He 
 aims to give a judicial epitome of practical medicine, and this is a well-prepared book." — Philadelphia Medi- 
 cal and Surgical Reporter. 
 
 CARSON, THE UNIVERSITY OF PENNSYLVANIA. 
 
 A History of the Medical Department of the University of Pennsylvania from 
 its foundation in 1765, with sketches of deceased Professors, etc. By the late 
 Joseph Carson, m.d. 8vo. Price $2.00 
 
 Originally a lecture delivered at the request of the Faculty, this essay has grown 
 into an important Historical work of the College and its promoters. 
 
 CAZEAUX'S GREAT OBSTETRICAL TEXT-BOOK. 
 
 A Theoretical and Practical Treatise, including the Diseases of Pregnancy 
 and Parturition. By P. Cazeaux, Adjunct Professor in the Faculty of Medi- 
 cine of Paris, etc. etc. Revised and Annotated by S. Tarnier, Former Clini- 
 cal Chief of the Lying-in-Hospital, etc., etc. Sixth American from the Seventh 
 French Edition. Translated by Wm. R. Bullock, m.d. One volume. Royal 
 Octavo, over iioo pages, with Lithographic and 175 other Illustrations on 
 Wood. Price, Cloth, ^6.00 ; Leather, $7.00 
 
 M. Cazeaux's great work on Obstetrics has become classical in its character, and 
 almost an Encyclopsedia in its fulness. Written expressly for the use of students of 
 medicine, and those of midwifery especially, its teachings are plain and explicit, 
 presenting a condensed summary of the leading principles established by the masters 
 of the obstetric art, and such clear, practical directions for the management of the 
 pregnant, parturient, and puerperal states, as have been sanctioned by the most 
 authoritative practitioners, and confirmed by the author's own experience. Collect- 
 ing his materials from the writings of the entire body of antecedent writers, carefully 
 testing their correctness and value by his own daily experience, and rejecting all such 
 as were falsified by the numerous cases brought under his own immediate observa- 
 tion, he has formed out of them a body of doctrine, and a system of practical rules, 
 which he illustrates and enforces in the clearest and most simple manner possible. 
 
 " The edition before us is one of unquestionable ex- 
 cellence. Every portion of it has undergone a thorough 
 revision, and no little modification ; while copious 
 and important additions have been made to nearly 
 every part of it. It is well and beautifully illustrated 
 by numerous wood and lithographic engravings, and 
 in typographical execution will bear a favorable com- 
 parison with other works of the same A3.%z." American 
 Medical journal. 
 
 " The translation of Dr. Bullock is remarkably well 
 done. We can recommend this work to those espe- 
 cially interested in the subject treated, and can espe- 
 cially recommend the American edition." — Medical 
 Times and Gazette. 
 
 " We do not hesitate to say that it is now the most 
 complete and best treatise on the subject in the Eng- 
 lish language." — Buffalo Medical Joitrnal. 
 
 " It is unquestionably a work of the highest excel- 
 lence, rich in information, and perhaps fuller in details 
 than any text-book with which we are acquainted. 
 The author has not merely treated of every question 
 which relates to the business of parturition, but he has 
 done so with judgment and ability." — British and 
 Foreign Medico- Chirurgical Reziicw. 
 
 " No work, in our estimation, bears any comparison 
 to Cazeaux, in its entire perfectness ; and if we were 
 called upon to rely alone on one work on accouch- 
 ments, our choice would fall upon the book before us 
 without any kind of hesitation." — West. your, of Med- 
 icine atid Surgery. 
 
 " We know of no work on this all-important branch 
 of our profession that we can commend to the student 
 or practitioner as a safe guide befcre this." — Chicago 
 Medical Journal. 
 
PUBLICA TIONS. 
 
 CHARTERIS, PRACTICE OF MEDICINE. 
 
 Hand-Book of the Practice of Medicine. By M. Charteris, m.d., Member 
 of Hospital Staff and Professor in University of Glasgow. With Microscopic and 
 other illustrations. Price $1.25 
 
 " We have not often met with a book whidi can be so confidently recommended to physicians or men in general 
 practice . ' ' — Lancet. 
 
 " The style in which it is writtea is clear and at-traetive. The illustrations are a marked feature in it. It can 
 be recommended as a very reliable, handy book, well adapted for ready reference." — New Remedies. 
 
 CHAVASSE ON CHILDREN. 
 
 The Mental Culture and Training of Children. By Pye Henry Chavasse. 
 
 i2mo. Price, Paper covers, .50; Cloth, fii.oo 
 
 The mental culture and training of children is of immense importance. Many 
 
 children are so wretchedly trained, or rather not trained at all, and so mismanaged, 
 
 that a few thoughts on this subject cannot be thrown away, even upon the most 
 
 careful. 
 
 CLAY ON OBSTETRIC SURGERY. Third Edition. 
 
 A complete Hand-Book of Obstetric Surgery, with Rules for every Emergency 
 and Descriptiens of the more difficult as well as the every day operations. By 
 Charles Clay, m.d., with numerous illustrations. From the Third London Edi- 
 tion. i2mo. Price $2.00 
 
 " It is a useful and convenient book of reference ; the illustrations are good, and the book will be found of value 
 to the student and young practitioner, as well as to the skilled Obstetrician." — American Journal of Obstetrics. 
 
 CLEVELAND, POCKET DICTIONARY. « 
 
 A Pronouncing Medical Lexicon, containing correct Pronunciation and Defi- 
 nition of terms used in medicine and the collateral sciences. By C. H. Cleve- 
 land, m.d. Twenty-ninth Edition. i6mo. 
 
 Price, Cloth, 75 cents ; Tucks with Pocket, ^i.oo 
 This is a most convenient size for the pocket, and contains all the principal words 
 in use, together with rules for pronunciation, abbreviations used in prescriptions, list 
 of poisons, their antidotes, etc. 
 
 COHEN, INHALATION. Enlarged Edition. 
 
 Inhalation, its Therapeutics and Practice, including a Description of the Ap- 
 paratus Employed, etc. By J. Solis Cohen, m.d. With cases and Illustrations. 
 A New Enlarged Edition. 8vo. Price $2.50 
 
 " The book has the merit of containing much information that cannot be found elsewhere." — N. Y. Medical 
 yournal. 
 " One of the best treatises we have seen on this subject." — Medical Times and Gazette. 
 
 BY SAME AUTHOR. 
 
 CROUP, 
 
 In its Relation to Tracheotomy. 8vo. Price $1.00 
 
 CLARKE, SURGERY. 
 
 Outlines of Surgery and Surgical Pathology, including the Diagnosis and 
 Treatment of Obscure and Urgent Cases. By F, LeGross Clarke, f.r.s. 
 Second Edition. 8vo. Price $2.00 
 
 COBBOLD, PARASITES. 
 
 A Treatise on the Entozoa of Man and Animals, including some account of 
 the Ectozoa. By T. Spencer Cobbold, m.d., f.r.s. With 85 illustrations. 
 8vo. Price $^.00 
 
PRESLEY B LA KIS TON'S 
 
 COLES, THE MOUTH. Third Edition, just ready. 
 
 Deformities of the Mouth, Congenital and Acquired, with Their Mechanical 
 Treatment. By Oakley Coles, d.d.s. Third Edition. 83 Wood Engravings 
 and 96 Drawings on Stone. 8vo. Price $4.50 
 
 " Altogether we must heartily congratulate Mr. Coles on this creditable completion of a work which cannot 
 but redound to his credit wherever it is known." — British yournal of Dental Science. 
 " We recommend this book to the study of both surgeons and dentists." — London Lancet. 
 
 BY SAME AUTHOR. 
 
 A MANUAL OF DENTAL MECHANICS. 
 
 Containing much information of a practical nature, upon the Materials and 
 Appliances used in Mechanical Dentistry. For Practitioners and Students. 
 Second Edition, with 140 Illustrations. i2mo. Price $2.00 
 
 THE DENTAL STUDENT'S NOTE-BOOK. 
 
 A new Edition. i6mo. Price $1.00 
 
 COLLIS, ON CANCER. 
 
 The Diagnosis and Treatment of Cancer and Tumors Analogous to it. By 
 M. H. COLLIS, M.D. With Colored Plates. Svo. Price $3.00 
 
 CORMACK, CLINICAL STUDIES. 
 
 Illustrated by Cases Observed in Hospital and Private Practice. By Sir 
 John Rose Cormack, m.d., k.b., etc. Illustrated. 2 vols. 1,127 PP- Price I5.00 
 
 Contents. — Vol. i. — Chapter l. Relapsing Fever, ii. Cholera, iii. Scarlatinous Nephritis, iv. Puer- 
 peral Convulsions, v. Glandular Degeneration of the Kidney and its Relation to Scrofula, vi. Infantile Re- 
 mittent Fever, vn! Labor Complicated with Cauliflower Excrescence of the Uterus, viii. Value of the 
 Dark Abdominal Line as a Test of Recent Delivery, ix. Dystocia from Cystous Kidney in the Mature 
 Fostus. X. Hernia of the Uterus. 
 
 Vol. IT. — Chapter i. Air in the Organs of Circulation, ii. Reflex Convulsions in Infancy, iii. Pharj'ngo- 
 Laryngo-Tracheal Diphtheria, rv. Diphtheria, v. Paralytic Affections, vi. Paralytic AflFections in Enteric 
 Fever, vii. Treatment of Paralytic Affections, viii. Non-Venereal Discharges from the Urethra, ix. Scar- 
 latinal Vaginitis. x. Congenital Syphilis. Xl. Chronic Poisoning by Chloroform, xii. Resection of the 
 Shoulder-joint, xiii. Concussion of the Brain, xiv. General Paralysis with Insanity, xv. Short Attacks 
 of Insanity. 
 
 " His peculiar opportunities and the manner in I " The work will make one of valuable reference 
 which he has availed himself of them give these upon the subjects embraced by it, many of which have 
 essays a value of their own." — London Practi- been treated at considerable length." — American 
 tioner. I Journal. 
 
 CURLING, ON THE TESTIS. 
 
 A Practical Treatise on the Diseases of the Testis, Spermatic Cord, and 
 Scrotum. By T. B. Curling, m.d., f.r.s. Fourth Edition, Enlarged and Il- 
 lustrated. Svo. Price $5.50 
 
 " We believe this work to be the most trustworthy that can be consulted in this Department of Surgery, 
 
 his pages abound with valuable suggestions and cautions that mark his intimate knowledge of the 
 
 subj ect.' ' — London Practitioner. 
 
 COOPER'S SURGICAL DICTIONARY. 
 
 A Dictionary of Practical Surgery and Encyclops:dia of Surgical Science. 
 By Samuel Cooper. New Edition, brought down to the present time. By 
 Samuel A. Lane, f.r.c.s., assisted by various eminent Surgeons. In two 
 vols. Price $12.00 
 
 COTTLE, ON THE HAIR. 
 
 The Hair in Health and Disease. By E. W. Cottle, m.d. Partly from the 
 notes of the late George Nayler. iSmo. Price .75 
 
 CORFIELD, DWELLING HOUSES. 
 
 The Sanitary Construction and Arrangement of Dwelling Houses. By W. 
 H. CoRFiELD, M.A., M.D. Enlarged Edition, with Plans and Illustrations. 
 i2mo. Price $1.25 
 
PUB Lie A TIONS. 
 
 13 
 
 COULSON, THE BLADDER. Sixth Edition. 
 
 Diseases of the Bladder and Prostate Gland. By Walter J. CouLSON, F.R.c.S. 
 Sixth Edition. Revised and Enlarged, with 22 Engravings. 8vo. Price $6.40 
 
 CRIPPS, THE RECTUM. 
 
 Cancer of the Rectum. Its Pathology, Diagnosis and Treatment. By. W. 
 Harrison Cripps, f.r.c.s. Illustrated by Plates. 8vo. Price $2.40 
 
 DAY ON CHILDREN. Second Edition. Just Ready. 
 
 The Diseases of Children. A Practical and Systematic Treatise for Practi- 
 
 tioners and Students, 
 very much Enlarged. 
 
 By Wm. H. Day, m.d. 
 8vo. 752 pp. 
 
 Second Edition. Rev/ritten and 
 Price, Cloth, $5.00 ; Sheep, $6.00 
 
 " Dr. Day brings to his task a large experience, and 
 evidences a very thorough knowledge of the literature, 
 native and foreign, pertaining to this special branch of 
 medicine. The book has been written with great care, 
 and the author is a good writer. The publisher's part 
 of the task has also been excellently performed." — 
 Boston Medical and Surgical Journal. 
 
 " Believing the work well adapted to meet the wants 
 of the Student as well as the Practitioner, I will recom- 
 mend it to the classes of Rush Medical College." — 
 DeLeskie Miller, m.d., Chicago. 
 
 " On the whole, we must confess we are pleased with 
 this book and can heartily recommend it — a recommen- 
 dation which it does not appear to need, as it has 
 already reached its second edition." — American Jour- 
 nal of Medical Science. 
 
 "DPCI ON HEADACHES. 
 
 The Nature, Causes, and Treatment of Headaches. Third Edition. Illus- 
 trated. By Wm. Henry Day, m.d. Price I1.25 
 
 Summary of Contents. — Headache from Cerebral Anaemia, Cerebral Hypersemia, Sympathetic, Congestive, 
 Dyspeptic or Bilious Headaches, Headache from Plethora, from Exhaustion, from Change in Cerebral Tissue, 
 from Affections of the"Periosteum, Nervous and Nervo-Hypersemic Headache, Toxaemic, Rheumatic, Arthritic 
 or Gouty Headache, Neuralgic Headache, and Headaches of Childhood, Early and Advanced Life. 
 
 " Well worth reading. The remarks on treatment are very sensible." — Boston Medical and Surg. Journal . 
 
 DALBY, ON THE EAR. 
 
 The Diseases and Injuries of the Ear. By W. B. Dalby, m.d., Surgeon and 
 Lecturer on Aural Surgery, St. George's Hospital. With Illustrations. i2mo. 
 
 Price $1.50 
 
 'A safe and readable introduction to aural surgery." 
 Medical Press and Circular. 
 
 " Dr. Dalby has presented us with a very readable 
 little book, which is destined to render rsuch service in 
 the saving of ears." — l\l. V. Medical Journal. 
 
 " The lectures occupy 2z6 pages, are clearly and 
 consisely written, contain a number of good illustrations, 
 and are well worth the careful study of both student 
 and practitioner. To aurists the work will be most 
 welcome and valuable." — Specialist. 
 
 DILLINGBERGER, WOMEN AND CHILDREN'S DIS- 
 EASES. 
 
 A Hand-Book of the Treatment of the Diseases Peculiar to Women and Chil- 
 dren. By Dr. Emil Dillingberger. i2mo. • Price $1.50 
 
 " It is a tnagnum in parvo. The style is simple, clear, lucid, and free from theoretical discussion. No one will 
 regret the small outlay for this volume. — Richmond and Louisville Medical Journal. 
 
 DUNGLISON, THE PHYSICIAN'S REFERENCE BOOK. 
 
 The Practitioner's Reference Book, containing Therapeutical and Practical 
 Hints, Dietetic Rules, and General Information. By Richard J. Dunglison, 
 M.D. Third Edition. Svo. Price $3.50 
 
 " The demand for a second edition so soon after the 
 publication of the first volume shows that this work is 
 appreciated by the profession." — Canada Lancet. 
 
 " We can heartily commend this book as one that 
 must prove very useful to the general practitioner." — 
 The Medical Record. 
 
 DURKEE, VENEREAL DISEASES. Sixth Edition. 
 
 Gonorrhoea and Syphilis. By Silas Durkee, m.d. Sixth Edition. Revised 
 and Enlarged, with Portrait and Eight Colored Illustrations. Svo. Price $3.50 
 
 "We may, finally, recommend Dr. Durkee's book as eminently practical, well written, full of excellent counsel, 
 and worthy of being corsiltcd by every member of the profession. A late number of the London Mrdical Times 
 atid Gazette also speaks of the book in terms of the highest approval." — Boston Medical and Surgical Journal, 
 
14 PRESLE V BLAKISTON'S 
 
 DAGUENET, OPHTHALMOSCOPY. 
 
 A Manual of Ophthalmoscopy, for the Use of Students. By Dr. Daguenet. 
 Translated from the French, by Dr. C. S. Jeaffreson, f.r.c.S.e. Illustrated. 
 i2mo. Price $1.50 
 
 "Its portable size, the condensed nature of its text, and the admirably systematic arrangement of its contents, 
 render it extremely useful as a pocket manual for Students. — Translator' s Preface. 
 
 DOBELL, WINTER COUGH AND CATARRH. 
 
 On Winter Cough, Catarrh, Bronchitis, Emphysema, Asthma, etc. By 
 Horace Dobell, m.d.. Lecturer at the Royal Hospital for Diseases of the 
 Chest. Third Edition. With Colored Plates. 8vo. Price {^3. 50 
 
 BY SAME AUTHOR. 
 
 ON LOSS OF WEIGHT. Revised Edition. 
 
 Blood Spitting and Lung Disease. Colored Frontispiece of Lung. Tabular 
 Map, etc. Second Edition Enlarged. 8vo. Price $4.00 
 
 DOMVILLE, ON NURSING. 
 
 A Manual for Hospital Nurses and others engaged in attending to the sick, 
 4th Edition. With Recipes for Sick Room Cookery, etc. Price .75 
 
 DRUITT'S MODERN SURGERY. Eleventh Edition. 
 
 The Surgeon's Vade Mecum; a Manual of Modern Surgery. By Robert 
 Druitt, f.r.c.s. Eleventh Enlarged Edition, with 369 Illustrations. 864 pp. 
 1878. Price §5.00 
 
 This is a most complete, accurate, and trustworthy Hand, or Text-Book of Sur- 
 gery. Unrivaled as a book for the Student. Fully illustrated, and brought up to 
 the present state of the science. In use in many Medical Colleges. 
 
 DULLES, ACCIDENTS. 
 
 What to do First, in Accidents and Poisoning. By C. W. Dulles, m.d. Il- 
 lustrated. i6mo. Price .50 
 
 " Its usefulness entitles it to a wide and permanent 
 circulation." — Boston Gazette. 
 
 " A complete guide for sudden emergencies. — Phila- 
 delphia Ledger. 
 
 " So plain and sensible that it ought to be introduced 
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 Pittsburgh. 
 
 EDWARDS, BRIGHT'S DISEASE. New Edition. 
 
 How a Person Affected with Bright's Disease Ought to Live. By Jos. F. Ed- 
 wards, M.D. Second Edition. i2mo. Price .75 
 
 BY same author. 
 
 DYSPEPSIA. Just Ready. 
 
 How to Avoid It. i2mo. .75 
 
 Contents. — Chap. i. — Food. 11. Digestion, iii. How to Cook Food. iv. How and What We Ought to Eat. 
 
 CONSTIPATION. New Edition. 
 
 Plainly Treated and Relieved Without the Use of Drugs. Second Edition. 
 i2mo. Price .75 
 
 MALARIA. 
 
 Malaria : What It Means ; How to Escape It ; Its Symptoms ; When and 
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 VACCINATION AND SMALL-POX. 
 
 Showing the Reasons in favor of Vaccination, and the Fallacy of the Argu- 
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 These are invaluable little treatises upon subjects that enter painfully into the 
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PUBLICA TIONS. 
 
 15 
 
 EKIN, WATER ANALYSIS. 
 
 Potable Water. How to Form a Judgment on the Suitableness of Water for 
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 ELLIS, DISEASES OF CHILDREN. 
 
 A Practical Manual of the Diseases of Children, with a Formulary. By Ed- 
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 BY SAME AUTHOR. 
 
 WHAT EVERY MOTHER SHOULD KNOW. 
 
 l2mo. Price .75 
 
 " It is only too true that our children have to dodge through the early part of life as through a labyrinth. We 
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 FENNER, ON VISION. 
 
 Vision ; Its Optical Defects, the Adaptation of Spectacles, Defects of Accommo- 
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 FENWICK, THE PRACTICE OF MEDICINE. 
 
 Outlines of the Practice of Medicine. With Appropriate Formulae and Illus- 
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 " It is an eminently practieal little treatise, pervaded with much common sense, and will doubtless be found 
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 BY SAME AUTHOR. 
 
 ON THE STOMACH. 
 
 The Morbid State of the Stomach and Duodenum, and Their Relations to 
 Diseases of Other Organs. With 10 Plates. 8vo. Price $4.25 
 
 Atrophy of the Stomach and Its Effect on the Nervous Affections of the Digest- 
 ive Organs. 8vo. Price %'i.io 
 
 FOTHERGILL, ON THE HEART. Second Edition. 
 
 The Heart and Its Diseases. With Their Treatment. Including the Gouty 
 Heart. By J. Milner Fothergill, m.d., Associate Fellow of the College of 
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 Price #3.50 
 
 " It is the best, as well as the most recent work on 
 the subject in the English language." — Medical Press 
 and Circular. 
 
 " The most interesting chapter is undoubtedly that 
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 by clinical ^bysicians, although they have not before 
 been stated, so far as we are aware, with the same 
 breadth of view and extended illustration." — Britith 
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 " To many an earnest student it will prove a Kght in 
 darkness ; to many a practitioner cast down with a 
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 " The work throughout is a masterpiece of graphie, 
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 dent. — Students' yournal. 
 
 FULTON, ON PHYSIOLOGY. 
 
 A Text-Book of Physiology. By J. Fulton, m.d., Professor at Trinity 
 Medical College, Toronto. Second Edition, Illustrated and Revised. Svo. 
 
 Price $4.00 
 
1 6 PRESLEY BLAKISTON'S 
 
 FLOWER, DIAGRAMS OF THE NERVES. 
 
 Diagrams of the Nerves of the Human Body. Exhibiting their Origin, 
 Divisions, and Connections, with their Distribution to the various Regions of the 
 Cutaneous Surface, and to all the Muscles. By William H. Flower, f.r.c.s., 
 F.R.S., Hunterian Professor of Comparative Anatomy, and Conservator of the 
 Museum of the Royal College of Surgeons. Third Edition, thoroughly revised. 
 With six Large Folio Maps, or Diagrams. Royal Quarto. Price $3.50 
 
 "Admirably arranged, and will be of incalculable aid to the student of anatomy. Each of the large and 
 beautiful plates is accompanied with explanatory text." — N. Y. Medical Record. 
 
 " The nerves and ganglia are clearly represented. The impressions are well made, and no doubt the diagrams 
 will prove useful." — Medical and Surgical Reporter . 
 
 FLAGG, PLASTIC FILLING. 
 
 Plastics and Plastic Filling; As Pertaining to the Filling of all Cavities of De- 
 cay in Teeth below Medium in Structure, and to Difficult and Inaccessible 
 Cavities in Teeth of all Grades of Structure. With some beautifully executed 
 Illustrations. By J. Foster Flagg, d.d.s.. Professor of Dental Pathology and 
 Therapeutics in Philadelphia Dental College. Octavo. Price $3.00 
 
 Contents. — Introductory. Article i. Plastic Filling. 2. Amalgam. 3. Amalgam continued. 4. Amalgam 
 continued. 5. Attributes of Metals used for Amalgam Alloys. 6. The Making of Amalgam Alloys. 7. Tests 
 for Amalgam. 8. Preparation of Cavities. 9. The Making of Amalgam. 10. Instrument for the Insertion of 
 Amalgam Fillings. 11. The Insertion of Amalgam Fillings. 12. General Considerations Pertaining to Amalgam. 
 13. Gutta-percha. 14. Oxy-chloride of Zinc. 15. Oxy-sulphate of Zinc. 16. Zinc Phosphate. 17. Temporary 
 Stopping. 18. Technicalities. Conclusion. 
 
 FOSTER, CLINICAL MEDICINE. 
 
 Lectures and Essays on Clinical Medicine. By Balthazar Foster, m.d. 
 Illustrated. 8vo. Price S3.00 
 
 "No one can peruse the thoughtful comments of our 
 author upon every subject he considers, without feeling 
 himself a wiser man for his pains."— A^. Y. Medical 
 Journal. 
 
 "It is the record of honest work, such as Dr. Foster 
 may be proud of; we can recommend it to the profession; 
 it may be read with profit and advantage by both prac- 
 titioner and %\.\<iA^Vi.t.— Edinburgh Medical yournal. 
 
 FOX, ATLAS OF SKIN DISEASES. 
 
 Complete in Eighteen Parts, each containing Four Chromo-Lithographic Plates, 
 with Descriptive Text and Notes upon Treatment. In all 72 large colored Plates. 
 By Tilbury Fox, m.d., f.r.c.p., Physician to the Department for Skin Diseases 
 in University College Hospital. Folio Size. 
 
 Price ^i.oo each, or complete, bound in cloth, $20.00 
 
 No Atlas of Skin Diseases has been issued in this country for many years, and no 
 complete work of the kind is now procurable by the Profession. This one, brought 
 out under the editorial supervision and care of Dr. Tilbury Fox (the most distin- 
 guished writer on Cutaneous Medicine now in the English language), is partly based 
 upon the classical work of Willan and Bateman (now entirely out of print), but com- 
 pletely rem.odeled, so as to represent fully the Dermatology of the present day. 
 
 " Preference v/ill be given to this work over Hebra ; not simply, however, because it is a home production, but 
 by reason of the manner of its execution, the excellent delineation of disease, and the natural coloring of the plates. 
 The' letter-press is entirely new. In the accuracy of the latter the subscriber may have the fullest confi- 
 dericej since it is from the pen of Dr. Tilbury 'Eox."— British and Foreign Medico-Chirurgical Review. 
 
 FRANKLAND, WATER ANALYSIS. 
 
 Water Analysis, For Sanitary Purposes, with Hints for the Interpretation of 
 Results. By E. Frankland, m.d., f.r.S. Illustrated. l2mo. Price $1.00 
 
 "The author's world-wide reputation will commend 
 this manual to all sanitarians, and they will not be dis- 
 appointed in finding all the essentials of the important 
 subject of which it treats."— TVi^ Sanitarian. 
 
 "The work is one which physicians practicing ia 
 the country and in villages and towns remote from 
 medical centres cannot aflford to be without." — Medical 
 and Surgical Reporter. 
 
 BY SAME AUTHOR. 
 
 CHEMISTRY. 
 
 How to Teach Chemistry; being Six Lectures to Science Teachers.^ Edited 
 by G. George Ghalo^er, f.c.s. Illustrated, izmo. Price 1^1.25 
 
PUB Lie A TIONS. 
 
 17 
 
 FOX, WATER, AIR AND FOOD. 
 
 Sanitary Examinations of Water, Air and Food. 
 M.D. 94 Engravings. 8vo. 
 
 By 
 
 Cornelius B. Fox, 
 Price %A..oo 
 
 gajLLAbin, diseases of women 
 
 The Student's Guide to the Diseases of Women. 
 M.D., F.R.c.P. Illustrated with 63 Engravings 
 
 By A. Lewis Gallabin, m.a., 
 i2mo. Price $1.25 
 
 "Among all the various works on diseases of women 
 with which we are acquainted, there is none which so 
 nearly approaches the perfection of what a student's 
 text-book should be . . . The work is well illustrated." 
 — Students' Journal. 
 
 " Though the book is a small one and the subject ex- 
 tensive, yet so admirable is the style of the writer, and 
 so careful his selection of words, that each disease is 
 thoroughly treated of" — Philadelphia Medical Times. 
 
 " Its style is clear, elegant, and concise: It contains 
 a great amount of information ; indeed, we do not think 
 the student or practitioner will find any book which 
 will convey to him in so small a compass so much accu- 
 rate knowledge about the pathology and diagnosis of 
 the diseases peculiar to women." — Medical Times and 
 Gazette. 
 
 GROSS, BIOGRAPHY OF JOHN HUNTER. 
 
 John Hunter and His Pupils. By S. D. Gross, m.d.. Professor of Surgery in 
 Jefferson Medical College, Philadelphia. With a beautifully executed full length 
 Portrait of the Author in his Study. A Handsome Octavo volume. Bound in 
 Beveled Cloth. Price $1.50 
 
 " It is refreshing to read the story of a life so fully devoted to science, and the reader will readily appreciate 
 Professor Gross's enthusiasm for his subject, which led him to extend what was originally intended for an essay to 
 its present size. 
 
 '• The phototype of Sharp's well-known engraving of Sir Joshua Reynold's portrait is an excellent reproduction, 
 and forms a fitting and handsome frontispiece. 
 
 " The volume will prove an ornament to the study table, where it will be a constant incentive to whatever is 
 best and noblest in a noble profession." — Baston Med. and Surgical Journal. 
 
 BY SAME AUTHOR. 
 
 AMERICAN MEDICAL MEN. 
 
 American Medical Biography of the Nineteenth Century, vi'ith portrait of Dr. 
 Benjamin Rush. Large 8vo. 
 
 GANT, A SYSTEM OF SURGERY. Enlarged Edition. 
 
 The Science and Practice of Surgery, including Special Chapters by different 
 Authors. By Frederick James Gant, f.r.c.s.. Senior Surgeon to the Royal 
 Free Hospital. Second Edition, rewritten and much enlarged throughout. 
 Illustrated by 969 wood engravings. In two Octavo volumes. 
 
 Price, Cloth $11.00; Leather $13.00 
 
 " This new and magnificent work on surgery sup- 
 plies all that can be required, whether for the most com- 
 plete study or for constant reference in practice." — 
 London Medical Press and Circular. 
 
 " The reader has the advantage of mature experience 
 in treating of special subjects, that are either omitted 
 or very lightly referred to in ordinary works on sur- 
 gery." — London Lancet. 
 
 " After the most patient analysis our limited time 
 has permitted, we feel compelled to say that this book 
 is a valuable and comprehensive addition to the surgical 
 literature of the profession and a monument to the care- 
 ful, conscientious and painstaking industry of the 
 author," — Cincinnati Lancet and Observer. 
 
 BY SAME AUTHOR. 
 
 ON THE BLADDER AND PROSTATE. 
 
 Diseases of the Bladder and Prostate Gland and Urethra, including a Practical 
 View of Urinary Diseases, Deposits and Calculi. Fourth Edition, Revised and 
 Enlarged, with New Illustrations. i2mo. Price $3.00 
 
 GIBBES, STUDENT'S PATHOLOGY. 
 
 Practical rfistology and Pathology. By Heneage Gibbes, m.b. i2mo. 
 Cloth. Price $1.00 
 
 Chap. i. Introduction. 2. On Preparing Tissues for Examination. 3. On Cutting Sections. 4. On Staining. 
 S- On Double Staining. 6. On Mounting. 7. Method of Obtaining Animal Tissues, etc. Practical Histology, 
 Pathoiogy, Memoranda and Formulffi. 
 
 " This excellent little work is admirably adapted to fulfill the purpose for which it has been written. It is 
 short, clear, and eminently practical. The author is evidently an accomplished histologist, and his book conveys 
 the impression that it is based upon his own personal experience." — The London Medical Record. 
 
i8 PRESLEY BLAKISTON'S 
 
 GODLEE'S ATLAS OF HUMAN ANATOMY. 
 
 Illustrating most of the Ordinary Dissections and many not usually practiced 
 by the Student. Accompanied by References and an Explanatory Text. Com- 
 plete. Folio Size. 48 Colored Plates. By Rickman John Godlee, m.d., 
 F.R.c.S. Forming a large Folio Volume, with References, and an Octavo 
 Volume of Letter-press. 
 
 Price of the two Volumes, Atlas and Letter-press, Cloth, $20.00 
 
 " It is likely to prove as useful to the physician and I " The explanatory text is concise, well written, and 
 surgeon as to the anatomist." — Medical Times and contains many valuable suggestions for the surgeon." 
 Gazette. \ — London Lancet. 
 
 GOWERS, SPINAL CORD. 
 
 Diagnosis of Diseases of the Spinal Cord. With Colored Plates and Engrav- 
 ings. A Second Edition, Revised and Enlarged. By William R. Cowers, 
 M.D., Assistant Professor Clinical Medicine, University College, London, 8vo. 
 Second Edition. Price $1.50 
 
 BY same author. 
 
 OPHTHALMOSCOPY. 
 
 A Manual and Atlas of Medical Ophthalmoscopy. With 16 Colored Auto" 
 type and Lithographic Plates and 26 Wood Cuts, comprising 112 Original Illus- 
 trations of the Changes in the Eye in Diseases of the Brain, Kidneys, etc. 8vq. 
 
 Price $6.00 
 EPILEPSY AND ITS TREATMENT. 
 
 Epilepsy and other Chronic Convulsive Diseases : Their Causes, Symptoms, 
 and Treatment. Octavo, ynst Ready. Price, Cloth, $4.00 
 
 NERVOUS DISEASES. 
 
 A Manual of Diseases of the Nervous System, for Practitioners and Students. 
 
 In Press. 
 
 " Dr. Gowers, while profoundly conversant with the literature of his subject, has not allowed himself to be 
 influenced to an undue extent by the writings of others, but while fairly stating their views, where this is neces- 
 sary, he at the same time brings to bear upon them the experience derived from his own extensive observations, 
 and when, consequently, they receive confirmation or not at his hands, they are all the more valuable as being the 
 outcome of the most searching and unbiased criticism. It would be impossible, within the limits of a short re- 
 view, to convey an adequate idea of the extent of Dr. Gowers' work." — Edinburgh Medical jfournal. 
 
 GREENHOW, BRONCHITIS. 
 
 On Chronic Bronchitis, especially as connected with Gout, Emphysema, and 
 Diseases of the Heart. By E. Headlam Greenhow, m.d. i2mo. Price $1.50 
 
 BY SAME AUTHOR. 
 
 ADDISON'S DISEASE. 
 
 Being the Croonian Lectures, delivered before the Royal College of Physi- 
 cians, London. Revised and Illustrated by Plates and Reports of Cases. 8vo. 
 
 Price $3.00 
 
 "The book forms a most interesting and valuable monograph, comprehensive and exhaustive." — British 
 Medical Journal. 
 
 GLISAN, TEXT-BOOK OF MODERN MIDWIFERY. 
 
 A Text-Book of Modern Midwifery. By Rodney Glisan, m.d., Emeritus 
 Professor of Midwifery and Diseases of Women and Children in the Medical 
 Department of Willamette University, Portland, Oregon, and Late President 
 of the Oregon State Medical Society. With 129 Illustratiolis. One Volume, 
 octavo, 624 pp. Price, in Cloth $4.00 ; in Leather I5.00 
 
 GILL, ON INDIGESTION. Third Edition. 
 
 Indigestion ; What It Is ; What It Leads To ; and a New Method of Treating 
 It. By John Beadnell Gill, m.d. Second Edition. i2mo. 
 
PUBLICA TIONS. 19 
 
 HABERSHON, ON THE STOMACH. 
 
 On Diseases of the Stomach — The Varieties of Dyspepsia — Their Diagnosis 
 and Treatment. By S. O. Habershon, m.d., f.r.c.p., Senior Physician to, and 
 Late Lecturer on, the Principles and Practice of Medicine at Guy's Hospital. 
 Third Edition, Revised. Crown 8vo. Price ^1.25 
 
 "As an expression of the results of long personal experience in both hospital and private practice, conveyed 
 in agreeable though not always perspicuous diction, this contribution of Dr. Habershon's has special value of its 
 own, and is so far entitled to the favorable consideration of the practitioner, as is already testified by a demand 
 for a third edition." — American yournal of Medical Sciences. 
 
 HALE, ON CHILDREN. 
 
 The Management of Children in Health and Disease. A Book for Mothers. 
 By Mrs. Amie M. Hale, m.d. Abounding in valuable information and com- 
 mon sense advice. New Enlarged Edition. i2mo. Price .75 
 
 " We shall use our influence in the introduction of this work to families under our care, and we urge the pro- 
 fession generally to follow our example." — Buffalo Medical and Surgical Journal. 
 
 HUGHES, QUIZ-BOOK OF PRACTICE. 
 
 A Compend of the Practice of Medicine, as used in the Quiz-Rooms and Ex- 
 aminations in the principal Medical Colleges. By Daniel E. Hughes, m.d., 
 Demonstrator of Clinical Medicine at Jefferson Medical College, Philadelphia. 
 In two parts. Quiz-CompendSeries Nos. 2 and 3. i2mo. Cloth. Price, each, ^1.25 
 
 HARDWICKE, MEDICAL EDUCATION. 
 
 Medical Education and Practice in All Parts of the World. Containing 
 Regulations for Graduation at the Various Universities throughout the World. 
 By Herbert Junius Hardwicke, m.d., m.r.c.p. 8vo.; Price ^3.00 
 
 " Dr. Hardwicke's book will prove a valuable source of information to those who may desire to know the 
 conditions upon which medical practice is or may be pursued in any or every country of the world, even to the 
 lemotest corners of the earth. The work has been compiled with great care, and must have required a vast 
 amount of labor and perseverance on the part of its author." — Dublin Medical yournal. 
 
 HARLEY, ON THE LIVER. Illustrated. 
 
 On Diseases of the Liver, with or without Jaundice. Diagnosis and Treat- 
 ment, By George Harley, m.d. Author of the Urine and Its Derangements. 
 With Colored Plates and Numerous Illustrations. Royal Octavo. 
 
 In Rapid Preparation. 
 HAYDEN, ON THE HEART. 
 
 The Diseases of the Heart and Aorta. By Thomas Hayden, m.d. With 81 
 Illustrations. 2 vols. 1232 pp. 8vo. Price $6.00 
 
 "The author evidently has had a very wide and well used experience in that of which he writes ; is well versed 
 in modern physiology and pathology, and holds a fluent pen, consequently the book is an excellent one, and as 
 the teachings of the text are abundantly illustrated by the reports of one hundred and fifty cases. Dr. Hayden's 
 efifort will probably attain the popularity it deserves." — i'hiladelphia Medical Titnes. 
 
 "There is not an unnecessary page in Dr. Hayden's work." — N. Y. Medical Record. 
 
 HOLDEN, HUMAN OSTEOLOGY. Sixth Edition. 
 
 Comprising a Description of tiie 15ones, with Colored Delineations of the At- 
 tachments of the Muscles. The General and Microscopical Structure of ]5one 
 and its Development. By the Author and A. Doran, f.r.c.s., with Lithographic 
 Plates, etc. By Luther Holden, f.r.c.s. Numerous Illustrations. Sixth 
 Edition, carefully Revised. Price $6.00 
 
 BY same AUTHOR. 
 
 ANATOMY. 
 
 Manual of Dissections of the Human Body. Fourth London Edition, Witli 
 170 Illustrations. Price ^z,.t,o 
 
 LANDMARKS. 
 
 Landmarks, Medical and Surgical. Third London Edition. Revised and 
 Enlarged. Price ;?i. 00 
 
 " Mr. Holden is the happy possessor of the faculty of writing interesting works on Anatomy. A part of the 
 charm consists in the frequent references to practical points, and in the explanation of the advantages ait' objects 
 of details of structures." — Boston Medical and Surgical yournal. 
 
20 PRESLE V BLAKISTON 'S 
 
 HEATH'S OPERATIVE SURGERY. 
 
 A Course of Operative Surgery, consisting of a Series of Plates, each plate 
 containing Numerous Figures, Drawn from Nature by the Celebrated Anatomi- 
 cal Artist, M. Leveille, of Paris, Engraved on Steel and Colored by Hand, 
 under his immediate superintendence, with Descriptive Text of Each Operation. 
 By Christopher Heath, f.r.c.s.. Surgeon to University College Hospital, and 
 Holme Professor of Clinical Surgery in University College, London. One Large 
 Quarto Volume. Price §14.00 
 
 The author has embodied in this work the experience gained by him during 
 twenty years of surgical teaching. It comprises all the operations that are required 
 in ordinary surgical practice. He has selected for illustration and description those 
 methods which appear to give the best results in practice, referring to the errors 
 likely to occur and the best methods of avoiding them. 
 
 BY SAME author. 
 
 THE STUDENT'S GUIDE TO SURGICAL DIAGNOSIS. 
 
 i2mo. Price gi. 25 
 
 " Mr. Heath is so well known, both as a practical surgeon, teacher and writer, that anything from his pen re- 
 quires no introduction from the hands of reviewers, and scarcely any notice but the announcement of the fact that 
 he has written a book." — Medical Record. 
 
 A MANUAL OF MINOR SURGERY AND BANDAGING. 
 
 Sixth Edition, Revised and Enlarged. With 115 Illustrations. i2mo. 
 
 Price $2.00 
 
 " This excellent work should not be termed a ' Minor ' Surgery, but it really consists of the sum and substance 
 ef Practical surgery. We would not exchange it for any book in our possession." — Southern Clinic. 
 
 HEATH'S PRACTICAL ANATOMY. Fifth London Edition. 
 
 Practical Anatomy. A Manual of Dissections. Fifth London Edition. 24 
 Colored Plates, and nearly 300 other Illustrations. Just Ready. Price $5.00 
 
 INJURIES AND DISEASES OF THE JAWS. 
 
 The Jacksonian Prize Essay of the Royal College of Surgeons of England, 
 1867. Second Edition, Revised, with over 150 Illustrations. Octavo. 
 
 Price $4-25 
 HOOD, ON GOUT AND RHEUMATISM. 
 
 A Treatise on Gout, Rheumatism, and the Alhed Affections. Their Treat- 
 ment, Complications, and Prevention. By Peter Hood, m.d. Second Edi- 
 tion, Revised and Enlarged. With some Considerations on Longevity. Octavo. 
 
 Price $3.50 
 
 " The Observations on Treatment are specially to be comme.nA&A."— London Lancet. 
 
 HOLDEN, THE SPHYGMOGRAPH. 
 
 The Sphygmograph. Its Physiological and Pathological Indications. By 
 Edgar Holden, m.d. Illustrated by Three Hundred Engravings on Wood. 
 8vo. P"^^ ^2-°° 
 
 HOLMES, THE LARYNGOSCOPE. 
 
 A Guide to the Use of the Laryngoscope in General Practice. By Gordon 
 Holmes, m.d., Physician to the Throat and Ear Infirmary. i2mo. Pnce $1.00 
 
 BY same author. 
 
 VOCAL PHYSIOLOGY. , ^ , . . 
 
 Vocal Physiology and Hygiene. With reference to the Cultivation ^and 
 Preservation of the Voice. Illustrated. i2mo. Pnce $2.00 
 
 HOFF, ON HiEMATURIA. 
 
 Hsematuria as a Symptom of the Diseases of the Genito-Urmary Organs, by 
 O, HoFF, M.D. Illustrated. i2mo. P"^*^ -75 
 
PUBLICATIONS. 21 
 
 HUNTER, MECHANICAL DENTISTRY. 
 
 A Practical Treatise on the Construction of the Various kinds of Artificial 
 Dentures, with Formulae, Receipts, etc. By Charles Hunter, d.d.s. 100 
 Illustrations. i2mo. Price $2,25 
 
 " It is the outcome ofhis own experience of some twenty years as aMechanical Dentist, and contains, moreover, 
 much derived from practical knowledge of other dentists. The value of the book is also much added to by illus- 
 trations. It will be very useful to the Dental Student, and to all Mechanical Dentists." — London Medical Times 
 And Gazette. 
 
 HUTCHINSON'S ILLUSTRATIONS OF CLINICAL SUR- 
 GERY. First Volume Complete. 
 
 Consisting of Plates, Photographs, Woodcuts, Diagrams, etc. Illustrating 
 Surgical Diseases, Symptoms, and Accidents; also Operations and other 
 Methods of Treatment. With Descriptive Letter-press. By Jonathan Hutch- 
 inson, F.R.C.S., Senior Surgeon to the London Hospital, Surgeon to the Moor- 
 fields Ophthalmic Hospital, and to the Hospital for Diseases of the Skin, Black- 
 friars. In Quarterly Fasciculi. ■ Imperial 4to. Volume i. (Ten Fasciculi) bound 
 complete in itself. Price $25.00. Parts Eleven, Twelve, Thirteen, and Fourteen 
 of Volume 2, Now Ready. Each I2.50 
 
 HEWITT, DISEASES OF WOMEN. Third Edition. 
 
 The Diagnosis, Pathology, and Treatment of Diseases of Women, Including 
 the Diagnosis of Pregnancy. Founded on a Course of Lectures Delivered at St. 
 Mary's Hospital Medical School. By Graily Hewitt, m.d., Lond., m.r.c.p.. 
 Physician to the British Lying-in Hospital ; Lecturer on Midwifery and Diseases 
 of Women and Children at St. Mary's Hospital Medical School; Honorary 
 Secretary to the Obstetrical Society of London, etc. The Third Edition. Re- 
 vised and Enlarged, with New Illustrations. Octavo. 
 
 Price, Cloth $4.00; Leather ^5.00 
 
 " Readers of the former editions will not require to 
 be told that the additions now made are of the highest 
 possible e.xcellence."— Zi'wz^.r and Gazette. 
 
 " It is one of the most useful, practical, and compre- 
 hensive works upon the subject in the English language, 
 a true guide to the student, and an invaluable means of 
 reference for the teacher."— iV. Y. Medical Record. 
 
 " The excellent work of Dr. Hewitt presents — in a 
 form well adapted to conduct the student to a knowledge 
 of the Diseases of Women, and to assist the young 
 practitioner in his study of these diseases at the bedside 
 of the patient — a very full and clear exposition of the 
 views entertained by the most authoritative teachers as 
 to their pathological treatment and their correct Diag- 
 nosis."— ylw^r. Med. yournai. 
 
 HAY, SARCOMATOUS TUMOR. 
 
 History of a Case of Recurring Sarcomatous Tumor of the Orbit in a Child. 
 By Thomas Hay, m.d. Illustrated. Paper. Price .50 
 
 HEWSON, EARTH IN SURGERY. 
 
 Earth as a Topical Application in Surgery, Being a Full Exposition of its Use 
 in Cases Requiring Topical Applications. By Addinell Hewson, m.d. Illus- 
 trated. 8vo. Price $2.50 
 
 HODGE, ON ABORTION. 
 
 On Foeticide or Criminal Abortion. By Hugh L. Hodge, m.d. 
 
 Price, Paper, .30; Cloth, .50 
 HODGE, CASE-BOOK. 
 
 Note-Book for Cases of Ovarian Tumors. By H. Lennox Hodge, m.d. With 
 Diagrams. Price, Paper, .50 
 
 HIGGINS, DISEASES OF THE EYE. Now Ready. 
 
 A Hand-Book of Ophthalmic Practice. By Charles Higgins, f.r.c.s. 
 Ophthalmic Assistant Surgeon at Guy's Hospital. Second Edition. i6mo. 
 
 Price .50 
 
 Contents. — Section i. Discharge from the Eyes. ii. Intolerance of Light, iii. Iritis and Glaucoma, iv. 
 Diseases of the Eyelids, v. Watering of the Eye. vi. Acuteness of Vision, Field of Vision, Anomalies of Re- 
 fraction, Astigmatism, Accommodation, Presbyopia, vii. Disturbance of Vision, Use of the Ophthalmoscope, 
 Normal and Morbid Appearances, vni. Injuries. 
 
 " We have rarely seen so much important information condensed in so short a space." — American Medical 
 yournai. 
 
22 PRESLEY BLAKISTON'S 
 
 HARRIS, THE PRACTICE OF DENTISTRY. Tenth Edition. 
 
 The Principles and Practice of Dentistry. Tenth Revised Edition. In great 
 part Rewritten, Rearranged, and with many new and important Illustrations. 
 By Chapin a. Harris, m.d., d.d.s. Edited by P. H. Austen, m.d., Professor 
 of Dental Science and Mechanism in the Baltimore College of Dental Surgery. 
 With nearly 400 Illustrations. Royal Octavo. Price, Cloth, $6.50 ; Leather, $7.50 
 
 This new edition of Dr. Harris' work has been thoroughly revised in all its parts, 
 more so than any previous edition. So great have been the advances in many 
 branches of dentistry that it was found necessary to rewrite the articles or subjects, 
 and this has been done in the most efficient manner by Professor Austen, for many 
 years an associate and friend of Dr. Harris, assisted by Professor Gorgas and Thomas 
 S. Latimer, m.d. The publishers feel assured that it will now be found the most 
 complete text-book for the student, and guide for the practitioner in the English 
 language. 
 
 BY SAME AUTHOR. 
 
 MEDICAL AND DENTAL DICTIONARY. Fourth Edition. 
 
 A Dictionary of Medical Terminologv', Dental Surgery, and the Collateral 
 Sciences. Fourth Edition, Carefully Revised and Enlarged. By Ferdinand 
 J. S. GoRGAS, M.D., D.D.S., Professor of Dental Surgery in the Baltimore College, 
 etc. Royal Octavo. Price, Cloth, $6.50; Leather, ^^7.50 
 
 This Dictionary, having passed through three editions, and been for some time 
 out of print, has been again carefully revised by F. J. S. Gorgas, m.d., Dr. Harris' 
 successor as Professor of Dental Surgery in the Baltimore College of Dental Surgery. 
 In his preface to this new edition, the editor says : — 
 
 " The object of the reviser has been to bring the book thoroughly up to the pres- 
 ent requirements of the profession, the Medical Y>ort\on having been as carefully re- 
 vised and added to as that devoted more especiall}' to Dental Science, while a 
 number of obsolete terms and methods have been omitted. In nearly every one of 
 the seven hundred and forty-three pages of the former edition corrections and addi- 
 tions have been made, and many new processes, terms and appliances described, 
 some of which are not found in any other work published." 
 
 HANDY, ANATOMY. 
 
 Text-Book of Anatomy and Guide to Dissections. For the Use of Students. 
 By W. R. Handy, m.d. 312 Illustrations. Price S3.00 
 
 HILLIER, DISEASES OF CHILDREN. 
 
 A Clinical Treatise on the Diseases of Children. By Thomas Hillier, m.d. 
 8vo. Price $2.00 
 
 HUFELAND, LONG LIFE. 
 
 The Art of Prolonging Life. By C. W. Hufeland. Edited by Erasmus 
 Wilson, m.d. i2mo. Price $i.co 
 
 " We wish all doctors and all their intelligent clients would read it, for surely its perusai would be attended 
 with pleasure and benefit." — American Practitioner. 
 
 " It certainly should be in the library of everj- physician."— 3/(?(/«:a/ Brief. 
 
 HUNTER, PORTRAIT OF. 
 
 Portrait of John Hunter. From Sharp's well-known Engraving ; a copy of 
 Sir Joshua Reynold's Portrait. For Framing. Large size, 9x11; sheet 16 x 20. 
 Price, in the Sheet, sent free by mail, 50 cents ; or. Handsomely Framed^ 
 
 Price %2..oo 
 
PUB Lie A TIONS. 
 
 HEADLAND, THE ACTION OF MEDICINES. Fourth Edition. 
 
 On the Action of Medicines in the System. By F. W, Headland, m.d. 
 Fourth American Edition, Revised and Enlarged. 8vo. Price $3.00 
 
 "It displays in every page the evidence of extensive knowledge and of sound reasoning; it will be useful alike 
 to those who are just commencing their studies, and to those who are engaged in the active pursuits of pro- 
 fessional Wilt."— Medical Times. 
 
 " The very favorable opinion which we were amongst the first to pronounce upon this essay has been fully 
 confirmed by the general voice of the profession, and Dr. Headland may now be congratulated on having pro- 
 duced a treatise which has been weighed in the balance, and found worthy of being ranked with our standard 
 medical works." — London Lancet. 
 
 JAMES, SORE THROAT. 
 
 On Sore Throat, Its Nature, Varieties and Treatment, Including its Con- 
 nection with other Diseases. By Prosser James, m.r.c.p. Fourth Edition, 
 Revised and Enlarged. With Colored Plates and Numerous Wood-cuts. i2mo- 
 
 Price $1.25 
 
 " We can confidently recommend his therapeutic teachings as well worthy of the careful consideration of the 
 Profession, for they set forth the practice of an enthusiastic worker, whose special experience has been large and 
 lengthened." — British Medical Journal. 
 
 " The practitioner who buys Dr. James' unpretending little book will provide himself with a wise and practical 
 clinical commentary, and with a well arranged digest of long and varied experience." — Westminster Review. 
 
 BY SAME AUTHOR. 
 
 LARYNGOSCOPY AND RHINOSCOPY. 
 
 Including the Diagnosis of Diseases of the Throat and Nose. Third Edition. 
 With Colored Plates. i8mo. Price $2.00. 
 
 " It gives in a succinct form the approved methods of examination and treatmen t of diseases of the nose, throat, 
 and larynx. The plan pursued is one well adapted to the needs of the general practitioner." — American Medical 
 yournal. 
 
 JONES, AURAL ATLAS. 
 
 An Atlas of Diseases of the Membrana Tympani. Being a Series of Colored 
 Plates, containing 62 Figures. With appropriate Letter-press and Explanatory 
 Text. By H. Macnaughton Jones, m.d.. Surgeon to the Cork Ophthalmic and 
 Aural Hospital. 4to. Price §4.00. 
 
 " The cases are well selected, the drawings executed from life, highly artistic and very conscientious, and the 
 commentaries indicate familiarity with the subject and good judgment in dealing with it." — British Medical 
 yournal. 
 
 BY SAME AUTHOR. 
 
 AURAL SURGERY. 
 
 A Practical Hand-book on Aural Surgery. Illustrated. Second Edition, Re- 
 vised and Enlarged, with new Wood Engravings, i2mo. Cloth. Price $2.75 
 
 JONES, SIEVEKING AND PAYNE, PATHOLOGICAL AN- 
 ATOMY. 
 
 A Manual of Pathological Anatomy. By C. Handfield Jones, m.d., and 
 Edward H. Sieveking, m.d.. Physician to St. Mary's Hospital. A New En- 
 larged Edition. Edited by J. F. Payne, m.d., Lecturer on Morbid Anatomy at 
 St. Thomas' Hospital. With Numerous Illustrations. Demi 8vo. Price $5.50. 
 
 JONES, ON SIGHT AND HEARING. 
 
 The Defects of Sight and Hearing, their Nature, Causes, and Prevention. By 
 T. Wharton Jones, m.d. Second Edition. i6mo. Price .50. 
 
 KIRBY, ON PHOSPHORUS. Fifth Edition. 
 
 Phosphorus as a Remedy for Functional Diseases of the Nervous System. 
 By E. A. KiRBY, m.d. Fifth Edition. Svo. Price gi.oo 
 
 KOLLMEYER, KEY TO CHEMISTRY. 
 
 Chemia Coartata, or Key to Modern Chemistry. By A. H. Kollmeyer, m.d. 
 With Numerous Tables, Tests, etc. Price $2.25 
 
 KIRKE, PHYSIOLOGY. Revised and Enlarged. 
 
 A Hand-book of Physiology. By Kirke. Tenth London Edition. By W. 
 Morrant Baker, m.d. 420 Illustrations. Now Ready. Price ^5.00 
 
 " This is undoubtedly the best work for students on Physiologj' extant." — Cincinnati Med. News. 
 
24 PRESLEY BLAKISTON'S 
 
 KANE, THE OPIUM, MORPHINE AND SIMILAR HABITS. 
 
 Drugs that Enslave. The Opium, Morphine, Chloral, Hashisch and Similar 
 Habits. By H. H. Kane, m.d., of New York. With Illustrations. Price $1.50 
 
 " It contains a large amount of information collected with much labor and presented in a systematic manner. 
 The subject of the chloral habit has not been investigated by any one, we believe, so thoroughly as Dy Dr. Kane." 
 — Medical Record. 
 
 " It deserves to be read by those who feel an interest in discouraging the use of these dangerous drugs. The 
 book is embellished by an excellent phototype frontispiece of Laocoon." — Ajnerican Journal of Pharmacy. 
 
 "A work of more than ordinary ability and careful research. . . . For the first time, reliable statistics on 
 the use of chloral are classified and published, . . . and it is shown that the use of (MaxsX causes a more 
 complete and rapid ruin of mind and body than either opium or morphine." — Druggists' Circular and Gazette. 
 
 KIDD, THERAPEUTICS. 
 
 The Laws of Therapeutics ; or, the Science and Art of Medicine. By Joseph 
 KiDD, M.D. i2mo. Cloth. Price $1.25. 
 
 Dr. Joseph Kidd, who, "by the way, was Lord Beaconsfield's medical adviser, and 
 an eminent physician of the regular school, briefly but clearly sketches the history of 
 medicine from the earliest period. He shows that the chief mistakes have been 
 made through deference to theory and negligence of the teachings of facts. Thence 
 he passes to an assertion of the value of the homoeopathic principle of similia simili- 
 bus in the treatment of many diseases. He is not a follower of Hahnemann, and 
 does not believe in iniinitessimal doses, but he claims, and enforces his position by 
 the citation of cases in his own practice, that the homoeopathic principle has performed 
 wonders where that of his own school was much less successful. 
 
 " Dr. Kidd acknowledges two laws — that oi contraria contrariis anisiinilia similibus ; but the cases he gives 
 in his chapter on ars medica show that, like a sensible practitioner, he does not allow himself blindly to follow 
 either the one or the other, but seeks out the cause of disease, and tries by rational measures to remove it. The 
 cases are the most valuable part of the book." — London Practitioner . 
 
 LEGG, ON THE URINE. 
 
 Practical Guide to the Examination of the Urine, for Practitioner and Student. 
 By J. WiCKHAM Legg, m.d. Fifth Edition, Enlarged. Illustrated. i2mo. 
 
 Price .75 
 
 This little work is intended to supply the Physician or Student with a concise guide 
 
 to the recognition of the different characteristics of the urine, and though small and 
 
 well adapted to the pocket, contains, probably, everything that could be gleaned 
 
 from a larger work. 
 
 LEARED, IMPERFECT DIGESTION. 
 
 The Causes and Treatment of Impeifect Digestion. By Arthur Leared, m.d. 
 The 7th Edition. Revised and Enlarged. i2mo. Price $2.00 
 
 LIEBREICH, ATLAS OF OPHTHALMOSCOPY. 
 
 An Atlas of Ophthalmoscopy, containing 12 Full-page Chromo-Lithographic 
 Plates, with 59 Figures. By R. Liebreich, m.d. Second Edition, Enlarged. 
 Large Quarto. Price $12.00 
 
 LIVEING, ON SICK HEADACHE. 
 
 Megrim, or Sick Headache and Some Allied Disorders. By Edward Live- 
 ING, M.D. With Plates, Tables, etc. 8vo. Price $5.50 
 
 LEBER AND ROTTENSTEIN, DENTAL CARIES. 
 
 Dental Caries and Its Causes. An Investigation into the Influence of Fungi 
 in the Destruction of the Teeth. By Drs. Leber and Rottenstein. Illustrated. 
 8vo. Price ,$1.25 
 
 " The work gives the result of patient observation, presents the deductions of its authors with a perspicuity and 
 modesty calculated to secure for its positions a thoughtful consideration. We heartily commend it as an educa- 
 tional work." — Dental Cosm.os. 
 
PUBLICA TIONS. 25 
 
 I.EWIN, ON SYPHILIS. 
 
 The Treatment of Syphilis. By Dr. George Lewin, of Berlin. Translated 
 by Carl Proegler, m.d., and E. H. Gale, m.d., Surgeons U. S. Army. Illus- 
 trated. i2mo. Price $1.25 
 
 " When such authorities as Dr. Drysdale (as we quoted a few weeks ago) condemn the use of mercury in syphilis 
 as " too dangerous," while, on the other hand, eminent surgeons, such as Professor Gross, will not treat'a case 
 without that drug, general practitioners will gladly welcome any media ■via which gives us all the good effects of 
 mercurials without any danger of their ill results appearing. This is what is accomplished by Dr. Lewin." — 
 Philadelphia hRdical and Surgical Reporter. 
 
 LIZARS, ON TOBACCO. 
 
 The Use and Abuse of Tobacco. By John Lizars, m.d. i2mo. Price 
 
 LONGLEY, POCKET MEDICAL LEXICON. 
 
 " Students' Pocket Medical Dictionary, Giving the Correct Definition and Pro- 
 nunciation of all Words and Terms in General Use in Medicine and the Collate- 
 ral Sciences, with an Appendix, containing Poisons and their Antidotes, Abbre- 
 viations Used in Prescriptions, and a Metric Scale of Doses. By Elias Longley. 
 24mo. Price, Cloth, ^i.oo ; Tucks and Pocket ^1.25 
 
 This is an entirely new Medical Dictionary, containing some 300 compactly 
 printed 24mo pages, very carefully prepared by the author, who has had much ex- 
 perience in the preparation of similar works, assisted by the Professors of Chemistry 
 and of Botany in one of our leading medical colleges. 
 
 " This little book will be welcomed by students in 
 medicine and pharmacy as a convenient pocket com- 
 panion, giving the pronunciation, acceptation, and 
 definition of medical, pharmaceutical, chemical and 
 botanical terms." — American yournal of Pharmacy. 
 
 " It would seem to be just the book for dental and 
 medical students." — Dental Advertiser. 
 
 " It is, we believe, also the only lexicon in existence 
 in v/hich the pronunciation of words is fully and dis- 
 tinctly marked." — Canada Medical Revie'w. 
 
 " This is a very compact a,nd complete little diction- 
 ary. We commend it as particularly useful to students." 
 — J^ew York Medical yournal. 
 
 MAYNE, MEDICAL DICTIONARY. Fifth Edition. 
 
 A Medical Vocabulary, Being an Explanation of all Terms and Phrases used 
 in the Various Departments of Medical Science and Practice, Giving their Deri- 
 vation, Meaning, Application, and Pronunciation. Intended specially as a Book 
 of Reference for the Student. By Drs. R. G. and J. Mayne. Fifth Edition. 
 Revised and Enlarged. Cloth. Price $4.00 
 
 MEDICAL REGISTER. 
 
 A Monthly Journal Devoted to the Literature of Medicine and Allied Sciences. 
 Containing Critical Reviews, Book Notices, Miscellaneous News, and complete 
 Bibliographical Lists of all New Books published on Medical and Scientific 
 Subjects. Terms, per Annum, $1.00 
 
 An invaluable Monthly Reference List for Librarians, Professors, Specialists, and 
 all wishing to keep acquainted with the Medical Literature of the day. 
 
 MACDONALD, MICROSCOPICAL EXAMINATION OF 
 WATER. 
 
 A Guide to the Microscopical Examination of Drinking Water. By J. D. 
 Macdonald, m.d. With Twenty Full-page Lithographic Plates, Reference 
 Tables, etc. 8vo. Price ^2.75 
 
 "The volume is an excellent hand-book and will greatly facilitate the study of the subject." — Popular Science 
 
 Monthly. 
 
 MACEWEN, ON OSTEOTOMY. 
 
 An Inquiry into the /Etiology and Pathology of Knock-knee, Bow-leg and 
 other Osseous Deformities of the Lower Limbs. By Wm. Macewen, m.d. Il- 
 lustrated. 8vo. Price %\.oo 
 
26 PRESLE Y BLAKISTON'S 
 
 MACKENZIE, ON THE THROAT AND NOSE. 
 
 Including the Pharynx, Larynx, Trachea, CEsophagus, Nasal Cavities, and 
 Keck. By Morell Mackenzie, m.d., London, Senior Physician to the Hos- 
 pital for Diseases of the Chest and Throat, Lecturer on Diseases of the Throat 
 at London Hospital Medical College, etc., etc. 
 
 Vol. L Including the Pharynx, Larynx, Trachea, etc. 112 Illustrations. 
 
 Now Ready. Price, Cloth, $4.00 ; Leather, $5.00 
 
 Vol. II. Including the CEsophagus, Nasal Cavities, Neck, etc' Illustrated. 
 
 Ill Preparation. 
 
 Author's Edition, issued under his supervision, containing all the original Wood 
 Engravings, and the essay on " Diphtheria, Its Causes, Nature, and Treatment," for- 
 merly published separately. Each volume sold separately; purchasers of Volume I. 
 will receive early information of date of issue and price of Volume II., upon sending 
 their address to the publishers. 
 
 "We have long felt the want of a thoroughly practical and systematic treatise on diseases of the throat 
 End nasal passages. Admirable essays have from time to time appeared ; no standard work has been written. 
 Any one familiar with laryngoscopic work must appreciate the valuable addition now made to this special 
 department in the work before us. The entire work will include the consideration of affections of the pharj-nx, 
 larynx, trachea, oesophagus, nasal cavities, and neck. The matter now presented complete for the first time is 
 the result of the author's large and unrivaled experience, both in hospital and private practice, extending over 
 a period of twenty years. There can be but one verdict of the profession on this manual — it stands without any 
 competitor in medical literature, as a standard work on the organs it professes to treat of." — Dublin jfouryzal. 
 
 " It is both practical and learned ; abundantly and well illustrated ; its descriptions of disease are graphic, and 
 the diagnoses the best we have anywhere seen. To give examples of the thoroughness of Dr. Mackenzie's book, 
 we may cite the chapter on diphtheria, which embraces 47 pages. The chapter on non-malignant tumors of the 
 larynx would appear to be absolutely exhaustive. Nowhere else have we seen so elaborate a statement of the sub- 
 ject. We can predict for this work a high position, and congratulate its distinguished author upon its appear- 
 ance." — Philadelphia Medical Times. 
 
 BY SAME AUTHOR. 
 
 THE PHARMACOPOEIA of the Hospital for Diseases of the 
 Throat and Nose. 
 
 The Fourth Edition, much enlarged, containing 250 Formulae, with Directions 
 for their Preparation and Use. i6mo. Price ^1.25 
 
 GROWTHS IN THE LARYNX. 
 
 Their History, Causes, Symptoms, etc. With Reports and Analysis of one 
 Hundred Cases. With Colored and Other Illustrations. 8vo. Price $2.00 
 
 MACNAMARA, DISEASES OF THE EYE. 
 
 A Manual of the Diseases of the Eye. By C. Macnamara, m.d. Fourth 
 Edition, Carefully Revised ; with Additions and Numerous Colored Plates, Dia- 
 grams of Eye, Wood-cuts, and Test Types. Demi 8vo. Price 
 
 "As a book of ready reference on diseases of the eye it has no superior, and we may safely say, no equal in our 
 language." — Cincituiati Lancet and Observer. 
 
 BY SAME AUTHOR. 
 
 ON THE BONES AND JOINTS. 
 
 Lectures on Diseases of the Bones and Joints. Second Edition. Demi 8vo. 
 
 Price $4.25 
 
 MADDEN, HEALTH RESORTS. 
 
 Health Resorts for the Treatment of Chronic Diseases. A Hand-Book, the 
 result of the author's ov/n observations during several years of health travel in 
 many lands, containing also remarks on climatology and the use of mineral 
 waters. By T. M. Madden, m.d. 8vo. Price $2.50 
 
 " Rarely have we encountered a book containing so much information for both invalids and pleasure seekers." 
 — The Sanitarian. 
 
 MEDICAL REGISTER. 
 
 Directory of Physicians in Philadelphia. Octavo. Cloth, $1.00 
 
PUB Lie A TIONS. 27 
 
 MARSHALL & SMITH, ON THE URINE. 
 
 The Chemical Analysis of the Urine. By John Marshall, m.d., and Edgar 
 F. Smith, m.d., of the Chemical Laboratory, Medical Department, University of 
 Pennsylvania. Illustrated by Phototype Plates. i2mo. Price f i.oo 
 
 MARSHALL, ANATOMICAL PLATES; 
 
 Or Physiological Diagrams. Life Size (7 by 4 feet) and Beautifully Colored. 
 By John Marshall, f.r.s. An Entirely New Edition, Revised and Improved, 
 Illustrating the Whole Human Body. 
 The Set, Eleven Maps, in Sheets, Price $5o.cx) 
 
 " " handsomely Mounted on Canvas, with 
 
 Rollers, and Varnished, Price ^80.00 
 An Explanatory Key to the Diagrams, Price .50 
 
 Dr. Marshall's Plates, from their size and perfection of drawing and coloring, excel 
 any diagrams that have been published. They have proved invaluable in Medical 
 Schools and Lecture Rooms. The low price at which they are offered brings them 
 within reach of all. 
 
 No. I. The Skeleton and Ligaments. No. 2. The Muscles, Joints, and Animal Mechanics. No. 3. The Vis- 
 cera in Position— The Structure of the Lungs. No. 4. The Organs of Circulation. No. 5. The Lymphatics or 
 Absorbents. No. 6. The Digestive Organs. No. 7. The Brain and Nerves. No. 8. The Organs of the Senses 
 and Organs of the Voice, Plate i. No. 9. The Organs of the Senses, Plate 2. No. 10. The Microscopic 
 Structure of the Textures, Plater. No. 11. The Microscopic Structure of the Textures, Plate 2. 
 
 MARSDEN, ON CANCER. 
 
 A New and Successful Mode of Treating Certain Forms of Cancer. By Alex- 
 ander Marsden, m.d. Second Edition. Colored Plates. 8vo. Price ^3.00 
 
 MARTIN, MICROSCOPIC MOUNTING. 
 
 A Manual of Microscopic Mounting. With Notes on the Collection and Ex- 
 amination of Objects, and upwards of 150 Illustrations. By John H. Martin. 
 Second Edition, Enlarged. Svo. Price $2.75 
 
 MORRIS, ON THE JOINTS. 
 
 The Anatomy of the Joints of Man. Comprising a Description of the Liga- 
 ments, Cartilages, and Synovial Membranes; of the Articular Parts of Bones, 
 etc. By Henry Morris, f.r.c.s. Illustrated by 44 Large Plates and Numerous 
 Figures, many of which are Colored. Svo. Price ^5.50 
 
 MUTER, MEDICAL AND PHARMACEUTICAL CHEMIS- 
 TRY. 
 
 An Introduction to Pharmaceutical and Medical Chemistry. Part One. — 
 Theoretical and Descriptive. Part Two. — Practical and Analytical. Arranged 
 on the principle of the Course of Lectures on Chemistry as delivered at, and the 
 Instruction given in the Laboratories of, the South London School of Pharmacy. 
 By John Muter, m.d., President of the Society of Public Analysts. A Second 
 Edition, Enlarged and Rearranged. The Two Parts bound in one large octavo 
 volume. Price $6.00 
 
 Part Two. — Practical and Analytical. Bound Separately, for the Special Con- 
 venience of Students. Large Svo. Cloth. Price $2.50 
 
 MAC MUNN, THE SPECTROSCOPE. 
 
 The Spectroscope in Medicine. By Chas. A. Mac Munn, m.d. With 3 
 Chromo-lithographic Plates of Physiological and Pathological Spectra, and 13 
 Wood Cuts. Svo. Price $3.00 
 
 " This book is, without question, the best that has yet been published on the subject ; to those not familiar with 
 Physiological Spectroscopy it will prove interesting, while to those who are worlang in this field it is a neces' 
 sity." — ye-u) York Medical yotirnal. 
 
28 
 
 PRESLEY BLAKISTON'S 
 
 MASON, ON THE FACE. 
 
 The Surgery of the Face. By Francis Mason, f.r.c.s. With loo Illustra- 
 tions, showing the various operations performed. 8vo. Price $2.25 
 
 Dr. Mason has for many years taken considerable interest in the surgery of the 
 face, mouth, throat, and contiguous parts, collecting several thousand cases of the 
 different operations having special reference to these regions, which, from their 
 conspicuousness, form a very important part of the human body. 
 
 MAUNDER, OPERATIVE SURGERY. 
 
 Operative Surgery. Adapted to the Living and Dead Subject. By C. F. 
 Maunder, f.r.c.s. Second Edition, with One Hundred and Sixty-four En- 
 
 gravings on Wood. 
 
 THE ARTERIES. 
 
 Price I2.25 
 
 BY SAME AUTHOR. 
 
 Surgery of the Arteries, including Aneurisms, Wounds, Hemorrhages, 
 Twenty-seven Cases of Ligatures, Antiseptic, etc. With Illustrations. Price $1.50 
 
 MAXON, ON PRACTICE. 
 
 The Practice of Medicine. By Edwin R. Maxon, m.d. 
 
 Bvo. Price txoo 
 
 yiPCi^, THE THERAPEUTIC FORCES; 
 
 Or, The Action of Medicine in the Light of the Doctrine of Conservation of 
 Force. By Thomas J. Mays, m,d. i2mo. Price $1.25 
 
 MEADOWS, ON MIDWIFERY. 
 
 A Text-Book of Midwifery. Including the Signs and Symptoms of Preg- 
 nancy, Obstetric Operations, Diseases of the Puerperal State, etc. By Alfred 
 Meadows, m.d. Third American, from Fourth London Edition. Revised and 
 Enlarged. With 145 Illustrations. Bvo. Price $2.00 
 
 " It is with great gratification that we are enabled 
 to class Dr. Meadows' Manual as a rare exception, 
 and to pronounce it an accurate, practical, and cred- 
 itable work, and to unhesitatingly recommend it to 
 both student and practitioner." — Ainerican yournal 
 of Obstetrics. 
 
 " We cannot but feel that every teacher of Obstet- 
 rics has good cause to congratulate himself on being 
 able to put in the hands of the student a book which 
 contains so much valuable and reliable information." 
 — Philadelphia Medical Times. 
 
 " On all questions of treatment, whether by medi- 
 cines, by hygienic regimen, or by mechanical or oper- 
 ative appliances, this treatise is as satisfactory as a 
 work of manual size could be : students and practi- 
 tioners can hardly do better than adopt it as their 
 vade mecum." — The Practitioner. 
 
 " The systematic arrangement of subjects, and the 
 concise, practical style in which it is written, make 
 the work especially valuable as a student's manual." 
 Chicago Medical Examiner, 
 
 MEARS, PRACTICAL SURGERY. 
 
 Practical Surgery. Including : Part i. — Surgical Dressings ; Part 11. — Band- 
 aging ; Part in. — Ligations; Part iv. — Amputations. With 227 Illustrations. 
 By J. EwiNG Mears, m.d.. Demonstrator of Surgery in Jefferson Medical Col- 
 lege, and Professor of Anatomy and Clinical Surgery in the Pennsylvania Col- 
 ' ~ " " Price $2.00 
 
 "It contains a great deal of information upon the 
 subjects of which it treats, in a convenient and con- 
 densed form. Each division is well illustrated, thereby 
 rendering the text doubly clear." — New York Medical 
 Record. 
 
 lege of Dental Surgery. i2mo. 
 
 " Professor Mears has written a convenient and use- 
 ful book for students. We can most cordially endorse 
 it as fulfilling well the promise made in its modest 
 preface." — Cincinnati Lancet and Clinic. 
 
 MILLER, ON ALCOHOL. 
 
 Alcohol. Its Place and Power. By James Miller, f.r.c.s. i2mo. Price .50 
 
 MILLER & LIZARS, ALCOHOL AND TOBACCO. 
 
 Alcohol. Its Place and Power. By James Miller, f.r.c.s. ; and, Tobacco, 
 Its Use and Abuse. By John Lizars, m.a. The two essays in one volume. 
 i2mo. Price $1.00 
 
PUB Lie A TIONS. 
 
 29 
 
 MENDENHALL, VADE MECUM. 
 
 The Medical Student's Vade Mecum. A Compend of Anatomy, Physiology, 
 Chemistry, The Practice of Medicine, Surgery^, Obstetrics, etc. By George 
 Mendenhall. m.d. Eleventh Edition. 224 Illustrations. 8vo. Price ^2.00 
 
 MEIGS AND PEPPER, DISEASES OF CHILDREN. 
 
 A Practical Treatise on the Diseases of Children. By J. Forsyth Meigs, m.d.. 
 Fellow of the College of Physicians of Philadelphia, etc., etc., and William 
 Pepper, m.d.. Physician to the Philadelphia Hospital, Provost University of 
 Pennsylvania. Seventh Edition, thoroughly Revised and Enlarged. A Royal 
 Octavo Volume of over 1000 pages. Price, Cloth, $6.00; Leather, ^7.00 
 
 " With the recent additions it may safely be pronounced one of the best and most comprehensive tvorks on Dis- 
 eases of Children." — New York Medical jfournal. 
 
 " Must be regarded as the most complete work on Diseases of Children in our language." — Edinburgh Medical 
 yournal. 
 
 " We have seldom met with a text-book so complete, so just and so readable as the one before us." — American 
 jfournal of Obstetrics. 
 
 MATHIAS, LEGISLATIVE MANUAL. 
 
 A Rule for Conducting Business in Meetings of Societies, Legislative Bodies, 
 Town and Ward Meetings, etc. By Benj. Mathias, a.m. Sixteenth Edition. 
 l6mo. Price .50 
 
 MORTON, REFRACTION OF EYE. 
 
 The Refraction of the Eye. Its Diagnosis and the Correction of its Eriors. 
 With Chapter on Keratoscopy. By A. Stanford Morton, m.b., f.r.c.s. i2mo. 
 
 Price ^i.oo 
 
 " The author has not only given very thorough rules for the objective and subjective examinations of the eye in 
 the various conditions of refraction which present themselves, but has entered into an explanation of the phenom- 
 ena observed, which is at once scientific and elementary."— Edinburgh Medical Journal. 
 
 OVERMAN, MINERALOGY. 
 
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30 PRESLE V BLAKISTON' S 
 
 BY SAME AUTHOR. 
 
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PUBLICATIONS. 31 
 
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32 PRESLE Y BLAKISTON 'S 
 
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PUB Lie A TIONS. 
 
 33 
 
 ROBERTS, PRACTICE OF MEDICINE. Fourth Edition. 
 
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 RUTHERFORD, PRACTICAL HISTOLOGY. 
 
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 SANKEY, MENTAL DISEASES. 
 
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34 PRESLEY BLAKISTON'S 
 
 SANDERSON AND FOSTER, THE PHYSIOLOGICAL LA- 
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 Medical Journal. 
 
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PUBLICATIONS. 
 
 35 
 
 SMITH, ON CHILDREN. 
 
 Clinical Studies of Diseases in Children. 
 
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 MEDICAL HERESIES, HISTORICALLY CONSIDERED. 
 
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35 PRESLEY BLAKISTON'S 
 
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PUBLICA TIONS. 
 
 37 
 
 THOMPSON, COUGHS AND COLDS. 
 
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 THOROWGOOD, MATERIA MEDICA. 
 
 The Student's Guide to Materia Medica. By John C. Thorowgood, m.d. 
 Illustrated. 318 pages. i2mo. Price $2.00 
 
 BY SAME author. 
 
 ON ASTHMA. 
 
 The Forms, Nature, and Treatment of Asthma. 
 
 i2mo. 
 
 TUSON, VETERINARY PHARMACOPCEIA. 
 
 A Pharmacopoeia, Including the Outlines of Materia Medica and Therapeu- 
 tics. For the Use of Students and Practitioners of Veterinary Medicine. By 
 Richard V. Tuson, f.c.s. Third Edition. i2mo. Price $2.50 
 
 " Not only practitioners and students of veterinary medicine, but chemists and druggists will find that this 
 book supplies a want in veterinary literature." — Druggist and Chemist. 
 
 THUDICHUM ON THE URINE. Second Edition. 
 
 The Pathology of the Urine and Complete Guide to Analysis. By John L. 
 W. Thudichum, m.d. Second Edition, Enlarged and Illustrated. 8vo. 
 
 Price $5.00 
 
 "The treatise of Dr. Thudichum is well known as one of the medical classics of the language, and in com- 
 pleteness, thoroughness, and originality, the volume before us has few rivals in any branch of our science. For 
 the specialist, for the physiological chemist, for the physiologist, the volume of Dr. Thudichum is a sine qzta 
 non, and to such the new edition must be a most welcome guest." — Philadelphia Medical Times. 
 
 TROUSSEAU, CLINICAL MEDICINE. 
 
 Lectures on Clinical Medicine, Delivered at the Hotel Dieu, Paris, by A. 
 Trousseau, Professor of Clinical Medicine to the Faculty of Medicine, Paris, 
 etc., etc. Translated from the Third Revised and Enlarged Edition by P. Vic- 
 tor Bazire, m.d., London and Paris ; and John Rose Cormack, m.d., Edin- 
 burgh, F.R.S., etc. With a full Index, Table of Contents, etc. 2 vols. 8vo. 
 Sold by Subscription only. Price, Cloth, $8.00; Leather, $10.00 
 
 Sydenham Edition, Same Work. 5 Vols. 8vo. Large Print. Price $15.00 
 
 Trousseau's Lectures have attained a reputation, both in England and in this 
 
 country, far greater than any work of a similar character heretofore written. In 
 
 order to bring the work within the reach of all the profession, the publishers now 
 
 issue an American edition, containing all the lectures as contained in the five-vol- 
 
 ume Sydenham edition, at a much lower price, 
 favorable opinions expressed of the work : — 
 
 Below are a few only of the many 
 
 " a clever translation of Prof. Trousseau's admirable 
 and exhaustive work ; the best book of reference upon 
 the Practice of Medicine." — Indiana Medical Gazette. 
 
 "The great reputation of Prof Trousseau as a prac- 
 titioner and teacher of Medicine in all its branches, 
 renders tlie present appearance of his Clinical Lectures 
 particularly welcome." — Medical Press and Circular. 
 
 " It treats of diseases of daily occurrence and of the 
 most vita! interest to the practitioner. .A.nd we should 
 think any medical library absurdly incomplete now 
 which did not have alongside of Watson, Graves, and 
 Tanner, the 'Clinical Medicine' of Trousseau." — 
 London Lancet. 
 
 " We scarcely know of any book better fitted for 
 presentation to a young man when entering upon """ ' 
 practical work of his life." — London Medical Tii 
 
 the 
 'imes 
 
 practi 
 
 ayid Gazette. 
 
 " The publication of Trousseau's Lectures furnishes 
 medical men with one of the best practical treatises 
 on disease as seen at the bedside. The conversational 
 style adopted by the author lends animation to the 
 work, and the translator deserves credit for having so 
 well preserved the easy and ready style of the origi- 
 nal." — British and Foreign Medico-Chirurgical Re- 
 view. 
 
 TIDY, MODERN CHEMISTRY. 
 
 A Hand-Book of Modern Chemistry. Organic and Inorganic. By C. Mey- 
 MOTT Tidy, m.d. 8vo. Price $5.00 
 
 "We doubt if any other chemical work containing so large an amount of information could be procured." — 
 Dttblin Medical yournal. 
 
38 PRESLEY BLAKISTON'S 
 
 TILT, THE CHANGE OF LIFE IN WOMEN. 
 
 The Change of Life in Health and Disease. A Practical Treatise on the 
 Diseases incidental to Women at the Dechne of Life. By Edward John Tilt, 
 M.D. Fourth London Edition. 8vo. Price, Cloth, fi.25; Paper cover, .75 
 
 " We believe Dr. Tilt brings much more than ordinary merit to bear on his subject, and handles it accord- 
 ingly. Few books are issued that are more indispensable to the general practitioner." — Phila. Med. Times. 
 
 " Dr. Tilt's clear and concise style makes the book at once a pleasant one to read and an easy guide to follow, 
 and we are quite sure it is the most valuable one we have on the subject." — Boston Med. &= Surg. Journal. 
 
 " The best work on the subject." — London Lancet. 
 
 TOMES, DENTAL ANATOMY. Second Edition. 
 
 A Manual of Dental Anatomy, Human and Comparative. By C. S. Tomes, 
 D.D.s. With 179 Illustrations. Second Edition, i2mo. Price $4.25 
 
 TOMES, DENTAL SURGERY. 
 
 A System of Dental Surgery. By John Tomes, f.r.s. The Second Edition, 
 Revised and Enlarged. By C. S. Tomes, d.d.s. With 263 Illustrations. i2mo. 
 
 Price $5.00 
 
 " We rejoice that such books as these (Dr. Tomes' Works) are demanded by the profession, and that the men 
 to write them are furnished by the profession. "^i?fKi'«/ Cosmos. 
 
 TAFT, OPERATIVE DENTISTRY. Fourth Edition. 
 
 A Practical Treatise on Operative Dentistry. By Jonathan Taft, d.d.s. 
 Fourth Revised and Enlarged Edition. Over 100 Illustrations. Bvo. 
 
 Price, Cloth, ^4.25 ; Leather, 5.00 
 
 "All the important operations, in all their modifica- | "It is a thorough and complete treatise on the Art 
 twns, are clearly discussed by the author, and the of Practical Dentistry." — London Medical Times and 
 work is highly practical throughout." — Dental Regis- Gazette, 
 
 ter. \ 
 
 TANNER, INDEX OF DISEASES. Second Edition. 
 
 An Index of Diseases and their Treatment. By Thos. Hawkes Tanner, m.d., 
 
 F.R.c.P. Sixth Edition. Revised and Enlarged. By W. H. Broadbent, m.d. 
 
 With Additions. Appendix of Formulse, etc. Bvo. Price ^3.00 
 
 By this useful hand-book the character of any disease may be determined in a 
 
 moment, and the general outline of treatment pursued by the best authorities made 
 
 apparent. 
 
 " Finally, a chapter on the climates, countries, mine- 
 ral springs, etc., best adapted to the various classes of 
 invalids, makes this work the most complete practi- 
 tioner's manual that we have yet seen. — Chicago Medi- 
 cal Tiines. 
 
 " This work, like others from the gifted author, has 
 already won for itself a reputation." . . . " It is 
 in truth what its title indicates." — New York Medical 
 Record. 
 
 BY same author. 
 
 THE DISEASES OF INFANCY. 
 
 A Practical Treatise on the Diseases of Infancy and Childhood. Third Edi- 
 tion. Carefully Revised and inuch Enlarged. By Alfred Meadows, m.d. 
 8vo. Price $3.00 
 
 Recommended as a Text-book at Jefferson Medical College and other schools of 
 Medicine. 
 
 "One of the most careful, ornate, and accessible 1 "We consider the views of the author on the subject 
 manuals on the subject." — London Lancet. of therapeutics as rational in the highest degree." — 
 
 1 Boston Medical and Surgical yoiirnal. 
 
 MEMORANDA OF POISONS. 
 
 A Memoranda of Poisons and their Antidotes and Tests. Fourth American 
 from the Last London Edition. Revised and Enlarged. Price .75 
 
 This most complete Toxicological Manual should be within reach of all physi- 
 cians and pharmacists, and as an addition to every family library, would be the 
 means of saving life and allaying pain when the delay of sending for a physician 
 would prove fataL 
 
PUBLICA TIONS. 39 
 
 TIBBETS, MEDICAL ELECTRICITY. 
 
 A Hand-book of Medical Electricity. Giving full directions for its Applica- 
 tion, etc. By Herbert Tibbets, m.d. 64 Illustrations. 8vo. 
 
 TOLAND, PRACTICAL SURGERY. 
 
 Lectures on Practical Surgery. By H. H. Toland, m.d., Professor of Surgery, 
 University of California. Second Edition. With Additions and Numerous Illus- 
 trations. 8vo. Price, Cloth, ^4.50; Leather, ^5.00 
 
 TRANSACTIONS OF THE COLLEGE OF PHYSICIANS. 
 
 The Transactions of the College of Physicians of Philadelphia. New Series. 
 Vols. I, II, III, IV and V. 8vo. Price, per volume, $2.50 
 
 TYSON, BRIGHT'S DISEASE AND DIABETES. 
 
 A Treatise on Diabetes and Bright's Disease. With Especial Reference to 
 Pathology and Therapeutics. By James Tyson, m.d., Professor of Pathology 
 and Morbid Anatomy in the University of Pennsylvania. With Colored Plate's 
 and many Wood Engravings. Svo. Price ;f3.5o 
 
 "This volume is the outcome of some fifteen years' 
 special study and observation, and will be found to be 
 a very well prepared monograph His direc- 
 tions are clear and minute. — Med. and Surg. Reporter. 
 
 " The symptoms are clearly defined, and the treat- 
 ment is exceedingly well described, so that every one 
 reading the book must be profited." — Cincinnati Lan- 
 cet and Clinic. 
 
 BY SAME AUTHOR. 
 
 GUIDE TO THE EXAMINATION OF URINE. 
 
 A Practical Guide to the Examination of Urine. For the use of Physicians and 
 
 Students. With Colored Plate, and Numerous Illustrations Engraved on Wood. 
 
 Third Edition. i2mo. Price $1.50 
 
 Advantage has been taken, in bringing out a new edition of this work, not only to 
 
 correct the previous one, but to make such additions of new Facts and Processes as 
 
 would add to its value without materially increasing its size. 
 
 "Dr. Tyson commences with a short account of the theory of renal secretion, the physical and chemical charac- 
 ters of the urine, and the reagents and apparatus used in its analysis. Excellent rules are then given for detecting 
 the presence of albumen, sugar, coloring-matters, bile, urea, uric acid, chlorides, phosphates and sulphates ; and 
 minute instructions for approximative and quantitative determination of most of those ingredients by volumetric 
 analysis are supplied." — Pliiladelphia Medical Times. 
 
 "We have experienced both pleasure and profit ftom the perusal of this book. It is agreeably written, contains 
 much practical information, and is, we believe, a reliable and satisfactory guide to the clinical examination ot 
 urine. We can recommend Dr. Tyson's book as one that amply supplies the clinical needs of the physician." — 
 Dublin Journal of Medical Science. 
 
 THE CELL DOCTRINE. Second Edition. 
 
 The Cell Doctrine. Its History and Present State. With a Copious Biblio- 
 graphy of the subject. Illustrated by a Colored Plate and Wood Cuts. Second 
 Edition. Svo. Price %i.oo 
 
 TURNBULL, ARTIFICIAL ANiESTHESIA. 
 
 The Advantages and Accidents of Artificial Anaesthesia ; Its Employment in 
 the Treatment of Disease ; Modes of Administration ; Considering their Rela- 
 tive Risks; Tests of Purity; Treatment of Asphyxia; Spasms of the Glottis; 
 Syncope, etc. By Laurence Turnbull. m.d., ph.g., Aural Surgeon to Jeffer- 
 son College Hospital, etc. Second Edition. Revised and Enlarged. With 27 
 Illustrations of Various Forms of Inhalers, etc. i2mo. Price #1.50 
 
 " Ansesthesia is a subject of great interest and importance to physicians .ind dentists, and everything that will 
 aid them in better understanding the subject is sought with great avidity. This work we regard as the best aid in 
 the study of the subject, and it presents the subject up to the present hour." — Dental Register. 
 
 TEALE, DANGERS TO HEALTH. Third Edition. 
 
 A Pictorial Guide to Domestic Sanitary Defects. By T. Pridjin Teale, m.d., 
 F.R.c.s. With Colored Plates. Svo. Price ;^3.3u 
 
40 PRESLE Y BLAKISTON'S 
 
 VACHER, CHEMISTRY. 
 
 A Primer of Chemistr>% Including Analysis. By Arthur Vacher. i8mo. 
 
 Price .50 
 
 VIRCHOW, POST-MORTEM EXAMINATIONS. Second Edi- 
 tion. 
 
 Post-mortem Examinations. A Description and Explanation of the Method 
 
 of Performing them in the Dead House of the Berlin Charite Hospital, with 
 especial reference to Medico-legal Practice. By Prof Virchow. Translated 
 by Dr. T. P. Smith. Second Edition. i2mo. With 4 Plates. Price gi.25 
 
 " Its low price and portability make it accessible and 
 convenient to every surgical registrar and practitioner." 
 — British Medical yournal. 
 
 "A most useful manual from the pen of a master. 
 
 . . . . For thorough and systematic method in 
 the performance of post-mortem examinations, there is 
 no guide like it." — Lancet. 
 
 WAGSTAFFE, HUMAN OSTEOLOGY. 
 
 The Student's Guide to Human Osteology. By William Warwick Wag- 
 STAFFE, F.R.c.s. With 23 Lithographic Plates of the Bones, Showing Muscle 
 Attachments, and 60 Wood Engravings. i2mo. Price $3.00 
 
 WALTON, DISEASES OF THE EYE. Third Edition. 
 
 A Practical Treatise on Diseases of the Eye. By Haynes Walton, m.d. 
 Third Edition. Rewritten and Enlarged. With five plain and three colored 
 full-page Plates; and many other Illustrations, Test Types, etc. Nearly 1200 
 pages. 8vo. Price $9.00 
 
 WARNER, CASE TAKING. 
 
 The Student's Guide to Medical Case Taking. By Francis Warner, m.d., 
 M.R.C.P., etc. i2mo. Cloth. Price $1.75 
 
 General Diseases. — Class i. Class 2. Arthritic Diseases. Diseases of the Nervous System. Of the Vas- 
 cular System. Of the Respiratory System. Of the Digestive System. Of the Liver. Of the Urinary System. 
 Instruction for Case Taking. 
 
 WATERS, DISEASES OF THE CHEST. Second Edition. 
 
 The Diseases of the Chest. Their Clinical History, Pathology and Treat- 
 ment. By A. T. H. Waters, m.d., Fellow Royal College of Physicians. With 
 Numerous Illustrative Cases and Lithographic Plates. 8vo. Price $4.00 
 
 " The present edition contains new chapters on haemoptj'sis, hay fever, aortic regurgitation, mitral constriction, 
 thoracic aneurism, and the use of chloral in certain diseases of the chest ; other chapters have received additions 
 of cases and remarks on treatment. Some characteristic sphygmographic tracings have also been added." — Bos- 
 ton Medical and Surgical journal. 
 
 WOOD, BRAINWORK. 
 
 Brainwork and Overwork. By Prof. H. C. Wood, Jr. 32mo. 
 
 Price, Paper cover, .30 ; Cloth .50 
 
 BY SAME author. 
 
 DENTAL PATHOLOGY. 
 
 With Special Reference to the Anatomy and Physiolog}' of the Teeth. With 
 Notes by Thos. B, Hitchcock, m.d., of Harvard University. 105 lUustra- 
 trations. 8vo. Price, Cloth, $3.50; Leather, 34.50 
 
 WHITTAKER, ON THE URINE. 
 
 Student's Primer on the Urine. By J. Travis Whittaker, m.d., Physician to 
 Anderson's College Dispensary. With Illustrations Etched on Copper. i6mo. 
 
 Price $1.50 
 
 Physiological Study of Urine — Sensation in Passing. Quantity. Color. Odor. Specific Gravity. History 
 and Behavior. Sediment or Deposits. Chemical Study of Urine — Reaction. Albumen. Chlorides. Ammonia. 
 Urea. Phosphates. Blood. Sugar. Bile. Microscopical Study of Urine and Urinary Deposits — Amorphous 
 Urates. Uric Acid. Triple Phosphates. Phosphate of Lime. Feathery Phosphates. Oxalate of Lime. Urate 
 of Soda and of Ammonia. Cystine. Tyrosine. Leucine. Cholesterine. Epithelium. Fat Globules, etc. 
 
 "The plates are po.ssessed of great versimilitude, as well as in other respects admirable." — Med. Times. 
 
 " Neat and concise, and the illustrations are very good testimony of the claim which he makes of the suitability 
 "f the etching needle for delineation of microscopical appearances." — Boston Med. and Surg. yourHol. 
 
PUBLICA TIONS. 41 
 
 WEST, THE DISEASES OF WOMEN. Fourth Edition. 
 
 Lectures on the Diseases of Women. By Charles West, m.d. Fourth 
 London Edition. Revised and in part re-written by the Author. With Numer- 
 ous Additions by J. Mathews Duncan, m.d.. Obstetric Physician to St. Bar- 
 tholomew's Hospital 8vo. Price $5.00 
 Drs. West and Duncan are, perhaps, the most celebrated London physicians 
 giving attention to the Diseases of Women, and together have made a most com- 
 plete work, either for the physician or student. 
 
 WILKES, PATHOLOGICAL ANATOMY. 
 
 Lectures on Pathological Anatomy. By Samuel Wilkes, f.r.s. Second 
 Edition. Revised and Enlarged by Walter Moxon, m.d., f.r.s.. Physician to 
 and Lecturer at Guy's Hospital, London. 8vo. Price ^6.00 
 
 BY same author. 
 
 DISEASES OF THE NERVOUS SYSTEM. 
 
 Lectures on Diseases of the Nervous System, Delivered at Guy's Hospital, 
 London. New Edition, with Additions, Numerous Illustrative Cases, etc. 8vo. 
 
 \^Preparing. 
 
 "A book of great value, embodying as It does the results of the experience and observation of one of the most 
 accomplished of the London Hospital Physicians." — Avierica7i jfournal of Medical Science. 
 
 WRIGHT, ON HEADACHES. Ninth Thousand. 
 
 Headaches, their Causes, Nature and Treatment, By Henry G. Wright, 
 M.D i2mo. Price .50 
 
 WILSON, ON DRAINAGE. 
 
 Drainage for Health ; or. Easy Lessons in Sanitary Science, with Numerous 
 Illustrations. By Joseph Wilson, m.d., Medical Director United States Navy. 
 One Vol. Octavo. Price JSi.oo 
 
 " Dr. Wilson is favorably known as one of the lead- 
 ing American writers on hygiene and public health. 
 The book deserves popularity." — Medical and Surgi- 
 cal Reporter. 
 
 " Easily understood, and briefly and concisely pre- 
 sented." — Providence Journal. 
 
 " Will be found of value." — Boston Transcript. 
 
 " Worthy of praise as a popular statement of the 
 
 " Well written and well illustrated. Attention to its j subject." — Boston Journal of Chemistry. 
 
 teachings may save much disease and perhaps many " Will be sure to be a harbinger of good in every fam- 
 
 lives." — Cincinnati Gazette. ily whose good fortune it may be to possess a copy." — 
 
 "Interesting as well as useful." — Philadelphia Led- | Builder and Wood Worker. 
 ger. 
 
 BY SAME author. 
 
 NAVAL HYGIENE. 
 
 Naval Hygiene, or. Human Health and Means for Preventing Disease. With 
 Illustrative Incidents derived from Naval Experience. Illustrated. Second 
 Edition. Svo. Price ^3.00 
 
 WILSON, HOW TO LIVE. 
 
 Health and Healthy Homes. A Guide to Personal and Domestic Hygiene. 
 By George Wilson, m.d., Medical Officer of Health. Edited by Jos. G. 
 Richardson, m.d.. Professor of Hygiene at the University of Pennsylvania. 
 314 pages. i2mo. Price $ 1. 00 
 
 Chapter \. — Introductory, page 17. II. The Human Body, 33. iii. Causes of Disease, 66. iv. Food and 
 Diet, 119. V. Cleanliness and Clothing, 169. vi. Exercise, Reoreation and Training, 187. vil. Home and Its 
 Surroundings, Drainage, Warming, etc., 221. viu. Infectious Diseases and their Prevention, 269. 
 
 "A most useful, and in every way, .icceptable book." — New York Herald. 
 
 " Marked throughout by a sound, scientific spirit, and an absence of all hasty generalizations, sweeping asser- 
 tions, and abuse cf statistics in support of the writer's particular views. . . . We cannot speak too highly of 
 a work which we have read with entire satisfaction." — Medical Timet and Gazette. 
 
 BY SAME author. 
 
 A HAND-BOOK OF HYGIENE 
 
 And Sanitary Science. With Illustrations. Fourth Edition. Revised and 
 Enlarged. Svo. Price ^2.75 
 
42 PRESLEY BLAKISTON'S 
 
 WILSON, HUMAN ANATOMY. Tenth Edition. 
 
 The Anatomist's Vade-Mecum. General and Special. By Prof. Erasmus Wil- 
 son. Edited by George Buchanan, Professor of Clinical Surgery in the Uni- 
 versity of Glasgow ; and Henry E. Clark, Lecturer on Anatomy at the Royal 
 Infirmary School of Medicine, Glasgow. Tenth Edition. With 450 Engravings 
 (including 26 Colored Plates). Crown 8vo. Price $6.00 
 
 Recommended as a Text-book at Rush Medical College, Chicago ; Bellevue Hos- 
 pital, New York; St. Louis Medical College; Yale and Dartmouth Schools; and 
 many other Colleges. 
 
 "The present edition of the 'Anatomist's Vade-mecum,' has been prepared under 
 the same editorial control as the Ninth Edition. 
 
 " Numerous additional wood cuts have been introduced, and full-page engravings 
 of the bones, which have been drawn and engraved with great care, to secure ac- 
 curacy, and to make them not mere anatomical diagrams, but artistic pictiures." 
 
 BY SAME AUTHOR. 
 
 HEALTHY SKIN. Eighth Edition. 
 
 A Practical Treatise on the Skin and Hair ; their Preservation and Manage- 
 ment. Eighth Edition. i2mo. Paper. Price ^1.00 
 
 WILSON, SEA VOYAGES FOR HEALTH. 
 
 The Ocean as a Health Resort. A Hand-book of Practical Information as to 
 Sea Voyages, for the Use of Tourists and Invahds. By Wm. S. Wilson, l.r.c.p. 
 Lond., m.r.c.s.e. With a Chart showing the Ocean Routes, and Illustrating the 
 Physical Geography of the Sea. Crown 8vo. Price $2.50 
 
 Chapter I. Curative Effects of the Ocean Climate. 2. The Various Health Voyages. 3. Time of Starting — 
 Choosing a Ship. 4. Preliminary Arrangements. 5. Life at Sea. 6. Climate and Weather. 7. Management of 
 the Health at Sea. 8. Occupations and Amusements at Sea. 9. Objects of Interest at Sea. 10. End of the 
 Voyage — Future Plans. 11. The Homeward Voyage. 12. Australia: its CUmate, Cities, and Health Resorts. 
 13. South Africa and its Climate. 14. The Meteorology of the Ocean. 
 
 Appendix A. — Outfit Required for a Voyage to Australia. B. Names and Addresses of some of the Principal 
 Shipping Firms. 
 
 "All the information is supplied by, or based upon, the actual experience of the author; and the book may be 
 confidently recommended to all who have to undertake, without previous experience, a sea voyage of any length. 
 Medical men may consult it with advantage, and commend it to those patients whom they may advise to try the 
 effect of a long voyage at sea." — Medical Times and Gazette. 
 
 " We have read every page of this book, and have derived both instruction and amusement." — Lancet. 
 
 WELLS, OVARIAN AND UTERINE TUMORS. Just Out. 
 
 The Diagnosis and Surgical Treatment of Ovarian and Uterine Tumors, By 
 
 T. Spencer Wells, m.d. Illustrated. 8vo. Price, Cloth, $7.00 
 
 So long a time having elapsed since Dr. Wells has collected the results of his 
 
 large experience in book form, the present volume will be eagerly looked for by all 
 
 interested in this very important subject. 
 
 WOLFE, ON DISEASES OF THE EYE. 
 
 A Practical Treatise on Diseases and Injuries of the Eye. Bemg a Course of 
 Systematic and Chnical Lectures to Students and Medical Practitioners. By M. 
 Wolfe, f.r.c.p.e., Senior Surgeon to the Glasgow Ophthalmic Institution, etc. 
 With 10 Colored Plates, and numerous other Illustrations. Octavo. Price ^^7.00 
 
 WALKER, INTERMARRIAGE. 
 
 Intermarriage, or, The Mode in which, and the Causes why, Beauty, Health 
 and Intellect result from certain Unions ; and Deformity, Disease and Insanity 
 from others. Illustrated. i2mo. Price $1.00 
 
PUB Lie A TIONS. 
 
 43 
 
 WOODMAN and TIDY, MEDICAL JURISPRUDENCE. 
 
 Forensic Medicine and Toxicology. By \V. Bathurst Woodman, m.d., 
 Physician to the London Hospital, and Charles Meymott Tidy, f.c.s., Pro- 
 fessor of Chemistry and Medical Jurisprudence at the London Hospital. With 
 Chromo-Lithographic Plates, representing the Appearance of the Stomach in 
 Poisoning by Arsenic, Corrosive Sublimate, Nitric Acid, Oxalic Acid ; the Spectra 
 of Blood and the Microscopic Appearance of Human and other Hairs ; and 
 Ii6 other Illustrations. Large octavo. Sold only by Subscription. 
 
 Price, Cloth, $7.50; Medical Sheep, $8.50; Law Leather, $8.50 
 
 " We have no hesitation in pronouncing the work to be one of unusual merit. More readable than Taylor, 
 more systematic in its arrangement, and more practical in its instruction, it will prove to the medical jurist, not 
 less than to the general practitioner, a storehouse of useful knowledge, conveyed in an unusually graphic style." — 
 Dublin Journal of Medical Science. 
 
 "The authors of this truly great work have largely supplied the want felt, sooner or later, by almost every 
 doctor." — Cincinnati LaKcet and Observer. 
 
 "All the best known works on Medical Jurisprudence have been laid under contribution for the production of 
 the present volume. It contains almost everything that can be found in other works on the subject; but it is no 
 mere compilation. Dr. Woodman and Dr. Tidy have both thought out the subject for themselves, and, with rare 
 industry and acumen, have brought together a mass of facts which is little short of astounding. The book is 
 worthy to take its place alongside of any work on the same subject, and must prove of great use to all who prac- 
 tice in criminal courts, and to all medical practitioners. We have no hesitation in recommending it to our read- 
 ers." — London Lancet. 
 
 " Altogether the work will rank with, the best of its class as a medico-legal hand-book, and cannot fail to gain 
 a wide popularity." — New York Medical Record. 
 
 " It cannot be otherwise than a valuable contribution to the boundless subject of medical jurisprudence." — 
 Albany La-ju yournal. 
 
 "The scope of this book is very wide, and its execution worthy of all commendation." — Philadelphia Legal 
 Intelligencer. 
 
 ^A^YTHE, ON THE MICROSCOPE. 
 
 The Microscopist. A Manual of Microscopy and Compendium of the Micro- 
 scopic Sciences, Micro-Mineralogy, Micro-Chemistry, Biology, Histology, and 
 Practical Medicine. By Joseph H. Wythe, a.m., m.d. Fourth Edition. 252 
 Illustrations. 8vo. Price, Cloth, $5.00; Leather, $6.00 
 
 An Index and Glossary have been combined in this edition, so as to be a source 
 of valuable information. Notices of recent additions to the microscope, together 
 with the genera of microscopic plants, have been given in an Appendix. 
 
 "From what we knew of the author of this work, as 
 a skilled practical Microscopist, a successful teacher of 
 the science, and a practitioner of medicine andsurgery 
 of long and varied experience, we had a right to expect 
 agoodbook from his hands. Our expectations are fully 
 realized in the volume before us. The style is clear 
 and distinct, and one reads the book with the utmost 
 facility of comprehension. It is the more valuable to 
 the physician and medical student on account of its 
 closer application of the microscope to medical subjects 
 than we find elsewhere. The numerous plates, many 
 of which are beautifully colored, are not to be excelled. 
 We feel proud of it as an American production." — 
 Pacific Medical and Surgical Journal. 
 
 " This is one of the most valuable text-books on mi- 
 croscopy ever offered to students or practitioners of 
 medicine. This edition has been greatly enhanced in 
 value by the addition of chapters on the use of the 
 microscope in pathology, diagnosis, and etiology, and 
 numerous new illustrations, some of which are from 
 Rindfleisch. 
 
 "The author very carefully brings out every neces- 
 sary fact and principle relating to the use of the micro- 
 scope, and now that this instrument has become an es- 
 sential part of every practitioner's armamentarium, a 
 practical guide and reference book is also a necessity, 
 and we are fully warranted in reiterating the statement 
 that this is one of the most valuable text-books ever 
 offered to students and practitioners of medicine." — 
 The Cincinnati Lancet and Clinic. 
 
 BY SAME AUTHOR, 
 
 DOSE AND SYMPTOM BOOK. Eleventh Edition. 
 
 The Physician's Pocket Dose and Symptom Book. Containing the Doses and 
 Uses of all the Principal Articles of the Materia Medica, and Original Prepara- 
 tions. Eleventh Revised Edition. 
 
 Price, Cloth, $i.oo\ Leather, with Tucks and Pocket, $1.25 
 
 "The chapter on Dietetic Preparations will be found useful to all practicing physicians, most of whom have but 
 Jittle acquaintance with the mode of preparing the various articles of diet for the sick." — Boston Medical and 
 Surgical Journal. 
 
 "Many a hard-worked practitioner will find it a useful little work to have on his study table." — Canada Medical 
 
 and Surgical Journal. 
 
44 PRESLE V BLAKISTON'S PUBLIC A TIONS. 
 
 WHEELER, MEDICAL CHEMISTRY. 
 
 Medical Chemistry, Including the Outlines of Organic and Physiological 
 Chemistry. By C. Gilbert Wheeler, m.d. Second Edition, i2mo. 
 
 Price I3.00 
 WOAKES, ON DEAFNESS AND GIDDINESS. 
 
 On Deafness, Giddiness and Noises in the Head ; or, The Naso-Pharyngeal 
 Aspect of Ear Disease. By Edward Woakes, m.d , Senior Aural Surgeon to 
 the Hospital for Diseases of the Throat and Chest. Third Edition. Revised and 
 Enlarged, with Additional Illustrations. i2mo. 
 
 "The early demand for a fresh edition of Dr. | "This book, although small, is evidently the result 
 
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DUE DATE 
 
 201-6503 
 
 Printed 
 In USA 
 
llllf 
 
 0027673740